Ulcer Stenosis Research Articles

Prevalence and Clinical Importance of Spontaneous Echo Contrast Within the Carotid Artery in Patients With Ischemic Cerebrovascular Disease

Spontaneous echo contrast (SEC) is composed of numerous microechoes swirling in the cardiovascular lumen, usually appearing during blood stasis. This study aimed to clarify the clinical importance of SEC in the carotid artery (CA) in patients with ischemic cerebrovascular disease (ICVD). In 264 CAs of 132 consecutive patients with ICVD and in 40 CAs of 20 healthy control subjects, SEC was classified as none, faint, or dense, and CA abnormalities, including plaque, plaque ulcer, mural thrombus, and internal CA stenosis, were assessed with 10-MHz sonography. The overall prevalence of SEC was greater in CAs of patients with ICVD (164/264 [62%]) than in CAs of control subjects (6/40 [15%]; P < .0001). Dense SEC was more specifically detected in CAs of ICVD with the prevalence of 81 (31%) of 264, which was greater than that of controls (1/40 [3%]; P = .0002). Dense SEC was more frequently detected in CAs with plaque (38/98 [39%]) than in those without (43/166 [26%]; P = .0285), in CA plaque with ulcerative lesions (7/10 [70%]) than in those without (31/88 [35%]; P = .0325), in CA plaque with a thrombus (11/12 [92%]) than in those without (27/86 [31%]; P < .0001), and in CAs with severe stenosis (11/13 [85%]) than in those with mild stenosis (25/75 [33%]; P = .0005) and in those without stenosis (45/176 [26%]; P < .0001). Dense SEC was frequently observed in CAs of patients with ICVD, especially in those with local atheromatous lesions, although the influence of systemic factors could not be excluded. Dense SEC within a CA may be a marker of ICVD.

Image of the Month: Ball In The Belly

A 69 year old patient with a history of diabetes mellitus and chronic obstructive lung disease was referred by his general practicioner for the evaluation of acute upper gastrointestinal bleeding. He complained of epigastric discomfort with the feeling of a "football” in the belly 2-3 hours after food intake, followed by emesis and weight loss of 6 kg over the last 6 weeks. During the physical examination a wandering, slightly tender mass was palpable in the upper abdomen (arrow Fig 1). Figure 1 Figure 1: Palpable mass in the upper abdomen An upper endoscopy was performed which showed a massively distended stomach with food retention. Additionally a large ulcer (arrow Fig 2) was seen in the antrum along the minor curvature. There was an inflammatory stenosis of the pylorus (dashed arrow Fig 2) which could hardly be passed with the endoscope. The biopsies revealed the diagnosis of moderately differentiated tubular adenocarcinoma of the stomach. Figure 2 Figure 2: Antral ulcer (arrow) and pyloric stenosis (dashed arrow)

Highly selective vagotomy and drainage for duodenal ulcer stenosis.

Abstract Thirteen cases of duodenal ulcer complicated by stenosis have been subjected to highly selective vagotomy and a gastro-enterostomy, the gastric stoma of which was situated on the greater curvature in order not to interfere with the antral motility. There was no radiological or clinical evidence of postoperative gastric retention.

Capsule Endoscopy for Obscure Gastrointestinal Bleeding

Purpose: Obscure gastrointestinal bleed (OGIB) is difficult problem requiring extensive investigations. Capsule endoscopy, a new and potentially effective method to evaluate small bowel, may be useful for patients with OGIB. Methods: 16 patients with OGIB were evaluated using capsule endoscopy (Given Imaging Ltd., Yoqneam, Israel) during 19-mo period (from November 2003 to May 2005) after standard bowel preparation. Each patient was clinically evaluated. The images were downloaded to a computer after 8-h and examined by single investigator using a software (Rapid Reader). The patients with a definite diagnosis on capsule endoscopy received specific treatment and were followed-up. Results: Of 16 patients (median age 57-y, range 25 to 76; 9 males), symptomatic for a median duration of 15 months (range: 0.5 to 240), bleed was occult, overt or combined in 4, 9 and 3, respectively requiring blood transfusions (median 11 units, range 0 to 30). One patient presented with recurrent bleed after right-hemicolectomy and one other had negative exploratory laparotomy, both done elsewhere. Capsule endoscopy could detect the lesions potentially causing OGIB in 13 of 16 (81%) patients and these included isolated bleeding lesion in distal small bowel in one (ulcerated Meckel's diverticulum with bleeding at surgery), ulcerated stricture in small bowel in three patients (verified at surgery in two and one responded to anti-tubercular drugs), worms infestation (successfully treated with ivermectin), anastomotic ulcer in one, multiple angiodysplasia in two (verified by colonoscopy in both), isolated bleeding spot in duodenum in one, multiple small intestinal varices in two, small intestinal tumor in two (both verified by surgery) and no specific lesion in three patient. Though one patient had delayed capsule expulsion, none developed intestinal obstruction due to retained capsule. Conclusions: Capsule endoscopy is effective and safe for diagnosing lesions causing OBGIB.

