Vascular Mass Research Articles

Ultrasonographic vascularity assessment for predicting future severe hemorrhage in retained products of conception after second-trimester abortion

Objectives: To investigate the spontaneous outcomes of vascularized retained products of conception (RPOC) detected by ultrasonography after second-trimester abortion, and to identify the predictive factors for the development of severe postpartum hemorrhage (SPPH).Study design: This is a retrospective cohort study on all cases after second-trimester abortion managed at our institute between January 2014 and December 2016. We assessed the associations between the occurrence of SPPH requiring invasive treatment and clinical factors including ultrasonographic findings (size and the vascularity status of RPOC classified as follows: type 1: vascularity confined to endometrium, type 2: vascularity reaching <1/2 myometrium, and type 3: vascularity reaching ≥1/2 myometrium) in vascularized RPOC cases.Results: Among 103 cases after second-trimester abortion, 19 patients (18.4%) were diagnosed as RPOC, and five patients eventually failed expectant management due to SPPH. Of them, 66.7% (4/6) of patients with type 3 developed SPPH as compared with 7.7% (1/13) of patients with type 1/type 2 (p < .05). The maximum vascularized mass diameter was significantly greater among the five patients who experienced SPPH than among the 14 patients who demonstrated spontaneous remission (43.0 ± 12.0 mm versus 20.7 ± 8.3 mm, p < .01). Patients with type 3 RPOC and a maximum vascularized mass diameter ≥30 mm, compared with other patients, demonstrated sensitivity, specificity, and risk ratio related to SPPH of 80, 92.9%, and 11.2, respectively.Conclusions: Our findings suggest that the ultrasonographic assessment of RPOC focused on the depth of vascularity in combination with the measurement of its size appears to be essential in determining women with RPOC who are at high risk for SPPH.

Nasopharyngeal cavernous hemangioma: an approach to remove

IntroductionFew nasal cavernous haemangiomas have been previously reported, only nasopharyngeal cavernous hemangiomas have been reported; both arise from the lateral wall of the nasopharynx. We reported the case of a 27-year-old woman who had repeated severe epistaxis and nasal obstruction of 6 months duration. Computed tomography showed a large vascular nasopharyngeal mass. Complete endoscopic removal of the mass that was found to arise from the posterior end of the nasal septum was achieved without complications. Histopathology showed a cavernous heamangioma. Epistaxis completely stopped throughout the 12-month follow-up. This is the first work to describe the management of nasopharyngeal cavernous heamangiomas originating from the posterior end of the nasal septum. Transnasal endoscopic approach permits adequate exposure of the lesion, control of bleeding, and complete hemangioma removal.

Fetal hepatic hemangioma: a case report

Fetal liver tumors represent approximately 5% of all congenital tumors and hemangiomas account for approximately 15% of all fetal liver tumors. Hemangioma and hemangioendothelioma are benign vascular tumors but they are associated with a significant morbidity and mortality due to high output congestive heart failure and arteriovenous shunting. Ultrasound features of hepatic hemangioma can overlap with arteriovenous malformation. This is a case report of fetal hepatic hemangioma with aretriovenous shunting detected on routine anomaly scan at 20 weeks of gestation in 22 years old Nepalese women who was asymptomatic. Prenatally, a 3.2cm x 2.8cm multicystic mass was seen in the left hypochondrium of the fetal abdomen displacing the stomach. On color Doppler examination, the mass showed internal color flow and multiple tortuous dilated vessels noted around the lesion. After counseling regarding the lesion to the mother and her family; decision to abort the fetus was made. Autopsy was done for the final diagnosis of the lesion, which showed vascular mass in the left lobe of liver insinuating between stomach and spleen.

