Diagnosis and treatment strategies for vascular complications after kidney transplantation / 器官移植

With persistent progress in donor-recipient evaluation criteria, organ procurement and preservation regimens and surgical techniques, the incidence of vascular complication after kidney transplantation has been declined, whereas it is still one of the most severe surgical complications of kidney transplantation, which may lead to graft loss and recipient death, and seriously affect the efficacy of kidney transplantation. Therefore, the occurrence, clinical manifestations, diagnosis and treatment strategies of common vascular complications after kidney transplantation, including vascular stenosis, arterial dissection, pseudoaneurysm, vascular rupture and thrombosis were reviewed in this article. In combination with the incidence, diagnosis and treatment of vascular complications after kidney transplantation in the First Affiliated Hospital of Xi'an Jiaotong University, diagnosis and treatment strategies for common vascular complications after kidney transplantation were summarized, aiming to provide reference for clinical diagnosis and treatment of vascular complications after kidney transplantation, lower the incidence of vascular complications, and improve clinical efficacy of kidney transplantation and survival rate of recipients.

Disección arterial cérvico-cefálica post trauma en pediatría / Cervicocephalic arterial dissection post trauma in children

Introducción: la disección arterial cérvico-cefálica (DACC) es una causa importante de accidente cerebrovascular (ACV) en pediatría. Dentro de los factores de riesgo más relevantes están los traumas cervicales y cefálicos, presentes en el 50% de los casos. El pronóstico es variable y depende de la magnitud de oclusión de la arteria afectada. Es importante la detección precoz de esta patología, que muchas veces se presenta con pocos síntomas en pediatría, lo que genera retraso en el diagnóstico y tratamiento. Objetivo:presentar la evidencia disponible sobre DACC incluyendo DACC post trauma para familiarizar a los médicos generales y especialistas sobre la sospecha diagnóstica, diagnóstico enfocado en neuroimágenes y posibles manejos de esta patología. Métodos: se llevó a cabo una revisión bibliográfica de la literatura científica sobre esta condición. Dentro de los criterios de selección de los estudios se consideró la fecha de publicación, el diseño y la relevancia.Conclusiones: la DACC post trauma es una causa frecuente de ACV en pediatría. Se puede presentar con escasa sintomatología, por lo que es importante mantener una alta sospecha en contexto de trauma cervical o cefálico, implementando un diagnóstico y tratamiento precoces para mejorar el pronóstico de los pacientes.

Introduction:Craniocervical arterial dissection (CCAD) is a major cause of arterial ischemic stroke (AIS) in children. The most important risk factors are cervical and cephalic traumas, present in 50% of all cases.The prognosis changes depending on the magnitude of the artery affected. Early detection of this pathology is important. It many times presents itself with few symptoms, which generates a de-lay in its diagnosis and treatment. Objective: To present the evidence available on CCAD, including CCAD post-trauma,to familiarize general physicians and specialists with this diagnosis, neuroimages required, and possible treatments.Methods: Extensive revision of bibliographic scientific literature about this condition. The criteria selection to include studies in this review were the date of publication, the design of the study, and their relevance.Conclusions: the CCAD post-trauma is asignificant cause of AIS in children. It can present itself with mild symptomatology, which is why it is relevant to suspect it in the context of cervical or cephalic trauma, aiming for an early diagnosis and treatment to improve the outcome of patients.

Symptomatic internal carotid artery dissection and kinking in a patient with fibromuscular dysplasia / Dissecção e acotovelamento sintomáticos da artéria carótida interna em paciente com displasia fibromuscular

Abstract Isolated dissection of the internal carotid artery (ICA) is rare in young patients and is a cause for strong suspicion of fibromuscular dysplasia (FMD), especially when associated with artery elongation and tortuosity. The natural history of cerebrovascular FMD is unknown and management of symptomatic patients can be challenging. We report the case of a 44-year-old female patient with a history of transient ischemic attack in the absence of cardiovascular risk factors, associated with an isolated left ICA dissection and kinking. Carotid duplex ultrasound confirmed the diagnosis of dissection and demonstrated severe stenosis of the left ICA. The patient underwent surgical repair and histopathological evaluation confirmed the diagnosis of FMD with dissection. An autogenous great saphenous vein bypass was performed and the patient had an uneventful recovery. Cervical carotid artery dissection can be related to underlying arterial pathologies such as FMD, and the presence of ICA tortuosity highlights certain peculiarities for optimal management, which might be surgical.

