Diffusion MR imaging of posterior reversible encephalopathy syndrome: diagnostic and prognostic values

The purpose of this study was to evaluate the role of diffusion magnetic resonance [MR] imaging in diagnosis of patients with posterior reversible encephalopathy syndrome [PRES] and to demonstrate to how extent can apparent diffusion coefficient [ADC] maps be of value in quantitative assessment of severity of the lesion and predicting the conversion to infarction which can affect patient management and outcome. Eleven patients with PRES were examined with isotropic diffusion weighted imaging [DWI]. Quantitative assessment of the severity of the lesion was done by measurement of ADC of the lesion and of normal white matter and obtaining the degree of elevation of ADC values. These were compared with T2/DWI signal intensity score in each lesion. All patients were followed up by MR examination after medical treatment using the same parameters and the lesions were assessed for changes in signal intensity on T2/FLAIR images, DWI and ADC values. T2/FLAIR signal abnormalities were always present in the posterior white matter. Grey matter [of the posterior and anterior circulation structures] were involved in 6 out of 11 patients. White matter of anterior circulation structures were involved in 3 out of 11 patients. ADC values in areas of abnormal T2/FLAIR signal were high. Higher T2/DW score was seen in patients with a poor outcome than in patients who recovered. In 3 out of 11 patients, areas of high DWI signal intensity were seen with ADC values that were paradoxically normal. Follow-up images in two patients showed progression to infarction in pseudonormalized ADC map regions. Although vasogenic edema in PRES involves the posterior circulation territories, anterior circulation structures are also frequently involved. The extent of combined T2 and DWI signal changes and degree of ADC value elevation were correlated with patient outcome. Developement of ischemic infraction was seen in lesions with high DWI signal intensity and pseudonormalized ADC values. This may represent the earliest sign of nonreversibility as severe vasogenic edema progresses to cytotoxic edema

Relation of angiotensin converting enzyme activity and gene polymorphism to restenosis after percutaneous transluminal coronary angioplasty

Early restenosis in up to 30% of cases limits the benefits of percutaneous transluminal coronary angioplasty [PTCA]. The mechanisms that underlie restenosis are uncertain, although experimental evidence suggests that the renin-angiotensin system is involved in the vascular response to angioplasty. The ACE gene is one of the major genes of the renin-angiotensin and kallikrein-kinin systems and is a candidate gene for several cardiovascular diseases for which a genetic predisposition has been established. The ACE gene contains a common insertion deletion polymorphism termed I and D, respectively. The three possible genotypes are DD, ID and II, and the plasma level of ACE is highest with the DD genotype. This work aimed to investigate whether ACE gene polymorphism influences the risk of restenosis after PTCA to explore a relation between the total ACE level and restenosis and to compare the ACE genotypes of the patients of the study with those of a control group of healthy subjects. This study included 53 patients with CAD, 48 males and 5 females, their age ranged from 36 to 63 years. All patients were compared to 46 control subjects with age and sex matched. The patients were divided into two groups: group [A][40 patients with no restenosis] and group [B][13 patients with restenosis]. All patients were subjected to: full history and clinical examination, laboratory investigations which include estimation of serum angiotensin converting enzyme levels and detection of genotypes of the ACE gene I/D polymorphism, 12-lead electrocardiogram, treadmill exercise stress testing, coronary angiography and PTCA. The distribution of ACE genotype [DD] was not significantly different in-group B patients with restenosis compared with group A patients with no restenosis [8 out of 13, versus 15 out of 40 respectively, P> 0.05]. Plasma ACE levels did not differ between patients and control subjects [P value > 0.05]. Although plasma ACE levels were significantly higher in relation to ACE genotypes [P value < 0.05], plasma ACE levels were insignificant in relation to restenosis [P value > 0.05]. Since there was no evidence that variation at the ACE gene defined by the I/D polymorphism influences the extent of restenosis, it could be concluded that determination of ACE I/D genotypes is unlikely to be useful in identifying patients at higher risk of restenosis after PTCA and continued studies with clinically different subsets of patients is warranted

new echocardiographic scoring of pulmonary valve for the prediction of the out come of balloon pulmonary valvualoplasty in children

Balloon pulmonary valvuloplasty is the treatment of choice for moderate to severe pulmonary stenosis in children. Abnormalities of valve-annulus-trunk structure could possibly determine the outcome after balloon valvuloplasty. The purpose of our study is to show the value of echocardiography In the prediction of the outcome of balloon valvuloplasty in children with pulmonary valve stenosis 104 patients [58 females and 46 males], their age ranged between 1-14 years with a mean of 6.49 +/- 4.4 years were included in our study. All patients had valvular pulmonary stenosis with pressure gradient across the pulmonary valve > 50 mmHg. All cases were subjected to balloon valvuloplasty, The morphologic features of pulmonary valve-annulustrunk structure were quantified by echocardiography and scored as follow a-Valve mobility 0, 1 or 2, b-Valve thickness 0,l or 2. c-Post stenotic narrowing 0,1 or 2. d-Post-stenotic dilatation 0 or 1 e-Diastolic deformity of sinus of valsalva 0 or 1, The total echocardiographic score ranged between 0 and 8. Balloon valvuloplasty was performed one day after echocardiographic examination. The follow up of our cases was done one day and 6 months after valvuloplasty by continuos wave Doppler for estimation of pressure gradient across the pulmonary valve. The studied cases were classified into two groups : Group I, when the gradient across the pulmonary valve immediately after valvuloplasty was 35 mmHg [successful] and group II, when the gradient was > 35 mmHg [unsuccessful]. There was a significant decrease in the transpulmonary valvular gradient [from 90.19 +/- 28.37 to 31.65 +/- 21.56 mmHg] with further reduction of gradient at follow up study after 6 months [to 26.65 +/- 11.92 mmHg]. The echocardiographic scoring of pulmonary valve was higher in group II [6.21 +/- 1.37] than in group I [2.7 +/- 1.29]. Patients with score less than two showed optimal results. Those with score more than four had a poor outcome, while very poor outcome was observed in patients with score more than six. The echocardiographic scoring can predict the outcome of balloon pulmonary valvuloplasty in children with pulmonary valve stenosis

