Pulsatile tinnitus. A 15-year experience

BACKGROUND: We have previously demonstrated by 31P nuclear magnetic resonance (NMR) that succinylcholine (SCh) induces metabolic changes in denervated muscle. To specify those changes, we attempted to inhibit them using two different kinds of drugs, dantrolene and vecuronium. METHODS: Three weeks after unilateral sciatic nerve section, 75 male Wistar rats were randomly assigned to one of the following 5 groups: (1) non-pretreated normal muscle group; (2) non-pretreated denervated muscle group; (3) denervated muscle group pretreated with a low dose of vecuronium (0.02 mg.kg(-1)); (4) denervated muscle group pretreated with a high dose of vecuronium (0.2 mg.kg(-1)); (5) denervated muscle group pretreated with dantrolene (2 mg.kg(-1)). The change of the inorganic phosphate/phosphocreatine (Pi/PCr) ratio of each muscle was measured by 31P-NMR before and after SCh (1 mg.kg(-1)) administration and the corresponding peak amplitude of the electromyograms (EMG) was determined. RESULTS: The high dose of vecuronium totally inhibited SCh-induced fasciculation on EMG (100%-->2%). In this group, though the Pi/PCr ratio significantly increased 10 min after SCh, the peak after 5 min disappeared. The inhibition with dantrolene was about the same order of magnitude as with the low dose of vecuronium (35%:21%). However, the increase in the Pi/PCr only lasted about 10 min, in contrast to the other drugs. CONCLUSION: Our findings indicate that the Pi/PCr increases 5 and 10 min after SCh, respectively, as a result of two different processes. The first peak is caused by an excessive energy consumption in response to excessive muscle contraction. This in turn triggers the second peak, caused by breakdown of glycogen, initiated by an increased Ca2+ concentration.     

Aneurysm of the hepatic artery. Report of a case

Hepatic artery aneurysms are considered a rare event even though their report in the literature are becoming more and more frequent. A case of a 50-year-old man with common hepatic artery arterial aneurysm is reported. Initially, aspecific upper abdominal symptoms were found, but the great improvement in the diagnosis of vascular disease allows us to recognize this pathology which has a high risk of rupture so that an aggressive treatment is required.     

A comprehensive approach to the treatment of popliteal artery aneurysms--personal experience]

During a five-year retrospective follow-up period the authors treated a group of 46 patients with the diagnosis of aneurysm of the popliteal artery (AAP). The group comprised 42 men (91%) and 4 women (9%). The mean age was 62 years. In 32 patients (69%) AAP was on both lower extremities, in the remaining 14 (31%) it was unilateral. Forty-one patients (90%) had surgery and a total of 48 AAP were operated. The remainder was treated by conservative methods (10%). The first symptoms of AAP in the investigated group were: claudication in 17%, thromboembolic complications in 46%, rupture of the AAP in 4%. An asymptomatic aneurysm was detected in 33%. RESULTS: The authors did not record any death or occlusion of the reconstruction during hospitalization. When using a vein the primary patency is 100%. When a prosthesis (PTFE) is used the results are worse but still satisfactory and the five-year secondary patency is 85%. Five patients with thromboembolic complications of AAP were successfully treated by i.a. fibrinolysis. In all exclusion of the aneurysm and revascularization of the extremity followed. In the conclusion the authors emphasize the necessity of early surgical treatment as soon as the condition is detected, before the development of thromboembolic complications of AAP. If they develop it is essential to attempt local fibrinolysis and in the second stage revascularization of the extremity, if possible by a vein.     

Femorotibial and femoroperoneal bypass vein grafts. A 15-year experience

Results with 111 femoral-infrapopliteal vein grafts in 105 patients were subjected to life-table analysis. The overall five-year cumulative graft patency rate of 46% was associated with a 60% limb salvage rate. In cases in which the infrapopliteal graft represented the initial operative procedure, the five-year limb salvage and patency rates (69% and 56%, respectively) were significantly higher (P less than .05) than those achieved with secondary grafts (38% and 22%, respectively). Most limbs (79%) with failed intrapopliteal grafts, without further attempts at reconstruction, required major amputation within six months. The site of the distal anastomosis (anterior tibial, posterior tibial, or peroneal arteries) proved not to be a significant factor in determining long-term limb salvage or graft patency rates. Furthermore, the differences between five-year salvage and patency rates in diabetics (45% and 32%, respectively) and nondiabetics (65% and 53%, respectively) approached but did not reach statistical significance. It is believed these observations support the established but controversial role of infrapopliteal bypass in advanced peripheral occlusive diseases.     

