Acute onset of massive epistaxis due to post-traumatic cavernous internal carotid artery pseudoaneurysm: A case report

Rationale: Cavernous internal carotid artery (ICA) pseudoaneurysm caused by non-penetrating head trauma is a rare cause of massive epistaxis. The sudden onset of epistaxis due to such a fatal aneurysm protruding into the sphenoid sinus is extremely rare in clinical practice. The management is often challenging because of anatomical inaccessibility of the bleeding point. Patient's concern: A 42-year-old man with a history of head trauma showing an ICA aneurysm eroding the sphenoid sinus followed by massive epistaxis. Diagnosis: A computerized tomography (CT) scan showed a fracture in the sphenoid sinus. CT angiogram revealed cavernous ICA pseudoaneurysm. Interventions: Endovascular coil embolization. Outcomes: The patient recovered well and was discharged without any neurological deficits Lessons: Cavernous ICA pseudoaneurysm may lead to a life-threatening situation. If a patient has a history of head trauma, post-traumatic cavernous ICA pseudoaneurysm should be considered a differential diagnosis of massive epistaxis.     

Endovascular treatment of an infected pseudoaneurysm secondary to retropharyngeal abscess in a child

We describe a rare case of carotid pseudoaneurysm secondary to a retropharyngeal abscess, treated with coil embolization in a 2-year-old boy. The patient presented to an emergency department with symptoms suggesting meningitis but was subsequently diagnosed with streptococcal pharyngitis. He was discharged home on oral antibiotics after a short hospitalization. He returned to the emergency department two weeks later with limited neck motion and pain. Neck CT demonstrated a retropharyngeal abscess with a large left cervical internal carotid artery (ICA) pseudoaneurysm. The petrous ICA distal to the pseudoaneurysm had thrombosed prior to treatment. The ICA proximal to the pseudoaneurysm was sacrificed with coil embolization. Post-treatment imaging demonstrated complete thrombosis of the pseudoaneurysm but also demonstrated acute strokes in the left MCA/ACA watershed distribution. His parents noted that the patient was clumsier and exhibited some mild speech changes and a steppage gait prior to evaluation in the ED; therefore, these were thought to be secondary to emboli from partial thrombosis of the pseudoaneurysm prior to treatment. The patient was discharged home in good condition and his neurological function improved.     

Flow-diverter stenting in post-traumatic pseudoaneurysm of cavernous internal carotid artery with epistaxis

This paper is a case report of a young patient after a major head trauma causing multiple skull base fractures. The trauma occasioned pseudoaneurysm (PSA) from intracavernous C4 segment of left internal carotid artery (ICA) protruding in the sphenoidal sinus. After two months, two episodes of massive epistaxis occurred. Consequently, the post-traumatic PSA was treated, after carotid occlusion test, with flow-diverter stent positioning. A computed tomography angiography study performed in the following days showed complete resolution of the post-traumatic PSA lesion and ICA patency.     

An emergency medicine-focused review of malignant otitis externa

IntroductionMalignant otitis externa (MOE) is a progressive infection of the external auditory canal (EAC). This disease is rare but has severe morbidity and mortality.ObjectiveThis narrative review provides an overview of malignant otitis externa for emergency clinicians.DiscussionMOE is an invasive external ear infection that spreads to the temporal bone and can further progress to affect intracranial structures. Complications of advanced MOE include cranial nerve involvement, most commonly the facial nerve, and intracranial infections such as abscess and meningitis. The most common causative agent of MOE is Pseudomonas aeruginosa, but others include methicillin-resistant Staphylococcus aureus and fungi. Major risk factors for MOE include diabetes mellitus, immunosuppression, and advanced age. Red flags for MOE include severe otalgia (pain out of proportion to exam) or severe otorrhea, neurologic deficits (especially facial nerve involvement), previously diagnosed otitis externa not responsive to therapy, and patients with major risk factors for MOE. Examination may show purulent otorrhea or granulation tissue in the EAC, and culture of EAC drainage should be performed. Diagnosis is aided by computed tomography (CT) with intravenous contrast, which may demonstrate bony destruction of the temporal bone or skull base. When suspecting MOE, early consultation with an otolaryngologist is recommended and antibiotics with pseudomonal coverage are needed. Most patients with MOE will require admission to the hospital.ConclusionsMOE is a rare, yet deadly diagnosis that must be suspected when patients with immunocompromise, diabetes, or advanced age present with severe otalgia. Rapid diagnosis and treatment may prevent complications and improve outcomes.     

