Postoperative anterior uveitis in a patient submitted to combined treatment with cataract surgery and iStent inject®. How to manage? / Uveíte anterior no pós-operatório de facectomia combinada com implante de iStent inject®. Como manejar?

ABSTRACT Minimally invasive glaucoma surgeries are surgical treatment alternatives for glaucoma aimed at reducing intraocular pressure with a better safety profile compared to traditional trabeculectomy. However, in spite of less invasive techniques, complications may develop in any surgical procedure. To the best of our knowledge, this is the first case report of anterior uveitis following combined treatment with cataract surgery and iStent inject® which addresses the management of postoperative inflammation.

RESUMO As cirurgias minimamente invasivas para glaucoma consistem em uma opção de tratamento cirúrgico para glaucoma, a qual promove redução da pressão intraocular com melhor perfil de segurança do que a trabeculectomia. Todavia, complicações são inerentes à realização de procedimentos cirúrgicos, apesar do uso de técnicas menos invasivas. Este é o primeiro relato que apresenta um caso de uveíte anterior após cirurgia combinada de catarata e iStent inject®, além de orientações quanto ao manejo do quadro inflamatório.

Bariatric surgery as a treatment for idiopathic intracranial hypertension in a male adolescent: case report / Cirurgia bariátrica como tratamento de pseudotumor cerebral primário em adolescente do sexo masculino: relato de caso

ABSTRACT Objective: To describe a case of a male adolescent with symptomatic idiopathic intracranial hypertension (IIH) associated with obesity treated with bariatric surgery. Case description: A 16-year-and-6-month-old severely obese boy [weight: 133.6 kg; height: 1.74 m (Z score: +0.14); BMI: 44.1 kg/m2 (Z score: +4.4)], Tanner pubertal stage 5, presented biparietal, high-intensity, and pulsatile headaches, about five times per week, associated with nocturnal awakenings, and partial improvement with common analgesics, for three months. Ophthalmologic evaluation evidenced bilateral papilledema. Cranial computed tomography revealed no mass or anatomic abnormalities. Lumbar puncture showed increased intracranial pressure of 40 cmH2O (reference value: <28 cmH2O) with a normal content. After being diagnosed with IIH, the patient was started on acetazolamide. However, after three months, he was still symptomatic. He was diagnosed with obesity due to excess energy intake and, as he had failed to lose weight after a conventional clinical treatment, bariatric surgery was indicated. The patient (at 16 years and nine months) underwent an uncomplicated laparoscopic sleeve gastrectomy. Ophthalmologic evaluation, performed five months after surgery, revealed normal visual acuity in both eyes and improvement of bilateral papilledema. Follow-up at 18 months showed a 67.5% loss of excess weight (weight: 94.5 kg and BMI: 31.2 kg/m2) and complete resolution of IIH symptoms. Comments: IIH is characterized by increased intracranial pressure with no evidence of deformity or obstruction of the ventricular system on neuroimaging. It has been associated with obesity. Bariatric surgery may be a valid alternative approach for morbidly obese adolescent patients with refractory symptoms.