Doppler echocardiographic determination of pulmonary pressure: a simultaneous doppler catheterization study in patients with pulmonary hypertension

Pulmonary artery pressure [PAP] was estimated by both catheter and Doppler techniques in 23 patients with pulmonary hypertension. All patients had tricuspid and pulmonary regurgitation. Utilizing different methods for estimating [PAP], the pulmonary regurgitant flow velocity method was used to estimate mean [PAP] and diastolic [PAP]. A good correlation was found between this method and cardiac catheter, p< 0.01, the sensitivity was 90% and specificity was 95%. Tricuspid regurgitant flow velocity method for estimation of systolic [PAP] showed high accuracy with systolic [PAP] determined by catheterization, p < 0.01 and sensitivity was 92% and specificity was 95%. Using time peak velocity of pulmonary flow [AT] to measure mean [PAP], there was a tendency for over estimation in patients with [AT] 80 msec., On the other hand patients with [AT] < 80 msec. showed 80% sensitivity and a 98% specificity for detection of elevated [PAP]. So peak tricuspid velocities provided unexpectedly difficult record in some patients but when successful, it provides excellent prediction of pressures. Recording of mean [PAP] from [AT] of pulmonary artery wave form was very easy but accuracy was limited was limited to whom [PAP] was high. In contrast, pulmonary regurgitation velocities were easily obtained and provided high accuracy results

Effect of tricuspid regurgitation on diastolic filling of the pressure overloaded right ventricle

Diastolic filling of right ventricle [RV] was assessed in 46 patients with pulmonary hypertension [PH] and in 15 controls by pulsed Doppler echo technique. According to different cardiopulmonary diseases, our patients were divided into Gr. I [patients with right ventricular hypertrophy [RVH], and Gr. II [patients with RVH and associated tricuspid regurgitation; TR]. A Doppler was utilized to measure: peak E and A velocities, E/A ratio rapid and atrial filling fractions [RFF, AFF]. Patients of group I had significantly reduced peak E and increased peak A as compared with controls [60 +/- 14 Vs 70 +/- 15 cm/sec., and 78 +/- 16 Vs 50 +/- 12 cm/sec, respectively]. There was also increase in AFF, and reduction in RFF as compared with controls [0.45 +/- 0.09 Vs 0.30 +/- 0.05 and 0.55 +/- 0.10 Vs 0.60 +/- 0.10 respectively]. On the other hand, E/A ratio was reduced significantly in Gr. I as compared to Gr. II and controls [0.9 +/- 0.2 Vs 1.3 +/- 0.4 Gp. II and 1.5 +/- 0.2 controls]. Patients in Gr. II had significantly increased peak E as compared with patients in Gr. I, p < 0.01. The peak A was not significantly changed between both groups [79 +/- 22 Vs 78 +/- 16 in Gr. I]. We conclude that pulsed Doppler echo is a clinically useful, noninvasive method in detecting a disturbance of diastolic filling of [RV], which may be one of the earliest manifestation of mechanical abnormality of the diseased [RV] in patients with RVH. Caution should be taken in patients with associated [TR] as it may augment early diastolic filling and may tend to normalize diastolic filling patterns in patients with RVH

Electrocardiographic and echo-doppler study in Duchenne muscular dystrophy

Twenty six patients with Duchenne muscular dystrophy [DMD] [4-18 years] and 16 controls [4-18 years] were subjected to cardiac and neurological examination. Patients were divided into gp I [early Duchenne 17 patients] and gp II [late Duchenne, 7 patients]. The electrocardiogram showed sinus tachycardia [77%], sinus arrhy thmias [69%] P wave abnormalities [19%], tall R in v 1 and V 2 [35%]. RSr [31%]. R/S >1 [54%], deep Q [42%] and ST-T changes in [58%]. Six cases [23%] had mitral valve prolapse by echocardiography. Ejection fraction [EF%] and fractional shortening [FS%] were significantly less in Duchenne patients compared to controls [p < 0.01]. EF and FS were significantly less in gp II [late Duchenne] compared to gp I [early Duchenne] [p < 0.01]. Significant impairement was also reported in peak velocity of early diastolic inflow [PE] [p < .05] and PE/peak velocity of late diastolic inflow PE/PA [p < 0.01] in the total gp and gp I compared to controls. PE/PA was significantly less in gp II compared to controls [p < 0.01] and compared to gp I [p < 0.01]. In 14 of the 26 patients we found significant impairment in atrial filling rat [p < 0.01] and rapid filling index [p < 0.05] as compared to controls. In other 10 patients impairement was reported in maximal diastolic posterior wall endocardial velocity [p < 0.001] and deceleration of early diastolic filling [p < 0.05]. We concluded that ECG is a sensetive tool in detecting cardiac involvement in DMD. Both systolic and diastolic functions are affected by myocardial dystrophy, such impairement is progressive throughout the course of the disease