Solid Gastric Emptying after Highly Selective Vagotomy and Pyloroplasty in Patients with Obstructing Duodenal Ulcer

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.

Capsule endoscopy in diagnosis of small bowel Crohn's disease.

To evaluate the effectiveness of wireless capsule endoscopy in patients with suspected Crohn's disease (CD) of the small bowel undetected by conventional modalities, and to determine the diagnostic yield of M2A Given Capsule. From May 2002 to April 2003, we prospectively examined 20 patients with suspected CD by capsule endoscopy. The patients had the following features: abdominal pain, weight loss, positive fecal occult blood test, iron deficiency anaemia, diarrhoea and fever. All the patients had normal results in small bowel series (SBS) and in upper and lower gastrointestinal endoscopy before they were examined. Mean duration of symptoms before diagnosis was 6.5 years. Of the 20 patients, 13 (65%) were diagnosed as CD of the small bowel according to the findings of M2A Given Capsule. The findings detected by the capsule were mucosal erosions (2 patients), aphthas (5 patients), nodularity (1 patient), large ulcers (2 patients), and ulcerated stenosis (3 patients). The distribution of the lesions was mainly in the distal part of the small bowel, and the mild degree of lesions was 54%. Wireless capsule endoscopy is effective in diagnosing patients with suspected CD undetected by conventional diagnostic methods. It can be used to detect early lesions in the small bowel of patients with CD.

Results of short-and long-term medical treatment of gastroesophageal reflux disease (GERD).

Symptomatic esophageal reflux affects a large number of individuals. Many find relief by avoiding trigger substances such as coffee or sweets; in other cases, lifestyle modifications do not suffice and drug treatment is necessary for symptom control. An adequate classification of gastroesophageal reflux disease (GERD) is currently lacking; esophagitis can be graded according to Savary and Miller or the more recent metaplasia ulcer stricture erosions (MUSE) classification. The control of symptoms should be achieved in all patients: in addition, if esophagitis is present, the healing of erosions/ulcers as well as the prevention of further complications, such as strictures, hemorrhage, Barrett's esophagus or ulceration, must be accomplished. SHORT-TERM TREATMENT: In the case of rare symptoms, control might be achieved by lifestyle modifications and by antacids or mucosal protectants taken on demand. In the case of continuous symptoms or signs of esophagitis, effective inhibition of gastric acid secretion with proton pump inhibitors (PPIs) is necessary in many patients. After discontinuation of medical therapy, almost all patients with esophagitis will experience a relapse within 30 weeks. The regimen offering the highest rate of remission in these patients is the one that induced remission in the first place. Reduction of PPI dose or a switch to H2 receptor antagonists increases the rate of relapse. RISKS OF LONG-TERM TREATMENT: Long-term acid suppressive therapy, as with the use of PPIs, may lead to hypergastrinemia, a situation in which the endocrine cells of the stomach may proliferate. In the presence of Helicobacter pylori infection, PPIs are more efficient in healing esophagitis; however, the occurrence of gastric mucosal atrophy, a potentially pre-cancerous condition, has been described. To date, however, no case of gastric cancer or endocrine neoplasia associated with PPI treatment has been documented; gastric mucosal atrophy is more likely to result from H. pylori infection and gastric carcinoid formation needs a genetic predisposition, such as multiple endocrine neoplasia (MEN) type I. Most cases of GERD can be effectively treated by non-surgical measures; in patients presenting with warning symptoms or persistent heartburn, endoscopy of the upper gastrointestinal tract is mandatory. Long-term use of PPIs seems to be a safe and efficient treatment for GERD. For the prevention of relapse, similar doses are needed as for the induction of remission in reflux esophagitis.

