Magnetic resonance imaging of third cranial nerve palsy and trigeminal sensory loss caused by herpes zoster.

A 44-year-old man with right-sided herpes zoster ophthalmicus (HZO) developed ipsilateral third and sixth cranial nerve palsies and first-division trigeminal (fifth cranial nerve) sensory loss. MRI revealed contrast enhancement of the cisternal and cavernous portions of the third cranial nerve and high signal on a FLAIR sequence within the ipsilateral medulla at the presumed location of the trigeminal nucleus and tract. To our knowledge, this is the first report of the combination of these imaging findings in HZO.     

Pulmonary resection for metastases from colorectal cancer

Aim: The prognosis of patients with disseminated colorectal carcinoma is poor except for those with single organ pulmonary or hepatic metastases. The objective of the present study was to evaluate the result of pulmonary metastasectomy for colorectal secondary and to identify the prognostic factors. Methods: This was a retrospective study of 80 patients who had pulmonary metastasectomy for pulmonary secondary from colorectal carcinoma in Queen Elizabeth Hospital, Hong Kong. Results: The overall 5‐year and 10‐year survival rates of the entire cohort were 42.5% and 35.5%, respectively. High premetastasectomy carcinoembryonic antigen (> 20 μg/dL), short disease‐free interval (< 12 months) and incomplete resection were the independent prognostic factors. Neither the characteristics of the primary colorectal tumour nor the number of metastatic nodules had a significant contribution to the long‐term survival. Six patients underwent second pulmonary metastasectomy and three were still free from tumour recurrence after the second operation. Conclusion: Patients with pulmonary metastases from colorectal carcinoma would benefit from pulmonary metastasectomy. High premetastasectomy carcinoembryonic antigen and short disease‐free interval were negative predictive factors for survival. Long‐term follow‐up study is required, as recurrence can occur more than 5 years after pulmonary metastasectomy. Also, whether the survival benefit is due to surgical treatment effect or lead‐time bias remains undecided.     

Particle size and morphology of UHMWPE wear debris in failed total knee arthroplasties--a comparison between mobile bearing and fixed bearing knees.

Osteolysis induced by ultrahigh molecular weight polyethylene wear debris has been recognized as the major cause of long-term failure in total joint arthroplasties. In a previous study, the prevalence of intraoperatively identified osteolysis during primary revision surgery was much higher in mobile bearing knee replacements (47%) than in fixed bearing knee replacements (13%). We postulated that mobile bearing knee implants tend to produce smaller sized particles. In our current study, we compared the particle size and morphology of polyethylene wear debris between failed mobile bearing and fixed bearing knees. Tissue specimens from interfacial and lytic regions were extracted during revision surgery of 10 mobile bearing knees (all of the low contact stress (LCS) design) and 17 fixed bearing knees (10 of the porous-coated anatomic (PCA) and 7 of the Miller/Galante design). Polyethylene particles were isolated from the tissue specimens and examined using both scanning electron microscopy and light-scattering analyses. The LCS mobile bearing knees produced smaller particulate debris (mean equivalent spherical diameter: 0.58 microm in LCS, 1.17 microm in PCA and 5.23 microm in M/G) and more granular debris (mean value: 93% in LCS, 77% in PCA and 15% in M/G).     

Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): immediate procedure result and short-term clinical outcomes.

BACKGROUND: Sleeve technique is a modified version of crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter. OBJECTIVES: The aim of this study was to examine the feasibility, safety, and early clinical outcomes of sleeve technique in stenting different types (de novo, in-stent restenotic or in-stent bifurcation) of coronary bifurcation lesions at different locations. METHODS: From August 2005 to May 2006, 41 consecutive patients with symptomatic, nonleft-main coronary bifurcation stenoses of diameter narrowing >or=50% were treated with two-stent strategy, using sleeve technique. RESULTS: The mean age was 63.6 +/- 11.6 years with male predominance (70.7%). High prevalence of diabetes mellitus (31.7%), total occlusion (22.0%), and multi-vessel disease (65.9%) was observed in this cohort. Intravenous abciximab was given in 35 (85.4%) patients. Final kissing balloon inflation was successfully performed in all patients. The minimal luminal diameter in main vessel and side branch was increased from 0.97 +/- 0.53 mm and 0.81 +/- 0.45 mm to 2.76 +/- 0.34 mm and 2.22 +/- 0.35 mm, respectively. The mean procedure time was only 66.6 +/- 24.6 min. There was one (2.4%) case of subacute stent thrombosis presented as non-Q-wave myocardial infarction at day 3 postprocedure. The resultant in-hospital and 30-day major adverse cardiac event rate were both 2.4%. CONCLUSIONS: Sleeve technique is a feasible and efficient approach in stenting of coronary bifurcation stenoses.     

Differential risks of subsequent vascular events for transient ischaemic attack and minor ischaemic stroke.

Using a prospective hospital-based registry, 146 patients with transient ischaemic attack (TIA) were compared with 376 patients with minor first-ever ischaemic stroke with respect to the 3-month risk of subsequent vascular events, in order to clarify the distinctions between the disease entities. All patients were enrolled within 48 h of onset. The risk factor distribution for the two groups was comparable, except that the TIA patients had more previous TIAs. Large artery atherosclerosis (34%) and small vessel occlusion (32%) were the main aetiologies in the TIA group, whereas small vessel occlusion (49%) was the major cause in the stroke group. The 3-month risk of combined endpoints of stroke, myocardial infarction, and vascular death for TIA patients was higher than that for the minor stroke group (15.1% vs. 3.2%; hazard ratio 4.6, 95% confidence interval 2.3-9.3 in multivariate analysis). Large artery atherosclerosis and male sex were the other significant predictors. TIA may demand more urgent management than minor stroke. The fact that aetiology is a predictor, highlights the need for rapid diagnostic tests to establish pathogenesis.     