Utility of cardiac computed tomography scanning in the diagnosis and pre-operative evaluation of patients with infective endocarditis

Transesophageal echocardiography (TEE) is the gold standard imaging study used in the diagnosis of infective endocarditis (IE). Computed tomography angiography (CTA) has undergone rapid advancement as a cardiac imaging technique and has previously shown promise in small non-randomized studies for evaluation of IE. We hypothesized that cardiac CTA would perform similarly to TEE in the detection of endocarditic lesions and that there would be no difference in clinical outcomes whether the coronary arteries were evaluated by CTA or invasive coronary angiography (ICA). 255 adults who underwent surgery for IE at the Mayo Clinic Rochester between January 1, 2006 and June 1, 2014 were identified retrospectively. 251 patients underwent TEE and 34 patients underwent cardiac CTA. TEE had statistically higher detection of vegetations (95.6 vs. 70.0%, p?<?0.0001) and leaflet perforations (81.3 vs. 42.9%, p?=?0.02) as compared to cardiac CTA. For detection of abscess/pseudoaneurysm TEE had a similar sensitivity to cardiac CTA (90.5 vs. 78.4%, p?=?0.21). There was no significant difference in peri-operative outcomes whether coronary arteries were evaluated by CTA or ICA. The greatest advantage of cardiac CT in the setting of IE is its ability to couple the detection of complex cardiac anatomic abnormalities with coronary artery delineation, serving two important components of the diagnostic evaluation, particularly among patients who will require surgical intervention due to IE complications. Cardiac CTA may be considered as an alternate coronary artery imaging modality in IE patients with low to intermediate risk of disease but meet guideline recommendations for coronary artery imaging.     

胸主动脉假性动脉瘤的MRI诊断

目的 评价MRI对胸主动脉假性动脉瘤的诊断价值,方法,对16例假性动脉瘤患者行心电图门控MRI扫描,结果 本组假性动脉瘤均位于主动脉轮廓之外,瘤体较大（2.8cm*3.2cm*4.0cm-4．3cm*5.6cm*10.0cm),偏于一侧,境界清楚,形状不规则,其中不多数（13例）瘤体内部可与血流信号相同的小瘤腔（0．1cm*0.6cm*0.8cm-0.3cm*2.0cm*3.0cm),瘤壁较厚,信号呈不均匀层状,在SE图像上为中等信号或中等度高信号,在GRE电影图像上为较低信号,可见裂隙状破口以及经破口向瘤腔内喷射的血液信号;3例无瘤腔者MRI未显示破口,瘤体信号与有瘤腔者相同。结论 MRI可显示假性动脉瘤的特异性征象,是假性动脉瘤影像学论断方法之一。     

Sonographic characteristics of massive ovarian edema.

Massive ovarian edema (MOE) is a very rare disease characterized by a tumor-like enlargement of the ovary. The ultrasound findings have been reported as a solid tumor-like mass or as a solid mass containing a cystic component. Recent reports using magnetic resonance imaging of MOE have demonstrated that multiple ovarian follicles situated around the periphery of the cortex of the enlarged ovary is the most important diagnostic indicator of MOE. This finding was first demonstrated by ultrasound in the case we present here. Thus we suggest that the ultrasound detection of multiple peripheral ovarian follicles in a solid ovarian tumor-like mass may make the preoperative diagnosis of MOE possible by ultrasound alone.     

Variation in bending strength properties in stem and branch woods as influenced by density and moisture levels in Entandrophragma cylindricum

