ALCAPA syndrome (anomalous origin of the left coronary artery from the pulmonary artery), which causes the left coronary artery to grow with an anomalous origin from the pulmonary artery, is a rare disease which may result in myocardial infarction, congestive heart failure, and sometimes death during the early infantile period. A 72 year old woman with ALCAPA syndrome is presented. The asymptomatic patient presented with a cardiac murmur which was discovered during a routine check up for a gynaecological intervention. Coronary cineangiography established the diagnosis. Although surgical correction is the usual treatment for such cases, medical treatment was preferred for this patient because she was asymptomatic without clinical signs of heart failure. (+info)
Venous thrombosis prophylaxis by inflammatory inhibition without anticoagulation therapy.
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OBJECTIVE: This study was performed to determine the effectiveness of recombinant P-selectin glycoprotein ligand Ig (rPSGL-Ig) pretreatment to decrease thrombosis and inflammation in experimental venous thrombosis. rPSGL-Ig, a unique mucin-like glycoprotein, has a high affinity for P-selectin. METHODS: Twelve juvenile baboons underwent inferior vena cava (IVC) thrombosis with temporary 6-hour IVC balloon occlusion. Before balloon placement, the animals received rPSGL-Ig (4 mg/kg; n = 8) or saline solution for control (n = 4). The animals underwent evaluation with duplex ultrasound scan imaging, magnetic resonance venography (MRV), phlebography, coagulation profile, and tissue analysis at death for cytokines and vein wall leukocyte morphometrics. With the MRV results, thrombus development, thrombus resolution, and inflammation (gadolinium; square millimeters of enhancement) were assessed. RESULTS: Each animal provided two time points for evaluation (days 2 and 6 after balloon occlusion). A significant decrease in IVC thrombosis between balloons was found in the rPSGL-Ig animals (1 of 16) versus the control animals (5 of 8; P <.01). The MRV results showed significantly less enhancement in the rPSGL-Ig animals at days 2 and 6 (P <.05). Spontaneous thrombus resolution (including balloon sites) was significantly greater from day 2 to day 6 in the rPSGL-Ig animals versus the control animals (23% vs 2%; P <.001), without pulmonary embolism. Lower interleukin-8, platelet factor IV, and monocyte chemotactic protein-1 levels were found in rPSGL-Ig vein walls without significant differences in vein wall leukocyte morphometrics. There were significantly lower D-dimer levels in the rPSGL-Ig-treated animals (P <.05), but there were no differences in measurements of coagulation. Adequate circulating rPSGL-Ig levels were documented. CONCLUSION: Pretreatment with rPSGL-Ig results in: (1) a significant inhibition of thrombosis and vein wall inflammation; (2) a decrease in vein wall cytokine expression; and (3) a promotion of thrombus resolution. Inflammatory inhibition by rPSGL-Ig without anticoagulation therapy provides effective venous thrombosis prophylaxis in experimental venous thrombosis. (+info)
Cerebral MR venography: normal anatomy and potential diagnostic pitfalls.
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BACKGROUND AND PURPOSE: MR venography is often used to examine the intracranial venous system, particularly in the evaluation of dural sinus thrombosis. The purpose of this study was to evaluate the use of MR venography in the depiction of the normal intracranial venous anatomy and its variants, to assess its potential pitfalls in the diagnosis of dural venous sinus thrombosis, and to compare the findings with those of conventional catheter angiography. METHODS: Cerebral MR venograms obtained in 100 persons with normal MR imaging studies were reviewed to determine the presence or absence of the dural sinuses and major intracranial veins. RESULTS: Systematic review of the 100 cases revealed transverse sinus flow gaps in 31% of the cases, with 90% of these occurring in the nondominant transverse sinus and 10% in the codominant transverse sinuses. No flow gaps occurred in the dominant transverse sinuses. The superior sagittal and straight sinuses were seen in every venogram; the occipital sinus was seen in only 10%. The vein of Galen and internal cerebral veins were also seen in every case; the basal veins of Rosenthal were present in 91%. CONCLUSIONS: Transverse sinus flow gaps can be observed in as many as 31% of patients with normal MR imaging findings; these gaps should not be mistaken for dural sinus thrombosis. (+info)
Vascularization of head and neck paragangliomas: comparison of three MR angiographic techniques with digital subtraction angiography.