RESUMO Objetivo: Descrever um caso de cirurgia bariátrica como tratamento de pseudotumor cerebral primário (PTCP) em adolescente do sexo masculino com obesidade. Descrição do caso: Adolescente, sexo masculino, 16 anos e 6 meses, com obesidade exógena [peso:133,6 kg; estatura:1,74 m (escore z: +0,14); IMC: 44,1 kg/m2 (escore z: +4,4)], estadiamento puberal de Tanner 5, apresentando cefaleia bi-parietal, pulsátil e de alta-intensidade, cerca de cinco vezes por semana, associada a despertares noturnos, e com melhora parcial com analgésicos comuns, há três meses. A avaliação oftalmológica evidenciou papiledema bilateral e a tomografia computadorizada de crânio não revelou massas ou alterações anatômicas. A punção lombar mostrou pressão intracraniana elevada de 40 cmH2O (Referência: <28 cmH2O) com conteúdo normal. Feito o diagnóstico, o paciente foi iniciou uso de acetazolamida. No entanto, após 3 meses, o paciente mantinha-se sintomático. Ele foi diagnosticado com obesidade devido ao consumo calórico excessivo e, como não havia obtido sucesso na perda de peso com tratamento clínico convencional, a cirurgia bariátrica foi indicada. Aos 16 anos e 9 meses, o paciente foi submetido a gastrectomia vertical laparoscópica sem complicações. A avaliação oftalmológica, cinco meses após a cirurgia, revelou melhora do papiledema bilateral com acuidade visual normal em ambos os olhos. Apresentou perda de excesso de peso de 67,5% (peso: 94,5 kg e IMC:31,2 kg/m2) e resolução completa dos sintomas de PPTC 18 meses após a cirurgia. Comentários: O PTCP é caracterizado pelo aumento da pressão intracraniana, sem evidência de deformidade ou obstrução do sistema ventricular na neuroimagem. Está associado à obesidade. A cirurgia bariátrica pode ser uma alternativa terapêutica válida para pacientes adolescentes obesos graves com sintomas refratários.

Ibuprofeno comparado con acetazolamida para prevención de mal agudo de montaña / Ibuprofen versus acetazolamide for prevention of acute mountain sickness

INTRODUCCIÓN: El mal agudo de montaña es una condición frecuente en individuos sanos, sin aclimatación que se exponen a alturas desde 2500 metros sobre el nivel del mar. Clásicamente se ha utilizado acetazolamida para prevenirlo, pero en los últimos años ha surgido evidencia a favor de ibuprofeno. Sin embargo, no está claro cuál de estos tratamientos es más efectivo. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos dos revisiones sistemáticas que en conjunto incluyeron un estudio primario, el cual corresponde a un ensayo aleatorizado. Concluimos que no es posible establecer con claridad si ibuprofeno es mejor o peor que acetazolamida debido a que la certeza de evidencia existente ha sido evaluada como muy baja.

INTRODUCTION: Acute mountain sickness is a common condition occurring in healthy subjects that undergo rapid ascent without prior acclimatization, as low as 2500 meters above sea level. The classic preventive agent has been acetazolamide, although in the last decade there has been evidence favoring ibuprofen. However, it is unclear which method is more efficient. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis) and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified two systematic reviews that included only one primary study, which is a randomized trial. We concluded it is not possible to establish whether ibuprofen is better or worse than acetazolamide because the certainty of evidence has been evaluated as very low.

Acetazolamide-Induced Type II Renal Tubular Acidosis and Muscle Weakness

No abstract available.

Effect of calcium hydroxide on inflammatory root resorption and ankylosis in replanted teeth compared with other intracanal materials: a review

Calcium hydroxide (CH) is the gold-standard intracanal dressing for teeth subjected to traumatic avulsion. A common complication after the replantation of avulsed teeth is root resorption (RR). The current review was conducted to compare the effect of CH with that of other intracanal medications and filling materials on inflammatory RR and replacement RR (ankylosis) in replanted teeth. The PubMed and Scopus databases were searched through June 2018 using specific keywords related to the title of the present article. The materials that were compared to CH were in 2 categories: 1) mineral trioxide aggregate (MTA) and endodontic sealers as permanent filling materials for single-visit treatment, and 2) Ledermix, bisphosphonates, acetazolamide, indomethacin, gallium nitrate, and enamel matrix-derived protein (Emdogain) as intracanal medicaments for multiple-visit management of avulsed teeth prior to the final obturation. MTA can be used as a single-visit root filling material; however, there are limited data on its efficacy due to a lack of clinical trials. Ledermix and acetazolamide were comparable to CH in reducing RR. Emdogain seems to be an interesting material, but the data supporting its use as an intracanal medication remain very limited. The conclusions drawn in this study were limited by the insufficiency of clinical trials.