Abdominal manifestations of hereditary hemorrhagic telangiectasia: a series of 333 patients over 15years.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multi-organ vascular disorder that commonly affects the gastrointestinal tract and the liver resulting in telangiectasias and arteriovenous malformations (AVMs). Previous studies looking at the prevalence of liver and abdominal organ involvement in HHT have been limited by differing imaging techniques and sample size limitations. We sought to define the prevalence of HHT related abdominal vascular abnormalities using optimized multiphasic contrast-enhanced abdominal computed tomography (CT) exams in a large cohort of HHT patients. Between January 2001 and May 2015; we identified a total of 333 consecutive HHT patients who had undergone a dedicated HHT protocol multiphase abdominal CT at our institution. The CT exams were reviewed by three board certified abdominal radiologists for the presence of vascular abnormalities involving the liver, pancreas, spleen, and other abdominal organs. Vascular abnormalities involving the liver were further categorized as telangiectasias, large confluent vascular masses, perfusion abnormalities, or hepatic shunts. In patients with abdominal vascular abnormalities, the liver was the most commonly involved organ, with 180 out of 333 (54.1%) patients demonstrating at least one hepatic vascular abnormality (telangiectasia, confluent vascular mass, transient perfusion abnormalities, and hepatic shunts), with most (70.0%) demonstrating multiple hepatic vascular abnormalities. The other most common organs involved included the pancreas (18.0%), spleen (6.3%), and small bowel (4.5%). In patients with the clinical diagnosis of HHT, greater than half demonstrate an abdominal vascular abnormality, with the most commonly involved organ being the liver. These may be under recognized on routine or single phase contrast-enhanced CT of the abdomen. This supports the use of optimized multiphasic abdominal CT exams as an important tool for the evaluation and screening of patients with HHT.

Gastrointestinal stromal tumor at an unusual site with an unusual presentation

Gastrointestinal tumors (GIST) are malignant and rare forms of soft tissue sarcoma arising from interstitial cells of Cajal. With most common site of origin being stomach, Jejunal GIST accounts for 0.1–3% of all GIST. Due to non specific signs and symptoms diagnosis is often delayed and patient mostly presents in advanced stage. 50 year old female presented with decreased appetite from 5 months and lump in upper abdomen from 3 months associated with dull abdominal pain from 15 days. CECT abdomen showed a large soft tissue mass in left lumbar region. Exploratory laparotomy showed a highly vascular mass of size 12x10x8 cm abutting mesentery of transverse colon lodged between middle colic artery and superior mesenteric artery. Resection of mass with a segment of jejunum was done. Histopathological examination showed spindle cell tumor with high mitotic index with CD 117+. Adjuvant chemotherapy was given and patient is currently asymptomatic after 9 months of postoperative follow up. Spectrum of clinical presentation is broad so a preoperative diagnosis is difficult. GIST primarily presenting as an abdominal lump is rare and only 25 cases have been reported so far. Surgery is the primary mode of treatment but imatinib has transformed the treatment. Newer drugs are under phase II trials and hopefully will change the course of management in near future.

Percutaneous endovascular tissue sampling of endoluminal tumors using directional atherectomy.

To evaluate technical feasibility and safety of endovascular tumor specimen sampling using an escalating endovascular biopsy strategy using a directional atherectomy device compared with forceps biopsy and catheter aspiration. Between 2013 and 2017, a cohort of ten consecutive patients (6 male; median age 56, range 39-73years) was referred for sampling of endovascular masses. Localizations included the abdominal aorta (n = 4), left brachiocephalic vein (n = 2), inferior vena cava (n = 1), and left pulmonary artery (n = 3). For each individual mass, all three endovascular tissue sampling approaches were applied including catheter-based aspiration, straight two-jaw biopsy forceps, and directional atherectomy during a single session. Aspiration and forceps biopsy did not provide sufficient material for histological analyses. In contrast, technical success for endovascular tumor sampling using directional atherectomy was 100%. After two atherectomy passages, sufficient material was available for each vessel region allowing histologic diagnosis, which revealed sarcoma and chronic inflammation for masses in the aorta, angiosarcoma for brachiocephalic vein, hepatocellular carcinoma for inferior vena cava, and angiosarcoma for pulmonary artery. In case of a histologically benign diagnosis, no malignant tumor proliferation was obvious on follow-up imaging studies after 3months and 1year. Thus, the rate of false-negative results was considered 0%. No procedure-associated complications, e.g., vessel perforation, were recorded. Preliminary results in a limited number of patients proved directional atherectomy beneficial as a safe and feasible technique for endoluminal tissue sampling of vascular masses. Additional large-scale studies are necessary and worthy for further evaluation in clinical practice. • Endovascular masses pose a challenge to appropriate clinical management. • Off-label directional atherectomy proved to be a safe and feasible technique for endoluminal tissue sampling of vascular masses. Furthermore, directional atherectomy was superior to aspiration or forceps biopsy in our small study cohort. • Directional atherectomy may represent the last or only option for tissue probing as a prerequisite for further treatment decisions.