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BACKGROUND AND PURPOSE: MR angiography of the head and neck region has been studied widely, but few studies have been performed concerning the efficacy of MR angiography for the identification of the specific vascular supply of the highly vascular head and neck paragangliomas. In this study, we compared three MR angiography techniques with respect to visualization of branch arteries in the neck and identification of tumor feeders in patients with paragangliomas. METHODS: Fourteen patients with 29 paragangliomas were examined at 1.5 T using 3D phase-contrast (PC), 2D time-of-flight (2D TOF), and multi-slab 3D TOF MR angiography. In the first part of the study, two radiologists independently evaluated the visibility of first-, second-, and third-order branch arteries in the neck. In the second part of the study, the number of feeding arteries for every paraganglioma was determined and compared with digital subtraction angiography (DSA), the standard of reference in this study. RESULTS: Three-dimensional TOF angiography was superior to the other MR angiography techniques studied (P < .05) for depicting branch arteries of the external carotid artery in the neck, but only first- and second-order vessels were reliably shown. DSA showed a total of 78 feeding arteries in the group of patients with 29 paragangliomas, which was superior to what was revealed by all MR angiography techniques studied. More tumor feeders were identified with 3D TOF and 2D TOF angiography than with 3D PC MR angiography (P < .05), with a sensitivity/specificity of 61%/98%, 54%/95%, and 31%/95%, respectively. Sensitivity was lowest for carotid body tumors. CONCLUSION: Compared with intra-arterial DSA, the 3D TOF MR angiography technique was superior to 3D PC and 2D TOF MR angiography for identifying the first- and second-order vessels in the neck. With 3D TOF angiography, more tumor feeders were identified than with the other MR angiography techniques studied. The sensitivity of MR angiography, however, is not high enough to reveal important vascularization. The sensitivity of MR angiography is too low to replace DSA, especially in the presence of carotid body tumors. (+info)
Significance of acute multiple brain infarction on diffusion-weighted imaging.
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BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) is superior to conventional MRI in identification of small new ischemic lesions and discrimination of recent infarcts from old ones. Thus, this technique is useful in the detection of acute multiple brain infarcts (AMBI). We sought to determine the frequency and the topographical and etiologic patterns of AMBI detected on DWI. METHODS: We studied 329 consecutive ischemic stroke patients who underwent DWI and MRI/MR angiography within 4 days of stroke onset. AMBI was defined as noncontiguous high signal intensities on DWI in >1 vascular territory. Stroke mechanism was determined according to the criteria of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). RESULTS: We detected AMBI in 95 patients (28.9%). AMBI in anterior circulation was found in 62 cases: in 1 hemisphere in 42 (group A) and in bilateral hemispheres in 20 (group B). Twenty-two patients had AMBI in the posterior circulation (group C) and 11 in both anterior and posterior circulations (group D). The most frequent cause of stroke was large-artery atherosclerosis in groups A (33/42), B (9/20), and C (15/22) (P=0.02) and cardioembolism in group D (6/11) (P=0.02). Elevated fibrinogen or hematocrit was significantly associated with group B (P=0.01). In 9 patients in groups B and D, anatomic variations of anterior or posterior cerebral arteries or patent posterior communicating artery contributed to AMBI. CONCLUSIONS: Different topographical patterns of AMBI are associated with different vascular pathologies and stroke mechanisms. Hemorheologic abnormality or vascular anatomic variations may be contributing factors in the pathogenesis of AMBI in bilateral cerebral hemispheres or in both anterior and posterior circulations. (+info)
Carotid and transcranial color-coded duplex sonography in different types of carotid-cavernous fistula.