Effect of Acetazolamide on Choroidal Morphology in Central Serous Chorioretinopathy

PURPOSE: We sought to elucidate the influence of acetazolamide on choroidal structure changes during the treatment of central serous chorioretinopathy (CSC).METHODS: This was a retrospective study of 45 eyes from 45 patients with acute CSC who were divided into an acetazolamide group (group 1, n = 20) and an observation group (group 2, n = 25). The main outcome measures were the changes in best-corrected visual acuity, subretinal fluid (SRF) height, subfoveal choroidal thickness (SFCT), and choroidal vascularity index (CVI) at one week, one month, two months, and three months, respectively.RESULTS: Although statistical significance was not reached, best-corrected visual acuity improved in both groups at month 3 (from 0.06 ± 0.07 to 0.01 ± 0.03 in group 1 and 0.17 ± 0.24 to 0.09 ± 0.18 in group 2; p = 0.083 and 0.183, respectively). Separately, SRF height and CVI showed a significant decrease at three months in both groups (all p < 0.05), while a significant SRF height decrease was also noted in group 1 at one month (p = 0.038). In group 1, a significant decrease in the SFCT and CVI started at one week and one month (p = 0.021 and 0.008), respectively. However, in group 2, a significant decrease in the SFCT and CVI started at one month and two months (p = 0.005 and 0.015), respectively.CONCLUSIONS: Acetazolamide has no effect on final functional or anatomical status at three months in eyes with CSC but does shorten the time for SRF absorption and accompanying choroidal structural changes.

Acetazolamida como tratamiento del mal agudo de montaña / Acetazolamide for the treatment of acute mountain sickness

INTRODUCCIÓN El mal agudo de montaña es la patología más prevalente relacionada con la exposición aguda a la altura, secundaria a los efectos de la hipoxia hipobárica en nuestro organismo. La acetazolamida se ha utilizado tradicionalmente para su prevención y tratamiento, sin embargo, aún existe controversia respecto al grado de utilidad que tiene este medicamento como monoterapia. MÉTODOS Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un meta análisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES Identificamos una revisión sistemática que incluyó dos estudios primarios, ambos correspondientes a ensayos aleatorizados. Concluimos que no es posible establecer con claridad si el tratamiento con acetazolamida disminuye los síntomas del mal agudo de montaña ni si aumenta el riesgo de efectos adversos, debido a que la certeza de la evidencia existente ha sido evaluada como muy baja.

INTRODUCTION Acute mountain sickness is the most prevalent illness related to acute exposure to high altitude, secondary to the hypobaric hypoxia effects in our body. Acetazolamide has been traditionally used for its prevention and treatment, however, there is still controversy regarding the degree of usefulness of this medication as monotherapy. METHODS We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified a systematic review that included two primary studies, both corresponding to randomized trials. We conclude that it is not possible to establish clearly whether treatment with acetazolamide reduces the symptoms of acute mountain disease or increases the risk of adverse effects, because the certainty of the existing evidence has been evaluated as very low.

Pseudotumor cerebri in childhood and adolescence: data from a specialized service / Pseudotumor cerebral na infância e adolescência: dados de um serviço especializado

ABSTRACT Objective: To report cases of children and adolescents diagnosed with pseudotumor cerebri associated or not with rheumatic disease. Methods: This was a retrospective study based on medical reports of 29 patients, up to 18 years of age and diagnosed with pseudotumor cerebri, followed up in the Pediatric Rheumatology and Neurology outpatient clinics of a tertiary hospital, until December 2016. Results: Among the 29 patients diagnosed with pseudotumor cerebri, 51.7% were girls and the mean age at the disease onset was 12.3 years. In 18 patients (62%) where an etiology was found, four were associated with a rheumatic disease. The most common symptom was headache (69%) and acetazolamide was the most used medication (69%). Two patients developed blindness and 10 are still being followed up. Conclusion: Although rare, pseudotumor cerebri should be considered in children with headaches, especially in patients with rheumatic disease.

