Pathogenesis of diabetic cerebral vascular disease complication

Diabetes mellitus is one of the most potent independent risk factors for the development of diabetic cerebral vascular disease(CVD). Many evidences suggested that hyperglycemia caused excess free fatty acids, the loss of endothelium-derived nitric oxide, insulin resistance, the prothrombotic state, endothelial dysfunction, the abnormal release of endothelial vasoactivators,vascular smooth muscle dysfunction, oxidative stress, and the downregulation of mi Rs participated in vessel generation and recovery as well as the balance of endotheliocytes. In turn, these abnormalities, mainly via phosphatidylinositol 3 kinase, mitogen-activated protein kinase, polyol, hexosamine, protein kinase C activation, and increased generation of advanced glycosylation end products pathway, play an important role in inducing diabetic CVD complication. A deeper comprehension of pathogenesis producing diabetic CVD could offer base for developing new therapeutic ways preventing diabetic CVD complications, therefore, in the paper we mainly reviewed present information about the possible pathogenesis of diabetic CVD complication.     

Usefulness of CT angiography for demonstrating cerebral aneurysms

We report the usefulness of computed cerebral angiotomography (CT angiography) for demonstrating cerebral aneurysm and the clinical significance of CT angiography for ruptured cerebral aneurysm. Our modified method of CT angiography was easy and less time-consuming. Fifteen seconds after starting a single bolus injection, 1 ml/kg/25 seconds via cubital vein, of contrast medium (60% urograffin), 5 serial 5 mm thick-CT slices were scanned in every 6.5 seconds including 2 seconds of interval, beginning from an axial level 20 mm above the orbitomeatal line and ending at a level 40 mm. A total of 103 patients were examined in this report, consisting of 70 unruptured asymptomatic, 8 unruptured symptomatic (oculomotor nerve palsy) and 25 subarachnoid hemorrhage (SAH). Seven unruptured aneurysms in 4 asymptomatic cases, 2 unruptured aneurysms in 2 symptomatic cases 27 aneurysms in 24 SAH cases were suspected by CT angiography. Of these 36 aneurysms suspected by CT angiography 32 aneurysms were confirmed by cerebral angiography. The detection rate of CT angiography in this report was 89%, higher than those of previous reports. Thirteen aneurysms were located at internal carotid-posterior communicating artery (ICPC) junction. 11 at anterior communicating artery (Acom), 7 at middle cerebral artery (MCA). CT angiography showed a false positive findings in 4 cases, which were all located at Acom. Four aneurysms were not detected in CT angiography, which were all located at MCA and were very small (2-3 mm) in diameter. There were no deteriorated cases during and after CT angiography. We suggest that CT angiography is a useful and safe method for predicting the location of not only unruptured but ruptured aneurysms.     

iFlow成像辅助诊断脑血管性病变

目的评估iFlow成像在脑血管性病变中的辅助诊断价值。方法对65例脑血管病变患者进行常规全脑2DDSA检查,对所采集的图像用iFlow软件编码,由低年资和高年资医师分别观察2D DSA图像及iFlow彩色编码血流图的血管解剖、病灶形态、大小、血流动力学情况,评估iFlow对脑血管病变是否具有辅助诊断价值。结果 iFlow成像能在一幅iFlow彩色编码血流图上完整显示脑血管DSA采集的动态序列所包含的病变信息,包括病灶的解剖形态、血流动力学变化及组织灌注情况,较2D DSA更加直观。低年资医师和高年资医师对iFlow辅助诊断价值认定的差异有统计学意义（χ2=6.032,P=0.014）。结论 iFlow较单独2D DSA图像显示病变更全面,能对临床医师、尤其是低年资医师诊断和评估脑血管病变提供帮助。     