Outcome in Children With Significantly Abnormal Cerebral Blood Flow Detected by Doppler Ultrasonography: Focus on the Survivors

BACKGROUND AND PURPOSE: The Doppler waveform patterns of loss of diastolic flow, appearance of retrograde diastolic flow, or no detectable flow in the cerebral arteries suggest significantly abnormal cerebral blood flow (CBF). A retrospective study was performed to show that significantly abnormal CBF alone, without clinical criteria, is not necessarily specific to brain death in the young pediatric population. PATIENTS AND METHODS: Forty-seven pediatric patients, from newborn to 4 years of age, were found to have significantly abnormal CBF, including 7 patients with loss of diastolic flow, 28 with retrograde diastolic flow, and 23 with no detectable cerebral flow on serial Doppler sonographic examinations. Their clinical data and sonographic results were collected and analyzed. RESULTS: Forty-two patients died, a few of whom had only transient improvement of cerebral flow. All of the patients with no detectable cerebral flow expired. Five patients survived with or without sequelae. Their underlying conditions that caused increased intracranial pressure were treated by medical and/or surgical intervention, and diastolic reversal of CBF corrected within 1 day in all 5. CONCLUSIONS: Although no detectable flow is a lethal sign, pediatric patients with loss or reversal of diastolic flow may survive with prompt and effective treatment. Using Doppler ultrasound to diagnose cerebral circulatory arrest should be done with caution in pediatric patients.     

GASTRIC CANCERS IN SINGAPORE: POOR PROGNOSIS ARISING FROM LATE PRESENTATION

Background : Mortality rates from gastric cancer, apart from those derived from Japanese series, remain poor. This paper sought to determine the present outcome of gastric carcinoma in a predominantly Chinese population in Singapore. Prognostic factors useful in predicting survival were also evaluated in this population. Method : All cases of histologically confirmed gastric adenocarcinoma presenting in 1992 were entered into a prospective database. Prognostic factors related to age, sex, site of disease, depth of invasion, histological grade, nodal status and stage of disease were evaluated in patients with resectable disease to determine their utility in predicting survival. Results : Of 1310 consecutive patients with histologically proven adenocarcinomas, 37% had distant metastases at presentation predominantly in the liver (21%) and peritoneal cavity (20%). Sixty-four per cent of patients underwent surgery and in only 51% of these patients was resection of the turnour possible. Stages 111 and IV (T4N2) locally advanced disease were present in 38% of patients. Thus the majority of patients presented with late or metastatic disease (75%, stages 111 and IV). Sixty per cent of patients were alive at I year and 40% at 2 years after resection of the tumour (Kaplan-Meier survival plots). In contrast, no patient survived longer than a year if the tumour was not resectable (P < 0.001, log-rank test). Median survival of patients without surgery was 12 weeks. Median survival for patients with resected stage IV disease was 23 weeks, compared to 18 weeks after surgical bypass. Age, sex, site, depth of invasion and histological grade did not significantly predict survival. Patients with node-negative disease survived longer (2 year, 70%) than those with nodal involvement (2 years, 44%; P = 0.06, log-rank test). Pathologic staging with the TNM system was useful in predicting survival (P < 0.001). Sixty per cent of patients with stage I and II disease were alive at 2 years compared to 54% with stage III disease and 0% with stage IV disease. Conclusion : The prognosis of stomach cancer remains poor, due predominantly to late presentation. Pathologic TNM staging and nodal status were useful in predicting survival outcome after resection. If the tumour were resectable, survival was appreciable even in patients with advanced stage III (2 years, 54%) and stage IV (1 year, 40%) disease. Strategies to improve outcome should focus on early detection of gastric carcinomas.     

Alterations of G-protein Coupling Function in Phosphoinositide Signalling Pathways of Rat Hippocampus by Ischaemic Brain Injury

The activation of membrane-associated phospholipase C is rapidly and transiently induced in the central nervous system by a variety of stimuli. Ischaemic brain injury is one of the situations that leads to a dramatic increase in polyphosphoinositide (PPI) turnover. In this study, stimulation of PPI hydrolysis by glutamate (500 μM) was measured in hippocampal slices from rats up to 21 days after an ischaemic insult of 30 min. Ischaemia was induced using the four-vessel occlusion method. PPI hydrolysis elicited by glutamate was significantly increased in the slices prepared from ischaemic rats 24 h after reperfusion, the accumulation of inositol phosphates (InsP_s) and inositol 1,4,5-trisphosphate (InsP₃) was 614±74% ( n = 8) and 182±11% ( n = 9) of the basal level respectively. This potentiation was also observed 21 days after ischaemia. Hyper-responsiveness to glutamate was also accompanied by an increase in AIF⁻₄-stimulated formation of [³H]inositol phosphates. In addition, global ischaemia did not change either high-affinity [³H]glutamate binding in hippocampal membranes or the stimulation of PPI hydrolysis by carbachol or noradrenaline in hippocampal slices. The present results suggest that the increased responsiveness to glutamate is the result, at least in part, of functional changes at the G-protein level, and may contribute to the pathophysiology of ischaemic brain injury or to the regenerative phenomena that accompany ischaemic damage.     

Mycotic aneurysm of the aorta: MRI and MRA features

Mycotic aneurysms of the abdominal aorta are potentially fatal but uncommon. We report the MRI and MRA features of an abdominal aortic mycotic aneurysm in a patient who presented with nonspecific low back pain. By delineating the saccular nature of the aneurysm and identifying the coexistence of vertebral enhancement, MRI was crucial for the final diagnosis. A potential pitfall of contrast-enhanced MRA is also demonstrated.