Usefulness of 3-Dimensional CT Angiograms Obtained by 64-Section Multidetector Row CT Scanner for Dural Arteriovenous Fistula

The authors reported a case of a dural arteriovenous fistula (DAVF) in the left transverse-sigmoid sinus, in which 3-dimensional computed tomography (CT) angiograms (3D-CTAs) by a 64-section multidetector row CT scanner were useful for its diagnosis and treatment. The DAVF in the left transverse-sigmoid sinus appeared on the digital subtraction angiogram. 3D-CTAs were obtained by a 64-section multidetector row CT scanner before an endovascular treatment. The feeders and draining veins of the DAVF were clearly demonstrated on the 3D-CTAs, which clarified the relationship between the normal dural sinuses and DAVF. The DAVF was successfully treated with endovascular surgery, a transvenous embolization through the mastoid emissary vein, which was easily detected by using the 3D-CTA, showing both the subcutaneous vein and calvalium. 3D-CTAs by a 64-section multidetector row CT scanner are useful for both diagnosis and treatment of DAVFs.     

Cross‐sectional and longitudinal studies of three‐dimensional stereotactic surface projection SPECT analysis in Parkinson's disease

Although dementia is increasingly recognized as a common feature in Parkinson's disease (PD), its pathological substrate remains unknown. We conducted cross‐sectional and longitudinal brain perfusion SPECT analyses to explore changes during the course of developing dementia in PD. Fifty‐five patients originally diagnosed with PD were imaged in the cross‐sectional study. Twenty‐one of these, nine without dementia and 12 with dementia (PDD), were included in the longitudinal study to observe perfusion changes during the course of their disease. Data were analyzed using three‐dimensional stereotactic surface projection SPECT analysis. The UK Parkinson's Disease Society Brain Bank criteria were used to diagnose PD and the revised criteria for the clinical diagnosis of dementia with Lewy bodies for PDD. The cross‐sectional study showed that patients with PDD had significantly reduced perfusion in the right posterior cingulate, the right precuneus and the left posterior cingulate area. In the longitudinal study, significantly reduced perfusion was observed in the left anterior frontal gyrus in PD without dementia, and in the right inferior parietal lobule in those that developed PDD. We suggest that a relationship exists between developing dementia in PDD and reduced perfusion in the posterior parietal area. © 2009 Movement Disorder Society     

The impact of fat distribution on the severity of nonalcoholic fatty liver disease and metabolic syndrome

The patterns of fat distribution and their relationship to severity of nonalcoholic fatty liver disease (NAFLD) are unknown. The objectives of this study were to define the fat distribution patterns and their relationship to histological severity and metabolic parameters in subjects with NAFLD. Anthropometric indices and total body fat were measured in 123 subjects. Fat distribution patterns were defined as: general, abdominal, limb, truncal, and dorsocervical lipohypertrophy (DCL) a novel finding in NAFLD. Eighty-one (66%) of the subjects were obese, and 94 (76%) had abdominal obesity. Thirty-five (28.5%) had DCL. Whereas body mass index (BMI) correlated best with the presence of diabetes (r = 0.22, P < 0.05), waist circumference (WC) correlated best with hypertension (r = 0.2, P < 0.05), hypertriglyceridemia (r = 0.37, P < 0.001), and insulin resistance (homeostasis model of assessment for insulin resistance [r = 0.68, P < 0.0001]). None of the patterns of fat distribution were significantly associated with severity of hepatic steatosis. Abdominal obesity (WC) correlated with inflammation (r = 0.2, P < 0.05) only. DCL correlated significantly with the severity of all histological parameters except steatosis. Whereas DCL was the single greatest contributor to the variability in severity of histological parameters, a model combining BMI, WC, and DCL showed the greatest contribution to the variability in severity of individual histological parameters. The addition of steatosis grade to the model significantly increased its contribution to the range of lobular inflammation. CONCLUSION: WC predicts metabolic risk profile with the most significance. However, DCL is most strongly associated with severity of steatohepatitis. WC and BMI added modestly to the contribution of DCL to severity of nonalcoholic steatohepatitis.     

Is hepatic transplantation justified for primary liver cancer?

A concise, yet objective overview of Hepatocellular Carcinoma (HCC) treatment in 2006 with an intent to transplant is presented. The most significant variables impacting on the use of hepatic transplantation as therapy for primary liver cancer are developed under the headings of: Staging Criteria; Organ allocation; Transplant dropout minimization therapies; and Effects on the HCC general population. The pertinent medical literature and update of an ongoing intent-to-treat HCC with transplant single center randomized control trial are reviewed.     

MELD-XI: a rational approach to "sickest first" liver transplantation in cirrhotic patients requiring anticoagulant therapy.

Priority for "sickest first" liver transplantation (LT) in the United States is determined by the model for end-stage liver disease (MELD). MELD is a good predictor of short-term mortality in cirrhosis, but it can overestimate risk when international normalized ratio (INR) is artificially elevated by anticoagulation. An alternate prognostic index omitting INR is needed in this situation. We retrospectively analyzed survival data for 554 cirrhotic veterans referred for consideration of LT prior to December 1, 2003 (training group). Using logistic regression we derived a predictive formula for 90-day pretransplant mortality incorporating bilirubin and creatinine but omitting INR. We normalized this formula to the same scale as MELD using linear regression. This yielded MELD-XI (for MELD excluding INR) = 5.11 Ln(bilirubin) + 11.76 Ln(creatinine) + 9.44. Accuracy of MELD-XI was validated in a holdout group of 278 cirrhotic veterans referred after December 1, 2003, and in an independent validation dataset of 7,203 cirrhotic adults listed for LT in the United States between May 1, 2001, and October 31, 2001. MELD-XI and MELD correlated well in training, holdout, and independent validation cohorts (r = 0.930, 0.954, and 0.902, respectively). In the holdout cohort, c-statistics of MELD vs. MELD-XI for mortality were, respectively, 0.939 vs. 0.906 at 30 days;0.860 vs. 0.841 at 60 days; 0.842 vs. 0.829 at 90 days; and 0.795 vs. 0.797 at 180 days. In the independent validation dataset, c-statistics for MELD vs. MELD-XI as predictors of 90-day survival were, respectively, 0.857 vs. 0.843 in noncholestatic liver diseases and 0.905 vs. 0.894 in cholestatic liver diseases. Comparable MELD and MELD-XI scores were associated with comparable prognosis. In conclusion, MELD-XI, despite omission of INR, is nearly as accurate as MELD in predicting short-term survival in cirrhosis. In patients treated with oral anticoagulants, substitution of MELD-XI for MELD may permit more accurate assessment of risk and more rational assignment of "sickest first" priority for LT.