Usefulness of the axillary artery as vascular access for cardiopulmonary bypass

AIM: In this paper we report our clinical experience with extended utilization of axillary artery cannulation for cardiopulmonary bypass (CPB) and discuss the indications and the results of the procedure in terms of complications and usefulness. METHODS: Between January 1999 and May 2004, 26 patients underwent right axillary artery cannulation for CPB. Fifteen patients presented acute type A aortic dissection and were operated urgently. Axillary cannulation was also used in 11 elective cases: 3 reoperative coronary surgery, 3 valve redo-operations and 5 cases of aortic valve regurgitation+aneurysm of the ascending aorta. RESULTS: All axillary artery cannulations were successful (21 direct and 5 with a side graft) without neurologic or vascular injuries to the right upper extremities. Hospital mortality was 7.7% and included 2 patients operated in an emergency procedure because of acute type A aortic dissection. In all cases, this cannulation site provided adequate perfusion, with a range of peak flows from 4.1 to 5.7 L/min. CONCLUSION: Our preliminary results demonstrate that the right axillary artery may be considered an alternative cannulation site for achieving full CPB and providing antegrade flow, thus avoiding complications related to retrograde flow when femoral artery perfusion is performed. This safe and useful method may be used not only in aortic surgery but in other such complex cardiac procedures as redo-operations.     

Usefulness of dynamic computed tomography for the diagnosis of mediastinal hemangioma

An asymptomatic 59-year-old female was admitted with an abnormal shadow on her chest radiography. Chest computed tomography (CT) revealed a mass measuring 20 mm in the anterior mediastinum. At the arterial phase on dynamic contrast-enhanced CT (dynamic CT), the pattern of "peripheral puddles", defined as discrete well-defined peripheral enhancing globles, was found in the mass. The tumor was completely resected via a median sternotomy, and was histopathologicaly diagnosed as hemangioma. In this case, dynamic CT was very useful for the preoperative diagnosis, and then the enhancement pattern of "peripheral puddles" on dynamic CT may be a conclusive finding for the diagnosis of mediastinal hemangiomas.     

Stellate ganglion block-therapy for cerebral vascular accidents

Editor—Using anterior paratracheal stellate ganglion blocks(APSGB), Gupta and colleagues¹ found that it ‘... decreasescerebral vascular tone without affecting the capacity of cerebralblood vessels to react to the changes in carbon dioxide or toautoregulate’. And, proposed that these results suggestedthat APSGB ‘... may have a therapeutic role in patientswhere cerebral insufficiency can be attributed to cerebral vasospasm’.     

Barbiturate therapy in traumatic cerebral vascular disease: report of two cases

We report two cases of traumatic cerebral vascular disease which were treated successfully with barbiturate. The first case sustained blunt trauma to the bilateral vertebral arteries, resulting in complete occlusion of both arteries. After ligation of the injured vertebral arteries, multiple cerebral infarction appeared. Cerebral angiography revealed dissection and stenosis of the bilateral internal carotid arteries. We treated this case with barbiturate (Thiamylal) in combination with administration of heparin. The second case sustained cerebral contusion and traumatic subarachnoidal hemorrhage as a result of a motor cycle accident. This patient deteriorated and cerebral angiography showed diffuse cerebral arterial vasospasms. When this was treated with induced hypertension, he developed recurrent subarachnoid hemorrhage. In order to protect the brain from ischemia without elevating blood pressure, we employed barbiturate therapy and the patient recovered without major neurological deficit. The condition of severe head injury with cerebral ischemia is complicated. Therefore it has been hard for neurosurgeons to cure the patient with this condition. But we treated it with barbiturate successfully. Barbiturate therapy in severe head injury with cerebral ischemia may decrease the mortality in that group of patients considered difficult to treat with the usual therapeutic modalities.     

Periorbital ultrasound findings. Hemodynamics in patients with cerebral vascular disease.

The direction of supraorbital and frontal artery flow and its response to compression of the superficial temporal, facial, and angular arteries were measured in 250 carotid arteries in 114 patients. All patients had arch and/or selective carotid arteriography. The carotid arteries were placed into the following three groups: hemodynamically normal, greater than 60% occlusion of the internal carotid artery, and total occlusion of the internal carotid artery. The test's accuracy was 94.5% in the hemodynamically normal group, 68.8% in the totally occluded group, and only 51.4% in the group with hemodynamically significant stenosis. Although the carotid Doppler examination is not reliable in detecting hemodynamically significant lesions of the internal carotid artery, it is valuable in assessing the adequacy of collateral cerebral circulation.     