Branchwood is being exploited as a supplement to stemwood in wood products manufacturing, and the wood’s bending strength properties are vital for structural and non-structural applications. Non-destructive methods are being adopted in determining wood properties, and wood density and moisture content are two variables that could be useful. This study assessed the influence of density and moisture content (MC) on the Modulus of Elasticity (MOE) and Modulus of Rupture (MOR) of branch and stem woods of Entandrophragma cylindricum (sapele) tested at two moisture levels (10 ± 4% MC and 17 ± 3% MC). Density was determined in accordance with ISO 3131. To determine bending strength properties, BS 373 was followed, using an INSTRON TCM Machine with a crosshead speed of 6.6 mm per minute. Results indicated that branchwood has higher density than its stemwood counterparts. MOE and MOR of both wood types were significantly higher at 10 ± 4% MC than their counterparts at 17 ± 3% MC. Differences in MOE and MOR between the wood types were not significant, although the branchwood had 87% and 93% respectively of the MOE and MOR of stemwood. From the two-way ANOVA, MC had a significant effect (P < 0.05) but wood type and the interactions of wood type and MC did not have a significant effect on MOE and MOR of stem and branch woods. The predictive powers of MC and density as a combined predictor for estimating bending strength properties were higher for branchwood than stemwood. Although density of E. cylindricum branchwood was significantly higher than its stemwood counterpart that did not translate into significant differences between MOE and MOR of branchwood and stemwood.     

胰源性门脉高压伴巨大脾假性动脉瘤并结肠脾区瘘致消化道大出血一例

脾假性动脉瘤所致消化道出血是一种少见的疾病。该文报道了1例43岁男性慢性胰腺炎致胰源性门脉高压伴脾假性动脉瘤并致消化道大出血患者的诊治过程。该患者既往有胰腺炎伴脾假性动脉瘤病史,因消化道大出血就诊,入院后行内镜及影像学等检查,诊断为胰源性门脉高压伴脾假性动脉瘤并结肠脾区瘘,经脾动脉栓塞术后,患者消化道出血症状消失,2个月后复查腹部CT提示原脾假性动脉瘤已基本消失。该例提示若患者既往患有胰腺炎伴脾假性动脉瘤,出现消化道出血症状时,应及时考虑是否存在动脉消化道瘘,做到及时诊治,挽救患者生命。     

膝下动脉假性动脉瘤的腔内治疗并文献回顾

目的 评估腔内治疗膝下假性动脉瘤的临床疗效.方法 解放军总医院血管外科自2010年4月至2011年7月对3例膝下假性动脉瘤患者采用腔内治疗,其中2例为外伤性胫前动脉假性动脉瘤,1例为白塞病所致胫腓干假性动脉瘤.手术均在局麻下进行,X线透视下覆膜支架在破口处经球囊扩张后释放,封闭动脉瘤,之后造影观察支架位置变化、瘤腔封闭情况及远端动脉血流情况.结果 修复胫腓干假性动脉瘤时支架远端刺破腓动脉,遂转行弹簧圈支架内栓塞,其余2例均成功完成支架置入.术后随访2-15个月,患肢均可负重活动.2例支架成功置入的患者超声或CT造影均显示支架内通畅性良好.结论 覆膜支架治疗膝下假性动脉瘤早期效果确切,适宜临床中开展.但对于白塞病血管病变,支架置入需慎重.其远期结果尚待进一步观察.     

Pseudoaneurysm of pulmonary artery: rare complication of systemic chemotherapy

Pulmonary artery pseudoaneurysm is an uncommon yet fatal clinical entity. Its presentation can mimic a number of common diseases and can be easily missed. As pseudoaneurysm is associated with a number of fatal complications, clinicians should be aware of imaging features which distinguishes pseudoaneurysms from its close differentials. Early recognition and treatment of pseudoaneurysm can prevent fatal outcomes including hemothorax, rupture, or death.     

Islet cell cytoplasmic autoantibody reactivity to glutamate decarboxylase in insulin-dependent diabetes.

Individuals with or at risk for insulin-dependent diabetes (IDD) frequently have autoantibodies against an islet cell cytoplasmic (ICA) antigen thought to be a sialoglycolipid. However, we now report that preabsorption of ICA-positive sera with recombinant glutamate decarboxylase (human GAD 65 and/or GAD 67) reduced or blocked the ICA reactivity of 5/18 (27%) new-onset IDD patients and 7/18 (39%) prediabetics. Interestingly, nondiabetic subjects with ICA of > or = 5 yr in duration had GAD-reactive ICA significantly more often (16/24, 67%, P < 0.04) than the diabetic groups. ICA reactivity to GAD was not related to serum ICA titer nor the age of the individual, and in all cases tested was blocked by GAD 65 or GAD 67 with equivalent efficiency. The ICA observed in 21/25 (84%) IDD patients with ICA long after clinical onset of disease (9-42 yr) was reactive to GAD. A natural history analysis of three individuals showed conversions from ICA which was reactive to GAD to a non-GAD-reactive ICA nearer to their clinical onsets of IDD. This study further defines the autoantigens reactive to ICA, and suggests that, whereas ICA that are not reactive to GAD may identify an advanced and more prognostic lesion, GAD-reactive ICA may typify the early or inductive lesion that may or may not progress to clinically significant beta cell injury.     