RESUMO Relatar os casos de crianças e adolescentes com diagnóstico de pseudotumor cerebral com ou sem doença reumática. Métodos: Estudo retrospectivo através de revisão de prontuários, 29 pacientes com idade até 18 anos e diagnóstico de pseudotumor, atendidos nos ambulatórios de Reumatologia Pediátrica e Neurologia de um hospital terciário, registrados até dezembro de 2016. Resultados: Dentre os 29 pacientes com diagnóstico de pseudotumor cerebral, 51,7% eram meninas. A média de idade de aparecimento dos sintomas foi de 12,3 anos. Em relação à etiologia do pseudotumor cerebral, em 18 pacientes (62%) foi possível identificar uma causa, sendo o diagnóstico de doença reumática associada em quatro desses casos. Cefaléia foi o sintoma mais frequente (69%), e a medicação mais utilizada foi a acetazolamida (69%). Dois pacientes evoluíram para cegueira e 10 ainda se encontram em seguimento ambulatorial. Conclusão: Concluímos que, apesar de raro, o diagnóstico de pseudotumor cerebral deve ser considerado em crianças com cefaleia, principalmente nos pacientes com doença reumática.

Manifestação ocular incomum em paciente com incontinência pigmentar / Unusual ocular manifestation in a patient with incontinentia pigmenti

RESUMO Incontinência pigmentar, também conhecida como síndrome de Bloch-Sulzberger, é uma doença rara de herança dominante ligada ao X cujas manifestações clínicas incluem lesões dermatológicas típicas combinadas com acometimento neurológico, oftalmológico e dentário. Alterações oculares são comuns e variadas, sendo o acometimento da retina o mais frequente e associado a perda visual severa. Foi relatado um caso de uma criança com perda visual grave decorrente de glaucoma, sem alteração retiniana significativa.

ABSTRACT Incontinentia pigmenti, also known as Bloch-Sulzberger syndrome, is a rare dominant X-linked inheritance disease whose clinical manifestations include typical dermatological lesions combined with neurological, ophthalmic and dental involvement. Ocular involvment is common and diverse and retinal changes are the most frequent and associated with serious visual loss. We reported a case of a child with severe visual loss due to glaucoma, with no significant retinal changes.

Mismatch between TOF MR Angiography and CT Angiography of the Middle Cerebral Artery may be a Critical Sign in Cerebrovascular Dynamics

PURPOSE: Although time-of-flight (TOF)-magnetic resonance angiography (MRA) can clearly depict intracranial arteries, the arterial flow of middle cerebral artery (MCA) is occasionally not detected. We evaluated this phenomenon with reference to cerebrovascular dynamics. MATERIALS AND METHODS: Seventeen patients with suspected occlusion of MCA or internal carotid artery on TOF-MRA were enrolled. All patients underwent CT angiography (CTA) and quantitative cerebral blood flow (CBF) examination for measurement of resting CBF and cerebrovascular reactivity (CVR). Depending on appearance, patients were categorized into three groups. Group A (n=6) had MCA delineation on both MRA and CTA, while groups B (n=6) and C (n=5) had no signal on MRA, but Group B had a MCA delineation on CTA.

Ultrasound biomicroscopy in acetazolamide-induced myopic shift with appositional angle closure / Biomicroscopia ultrassônica em mudança miópica induzida por acetazolamida no fechamento de ângulo

ABSTRACT We report a case of a 49-year-old female who presented to the emergency department with blurred vision and vomiting, hours after taking two tablets of 250 mg of acetazolamide. The anterior chamber was bilaterally flat, with normal intraocular pressure in both eyes. An ultrasound biomicroscopic (UBM) examination showed bilateral ciliary effusion and complete appositional angle closure in all quadrants. Acetazolamide-induced bilateral angle closure was diagnosed. Steroid and cycloplegic therapy were initiated, and acetazolamide was discontinued. The following day, the anterior chamber had regained its volume without substantial change in the effusion size. Three weeks later, complete resolution of the ciliary effusion was verified by means of a third UBM scan.