Usefulness of antegrade selective cerebral perfusion during aortic arch operations

BACKGROUND: To evaluate the safety and usefulness of antegrade selective cerebral perfusion (SCP) during arch aneurysm or aortic dissection operations. METHODS: Between January 1986 and December 2001, 330 patients underwent aortic arch repair using SCP. Operations were performed with the aid of hypothermic extracorporeal circulation, SCP, and systemic circulatory arrest in most cases. In all, 89 patients (27%) were operated on for acute aortic dissection, 77 (23%) for chronic aortic dissection, and 164 (50%) for degenerative aneurysm. Total arch replacement using a branched graft was performed in 288 patients (94%). Mean SCP time was 86.2 +/- 28.5 minutes. RESULTS: The overall in-hospital mortality rate was 11.2% (falling to 3.2% in the 124 patients operated on between 1997 and 2001). Independent determinants of hospital mortality were pump time, renal/mesenteric ischemia, chronic renal failure, increasing age, period of operation, and nonuse of four-branched arch graft. The overall postoperative incidences of temporary and permanent neurologic dysfunction were 4.2% and 2.4%, respectively. There was no significant correlation between SCP time and in-hospital mortality or neurologic outcome. CONCLUSIONS: Selective cerebral perfusion is a reliable technique for cerebral protection and it facilitates complex and time-consuming total arch replacement.     

Lung transplantation for pulmonary vascular disease

BACKGROUND: Pulmonary hypertension (PHT) is a lethal condition resulting in markedly diminished life expectancy. Continuous prostaglandin I2 infusion has made an important contribution to symptom management, but it is not a panacea. Lung or heart-lung transplantation remains an important treatment option for end-stage PHT patients unresponsive to prostaglandin I2. This study reviews the outcomes after transplantation for PHT in our program. METHODS: A retrospective chart review was performed for 100 consecutive patients with either primary PHT (48%) or secondary PHT (52%) transplants since 1989. Living recipients were contacted to confirm health and functional status. RESULTS: Fifty-five adult and 45 pediatric patients underwent 51 bilateral lung transplants, 39 single lung transplants, and 10 heart-lung transplants. Mean age was 23.7 years (range, 1.2 months to 54.8 years) and mean pre-transplant New York Heart Association class was 3.2. Pre-transplant hemodynamics revealed a mean right atrial pressure of 9.6+/-5.4 mm Hg and mean pulmonary artery pressure of 64+/-14.4 mm Hg. Hospital mortality was 17% with early death predominantly because of graft failure and infection. With an average follow-up of 5.0 years, 1- and 5-year actuarial survival was 75% and 57%, respectively. Mean pulmonary artery pressure on follow-up catheterization was 22+/-6.0 mm Hg, and mean follow-up New York Heart Association class was 1.3 (p < 0.001 for both compared with pre-transplant). Diagnosis and type of transplant did not confer a significant difference in survival between groups. CONCLUSIONS: Whereas lung or heart-lung transplant for PHT is associated with higher early mortality than other pulmonary disease entities, it provides similar long-term outcomes with dramatic improvement in both quality of life and physiologic aspects.     

Reversibility of cerebral ischaemia dynamic and xenon computed tomography study on ischaemic cerebrovascular disease

Summary Flow studies using dynamic CT and xenon (Xe) CT were carried out in 25 patients with ischaemic stroke in the territory of the middle cerebral artery to define the clinical characteristics of cerebral ischaemia at a chronic stage.The parameter of peak height/mean transit time (PH/MTT) obtained from dynamic CT can provide an accurate index for blood circulation in the cerebral vascular bed. Xe CT measurements revealed various kinds of ischaemia around the infarction even in the chronic stages. In mild ischaemia of more than 30ml/100g/min, reduction of cerebral blood flow (CBF) was well correlated to the PH/MTT. However, in severe ischaemia between 20 and 30 ml/100 g/ min, changes of CBF were no longer correlated with the PH/MTT. There were cases showing severe reduction of CBF but which showed sufficient blood circulation (moderate value of PH/MTT). Mild reductions of CBF in parallel with decreased blood supply were often found in the peri-infarct area of infarctions in the centrum semiovale. On the other hand, infarctions in the cortico-subcortical region showed severe ischaemia, in even where blood circulation was relatively well sustained.