超声引导下假性动脉瘤内注药封堵术的安全性和有效性研究

目的 探讨超声引导下假性动脉瘤内注药封堵术的安全性和有效性。方法 对2015年至2018年在陆军军医大学第二附属医院超声科行超声引导下凝血酶注射治疗的354例医源性假性动脉瘤患者的临床资料进行回顾性分析。结果 21.8%的患者诊断为复杂性假性动脉瘤（77/354）,2例患者同时合并动静脉瘘。凝血酶注射剂量50~800UI,平均（213.6±124.2）UI,首次治疗成功率92.9%（329/354）。单纯性假性动脉瘤与复杂性假性动脉瘤治疗成功率之间差异无统计学意义（p＞0.05）。假性动脉瘤大小与凝血酶使用剂量之间存在一定相关性(p=0.01)。凝血酶注射后临床及超声检查未发现并发症发生的确切证据,假性动脉瘤闭塞后未发现肢体血液供应恶化。结论 超声引导下假性动脉瘤内注药封堵术是一种安全有效的治疗方法。     

An intrinsic adrenergic system in mammalian heart.

We have identified a previously undescribed intrinsic cardiac adrenergic (ICA) cell type in rodent and human heart. Northern and Western blot analyses demonstrated that ICA cell isolates contain mRNA and protein of enzymes involved in catecholamine biosynthesis. Radioenzymatic catecholamine assays also revealed that the catecholamine profile of adult rat ICA cell isolates differed from that of sympathetic neurons. Unlike sympathetic neuronal cells, isolated ICA cells have abundant clear vesicles on electron microscopy. Endogenous norepinephrine and epinephrine constitutively released by ICA cells in vitro affect the spontaneous beating rate of neonatal rat cardiac myocytes in culture. Finally, ICA cells could be identified in human fetal hearts at a developmental stage before sympathetic innervation of the heart has been documented to occur. These findings support the concept that these cells constitute an ICA signaling system capable of participating in cardiac regulation that appears to be independent of sympathetic innervation.     

Treatment of an extracapsular post‐renal biopsy pseudoaneurysm with ultrasound‐guided thrombin injection

Percutaneous renal biopsy is a convenient method to obtain allograft tissue for histologic evaluation. Vascular complications, such as arteriovenous (AV) fistula and pseudoaneurysm, following renal biopsy are well known, and they usually resolve without further intervention. When symptomatic, they should be treated. We present a patient on chronic anticoagulation who developed a pseudoaneurysm after percutaneous renal biopsy. Applying techniques learned in the management of femoral artery pseudoaneurysm, we treated our patient with ultrasound‐guided thrombin injection. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2010     

Pseudoaneurysm of the abdominal aorta diagnosed by color duplex Doppler sonography.

A pseudoaneurysm of the abdominal aorta is rare, accounting for only 1% of all abdominal aneurysms. More than 1 imaging method may be needed to demonstrate an abdominal aortic pseudoaneurysm. We report a case in which the presence of continuous bidirectional flow in the neck of a pseudoaneurysm on color duplex Doppler sonography confirmed the diagnosis.     

相位对比电影MR成像评估婴幼儿脑血流特点

目的 采用相位对比电影MR成像(PC cine MRI)观察婴幼儿颈内动脉(ICA)血流动力学特点,评估脑血流量(CBF).方法 对37例婴幼儿行MR检查,以多个编码流速度PC cine MR序列测量ICA峰值流速(Vp)及血流量,计算单位体积CBF.采用Pea rson线性相关分析观察周龄与ICA Vp、ICA血流量...     