Resumo A dissecção isolada da artéria carótida interna em pacientes jovens é rara, e a displasia fibromuscular deve ser altamente suspeitada principalmente quando estiver associada a alongamento e tortuosidade da artéria. A história natural da displasia fibromuscular cerebrovascular é desconhecida, e o manejo de pacientes sintomáticos pode ser desafiador. Apresentamos o caso de uma paciente de 44 anos com histórico de ataque isquêmico transitório sem fatores de risco cardiovasculares, associado a dissecção e acotovelamento isolados da artéria carótida interna esquerda. O ultrassom duplo das carótidas confirmou o diagnóstico de dissecção e demonstrou estenose grave na artéria carótida interna esquerda. A paciente foi submetida a reparo cirúrgico, e a avaliação histopatológica confirmou o diagnóstico de displasia fibromuscular com dissecção. Foi realizada cirurgia de ressecção do segmento e reconstrução com veia safena magna autógena, e a paciente se recuperou sem complicações. A dissecção da artéria carótida cervical pode estar relacionada a doenças arteriais subjacentes, como a displasia fibromuscular, e a presença da tortuosidade da artéria carótida interna destaca algumas particularidades no manejo ideal, o qual pode ser cirúrgico.

Diagnosis and Management of Isolated Superior Mesenteric Artery Dissection: A Systematic Review and Meta-Analysis

The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33–85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4–18 months), 12 months (IQR, 6–19 months) and 14 months (IQR, 6–20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.

Application of vessel wall magnetic resonance imaging in intracranial artery dissection / 中国脑血管病杂志

Intracranial artery dissection is rare in the clinic, but could account for a large proportion of young patients with intracranial vascular diseases. High-resolution magnetic resonance imaging is a direct method of vessel wall imaging and widely used in clinical practice due to advantages including high spatial resolution, high signal-to-noise ratio and strong reproducibility. The article briefly introduces the typical findings of intracranial artery dissection in high-resolution magnetic resonance imaging and the unique advantages of features such as intimal flap, double-lumen, lumen diameter change and intramural hematoma. It makes up for the deficiency of traditional lumen imaging in the diagnosis and differential diagnosis of intracranial artery dissection, providing a strong basis for the diagnosis and intervention of intracranial vascular dissection.

Evaluation of Arterial Elasticity, Left Ventricular Function and Correlation by 256- slice Spiral CT in Patients with Aortic Dissection / 昆明医科大学学报

Objective Using the function of 256-layer iCT in the determination of cardiac function and arterial elasticity index, to compare the arterial elasticity, left ventricular function and their correlation between patients with aortic dissection and non-dissected controls, and to provide a reference for the clinical treatment of patients with aortic dissection. Methods This study selected 36 cases in our emergency department,with chest, back or abdominal pain, whose clinical symptoms were highly suggestive of aortic dissection, and plain or enhanced diagnosis confirmed aortic dissection as a case group. At the same time, we randomly selected 40 cases without aortic dissection as the control group. All subjects underwent CTA one-stop scanning and measurement of elastic and cardiac function at the same level. According to the measurement results, the arterial elasticity indexes and the measured cardiac function of the case group and the control group were evaluated and compared so that to evaluate the arterial elasticity and its correlation with left ventricular function in patients with aortic dissection. Results patients's arterial expansion and compliance in patients with aortic dissection were significantly lower than the control group (P＜0.05) . The mean diameter change rate and stiffness of the patients with dissection were significantly lower than those in the control group (P＞0.05) . The difference was not statistically significant. The mean stiffness in patients with aortic dissection was significantly higher than non-aortic dissection patients. In patients with aortic dissection, the mean arterial diameter change rate, expandability and arterial stiffness showed a highly negative correlation. There was no significant correlation between arterial elasticity index and cardiac function in patients with Stanford type A and Stanford type B aortic dissection. There was no significant correlation between each elasticity index and cardiac function in the control group (r＜0.3) . Conclusion CTA one-stop scan can be used as an important measure of arterial elasticity, cardiac function and other parameters in patients with aortic dissection. Significantly lower aortic expansion and compliance, increased stiffness, insignificant changes in cardiac function, and insignificant correlation between cardiac function and each elasticity index in patients with early aortic dissection all have a clinical significance.