Mediastinal needle biopsy. A 15-year experience with 139 cases

BACKGROUND: Radiologically guided needle biopsy and cytologic evaluation provide a reliable method of diagnosis for planning definitive therapy of patients with mediastinal lesions. MATERIALS AND METHODS: In this retrospective study of one of the largest series from a single institution, 141 consecutive mediastinal needle biopsies from 139 patients were reviewed during a 15-year period. RESULTS: Adequate material was obtained with a diagnosis achieved in 128 cases (92%). Of these, 33 cases (26%) had benign diagnoses; the remaining 95 (74%) had malignant diagnoses, including 81 carcinomas, 3 sarcomas, 8 lymphoproliferative lesions, 2 malignant germ cell tumors, and 1 malignant thymoma. All benign cases were diagnostically confirmed, and 94 of 95 malignant cases were classified correctly. The only discrepancy that occurred involved a malignant lymphoma diagnosed as a malignant germ cell tumor. Of the 13 inadequate samples, the major category included a nodular sclerosis variant of Hodgkin's disease (4 cases), 1 case of thymoma, 1 case of tuberculous lymphadenitis, and 7 cases for which no follow-up data were available. CONCLUSION: Needle biopsy is reaffirmed as a reliable and sensitive diagnostic tool for mediastinal lesions, with an overall cytologic diagnostic accuracy of 99% with adequate material. Sclerotic lesions may pose a limitation to this technique and require generous sampling before a more invasive diagnostic procedure is undertaken.     

Glomangioma of the popliteal fossa. Apropos of a case

Glomus tumours are relatively uncommon lesions most frequently found in the extremitis, usually in the digits. They are most often solitary lesions but multiple tumours have been reported. If the triad of pain, tenderness and cold intolerance should raise the clinical suspicion of a digital glomus. The histological exam is necessary in the extra digital glomus. We reported a case of fossa poplitea glomangioma with tibialis nerve compression. The treatment of choice was a surgical exision. But the tumour have been redivided a year later without malign transformation.     

Entrapment of the popliteal artery

Popliteal artery entrapment is a rare but recognized cause of vascular insufficiency of the lower extremity. The authors describe the condition in a 26-year-old man. Diagnosis depends on arteriographic demonstration of the lesion. Treatment is surgical and should consist of either a bypass procedure or excision with graft interposition. Acute onset of peripheral vascular symptoms in a young person should arouse suspicion of such a lesion.     

Aneurysm of a subclavian-vertebral artery saphenous vein bypass graft: case report

OBJECTIVE AND IMPORTANCE: Although an autogenous saphenous vein is frequently used as a bypass graft, an aneurysm of a venous graft is a rare complication, especially in the case of cerebrovascular revascularization. We report a case of a successfully treated aneurysmal change in a venous graft after short vein bypass grafting. CLINICAL PRESENTATION: A 60-year-old man underwent a left subclavian-to-vertebral artery bypass operation with an interposed saphenous vein graft because of severe stenosis of the vertebral artery bilaterally. Angiograms of the left subclavian artery, obtained 4 months later, showed good patency of the graft without any dilation or stenosis. One year after the bypass surgery, the patient became aware of a pulsating mass in the left supraclavicular region, which was regarded as the grafted vein itself. A giant aneurysm of the vein graft, which developed at the nonanastomotic site, was shown in the angiogram 4 years later. INTERVENTION: The aneurysm was resected, and patch grafting of the orifice of the aneurysmal neck covered with an artificial vessel as a reinforcement was performed. CONCLUSION: The aneurysm seemed to have developed in a curved segment because of hemodynamic stress.     