Coiling of a recurrent broad-necked posterior communicating aneurysm incorporating a fetal cerebral artery: A technical case report

We describe a case of a right broad-necked posterior communicating artery (PcomA) aneurysm with a fetal posterior cerebral artery (PCA) incorporated in the aneurysm neck. We performed waffle cone stent-assisted coiling and achieved almost complete occlusion of the aneurysm. At 18-month follow-up angiography, the aneurysm was recanalized and further coiling was needed. The same waffle cone method of coiling might be expected to produce the same unsatisfactory results on follow-up, so we decided to use retrograde stent navigation and placement through the anterior communicating artery (AcomA) from the contralateral internal carotid artery (ICA) to the ipsilateral ICA and fetal PCA. The stent delivery microcatheter from the contralateral ICA could not be introduced in the AcomA. So 2 mg nimodipine was infused through the stent delivery microcatheter to the AcomA and the stent delivery microcatheter was passed through the AcomA easily and could be navigated to the ipsilateral A1, ICA, and to the fetal PCA. With this additional stent, the aneurysm was completely separated from the fetal PCA and ICA. Further coiling could be performed safely through the microcatheter in the ipsilateral ICA. The patient had stable aneurysm occlusion at the six-month follow up.     

Carotid artery stenosis: grayscale and Doppler ultrasound diagnosis--Society of Radiologists in Ultrasound consensus conference

The Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts in the field of vascular ultrasonography (US) to come to a consensus regarding Doppler US for assistance in the diagnosis of carotid artery stenosis. The panel's consensus statement is believed to represent a reasonable position on the basis of analysis of available literature and panelists' experience. Key elements of the statement include the following: First, all internal carotid artery (ICA) examinations should be performed with grayscale, color Doppler, and spectral Doppler US. Second, the degree of stenosis determined at grayscale and Doppler US should be stratified into the categories of normal (no stenosis), less than 50% stenosis, 50 to 69% stenosis, > or =70% stenosis to near occlusion, near occlusion, and total occlusion. Third, ICA peak systolic velocity (PSV) and the presence of plaque on grayscale and/or color Doppler images are primarily used in the diagnosis and grading of ICA stenosis. Two additional parameters (the ICA-to-common carotid artery PSV ratio and ICA end diastolic velocity) may also be used when clinical or technical factors raise concern that ICA PSV may not be representative of the extent of disease. Fourth, ICA should be diagnosed as normal when ICA PSV is less than 125 cm/second and no plaque or intimal thickening is visible, less than 50% stenosis when ICA PSV is less than 125 cm/second and plaque or intimal thickening is visible, 50 to 69% stenosis when ICA PSV is 125 to 230 cm/second and plaque is visible, > or =70% stenosis to near occlusion when ICA PSV is more than 230 cm/second and visible plaque and lumen narrowing are seen, near occlusion when there is a markedly narrowed lumen on color Doppler US, and total occlusion when there is no detectable patent lumen on grayscale US and no flow on spectral, power, and color Doppler US. Fifth, the final report should discuss velocity measurements and grayscale and color Doppler findings. Study limitations should be noted when they exist. The conclusion should state an estimated degree of ICA stenosis as reflected in these categories. The panel also considered various technical aspects of carotid US and methods for quality assessment, and identified several important unanswered questions meriting future research.     

Spatiotemporal independent component analysis of event-related fMRI data using skewed probability density functions.

We introduce two independent component analysis (ICA) methods, spatiotemporal ICA (stICA) and skew-ICA, and demonstrate the utility of these methods in analyzing synthetic and event-related fMRI data. First, stICA simultaneously maximizes statistical independence over both time and space. This contrasts with conventional ICA methods, which maximize independence either over time only or over space only; these methods often yield physically improbable solutions. Second, skew-ICA is based on the assumption that images have skewed probability density functions (pdfs), an assumption consistent with spatially localized regions of activity. In contrast, conventional ICA is based on the physiologically unrealistic assumption that images have symmetric pdfs. We combine stICA and skew-ICA, to form skew-stICA, and use it to analyze synthetic data and data from an event-related, left-right visual hemifield fMRI experiment. Results obtained with skew-stICA are superior to those of principal component analysis, spatial ICA (sICA), temporal ICA, stICA, and skew-sICA. We argue that skew-stICA works because it is based on physically realistic assumptions and that the potential of ICA can only be realized if such prior knowledge is incorporated into ICA methods.