Microsurgical Resection of a Solitary Spinal Epidural Cavernous Angioma: 3-Dimensional Operative Video.

Solitary spinal epidural cavernous angiomas are rare vascular malformations. Surgical excision is the treatment of choice, as these lesions tend to grow or bleed at some point. In this 3-dimensional, narrated video, we present the case of a 61-year-old male who presented with progressive pain in the right paravertebral region secondary to an epidural cavernous angioma located at the T6/T7 level. Under intraoperative neurophysiological monitoring, a laminectomy between T5 and T7 was performed. A reddish, well delimited, and highly vascularized epidural mass was identified and dissected from the adjacent dura and nerve root, and an en bloc total resection was achieved. The patient was discharged neurologically intact on postoperative day 4, presenting a remarkable improvement of his pain at 2-month follow-up. Total excision of these lesions is possible in most of cases, remaining the standard treatment, with minimum complications. All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All data related to patient identification were removed from this surgical video and manuscript, with no need of a written informed consent.

A Primary Large Anorectal Melanoma That Causes Intermittent Rectal Bleeding and Appears as a Hemorrhoid

A 70-year-old Ethiopian man underwent a colonoscopy because of recent onset of intermittent painless rectal bleeding. Digital rectal exam revealed a rubbery textured mobile mass protruding from the anal verge, initially thought to be a hemorrhoid (Figure A). Colonoscopy showed a 4-cm pigmented and vascular anorectal mass on a stalk, which was best seen on retroflexion (Figure B). Oozing of blood was noted on performing biopsies. Histology revealed pleomorphic cells with high mitotic activity with intervening brown pigment (Figure C).

The Evolving Efficacy of Transthoracic Echocardiography and Ultrasound Enhancing Agents (UEAs) when Characterizing Cardiac Masses

Between mid-2016 and early 2017, a series of transthoracic echocardiograms augmented by ultrasound enhancing agents (UAEs) were performed on a 59-year-old man after he was referred for known mobile echo densities within the right ventricle (RV), fevers, ongoing fatigue, and progressive exertional dyspnea. He had a history of a few small pulmonary embolisms and acute kidney injury. The initial echocardiogram showed a large mass within the RV cavity both before and following the administration of a UAE. It occupied almost the entire RV with mobile components that not only attached to and prolapsed through the tricuspid valve (TV), but also protruded into the right ventricular outflow tract (RVOT) but not across the pulmonary valve (PV). The administration of a UEA demonstrated avascular and vascular components of the mass. Intraoperative pathology diagnosed the mass as a mucinous adenocarcinoma. The mass was removed and the TV was replaced with a bioprosthetic valve. A non-UEA post-surgical transthoracic echocardiogram showed an RV void of any obvious masses. Six months later, despite postoperative radiotherapy and thrombolytic treatments, a follow-up echocardiogram augmented by UEAs showed a large homogenous echodensity with mobile components within the RV. The administration of a UEA demonstrated avascular and vascular components of the mass. Not only does this case study showcase echocardiography as the most easily available, non-invasive, and cost-effective imaging modality for serial assessments of cardiac masses, but also the valuable combination of echocardiography and UEA in distinguishing avascular thrombus and endocarditis from vascular masses when characterizing masses within the heart. We should continue to expand our clinical utility of UEA to better characterize and diagnose cardiac masses within the heart.