Treatment of intracranial ependymomas of children: review of a 15-year experience

PURPOSE: There are still major controversies in the optimal management of children with intracranial ependymomas. To assess the impact of tumor site, histology, and treatment, the outcome of children treated at the Institut Gustave Roussy was reviewed retrospectively. METHODS AND MATERIALS: Between 1975 and 1989, 80 children aged 4 months to 15.8 years were seen at the Institut Gustave Roussy for postoperative management of an intracranial ependymoma. Location of tumor was infratentorial in 63 cases and supratentorial in 17. Surgical treatment consisted of complete resection in 38, incomplete resection in 38 and biopsy only in 4. Postoperative irradiation was done in 65 patients and chemotherapy in 33. Surviving patients have been followed from 12-197 months with a median of 54 months. RESULTS: The 5-year actuarial survival and event-free survival are 56% and 38%, respectively. Thirty-four patients relapsed from 3-72 months after diagnosis (median 25 months). In 20 patients, the only site of failure was the original tumor site. Three patients failed locally and at distance, while 10 others failed only at distance. Survival at 5 years was significantly better for patients who had complete resection of the tumor (75% vs. 41%, p = 0.001) and for those who received radiation therapy (63% vs. 23%, p = 0.003). Event-free survival at 5 years was superior in patients with complete resection of the tumor (51% vs. 26%, p = 0.002) and in patients who received radiation therapy (45% vs. 0%, p < 0.001). Sex and tumor site had no impact on survival or event-free survival. There was no difference in survival, event-free survival, or pattern of failure between patients treated with local field, whole brain or craniospinal irradiation, while severe longterm sequelae were noted predominantly in the latter two groups. CONCLUSION: Considering that failures were predominantly local and that there was no apparent benefit from prophylactic irradiation, we recommend local field irradiation with doses above 50.0 Gy for all children with intracranial ependymomas, without meningeal dissemination at diagnosis. Special considerations are necessary for children < 3 years of age.     

Epidural spinal cord stimulation for treatment of chronic pain--some predictors of success. A 15-year experience

BACKGROUND: We have used epidural spinal cord stimulation (SCS) for pain control for the past 15 years. An analysis of our series of 235 patients has clarified the value of specific prognostic parameters in the prediction of successful SCS. METHODS: Patients were followed up for periods ranging from 6 months to 15 years with a mean follow-up of 66 months. The mean age of the 150 men and 85 women in the study was 51.4 years. Indications for SCS included failed back syndrome (114 patients), peripheral vascular disease (39 patients), peripheral neuropathy (30 patients), multiple sclerosis (13 patients), reflex sympathetic dystrophy (13 patients), and other etiologies of chronic intractable pain (26 patients). RESULTS: One hundred and eighty-nine patients received permanent devices; 111 (59%) of these patients continue to receive satisfactory pain relief. Pain attributable to failed back syndrome, reflex sympathetic dystrophy, peripheral vascular disease of lower limbs, multiple sclerosis, and peripheral neuropathy responded favorably to spinal cord stimulation. In contrast, paraplegic pain, cauda equina syndrome, stump pain, phantom limb pain, and primary bone and joint disease pain did not respond as well. Cases of cauda equina injury had promising initial pain relief, but gradually declined after a few years. After long-term follow-up, 47 of the 111 successfully implanted patients were gainfully employed, compared with 22 patients before implantation. The successful patients reported improvements in daily living as well as a decrease in analgesic usage. Multipolar stimulation systems were significantly more reliable (p < 0.001) than unipolar systems. Complications included hardware malfunction, electrode displacement, infection, and tolerance. CONCLUSION: Aside from etiologies of pain syndromes as a prognostic factor, we have identified other parameters of success. In patients who have undergone previous surgical procedures, the shorter the duration of time to implantation, the greater the rate of success (p < 0.001). The diagnosis of failed back syndrome must be considered a confounding factor in our analysis. Those patients whose pain did not follow a surgical procedure had better responses to SCS than patients who had multiple surgical procedures prior to their first implant. The advent of multipolar systems has significantly improved clinical reliability over unipolar systems. Age, sex, and laterality of pain did not prove to be of significance.     

Bilateral aneurysms of the popliteal artery

INTRODUCTION: Popliteal artery aneurysms are the most common of peripheral arterial aneurysms. Popliteal aneurysms are bilateral in 42% of patients. Atherosclerosis and bacterial invasion of the arterial wall are the predominant etiologic factors of popliteal artery aneurysms. CLINICAL CASE: A male of 67 years old was referred to our institution for bilateral claudication and 150 m. free interval. The angiogram showed a partial occluded aneurysm of the right popliteal artery and a complete thrombosis of the left popliteal artery aneurysms. The left aneurysm was resected and a femoral popliteal by-pass was performed, using the inverted saphenous vein graft, associated with left lumbar sympathectomy. Six months later the contralateral aneurysm was excised and a Dacron femoro-popliteal by-pass graft was performed. Two years later Arteriographic and Doppler examination showed patent by-pass bilaterally. CONCLUSION: Popliteal artery aneurysms can be a threaten for the lower limbs, because of thromboembolic phenomena and occasional rupture. Surgery is the best treatment before the appearance of an acute complication and a by-pass with an autogenous vein graft or a Dacron graft are the most common surgical procedures performed. Thrombolytic therapy offers good results where an acute complication appears.     