Isolated Posteroinferior Cerebellar Artery Dissection Diagnosed by High-Resolution Vessel Wall MRI

Arterial dissection is an important cause of stroke. We report two cases of isolated posterior inferior cerebellar artery (PICA) dissection diagnosed by high-resolution vessel-wall MRI (HRVW-MRI). One subject complained of abrupt-onset vertigo and headache, and the other subject had headache, vertigo, and Horner syndrome. Conventional MRA showed only focal dilatation of the PICA, but HRVW-MRI revealed intramural hematoma and double-lumen contour in the PICA, suggesting arterial dissection. We suggest that the use of HRVW-MRI should be considered when diagnosing isolated PICA dissection in a PICA infarct with an unknown cause.

Assessments of intracranial arterial dissection causing ischemic stroke with magnetic resonance imaging / 中国脑血管病杂志

Objective To investigate the values of conventional magnetic resonance imaging (MRI),magnetic resonance angiography (MRA),and high-resolution MRI for diagnosing intracranial arterial dissection (IAD)caused ischemic stroke. Methods From August 2008 to April 2015,59 consecu-tive patients (age 45 ±15years,41males)with IAD caused ischemic stroke admitted to the First Affiliated Hos-pital of Sun Yat-Sen University were enrolled prospectively. All patients underwent conventional cranial MRI/MRA examination,25 of them underwent whole brain DSA examination,and 10 underwent high-resolution MRI. The findings of conventional MRI/ MRA and high-resolution MRI of IAD were analyzed. For patients undergoing DSA,the proportions of detection and compliance of IAD were compared between DSA and conventional MRI / MRA. Results (1)Conventional MRI / MRA revealed typical sign of artery dissection in 42 patients (71. 2%),among them,the intramural hematoma (n = 22,52. 4%)was most common. Other common signs included intimal flap/ double lumen sign (n = 13,31. 0%)and long irregular or thread-like stenosis (n = 9,21. 4%);while dissecting aneurysm (n = 7,16. 7%)and rat tail-shaped occlusion (n = 3, 7. 1%)were relatively rare. In 17 patients (28. 8%)with IAD that conventional MRI/ MRA did not detect the typical dissection sign,the dissections were involved in the middle cerebral artery (11 / 17,64. 7%), they were more common than the 42 patients with IAD (10 / 42,23. 8%)detected the typical dissection sign by conventional MRI/ MRA. There was significant difference (P = 0. 006). (2)Among the 25 patients undergoing DSA,DSA revealed that 15 patients (60%)had the typical dissection sign,and conventional MRI/ MRA only revealed 8 of them (32%)with the typical dissection sign,but there was no significant difference (P = 0. 088). In 15 patients with IAD that DSA detected the typical dissection sign;conventional MRI / MRA detected the typical dissection sign in 8 of them. The diagnostic coincidence rate was 8 / 15. (3)Both conventional MRI/ MRA and DSA revealed non-specific limitation stenosis or cut-off occlusion in 10 patients (16. 9%)with IAD,while the high-resolution MRI revealed intimal flap in 5 of them,intramural hematoma in 4,and intimal flap and intramural hematoma in 1. Conclusion Conventional cranial MRI/MRA is an effective technique for revealing IAD,whereas high-resolution MRI has the unique advantages for diagnosing IAD without typical dissection in other vascular imaging.

Dissecção espontânea da artéria carótida interna em paciente jovem: relato de caso / Spontaneous dissection of the internal carotid artery in a young patient: case report

O objetivo é relatar um caso de acidente vascular encefálico isquêmico provocado por dissecção não traumática da artéria carótida interna em uma paciente jovem. Dissecções espontâneas de carótida interna e de artéria vertebral ocasionam aproximadamente 25% dos acidentes vasculares encefálicos isquêmicos em indivíduos com idade inferior a 45 anos. Confirmou-se o diagnóstico dessa entidade com imagens de ressonância magnética e angiotomografia cerebral. Seu tratamento incluiu anticoagulantes, fonoterapia e fisioterapia. Com melhora clínica, recebeu alta para controle ambulatorial, orientada sobre os riscos de anticoncepcionais orais. Relatos de caso podem aumentar o índice desuspeita dessa condição pouco diagnosticada.