Ultrasound assessment of the paediatric neck

In children ultrasound is the best tool we have to evaluate any change in the neck, high resolution ultrasound allows excellent details of the anatomy, it´s possible to asses vessels, muscles and glands as the thyroid gland, Which begins it´s formation 24 days after fecundation, it begins at the floor of the larynx and migrates through the thyroglossal duct, by the 7 th week it completes this process, and starts functioning during the 3rd month of intrauterine life, this knowledge of the embryology of the gland is important due to the fact that in the evaluation of the neck ultrasound will allow to differentiate congenital abnormalities that will behave like a mass But it´s not only enlargement or presence of mass the reason to explore the pediatric neck, some patients under the suspicion of endocrinological disfunction, will use it to confirm the suspicion of pathology of the thyroid or absence of thyroid tissue. Wtih Doppler we are able to assess the vascularity of the gland in general to orientate possible diagnosis, or in case of focal abnormality to asses its vascularity. In the thyroid will see benign cyst with the same ultrasound appearance in any other part of the body, isolated or as part of other pathology of the gland. Malignancy is rare but we must be aware of it because when present it´s very aggressive. In children between the age of 4 and 8 the most common cause of mass in the neck, is lymph node enlargement secondary to viral or infectious process, with ultrasound we are able to confirm the etiology of the abnormality as well as do follow up until resolution, or if necessary guide a fine needle aspiration or biopsy Among other pathology we have in the neck, are those related to that of the sternocleidomastoid muscle congenital or acquired. Vascular lesions such as the hemangioma, or masses which have its origin in the fatty tissue such as lipomas, are very well defined by ultrasound. The aid of Doppler to let us know not only the relationship to vessels but to know if it´s a vascular mass or not.

B-mode and Doppler ultrasonography in the assessment of the common carotid arteries of equines and mules and the relation with body mass, age and neck circumference

ABSTRACT: As age increases, changes in cardiovascular anatomy and physiology occur, even in the absence of disease. Thus, studies of vessel hemodynamics are considered primordial to detect any cardiovascular changes. The objective of this study has been to describe the parameters of B-mode and spectral Doppler ultrasonography in the evaluation of the common carotid arteries of 11 equine and 11 mules, and correlate with age, body mass and neck circumferences. The diameters, intima - media thickness (IMT), resistivity index (RI), pulsatility index (PI), systolic velocity (SV), diastolic velocity (DV), maximum velocity (MV), vascular flow index (VFI), body mass, age, circumference and neck length. Ultrasonographic variables were evaluated in three different region called cranial, middle and caudal. Equine females presented higher values regarding the body mass, age and neck length, as compared to the neck circumferences of the animals, those of the mules were superior. The age of the mules had a positive correlation with the body mass, diameter and neck circumferences, it has a negative correlation between age and vessel diameters. The body mass of the mules had a positive correlation with age and vessel diameters, and with vessel diameters and neck circumferences in equine females. The RI and PI variables had a positive correlation with body mass for mules, and with age for equine females. The DV had a negative correlation with body mass for both equine and mule females. Regarding the variables MV and VFI, age correlated negatively for mules, while it was not significant for equine females. It found a difference between equine females and mules in the correlations performed, with body mass, age, neck circumferences and between B-mode and Doppler ultrasonography variables.

First report of granulosa cell tumour associated with an endometrial adenoma in a crossbreed cow in Portugal

A 12.5 year-old female crossbred cow without clinical signs at ante mortem inspection was slaughtered. The post-mortem inspection revealed poor carcass condition, interstitial nephritis and generalized lymphadenitis. The reproductive tract presented an unilateral and highly vascularized yellowish-white mass, with huge dimensions (60 x 40 cm and 20 Kg, approximately) described as granulosa cell tumour (GCT) and a endometrial adenoma, after histopathological analysis. GCT has been described as the most frequent ovarian tumour in cattle. Since clinical signs are usually unspecific, the post mortem diagnosis by histopathology examination is always necessary. The endometrial adenoma could be asymptomatic, with only absence of calving, or associated with GCT. This is, of our knowledge, the first report of a GCT associated with endometrial adenoma in a cow in Portugal.