The treatment results of 40 patients with localized endobronchial cancer with external beam irradiation and intraluminal irradiation using low dose rate 192Ir thin wires with a new catheter

Background and purpose: While bronchial intraluminal irradiation is valued highly as a useful palliative treatment for lung cancer, its role as a curative treatment is unclear. The treatment results of 40 localized enbobronchial tumors (including tracheal cancer) who underwent external beam irradiation (EBR) and intraluminal irradiation (IR) as a curative treatment is reported, and the role of combined EBR and IR as a curative potential treatment is examined. Materials and methods: Forty patients, including 22 with roentgenographically occult lung cancer (ROLC), 14 (18 lesions) with postoperative recurrent lung cancer (PORLC) and four with tracheal cancer, who underwent EBR and IR from February 1987 to August 1996, were studied. IR was conducted using low dose rate (1.48 GBq) 192Ir thin wires at a bronchial mucosal dose of 4–6 Gy per fraction, with a total dose of 10–57 Gy (median 28 Gy). All patients were also given combined external Linac X-ray irradiation for a total dose of 30–77 Gy (median 52 Gy). Results: As for the primary effect, complete response (CR) was obtained in all 22 ROLC cases; CR was obtained in 12 (16 lesions), partial response (PR) in one and minor response (MR) in one of the PORLC cases; and CR was obtained in three and PR in one of the tracheal cancer cases. The 3-year and 5-year local control rate by Kaplan–Meier method was 75 and 65%, respectively. Twenty-two patients survived for 3 years or longer. Complications included one case each of fatal tracheal hemorrhage, bronchial mucosal ulcer and bronchial stenosis. Conclusions: Combined EBR and IR is useful as a curative potential treatment, and long-term survival can be expected in ROLC, tracheal cancer and a portion of PORLC cases.

Paediatric upper gastro-intestinal endoscopy in developing countries.

A retrospective study of 200 endoscopies performed on 168 children (90 girls and 78 boys) aged 3 months to 18 years (median 6 years) is reported. All procedures were completed successfully in an adult endoscopy unit in a comprehensive health centre. Most children of less than 6 months and above 12 years of age needed no intravenous sedation. One child developed respiratory depression and was successfully resuscitated. Indications for endoscopy were: small intestinal biopsy, 78 (46%); recurrent abdominal pain, 40 (24%); acute epigastric pain, 13 (8%); persistent vomiting, 12 (7%); haemorrhage, 10 (6%); caustic substance ingestion, six (4%); and dysphagia, four (2%) children. Positive diagnoses were obtained in 123 (62%) procedures. Coeliac disease (26 cases) was the most common histological diagnosis, followed by gastritis (19 cases), oesophagitis (18 cases), duodenitis (16 cases), duodenal ulcer (11 cases), hiatus hernia (six cases), gastric ulcer (three cases) and oesophageal stricture (two cases). Where specialized paediatric endoscopy units are not feasible, e.g. in developing countries, endoscopic services for children can be safely provided by paediatric endoscopists as part of an adult endoscopy service, provided that suitable resuscitation equipment is available and the necessary modifications to meet the medical and psychological needs of children and their parents are taken into consideration.