Aneurysm of the internal auditory artery: our experience and review of the literature

The aneurysms of the internal auditory artery (IAA) situated distal from anterior inferior cerebellar artery (AICA)-IAA junction, are extremely rare lesions. A case of distal aneurysm if IAA is presented causing subarachnoid haemorrhage (SAH) and complete ipsilateral deafness. After the neurosurgical treatment the hearing of the patient definitely improved. The literature of distal aneurysms of AICA is reviewed focusing on the clinical features of these malformations, causing cerebello-pontine angel (CPA) symptoms with or without SAH.     

Gastric cancer with metastases to the distant peritoneum: a 20-year surgical experience

BACKGROUND/AIMS: The efficacy of palliative gastrectomy in gastric cancer with peritoneal metastases remains uncertain. The aim of the present study was to evaluate the benefits of gastrectomy on the postoperative course of patients with gastric cancer and simultaneous metastases to the distant peritoneum. METHODOLOGY: A total of 122 patients who had gastric cancer and metastases to the distant peritoneum were studied with respect to survival. RESULTS: The extent of peritoneal metastases did not significantly affect the prognosis. Moreover, multivariate analysis indicated that surgery without gastrectomy was the only significant prognostic factor (relative risk, 2.587). CONCLUSIONS: Our results suggest that the decision to perform gastrectomy does not depend on the extent of peritoneal metastasis in gastric cancer. Furthermore, palliative gastrectomy, if feasible, seems to have a beneficial effect on the postoperative course and is indicated for patients regardless of metastasis to the peritoneum, if the primary tumor is surgically resectable and there is no evidence of liver metastasis.     

An unusual presentation of simultaneous bilateral popliteal artery embolism--a case report

We present what we believe is the first case in the literature of carcinoma of the lung presenting de novo as an intracardiac mass with bilateral, simultaneous popliteal artery embolization. Arterial thromboembolism of cardiac origin and in situ thrombosis of a preexisting atherosclerotic lesion or aneurysm account for the majority of cases of acute lower extremity ischemia. Less common causes include trauma, aortic dissection, venous ischemia, and foreign body or tissue embolization. Although the history, physical examination, and electrocardiographic findings may provide a likely explanation in many cases, noninvasive studies such as echocardiography may help further elucidate the embolic source.     

Spontaneous regression of a sub-adventitial cyst of the popliteal artery

In order to examine whether the existence of microalbuminuria can predict the development of overt proteinuria and cardiovascular death in Japanese subjects with non-insulin-dependent diabetes mellitus (NIDDM), we investigated 47 patients for a 10-year follow-up period. Patients were divided into two groups by the initial values of urinary albumin excretion rates. The percentage of patients who developed overt proteinuria during the follow-up period was significantly higher in patients who were initially classified as microalbuminuric group (63.6%) than in normoalbuminuric group (17.4%). During the follow-up period, one of the patients with normoalbuminuria had died of congestive heart failure, while four of those with microalbuminuria had died; one of stroke and three from noncardiovascular diseases. These results indicate that the existence of microalbuminuria had the predictive power for the development of overt proteinuria, but not for cardiovascular death in Japanese subjects with NIDDM.     

Subclavian steal syndrome. A 12-year experience

Over a 12-year period, 43 operations were performed on 40 patients for correction of the subclavian steal syndrome. Eleven of these patients also underwent endarterectomy for coexisting carotid artery disease. There were 16 transthoracic procedures and 27 transcervical procedures. Graft failure in two patients was corrected by a second operation. There was one early death and one late death. The remaining 38 patients have been carefully studied for up to 12 years, with an average follow-up period of 60 months. These 38 patients have remained asymptomatic and their revascularization procedures have remained functional, as determined by blood pressure determinations in the involved extremity and, in some cases, by arteriography.