RESUMO Relatamos um caso de uma mulher de 49 anos que se apresentou ao departamento de emergência informando visão borrada e vômitos, horas após ter tomado dois comprimidos de 250 mg de acetazolamida. A câmara anterior era bilateralmente plana com pressão intraocular normal em ambos os olhos. Um exame de biomicroscopia ultrassônica (UBM) mostrou efusão ciliar bilateral e fechamento completo do ângulo aposicional em todos os quadrantes. O bloqueio angular bilateral induzido por acetazolamida foi diagnosticado. O tratamento com esteróides e cicloplégicos foi iniciado e a acetazolamida foi descontinuada. No dia seguinte, a câmara anterior recuperou seu volume sem alterações substanciais no tamanho da efusão. Três semanas depois, a resolução completa da efusão ciliar foi verificada por meio de uma terceira biomicroscopia ultrassônica.

Neural Correlates of Motor Recovery Measured by SPECT at Six Months After Basal Ganglia Stroke

OBJECTIVE: To investigate neural correlates associated with recovery of motor function over 6 months in patients with basal ganglia (BG) stroke using acetazolamide (ACZ) stress brain-perfusion single-photon emission computed tomography (SPECT). METHODS: Medical records of 22 patients presenting first-ever BG stroke were retrospectively reviewed. Regional cerebral blood flow (CBF) and cerebrovascular reserve (CVR) were measured for 9 regions in each cerebral hemisphere (primary motor cortex, supplementary motor area, premotor cortex, prefrontal cortex, temporal lobe, parietal lobe, occipital lobe, BG, and thalamus). The Fugl-Meyer Assessment (FMA) motor score was used to assess motor function. RESULTS: After ACZ injection, CBF of all regions of interest (ROIs) increased compared with baseline. Baseline CBF of all ROIs was not significantly correlated with changes in FMA upper or lower motor score. However, multivariate analysis revealed CVR was significantly associated with change in FMA upper score in the ipsilateral primary motor cortex (R2=0.216, p=0.017), the ipsilateral parietal lobe (R2=0.135, p=0.029), and the contralateral primary motor cortex (R2=0.210, p=0.041). CONCLUSION: CVR in the bilateral primary motor cortex and ipsilateral parietal lobe was associated with restoration of upper motor function 6 months after BG stroke. SPECT is a readily available imaging modality useful in studying brain residual function in patients with BG stroke.

Neural Correlates of Motor Recovery Measured by SPECT at Six Months After Basal Ganglia Stroke

OBJECTIVE: To investigate neural correlates associated with recovery of motor function over 6 months in patients with basal ganglia (BG) stroke using acetazolamide (ACZ) stress brain-perfusion single-photon emission computed tomography (SPECT). METHODS: Medical records of 22 patients presenting first-ever BG stroke were retrospectively reviewed. Regional cerebral blood flow (CBF) and cerebrovascular reserve (CVR) were measured for 9 regions in each cerebral hemisphere (primary motor cortex, supplementary motor area, premotor cortex, prefrontal cortex, temporal lobe, parietal lobe, occipital lobe, BG, and thalamus). The Fugl-Meyer Assessment (FMA) motor score was used to assess motor function. RESULTS: After ACZ injection, CBF of all regions of interest (ROIs) increased compared with baseline. Baseline CBF of all ROIs was not significantly correlated with changes in FMA upper or lower motor score. However, multivariate analysis revealed CVR was significantly associated with change in FMA upper score in the ipsilateral primary motor cortex (R2=0.216, p=0.017), the ipsilateral parietal lobe (R2=0.135, p=0.029), and the contralateral primary motor cortex (R2=0.210, p=0.041). CONCLUSION: CVR in the bilateral primary motor cortex and ipsilateral parietal lobe was associated with restoration of upper motor function 6 months after BG stroke. SPECT is a readily available imaging modality useful in studying brain residual function in patients with BG stroke.