Multifocal stenosing ulcerations of the small intestine revealing vasculitis associated with C2 deficiency

A patient with cryptogenic multifocal ulcerous stenosing enteritis characterized by repeated bouts of intestinal obstruction, ulcerative stenosis of the small bowel relapsing after surgical resection, and steroid sensitivity is described. Fourteen strictures of the jejunum were found at laparotomy. Despite resection, abdominal pain persisted. Steroid therapy was effective but led to dependence. In our patient, cryptogenic multifocal ulcerous stenosing enteritis was associated with fever, asthma, Raynaud's phenomenon, sicca syndrome, heterozygous type I C2 deficiency (28-base pair gene deletion), stenosis, and aneurysms in selective mesenteric angiography. It is hypothesized that cryptogenic multifocal ulcerous stenosing enteritis might be related to a particular form of polyarteritis nodosa with mainly intestinal expression or to a yet unclassified independent vasculitis. (Gastroenterology 1996 May;110(5):1628-32)

Silent Brain Infarct After Carotid Artery Surgery: Incidence and Prevention

To determine the prevalence and mechanisms of postoperative silent brain infarct, brain CT was routinely performed before and after carotid endarterectomy during the same period of hospitalization. Between June 1991 and May 1993, 69 patients who underwent 74 carotid endarterectomies (five two-staged bilateral procedures) were enrolled in the study. Ipsilateral brain infarct was observed on the preoperative CT scans in 25 cases. Of these 25 infarcts, three occurred in 20 patients (15%), without symptoms, 13 in 41 patients (32%) with transient ischemic attacks (TIAs), and 9 in 13 patients (70%) with cerebrovascular accident. After surgery, two patients (2.7% of procedures) had monoparesia of an upper limb with no corresponding abnormality seen on CT scans, and two (2.7%) had TIAs, associated with CT evidence of a new lesion in one patient. Five silent brain infarcts (6.8%) were detected, including four in the hemisphere contralateral to the restored carotid artery. These study results indicate there is no correlation between the occurrence of postoperative silent brain infarct and the presence of ulcerated stenosis of the carotid artery documented by Doppler ultrasound examination. Silent infarct was not observed in any of the 24 patients (32%) in whom a shunt had been used during the procedure. After a review of the literature, we propose wider use of intraoperative shunts to prevent postoperative silent brain infarct.

Perioperative endoscopy of the whole small bowel in Crohn's disease

The aim of this study was to search for small bowel lesions by means of a perioperative endoscopy in 20 patients operated on for Crohn's disease. Seven women and 13 men (mean age 29 years) had a total retrograde exploration to the angle of Treitz during an ileocolectomy (16 of 20 patients) or a colonic or ileal resection (four of 20 patients). Endoscopic exploration was completed, through an enterotomy, from the surgical area to the angle of Treitz. Periendoscopic biopsy samples were taken on macroscopic lesions and every 20 cm systematically. In 13 of 20 cases, various lesions scattered over the whole small intestine were found. These were aphthoid ulcerations (10 patients), superficial ulcerations (seven patients), mucosal oedema (three patients), non-ulcerative stenosis (three patients), erythema (two patients), pseudopolyps (two patients), deep ulcerations (two patients), and ulcerative stenosis (one patient). In seven patients none of the lesions detected at perioperative endoscopy had been recognised by preoperative evaluation or surgical inspection of the serosal surface. A typical granuloma was found at biopsy of lesions identified by endoscopy in three cases and at biopsy of an apparently healthy area in one case. Thus 65% of patients operated on for Crohn's disease had lesions of the small intestine detected by endoscopy, which were unrecognised before surgery in more than half of the cases.

Evaluation of Focal Carotid Ischemia: Will Duplex Scanning Suffice, or Is Angiography Needed?

We compared duplex scanning and cerebral angiography in patients with hemispheric ischemia, testing the premise that carotid endarterectomy (CEA) or medical management may be recommended on the basis of duplex scanning alone. Charts of 152 patients who had both studies were reviewed. A positive study (implying an operable lesion) showed any ulcerated plaque or stenosis of 50% to 99% on the symptomatic side. A positive duplex scan correctly predicted the need for CEA (with no additional essential information gained from angiography) more than 98% of the time. Equally important, patients with a negative duplex or patients in whom carotid occlusion is suspected ought to have angiography.

Perioperative endoscopy of the whole small bowel in Crohn's disease.