A Case of Gastrointestinal Kaposiʼs Sarcoma

Kaposi's sarcoma (KS) is a neoplasm characterized by vascular nodules with a broad range of involvement, from cutaneous and lymphatic to visceral disease; it is the most common malignancy in HIV patients. The gastrointestinal (GI) tract is the most common extracutaneous site in AIDS patients and is associated with a poor prognosis; however, patients are usually clinically asymptomatic, making identification difficult. Recent studies have attempted to identify predictive factors of GI-KS. We describe a case of a 28-year-old man with melena. History is significant for a recent diagnosis of AIDS, after presenting with black skin lesions. Antiretroviral therapy (ART) was begun. Abdominal nodule biopsy was positive for HHV8, consistent with cutaneous KS. On presentation, patient was afebrile and normotensive. Physical exam significant for multiple purple papules. Laboratory studies revealed mild anemia, thrombocytopenia, elevated viral load of 172,498 copies/mL, and CD4 count of 56 cells/mcl. Upper endoscopy was performed for evaluation of melena. Endoscopic findings revealed protruding vascular masses in the gastric fundus and body and a flat vascular lesion in the duodenal bulb (Images 1-3). Immunostaining was positive for HHV8, confirming GI-KS. CT imaging demonstrated pulmonary and lymphatic involvement. Brain imaging demonstrated toxoplasmosis. Patient was continued on ART while receiving pyrimethamine/sulfadiazine for toxoplasmosis; systemic therapy for KS was held while this treatment was ongoing. Patient's cutaneous lesions continued to improve with ART; he had no further GI symptoms. CD4 count and viral load were 210 cells/mcl and 99 copies/mL, respectively, 6 weeks post-presentation. Characterization of the extent of disease is paramount in KS, as this dictates treatment and prognosis, with visceral disease requiring systemic therapy and associated with poor outcomes. Most patients with GI-KS are asymptomatic, with the majority of KS lesions found in the upper GI tract. Given the potential for severely advanced disease, the question is raised as to how to determine which KS patients should undergo endoscopy, given that the most common lesions are clinically silent. Recent studies suggest that in HIV patients, MSM status, ART-naïvity, CD4 count < 100 cells/mcl, HIV RNA ≥ 10,000 copies/mL, and cutaneous KS were associated with GI-KS. Clinicians should maintain a high index of suspicion for GI-KS in patients with these characteristics.1975_A Figure 1. Vascular mass of gastric fundus.1975_B Figure 2. Vascular mass of gastric body.1975_C Figure 3. Flat vascular lesion of duodenal bulb.

Hemosuccus Pancreaticus: Side-Viewing Endoscopic Diagnosis of a Rare but Fatal Cause of Gastrointestinal Hemorrhage

Hemosuccus pancreaticus (HP) is an extremely rare disease that is usually defined as bleeding in the pancreatic duct. Although it is infrequent, HP can lead to massive gastrointestinal bleeding, which is potentially life threatening. 70-year-old male with a history of chronic alcohol abuse, chronic pancreatitis and UGIB presented with melena. Initial physical examination was unremarkable and vitals were stable. Laboratory studies were significant for hemoglobin of 8.7 g/dL. Endoscopy was insignificant. Patient had repeat episode of melena but repeat endoscopy was again insignificant for cause of bleed. After 3 days, LFT's increased: possibly from drug-induced liver injury or obstructing lesion. CT scan showed a large 4.2x2.9 cm pseudoaneurysm in the head of the pancreas possibly from gastroduodenal artery. Interventional radiology (IR) performed coil embolization, but follow-up ultrasound showed vascular mass enlarged to 5.6x5.8cm. Patient reported melena again and dark blood noted on rectal examination. CT angiography also could not identify the cause of his bleeding. The patient underwent repeat endoscopy with side-viewing scope, Blood extravasation was noted from the ampulla consistent with HP (Figure 1A,B,C). Patient continued to have intermittent bleeding requiring transfusions. After discussion with IR, decision was made to attempt repeat embolization, but the patient clinically worsened and passed away. Although HP is a rare cause of gastrointestinal hemorrhage, it is very important to include it in the differential in patients with history of chronic pancreatitis. HP frequently occurs as a complication of pancreatitis with rupture of a visceral artery aneurysm, but can be caused by trauma, neoplasms, or iatrogenic causes. [1,2] Although CT angiography is the gold standard, it can fail to diagnose HP. In terms of management, surgery or endovascular therapy by interventional radiology showed promising outcomes. [3] In this case, repeated attempt with endoscopy and CT angiography could not identify the HP lesion, which was subsequently successfully detected utilizing a side-viewing endoscope.1378_A.tif Figure 1: No Caption available.1378_B.tif Figure 2: No Caption available.1378_C.tif Figure 3: Repeat endoscopy using side-viewing endoscope showing blood extravasation from ampulla in the duodenum consistent with hemosuccus pancreaticus.