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BACKGROUND AND PURPOSE: Patients with carotid-cavernous fistula (CCF) may undergo direct or indirect shunting. Ultrasonography has value that is complementary to angiography in the assessment and follow-up of these patients. The aim of this study was to characterize findings provided by carotid duplex sonography (CDS) and transcranial color-coded duplex sonography (TCCD) in patients with different types of CCF. METHODS: CDS and TCCD were independently performed by technologists and neurologists. Digital subtraction or MR angiography was interpreted by a neuroradiologist. Ultrasonographic studies were categorized into 4 types: I, direct shunting only; II, direct shunting with a carotid aneurysm; III, indirect shunting only; and IV, mixed (direct and indirect) shunting. In addition to carotid and intracranial flow velocities, volume, and pulsatility, other direct and indirect ultrasound signs of shunting were evaluated. The direct sign of CCF was a mosaic flash detected by TCCD. Alteration of hemodynamic parameters on CDS and demonstration of draining veins with the use of TCCD were considered indirect signs. RESULTS: Fifteen patients (8 men, 7 women) were included in the study. According to angiographic results, patients in ultrasonographic classification types I (n=7) and II (n=3) corresponded to type A of Barrow's classification. Patients with type III (n=8) were Barrow's type C. Type IV (n=1) had a combination of Barrow's types A and C. On ultrasound, both direct and indirect signs were seen in types I, II, and IV CCF. The presence of a 2-colored oval mass divided by a zone of separation without turbulence differentiated type I from type II CCF. All patients with type III CCF had indirect signs, and only 1 patient had direct signs on TCCD. Abnormal TCCD findings were most commonly seen through the transorbital window (100%), followed by the transtemporal window (63%) and transforaminal window (40%). CONCLUSIONS: If only indirect ultrasonographic signs of CCF are present, TCCD can be used to predict an indirect CCF type on the basis of the origin of the fistula. With direct communication between carotid artery and cavernous sinus, both direct and indirect ultrasonographic signs can be found. The combination of CDS/TCCD may provide a noninvasive and reliable way to classify patients with CCF. (+info)
Advances in non-invasive imaging of intracranial vascular disease.
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Intra-arterial catheter angiography has, in the past, been the mainstay for the investigation of intracranial vascular disease. It is, however, invasive, usually requires in-patients admission, and is associated with a rate of neurological complications between 1% and 3%. In recent years, magnetic resonance angiography (MRA) and CT angiography (CTA) have emerged as non-invasive alternatives for imaging blood vessels and have made a significant impact on neuroradiological investigations. It is the purpose of this article to explain the basic technical principles of these two methods and to give an overview of their current clinical applications. (+info)
Contrast-enhanced transcranial color-coded duplexsonography in stroke patients with limited bone windows.
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BACKGROUND AND PURPOSE: Thickening of the temporal bone in stroke-age patients may obviate sonographic evaluation of the circle of Willis in 20% to 30% of patients. We assessed the diagnostic efficacy of contrast-enhanced transcranial color-coded duplexsonography (TCCD) for noninvasive evaluation of the circle of Willis in stroke patients with limited bone windows. METHODS: Of 171 consecutive patients who presented with ischemic symptoms in the middle cerebral artery (MCA) territory, 49 patients (32 female, 17 male; age range, 70.5+/-10.6 years) had no detectable colorflow signals from the circle of Willis by TCCD because of limited acoustic windows. These 49 patients received an IV injection of a sonographic contrast-enhancing agent, Levovist (Schering; Berlin, Germany), and were re-examined. Correlative imaging studies of the circle of Willis were obtained in 42 of 49 of these patients. RESULTS: In 38 of 49 patients, contrast-enhanced TCCD enabled full visualization of the circle of Willis bilaterally; in an additional five patients, contrast-enhanced TCCD revealed only the portion of the circle of Willis ipsilateral to the probe through one temporal bone. In six of these 43 patients, contrast-enhanced TCCD showed MCA stenosis and MCA occlusion in three; three of the six cases of MCA stenosis and all three cases of the MCA occlusion were found on the symptomatic side. In six of 49 patients, no colorflow signals were obtained after contrast enhancement. All contrast-enhanced TCCD findings were confirmed by CT angiography, transfemoral digital subtraction angiography, MR angiography, or a combination of all three correlative studies. Levovist produced no serious adverse events. CONCLUSION: In stroke-age patients with limited acoustic windows, contrast-enhancement with Levovist can markedly increase the sensitivity of TCCD and increase the detection of clinically relevant intracranial arterial disease. (+info)