An update on Behçet''s disease

Behçet's disease (Adamantiades‐Behçet's disease, ABD) is a multisystemic inflammatory disease, the pathogenesis of which is still a mystery. Many questions are still to be answered and the available diverse data need to be brought together to be compared and analysed. There is at least consensus on the effect of possible, but currently unknown, environmental triggering factor(s) against a background of genetic susceptibility. The possible aetiological factors form a broad spectrum, with infectious agents being the most probable ones. Whatever the stimulus is, the target tissue seems to be the small blood vessels, with various consequences of either vasculitis and/or thrombosis in many organ systems. The endothelium seems to be the primary target in this disease; however, it may just be the subject of the bizarre behaviour of the immune system. The diverse existing data could be interpreted in favour of either explanation. A similar confusion exists about the thrombotic tendency in Adamantiades‐Behçet's disease, in terms of whether a primary hypercoagulability is present or whether it is secondary to inflammation. Recent interesting immunological data promise a way out of the existing dilemma. These findings will be outlined within the context of possible hypotheses and attention will be paid to further investigations that are needed.     

Stroke risk after abrupt internal carotid artery sacrifice: accuracy of preoperative assessment with balloon test occlusion and stable xenon-enhanced CT.

PURPOSETo evaluate stable xenon-enhanced CT cerebral blood flow with balloon test occlusion as a predictor of stroke risk in internal carotid artery sacrifice.METHODSAbrupt internal carotid artery occlusion was performed by surgical or endovascular means below the origin of the ophthalmic artery in 31 normotensive patients who were assessed preoperatively by a 15-minute clinical balloon test occlusion followed by an internal carotid artery-occluded xenon CT cerebral blood flow study.RESULTSOne patient, who passed the clinical test occlusion but exhibited regions of cerebral blood flow less than 30 mL/100 g per minute on the occlusion xenon CT cerebral blood flow study went on to have a fatal stroke corresponding exactly to the region of reduced blood flow. Thirty patients passed both components of the preoperative stroke-risk assessment. Neuroimaging demonstrated possible flow-related infarctions, which subsequently developed in three patients. Two patients were asymptomatic, and one patient was left with a mild residual hemiparesis.CONCLUSIONSOur protocol provided a statistically significant reduction in subsequent infarction rate and infarction-related death rate when compared with a control group of normotensive abrupt internal carotid artery occlusion patients who did not undergo any preoperative stroke-risk assessment (reported in the literature). The estimated false-negative rate for our preoperative assessment protocol ranged from 3.3% to 10% depending on the assessment of the cause of the three potentially flow-related infarctions. Although life-threatening major vascular territory infarctions have been avoided, our protocol is less sensitive to changes predicting smaller, often minimally symptomatic, vascular border zone infarctions and does not predict postoperative thromboembolic strokes.     

Localization of pancreatic insulinoma: comparison of pre- and intraoperative US with CT and angiography

Methods of preoperative radiologic localization of insulinoma were compared in 52 patients, 44 of whom had solitary tumors. Examinations performed in these 44 patients were preoperative ultrasonography (US) in 28, angiography in 26, and computed tomography in 23. Prospective sensitivities were 61%, 54%, and 30%, respectively. Imaging sensitivities were lower for the eight patients with multiple insulinomas. In 28 of the 44 patients, intraoperative US was performed without the examiner being aware of the surgical findings. The sensitivity was 84%. Four insulinomas were not palpable but were visualized sonographically. The combined sensitivity of intraoperative US and surgical palpation for detecting solitary insulinomas was 100%. High-frequency intraoperative US is valuable for detecting occult solitary insulinomas and considerably useful for determining the proximity of insulinomas to the pancreatic and bile ducts.