SPINAL DURAL ARTERIOVENOUS FISTULA: CLINICAL CASE AND LITERATURE REVIEW

Spinal dural arteriovenous fistula (SDAVF) is a rare disease, however, with nonspecific initial symptoms, like back pain, parestesias, gait imbalance, weakness and numbness in extremities. Para- or tetraparesis, disturbance of deep sensation and pelvic organs functions may develop during the course of disease. There isn’t any specific laboratory tests. So, the diagnostics of dural fistulas is complex. The main screening method is magnetic resonance tomography (MRI), which may suspect or reveal dural fistula. Spinal angiography is a «golden standard» in diagnostics. Options of treatment include microsurgical separation or endovascular embolisation of fistula. The article presents a clinical case of SDAVF in thoracic region of spine. Related to complains, neurological exam and MRI data, the vascular mass was suspected and spinal angiography was per-formed to confirm the presence of SDAVF. After surgical treatment the patient was observed to rehabilitation course, which had improved his status. In sum, appropriate diagnostics, surgical intervention and rehabilitation are the main factors related to successful treatment of patients with SDAVF.

A purinergic P2Y6 receptor agonist prodrug modulates airway inflammation, remodeling, and hyperreactivity in a mouse model of asthma.

BackgroundPurinergic receptors control cell proliferation, apoptosis, migration, inflammation, and cytokine secretion. Increased expression of specific purinergic receptors is reported in asthma. The role of purinergic P2Y6 receptors (P2Y6R) in asthma is controversial.HypothesisP2Y6R activation in asthma improves pulmonary function and reduces inflammation and smooth muscle amount.MethodsFemale mice (C57/BL6, age 30 days) were randomly assigned to receive intranasal house dust mite (HDM) antigen (40 or 80 µg) or saline, 5 days/week, for 6 weeks. Randomly selected subgroups received intraperitoneal P2Y6R agonist prodrug (GC021109; 10 or 100 µg/kg weight/dose) simultaneously with HDM. After 6 weeks, lung function was measured. Lung lavage fluid (LLF) was used to measure total cell count, total protein, and cytokines. Immunohistochemistry for alpha smooth muscle actin (α-SMA) was done. Airway wall thickness was measured on micro-computed tomography (micro-CT) images.ResultsPulmonary function testing revealed a HDM dose-dependent airway hyperresponsiveness. Airway resistance was increased 2-fold while compliance was decreased by 50% at the higher HDM dose (P<0.05). GC021109 prevented these changes. HDM-exposed mice had elevated inflammatory cell and total protein levels in LLF which were prevented by GC021109 (P<0.05). HDM mice also had elevated LLF levels of interleukin (IL)-4, IL-5, IL-12, granulocyte colony stimulating factor, chemokine (C-X-C) motif ligand 1, and leukemia inhibitory factor that were reduced by GC021109 with a dose-dependent pattern. HDM mice had increased peribronchial and perivascular inflammatory cell infiltration and increased α-SMA; these changes were absent with GC021109. Airway wall thickness measured on micro-CT images was increased after HDM exposure and significantly reduced by GC021109 treatment.ConclusionThe P2Y6R prodrug GC021109 inhibited allergen-induced changes in pulmonary function, inflammatory responses, and airway and vascular smooth muscle mass. P2Y6R activation may be an effective therapeutic maintenance strategy in asthma.

