Sonographic patterns by transcranial Doppler in acute cerebral infarction

Microcirculatory changes occur early in insulin-dependent diabetes mellitus (IDDM) and are believed to be an early feature of late diabetic complications, leading to reduced oxygen pressure and hypoxia in the skin and other tissues. Whether muscle oxygen supply is also altered is unknown. Therefore, the authors analyzed polarographic measurements of muscle oxygen tension in 44 healthy type I diabetic patients (mean age 28 years; mean diabetes duration 7 years) and in 57 healthy controls, matched for age, sex, and body mass index, and the corresponding influencing factors. Two measurements were taken at rest 60 minutes apart in the anterior tibial muscle. Muscle oxygen tensions did not differ between IDDM patients and controls (23.0 +/- 8.6 vs 25.3 +/- 9.0 mmHg) and were reproducible on repeated measurements (25.3 +/- 9.7 vs 25.5 +/- 7.4 mmHg). Coefficients of variation were 13.5 +/- 10.8% in IDDM patients and 13.1 +/- 9.3% in controls. Compared with controls, in IDDM patients hemoglobin A1c (HbA1c) and blood glucose concentrations were elevated, and arterial oxygen pressure was significantly lower. Muscle oxygen tensions were positively correlated with blood glucose concentrations in IDDM patients (Rho=0.48, P=0.002) but not with HbA1c or with insulin concentrations. The authors conclude that the polarographic measurement of muscle oxygen tension is a reliable method with good reproducibility. Hypoxia in the anterior tibial muscle of type I diabetic patients can be excluded. In IDDM patients the level of muscle oxygen tension is correlated with the level of blood glucose concentration.     

Early diagnosis of pulmonary embolism by means of scintigraphy

The occasions on which lung embolism is likely to occur and proceed with or without initial clinical symptoms are described. Lung scintiscanning technique, complemented by special expedients and personal experience, is explained. It is felt that the method helps in the early detection of suspect or clinically silent forms, as well as in the corroboration or ruling out of a clinical diagnosis as soon as this is possible. Scintiscanning is also of assistance in showing the anatomopathological features and extent of the process. The technique is simple and readily tolerated, even by patients with slight respiratory or circulatory disturbances. On the other hand, it is not competitive with conventional and well-tried angiopneumography.     

The traps of pulmonary embolism

The clinical diagnosis of pulmonary embolism (PE), even massive, remains difficult and perplexing. In our hospital, the percentage of exact clinical diagnoses has not significantly changed over recent years, with a false-negative rate of 78%, and a false-positive rate of 2%. In approximately 20% of cases, autopsy showed several emboli and pulmonary infarctions of various ages, indicating recurrent embolic episodes. The diseases most frequently associated were cardiac diseases (51%) and tumours (24%). Pneumonia considerably decreases the probability of an exact diagnosis of PE; hospitalisation in the Cardiology department or Intensive Care Unit increased the probability of this diagnosis. While the numerous diagnostic algorithms recently proposed have a limited value, the process integrating clinical and instrumental data in order to establish a prospective clinical probability, should facilitate identification of acute PE in live patients.     

Treatment of severe pulmonary embolism

Acute circulatory failure is the major complication of acute pulmonary embolism. It may be clinically silent, but sometimes leads to systemic hypotension, shock, or clinical manifestations of right ventricular failure. In these patients, oxygen, inotropic drugs, and fluid loading are indicated. Unless contra-indicated, thrombolytic therapy should be undertaken when clinical signs of circulatory failure occur. Surgical embolectomy is now undertaken in the very few patients not responding to maximal medical treatment. Vena cava interruption is not more often useful in massive pulmonary embolism than in non massive pulmonary embolism.     

Noninvasive diagnosis of pulmonary embolism

With the development of new methods for detecting pulmonary embolism, the need for angiography has been greatly reduced. Plasma D-dimer assays, lower-limb ultrasonography, and ventilation/perfusion lung scans in combination with the clinical assessment enable safe, cost-effective diagnoses.     

Clinical and instrumental diagnosis of pulmonary embolism

Pulmonary embolism shows a high mortality especially for the difficulty in establishing an early correct diagnosis. The pathophysiology and thus the clinical manifestations of pulmonary embolism (PE) are essentially conditioned by three factors: the size of the embolus, the pre-existing cardiorespiratory condition, the release caused by the embolus, of some substances or the activation of reflexes which tend to worsen the purely mechanical consequences of PE. The clinical manifestations resulting from the combination of these factors result in three clinical patterns: acute cor pulmonare, pulmonary infarction, acute dyspnea. PE symptoms may be absent in a moderate percentage of cases and if present, they are nonspecific. Some laboratory tests were shown to be of no diagnostic accuracy, as enzyme determination, a sign of necrosis, blood gas analysis, and determination of alveolar arterial oxygen gradient. Among blood coagulation tests, D-dimer determination was shown to be of some relevance. However, at present, it cannot be used to confirm the diagnostic suspicion of PE. Among the instrumental cardiologic procedures, while ECG has a poor diagnostic reliability, transesophageal echocardiography in central embolism may be able to visualize the embolus and to accurately assess the hemodynamic effects, supplying sufficient information for PE therapy. Even if imaging procedures as pulmonary angiography and more recently CT or MRI are the most reliable diagnostic tools, the diagnostic suspicion of PE in subjects at risk, the use of the examined methods and the search in these patients for the presence of lower limb deep vein thrombosis, often asymptomatic, may increase the number of treated patients thus decreasing the mortality of this disease.     