Neurocognitive Dysfunction According to Hypoperfusion Territory in Patients With Moyamoya Disease

OBJECTIVE: To demonstrate the prevalence of cerebral hypoperfusion without focal cerebral lesions in patients with Moyamoya disease (MMD), and the relationship between areas of hypoperfusion and cognitive impairment. METHODS: Twenty-six MMD patients were included. Patients were categorized according to the presence/absence of hypoperfusion in the frontal, parietal, temporal, and occipital lobes on brain single-photon-emission computed tomography (SPECT) after acetazolamide challenge. Computerized neuropsychological test (CNT) results were compared between groups. RESULTS: Only 3 patients showed normal cerebral perfusion. Baseline characteristics were similar between groups. Patients with frontal lobe hypoperfusion showed lower scores in visual continuous performance test (CPT), auditory CPT, forward digit span test, backward digit span test, verbal learning test, and trail-making test. Patients with parietal lobe hypoperfusion showed lower backward digit span test, visual learning test, and trail-making test scores. Related to temporal and occipital lobes, there were no significant differences in CNT results between the hypoperfusion and normal groups. CONCLUSION: MMD patients without focal cerebral lesion frequently exhibit cerebral hypoperfusion. MMD patients with frontal and parietal hypoperfusion had abnormal CNT profiles, similar to those with frontal and parietal lesions. It is suggested that the hypoperfusion territory on brain SPECT without focal lesion may affect the characteristics of neurocognitive dysfunction in MMD patients.

Altitude Stress During Participation of Medical Congress / 신경중재치료의학

Medical congresses often held in highlands. We reviewed several medical issues associated with altitude stress especially while physicians have participated medical congress held in high altitude. Altitude stress, also known as an acute mountain sickness (AMS), is caused by acute exposure to low oxygen level at high altitude which is defined as elevations at or above 1,200 m and AMS commonly occurs above 2,500 m. Altitude stress with various symptoms including insomnia can also be experienced in airplane. AMS and drunken state share many common features in symptoms, neurologic manifestations and even show multiple microbleeds in corpus callosum and white matter on MRI. Children are more susceptible to altitude stress than adults. Gradual ascent is the best method for the prevention of altitude stress. Adequate nutrition (mainly carbohydrates) and hydration are recommended. Consumption of alcohol can exacerbate the altitude-induced impairments in judgment and the visual senses and promote psychomotor dysfunction. For prevention or treatment of altitude stress, acetazolamide, phosphodiesterase inhibitors, dexamethasone and erythropoietin are helpful. Altitude stress can be experienced relatively often during participation of medical congress. It is necessary to remind the harmful effect of AMS because it can cause serious permanent organ damage even though the symptoms are negligible in most cases.

Tumoral Calcinosis as an Initial Complaint of Juvenile-Onset Amyopathic Dermatomyositis

Calcinosis is rarely observed in juvenile-onset amyopathic dermatomyositis in contrast to juvenile-onset dermatomyositis. A 6-year-old female presented with several 0.5 to 2 cm-sized painless grouped masses on both knees for 3 years. The patient also presented with multiple erythematous scaly patches and plaques on both elbows, knuckles, buttock, ankles and cheeks. Her mother had similar skin lesions which were erythematous scaly patches on the knuckles and elbows, since her childhood. When skin biopsy was performed from a left knee nodule, liquid chalky discharge was observed. The biopsy results were consistent with calcinosis cutis. Other biopsies from erythematous patch of the patient and erythematous patch of her mother showed vacuolization of basal cell layer with inflammatory cell infiltrations. Laboratory findings showed normal range of serum phosphorus (4.5 mg/dl), calcium (9.3 mg/dl), 1,25-dihydroxy-vitamin D (10.8 ng/ml) and parathyroid hormone levels (11 pg/ml). Both patient and her mother had no history of muscle weakness and showed normal levels of muscle-specific enzyme. Both patients were diagnosed with juvenile-onset amyopathic dermatomyositis based on histopathology and cutaneous manifestations with no evidence of muscle weakness and no serum muscle enzyme abnormalities. Tumoral calcium deposits observed in daughter was diagnosed as dystrophic calcinosis which can be rarely seen in juvenile-onset amyopathic dermatomyositis. The patient is being treated with oral acetazolamide (40 mg/kg/d) for calcinosis.