DIAGNOSIS OF CAROTID PARAGANGLIOMA: MULTIDISCIPLINARY ASPECTS

Objective: to enhance the efficiency of diagnosis and treatment of carotid paragangliomas, by introducing of a multidisciplinary approach into clinical practice.Material and methods. A total of 15 cases of paragangliomas have been followed up for 10 years. The age of the patients was 18 to 58 years (mean age 38±12 years). Primary multiple sites of chemodectomas were noted in 2 cases. Bilateral involvement was observed in one case. In the other, two unilateral vascular tumors successively developed with an interval of almost 6 years. A set of studies was conducted, which embraced ultrasound duplex scanning (USDS) of the neck vessels, computed tomography (CT), and selective carotid angiography (SCAG) in various combinations. The investigators made a successive examination of the symmetrical areas of the face and neck and polypositional scanning of the zone of interest and studied quantitative parameters, including linear blood flow velocity (LBFV) and volumetric blood flow velocity. Native and contrast-enhanced X-ray CT and magnetic resonance imaging (MRI) were carried out. SCAG was performed as digital subtraction angiography.Results.USDS can confirm the hypervascular nature of the tumor and its close relationship with the carotid artery branches and measure blood flow velocity (LBFVmean, 0.46 m/sec). X-ray CT and MRI examinations in combination with vessel contrasting make it possible to accurately determine the localization and topography of the tumor, its association with the carotid artery system and to type afferent vessels. SCAG is a highly informative technique that can identify the afferent vessels of the tumor and its relationship with the great vessels and, if technically possible, perform selective microembolization of the afferent tumor vessels, which will further facilitate surgical treatment, reducing the risk of intraoperative bleeding. Conclusion.The multidisciplinary approach to diagnosing carotid paragangliomas in the maxillofacial area and neck makes it possible to determine the type, size, and velocity characteristics, to verify the diagnosis, and to work out optimal treatment policy. Among the non-invasive techniques, CT angiography and MR angiography are most valuable for final diagnosis. Selective angiography of the branches of the external carotid arteries remains the gold standard and is the final and most important stage of the study, which make it possible to detail angioarchitectonics, to determine afferent vessels, and to plan further treatment, including endovascular embolization. The diagnosis of carotid paragangliomas requires a multidisciplinary approach with the equal attraction of endovascular diagnosis and treatment specialists, maxillofacial surgeons, angiologists, ultrasound and radiology diagnosticians, and pathologists both at the stages of diagnosis and subsequent treatment. This problem can be effectively solved in a multidisciplinary hospital that has skilled staff with sufficient clinical experience in diagnosing vascular masses and is equipped with modern equipment, which allows optimization of further treatment.

Vascularized Parenchymal Mass Preserved with Partial Nephrectomy: Functional Impact and Predictive Factors