The aim of this study was to search for small bowel lesions by means of a perioperative endoscopy in 20 patients operated on for Crohn's disease. Seven women and 13 men (mean age 29 years) had a total retrograde exploration to the angle of Treitz during an ileocolectomy (16 of 20 patients) or a colonic or ileal resection (four of 20 patients). Endoscopic exploration was completed, through an enterotomy, from the surgical area to the angle of Treitz. Periendoscopic biopsy samples were taken on macroscopic lesions and every 20 cm systematically. In 13 of 20 cases, various lesions scattered over the whole small intestine were found. These were aphthoid ulcerations (10 patients), superficial ulcerations (seven patients), mucosal oedema (three patients), non-ulcerative stenosis (three patients), erythema (two patients), pseudopolyps (two patients), deep ulcerations (two patients), and ulcerative stenosis (one patient). In seven patients none of the lesions detected at perioperative endoscopy had been recognised by preoperative evaluation or surgical inspection of the serosal surface. A typical granuloma was found at biopsy of lesions identified by endoscopy in three cases and at biopsy of an apparently healthy area in one case. Thus 65% of patients operated on for Crohn's disease had lesions of the small intestine detected by endoscopy, which were unrecognised before surgery in more than half of the cases.

Combined carotid and coronary artery surgery: early and late results.

Patients with coronary artery disease can exhibit substantial vascular involvement; and vascular patients have a high incidence of coronary disease. Combined coronary artery bypass grafting (CABG) and treatment of extracranial cerebrovascular disease was performed in 52 patients, presenting strong indications for surgical treatment of coronary artery disease and symptomatic carotid disease and/or asymptomatic carotid bruit that reflected an ulcerative lesion or stenosis exceeding 75%. Overall hospital mortality was 3.8%. Clinical presentation determined the risk of the combined procedure: early mortality was much higher in urgent and emergency cases than in elective cases. Eight-year actuarial survival was 86%. This group of patients was compared with staged procedures in 45 patients (including carotid endarterectomy followed by CABG several weeks later) and with 42 patients who underwent coronary artery bypass in the presence of carotid bruits. Both early cardiac complications in the former group and neurologic complications in the latter were significantly more frequent than in combined procedures. Combined procedures can be performed with acceptable risk and with encouraging long-term results also in this special group of patients; they may improve the long-term prognosis of patients with diffuse atherosclerosis much more.

Angioplasty in ulcerative coronary artery disease: Acute results and early follow‐up

The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) for stenoses involving ulcerative lesions were retrospectively studied. Seventy-seven patients (62 men and 15 women, mean age 62 +/- 10 years) representing 3.4% of 2,250 patients treated with PTCA during the period January 1, 1988 and June 30, 1990, had pre-PTCA stenoses defined as ulcerated. Twenty-eight (36%) of the stenoses were localized in the left anterior descending coronary artery, 9 (12%) in the left circumflex and 40 (52%) in the right coronary artery. During angioplasty, percent diameter stenosis was reduced from 73 +/- 14% to 22 +/- 13% and transstenotic gradient decreased from 48 +/- 18 to 12 +/- 6 mm Hg. Clinical success (freedom from angina at discharge without coronary bypass surgery, infarction or death) was achieved in 70 patients (90.9%). There were seven unsuccessful cases: three underwent elective coronary bypass surgery, one was managed medically, and three developed a major flow interrupting dissection during the procedure requiring emergency coronary bypass surgery. There were no deaths. At mean follow-up of 7.6 months, 45 of 61 patients (73.7%) remained asymptomatic. One patient needed an elective coronary bypass surgery and five patients had a successful repeat PTCA. In conclusion, PTCA for an ulcerated stenosis can be performed safely with a high primary success rate and a favorable early clinical course.

Unilateral sudden hearing loss as a result of anomalous carotid anatomy

The term sudden hearing loss refers to hearing losses of sensorineural origin that evolve over a short period of time and are often of unknown origin. Common causes include damage to the cochleovestibular nerve by viral infection, autoimmune disease, vascular insult, and labyrinthine membrane rupture. A 70-year-old man had a history of recent diplopia, dysarthria, syncopal episodes, dysequilibrium, and the sudden onset of deafness in his right ear. Angiography demonstrated severe ulcerative stenosis of the right internal carotid origin and an anomalous vessel (probable remnant of hypoglossal artery) originating from the distal right internal carotid artery that perfused the entire distal vertebral and basilar artery circulation. Arch angiograms confirmed the absence of a proximal right vertebral artery and revealed a small left vertebral artery that ended in the cervical region without reaching the posterior fossa. Standard right carotid endarterectomy with patch angioplasty resolved all neurologic symptoms except for persistent unilateral deafness at 9 months' follow-up. Presumed embolization through this anomalous vessel to the internal auditory artery and subsequent cochlear and vestibular branches represents the first reported case of sudden hearing loss as a result of anterior circulatory ulcerative disease.