The objective of this work is to report a case of ischemic brain stroke due to non-traumatic dissection of the internal carotid artery in a young patient.Spontaneous dissections of the internal carotid and of the vertebral artery cause nearly 25% of all ischemic strokes in individuals younger than 45 years of age. Imaging studies obtained from magnetic resonance and angiotomography of the brain confirmed the diagnosis. Treatment involved anticoagulation drugs, phonotherapy and physiotherapy. Based on herclinical improvement, she was discharged from the hospital and is now receiving outpatient care and has been advised about the risks of oral contraceptives. Case reports may raise the suspicion index about thisunderdiagnosed condition.

Coexisting Dissecting Aneurysms of the Internal Carotid and Basilar Arteries Following Flexion Injury: Case Report / 대한뇌혈관외과학회지

Traumatic or sponataneous arterial dissections have been well recognized at the cervical portion of the internal carotid artery and extracranial vertebral artery as an important cause of stroke, especially in young and middle-aged patients. Multiple arterial dissections following craniocervical injury are exceedingly rare. We describe a patient with brain stem infarction caused by basilar occlusion secondary to basilar artery dissection, associated with left ICA dissecting aneurysm after following minor craniocervical trauma without known underlying arteriopathy.

Dissection of Middle Cerebral Artery diagnosed by Magnetic Resonance Imaging

Arterial dissections usually arise from an intimal tear and can allow the development of an intramural hematoma. Dissection occurs frequently in the aorta or its branches and also occurs commonly in the internal carotid or vertebro-basilar arteries. The condition is rare in the intracranial cerebral arteries, especially above the supraclinoid segment of the internal carotid artery. The diagnosis of arterial dissection used to be made by conventional cerebral angiography. But recently, magnetic resonance imaging (MRI) is helpful to diagnose arterial dissection. We report two cases of middle cerebral arterial dissection using MRI.

Treatment of Vertebrobasilar Arterial Dissection / 대한뇌혈관학회지

This study was designed to elucidate the clinical course of patients with vertebro-basilar arterial dissection and to show the guidelines for options of the management. Between 1992 and 2001, 23 patients were diagnosed as having vertebro-basilar arterial dissection by clinical course, magnetic resonance imaging (MRI) and angiography. The male to female ratio was 20 to 3, showing male dominance. Their clinical data were analyzed retrospectively. Fourteen cases presented with subarachnoid hemorrhage (SAH) and the other 9 with ischemic symptoms. Among those with SAH, there were 6 mortalities. The causes of mortalities were rebleeding in five cases and initial poor Hunt-Hess grade in one case. In most cases, rebleeding happened within 14 days after initial bleeding and in five patients within 4 days. Five patients were managed by surgical treatment, twelve by endovascular treatment and the other 2 by conservative management. Recently, since 1999, initially endovascular techniques had been tried to patients immediately after diagnosis and the results were good. Previous cases underwent endovascular management only when surgical treatment failed or was inappropriate. These patients showed poor prognosis. Nine cases with ischemic symptoms showed benign clinical course with no mortality and only one symptomatic recurrence following endovascular treatment. Six patients were treated by antiplatelet and/or anticoagulation therapy, two by endovascular treatment and the other one by surgery. Four of these nine patients had history of severe exercise or trauma immediately before onset of symptoms and two others had similar history several months before. In conclusion, among patients diagnosed as vertebro-basilar arterial dissection, those with SAH should be managed aggressively by either surgical or endovascular techniques because these patients showed rapid deterioration with high incidence of rebleeding and mortality. Since those with ischemic symptoms demonstrated benign clinical course, the authors recommend initial conservative management such as antiplatelet and/or anticoagulation or endovascular treatment.

Management of Dissecting Aneurysm of Cervicocephalic Carotid and Vertebral Artery / 대한뇌혈관학회지

The pathogenesis of spontaneous cervicocephalic arterial dissection is still incompletely understood. The clinical presentation of the arterial dissection depends on the plane where the dissection occurred in the arterial wall. When the outer media or subadventitia is dissected, the intramural hematoma bulges outward to make dissecting aneurysm. When located in the subintima or inner media, the intramural hematoma produces narrowing or occlusion of the vessel lumen. Authors review etiopathogeness, clinical features, diagnosis and management of cerviococephalic arterial dissection.