BackgroundPercentage parenchymal mass preserved (PPMP) is a key determinant of functional outcomes after partial nephrectomy (PN); however, predictors of PPMP have not been defined. ObjectiveTo provide a comprehensive analysis of the functional impact of and potential predictive factors for PPMP. Design, setting, and participantsWe analyzed data for 464 patients managed with PN at our center with necessary studies to determine vascularized parenchymal mass and function preserved within the operated kidney. PPMP was measured from computed tomography scans <2 mo before and 3–12 mo after PN. InterventionPN. Outcome measurements/statistical analysisRecovery from ischemia was defined as percentage ipsilateral glomerular filtration rate (GFR) preserved normalized by PPMP. We used Pearson correlation to evaluate the relationships between GFR preserved and PPMP. Multivariable logistic regression was used to assess predictors of PPMP. Result and limitationsNinety-six patients (21%) had a solitary kidney. The median tumor size and RENAL score were 3.5cm and 8, respectively. Cold/warm ischemia were utilized in 183/281 patients for which the median ischemia time were 28/20min. The median preoperative and postoperative vascularized parenchymal mass in the operated kidney were 194 and 157cm3, respectively, resulting in median PPMP of 84%. GFR preservation correlated strongly with PPMP (r=0.64; p<0.001). Recovery from ischemia was suboptimal (<80%) in 71 patients (15%), while suboptimal PPMP (<80%) was a more common adverse event, occurring in 160 patients (34%; p<0.001). Multivariable analysis demonstrated that greater tumor size and complexity were associated with lower PPMP (p≤0.04), while solitary kidney and hypothermia were associated with higher PPMP (p<0.001). Longer ischemia time was also associated with lower PPMP (p=0.003), probably reflecting the complexity of the surgery. Limitations include the retrospective design. ConclusionPPMP correlates strongly with functional outcomes after PN, and lower PPMP is the most common and important source of functional decline after PN. Larger tumors, greater tumor complexity, and prolonged ischemia time were associated with lower PPMP, while PPMP tended to be greater for solitary kidneys, confirming that PPMP is a modifiable factor. Patient summaryKidney function after partial nephrectomy primarily depends on the amount of vascularized kidney preserved by the procedure. Lower recovery of function is seen when operating on larger tumors in unfavorable locations, but preservation of the parenchymal mass can be improved when truly necessary, such as when operating on a tumor in a solitary kidney.

Extranasopharyngeal Angiofibroma: A Diagnostic Dilemma

Objective: To report two cases of extranasopharyngeal angiofibroma, highlighting the diagnostic challenges involved.&#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Teaching Hospital and Medical School&#x0D; Patients: Two (2)&#x0D; Results: A 13-year-old boy who presented with epistaxis and a vascular mass on the posterior nasal septum that enhanced on contrast-enhanced computed tomography (CECT), and a 3-year-old boy who presented with dysphagia and mild respiratory difficulty, with a large naso-oropharyngeal mass arising from the soft palate on physical and x-ray examination that could not be corroborated because stridor developed during sedation for CECT, both underwent endoscopic tumor excision.&#x0D; Conclusion: As illustrated in these cases, atypical presentations of extranasopharyngeal angiofibromas can pose a considerable diagnostic and surgical challenge for clinicians. &#x0D; &#x0D; Key words: angiofibroma: classification; diagnosis; diagnostic imaging; extranasopharyngeal

High Concordance between Trained Nurses and Gastroenterologists in Evaluating Recordings of Small Bowel Video Capsule Endoscopy (VCE)

Background &amp; Aims: The video capsule endoscopy (VCE) is an accurate and validated tool to investigate the entire small bowel mucosa, but VCE recordings interpretation by the gastroenterologist is time-consuming.A pre-reading of VCE recordings by an expert nurse could be accurate and cost saving. We assessed the concordance between nurses and gastroenterologists in detecting lesions on VCE examinations.Methods: This was a prospective study enrolling consecutive patients who had undergone VCE in clinical practice. Two trained nurses and two expert gastroenterologists participated in the study. At VCE pre-reading the nurses selected any abnormalities, saved them as “thumbnails” and classified the detected lesions as a vascular abnormality, ulcerative lesion, polyp, tumor mass, and unclassified lesion. Then, the gastroenterologist evaluated and interpreted the selected lesions and, successively, reviewed the entire video for potential missed lesions. The time for VCE evaluation was recorded.Results: A total of 95 VCE procedures performed on consecutive patients (M/F: 47/48; mean age: 63 ± 12years, range: 27−86 years) were evaluated. Overall, the nurses detected at least one lesion in 54 (56.8%) patients.There was total agreement between nurses and gastroenterologists, no missing lesions being discovered at a second look of the entire VCE recording by the physician. The pre-reading procedure by nurse allowed a time reduction of medical evaluation from 49 (33-69) to 10 (8-16) minutes (difference: -79.6%).Conclusions: Our data suggest that trained nurses can accurately identify and select relevant lesions in thumbnails that subsequently were faster reviewed by the gastroenterologist for a final diagnosis. This could significantly reduce the cost of VCE procedure.