Hemodynamic Significance of Internal Carotid or Middle Cerebral Artery Stenosis Detected on Magnetic Resonance Angiography

PURPOSE: We evaluated hemodynamic significance of stenosis on magnetic resonance angiography (MRA) using acetazolamide perfusion single photon emission computed tomography (SPECT). MATERIALS AND METHODS: Of 171 patients, stenosis in internal carotid artery (ICA) and middle cerebral artery (MCA) (ICA-MCA) on MRA and cerebrovascular reserve (CVR) of MCA territory on SPECT was measured using quantification and a 3-grade system. Stenosis and CVR grades were compared with each other, and their prognostic value for subsequent stroke was evaluated. RESULTS: Of 342 ICA-MCA, 151 (44%) presented stenosis on MRA; grade 1 in 69 (20%) and grade 2 in 82 (24%) cases. Decreased CVR was observed in 9% of grade 0 stenosis, 25% of grade 1, and 35% of grade 2. The average CVR of grade 0 was significantly different from grade 1 (p<0.001) and grade 2 stenosis (p=0.007). In quantitative analysis, average CVR index was -0.56+/-7.91 in grade 0, -1.81+/-6.66 in grade 1 and -1.18+/-5.88 in grade 2 stenosis. Agreement between stenosis and CVR grades was fair in patients with lateralizing and non-lateralizing symptoms (kappa=0.230 and 0.346). Of the factors tested, both MRA and CVR were not significant prognostic factors (p=0.104 and 0.988, respectively), whereas hypertension and renal disease were significant factors (p<0.05, respectively). CONCLUSION: A considerable proportion of ICA-MCA stenosis detected on MRA does not cause CVR impairment despite a fair correlation between them. Thus, hemodynamic state needs to be assessed for evaluating significance of stenosis, particularly in asymptomatic patients.

Primary Angioplasty for Symptomatic Atherosclerotic Middle Cerebral Artery Stenosis

OBJECTIVE: The objective of this study is to evaluate the clinical and angiographic outcomes after primary balloon angioplasty in patients with symptomatic middle cerebral artery (MCA, M1 segment) stenosis refractory to medical therapy. MATERIALS AND METHODS: Eleven patients with intracranial stenosis were treated with primary balloon angioplasty. All patients had MCA stenosis with recurrent transient ischemic attack (TIA). The indication for balloon angioplasty was patients with significant MCA stenosis: 1) age older than 18 years with recurrent or progressive TIA or infarction despite optimal medical therapy, including anti-coagulation, dual anti-platelet, and anti-lipid medication; 2) previous ischemic events or asymptomatic severe stenosis (more than 50%) with poor collateral cerebral circulation, or diminished cerebral perfusion on single photon emission computed tomography before and after administration of the intravenous dosage of acetazolamide. RESULTS: The median age of patients was 53 years (range 44-79). The technical success rate was 100%. Mean pretreatment stenosis degree was 83.63 +/- 9.53% and 29.1 +/- 15.4% before and after angioplasty, respectively. Procedural-related complications occurred in four of 11 patients (36%), but none of the patients had permanent neurological deficit. All patients were available for an average follow-up period of 19.4 +/- 5.1 months. One patient had a stroke in the territory of angioplasty at two months after angioplasty. The stroke free survival rate at 30 days and 12 months was 100% and 91%, respectively. Restenosis over 50% was observed in three of 11 patients (27%); all were asymptomatic. CONCLUSION: Intracranial angioplasty for symptomatic MCA stenosis refractory to medical therapy can be a treatment option to reduce the risk of further TIA or stroke.