Reminiscences on venous thrombosis and pulmonary embolism

In a one week study of 236 patients, soft gelatine capsules containing 10 mg temazepam (Euhypnos) were evaluated as a hypnotic in general practice. Doses of 10-30 mg were generally well tolerated and performed satisfactorily in 76% of the patients. Seventy-two per cent experienced no hangover effect and 72% rated Euhypnos as good as or better than their previous hypnotic drugs.     

Angiographic evaluation of chronic pulmonary embolism

In some patients acute pulmonary emboli may fail to resolve normally, resulting in chronic pulmonary embolism. This may lead to pulmonary hypertension, respiratory insufficiency, cor pulmonale, and death. The angiographic evaluation in nine patients with chronic pulmonary embolism who underwent embolectomy is presented. Particular emphasis on the predictive value of selective bronchial arteriography in four of these patients is considered. In chronic pulmonary embolism, pulmonary arteries distal to obstructed areas may remain patent and be supplied by hypertrophied bronchial arteries. Since back-bleeding of arterial blood from the bronchial circulation at surgery may predict the success of embolectomy, preoperative bronchial arteriography may be useful for predicting potential surgical success.     

Factor V Leiden and fatal pulmonary embolism

The cercariae of Pseudechinoparyphium echinatum and Echinostoma revolutum approach their intermediate host snails by turning back when swimming in decreasing concentration gradients of snail conditioned water. Host stimuli are small molecular amino compounds, probably amino acids. This response was inhibited reversibly when the cercariae were treated with 0.45 microM-silver nitrate. As silver nitrate binds to the ciliated papillae of the cercarial surface, papillar chemoreceptors may be involved. Snail conditioned water from different snail species stimulated different intensities of chemo-orientation in both species of digeneans. However, when the samples of water conditioned with different snail species or even fish, tadpoles and leeches were diluted to the same total amino acid concentrations, the intensities of cercarial responses were similar. Therefore, some specificity of the chemo-orientation seemed to be achieved only by the total concentration of amino acids and not by particular mixtures of amino acids. In fact, amino acid spectra released by freshwater snails varied not only among different snail species, but also within the same species.     

Diagnosis of deep venous thrombosis and pulmonary embolism

Diagnostic evaluation in the patient with suspected deep vein thrombosis (DVT) and pulmonary embolism (PE) includes a clear correlation between clinical probability, test selection and test interpretation. Real-time B-mode ultrasound with color Doppler remains the imaging technique of choice in suspected DVT. The ventilation/perfusion (V/Q) lung scan is the preferred diagnostic modality in suspected PE. The D-dimer assay may be useful in excluding PA. New diagnostic techniques, including spiral computerized tomography may further modify the diagnostic algorithm.     

The role of 2D-doppler electrocardiography in the early diagnosis of massive acute pulmonary embolism and therapeutic monitoring

To clarify the histopathological progression of invasive tumors in the pituitary pars distalis due to estrogen, female Fischer 344 (F344) rats were treated subcutaneously with 5 mg/animal of estradiol dipropionate (ED) once every 2 wk for 13 wk. The animals were killed serially at 2-wk intervals during the investigation. The pituitaries with surrounding tissues were examined light microscopically. At week 7, pituitary cells showed proliferation and atypia with formation of blood-filled spaces. Lesions with these characteristics were diagnosed as adenomas. At week 9 or later, neoplastic cells exhibited extensive proliferation and infiltration into the surrounding tissues, suggesting development of carcinoma. Both proliferating cell nuclear antigen (PCNA) and 5-bromo-2'-deoxyuridine (BrdU) labeling index, markers of cell proliferation, were significantly increased in animals with adenoma or carcinoma. To detect sequential changes in pituitary weight, its signal intensity was periodically monitored in identical rats by using magnetic resonance (MR) imaging. The estimated pituitary weights revealed by MR imaging were comparable to the tumor weights obtained from rats at scheduled sacrifices. These results indicate that ED possesses the potential to cause carcinoma in rat pituitary and MR imaging is an effective tool for estimating the pituitary weight.     

Paradoxical cerebral embolism during fibrinolysis therapy in deep vein thrombosis and pulmonary embolism

A 37-year-old woman with increasing dyspnoea over several months suddenly developed severe ortho- and tachypnoea as well as cyanosis of the lips and acrocyanosis. Pulmonary angiography revealed massive bilateral pulmonary emboli with a systolic pulmonary artery pressure of 75 mm Hg. Phlebography demonstrated a thrombotic occlusion of the deep veins of the left leg extending to the distal femoral vein. Thrombolysis treatment was started via an indwelling pulmonary artery catheter (500,000 IU urokinase and 10,000 IU heparin as bolus, then 1 mill. IU urokinase and 1,000 IU heparin per hour). After two hours an incomplete left-sided paresis occurred (involving ocular and facial muscles, dysarthria, left arm and left leg) and the thrombolytic infusion was stopped. But cerebral computed tomography (CT) did not demonstrate any intracerebral haemorrhage. The heparin infusion was restarted (partial thromboplastin time between 70 and 90 s). CT examinations during the next few days showed the development of an ischaemic infarction in the distribution of the right medial cerebral artery. Angiography demonstrated occlusion of the right internal carotid artery. The diagnosis of a paradoxical embolus was supported by easy cardiac catheter passage through a patent foramen ovale. Subsequent pulmonary angiography demonstrated a thrombus-free pulmonary arterial circulation with a normal pulmonary arterial pressure. There was gradual and extensive regression of the incomplete hemiparesis.