Unilateral sudden hearing loss as a result of anomalous carotid anatomy

The term sudden hearing loss refers to hearing losses of sensorineural origin that evolve over a short period of time and are often of unknown origin. Common causes include damage to the cochleovestibular nerve by viral infection, autoimmune disease, vascular insult, and labyrinthine membrane rupture. A 70-year-old man had a history of recent diplopia, dysarthria, syncopal episodes, dysequilibrium, and the sudden onset of deafness in his right ear. Angiography demonstrated severe ulcerative stenosis of the right internal carotid origin and an anomalous vessel (probable remnant of hypoglossal artery) originating from the distal right internal carotid artery that perfused the entire distal vertebral and basilar artery circulation. Arch angiograms confirmed the absence of a proximal right vertebral artery and revealed a small left vertebral artery that ended in the cervical region without reaching the poterior fossa. Standard right carotid endarterectomy with patch angioplasty resolved all neurologic symptoms except for persistent unilateral deafness at 9 months' follow-up. Presumed embolization through this anomalous vessel to the internal auditory artery and subsequent cochlear and vestibular branches represents the first reported case of sudden hearing loss as a result of anterior circulatory ulcerative disease.

Clinical, biological, and endoscopic picture of attacks of Crohn's disease: Evolution on prednisolone

One hundred forty-two patients with active colonic or ileocolonic Crohn's disease were included in a multicenter prospective study. Data collection included 28 clinical, biological, and endoscopic items; the latter were recorded according to a standardized colonoscopic protocol; a previously validated endoscopic index of severity was calculated. Oral prednisolone (1 mg/kg body wt per day) was started and maintained until clinical remission and for at least 3 and at most 7 wk. A second clinical biological and endoscopic evaluation was then performed. At initial colonoscopy, mucosal lesions were, by decreasing order of frequency, superficial ulcerations, deep ulcerations, mucosal edema, erythema, pseudopolyps, aphthoid ulcers, ulcerated stenosis, and nonulcerated stenosis (93%, 74%, 48%, 44%, 41%, 35%, 10%, 8%, and 2% of cases, respectively). No correlation was found between the clinical activity index and any of the endoscopical data (lesion frequency and surface, endoscopic severity index). Ninety-two percent of patients underwent clinical remission within 7 wk of treatment. None of the 28 clinical biological and endoscopical items collected just before treatment could predict clinical response to steroids. Only 38 of the 131 patients in clinical remission were also in endoscopic remission. In conclusion, (a) the description and severity of colonoscopic lesions in active Crohn's disease have been quantified; (b) no correlation exists between clinical severity and nature, surface, or severity of endoscopic lesions; (c) Oral prednisolone (1 mg/kg body wt per day) induces a clinical remission in 92% of patients within 7 wk; (d) resistance to steroids cannot be predicted from the data collected before treatment onset; and (e) only 29% of patients in clinical remission also achieve endoscopic remission.

Variable angiographic findings in patients with stroke and neurosyphilis.

We describe four patients with cerebral infarction and active neurosyphilis who had variable angiographic findings. Patients 1 and 2 had evidence of arteritis and an atheromatous ulcerated stenosis of the extracranial carotid artery, respectively. The third and fourth patients had symptoms of lacunar infarction, but cerebral angiography was normal in patient 3, whereas patient 4 had evidence of concomitant atheromatous and arteritic lesions. Neither age nor presence of cerebrovascular risk factors was of aid in predicting angiographic features. The concomitance of cerebral infarction and active neurosyphilis does not imply a cause-and-effect relation, since atherosclerotic lesions may coexist with arteritis or may even represent the only angiographic feature. Our findings underscore the importance of angiography to confirm the diagnosis in cases of suspected syphilitic arteritis.