Factors Associated with Severe Carotid Artery Stenosis in a Population with One of the Highest Incidences of Ischemic Stroke in Europe - Single National Center Analysis.

Introduction: Despite significant advances in its prevention and acute-phase treatment, stroke is still one of the leading causes of disability and death worldwide. Ischemic stroke accounts for 80 to 87% of all strokes, with 15-30% of cases being caused by extracranial carotid artery (CA) stenosis. Methods: This is an observational, cross-sectional, single-center, prospective, registry-based study. The current research presents the preliminary results after analyzing the demographic features, biological data, and cardio- and cerebro-vascular risk factors of the first 74 patients included in the first "Romanian registry for cervical and cerebral arterial stenosis." Results: In our group of patients, the severity of carotid artery stenosis was related to fibrinogen, total cholesterol, and triglyceride blood levels. Moreover, patients who underwent carotid artery stenosis were more prone to having peri-procedural complications if they had a low blood platelet count. Concerning the associated pathologies of patients with severe carotid atheromatosis, the risk of having lower cognitive abilities was higher in subjects with atrial fibrillation, regardless of the severity of carotid artery stenosis. Conclusions: The presented study brings essential information about a population more prone to cerebral ischemic events than that of most other countries. All data obtained until this moment and which will further result from analyzing the clinical, demographic, and biological features of patients included in this registry should be used for implementing populational strategies for preventing further strokes.

Decompressive Craniectomy: the Right Call at the Right Moment.

Introduction:Massive intracerebral hemorrhages and large internal carotid artery infarcts may cause early death due to severe cerebral edema with elevated intracranial pressure, despite maximal medical therapy. Decompressive craniectomy may be of benefit to these patients in terms of survival and even functional outcome. The aim of our paper is to present two cases that illustrate the use of decompressive craniectomy both in ischemic and hemorrhagic stroke, followed by a discussion on the indication and right timing of the intervention, but also on the outcome of these patients. Materials and methods: We present the cases of a 38-year-old man with a right lenticular and capsular hemorrhage who underwent decompressive craniectomy in the first 24 hours from onset of symptoms and a 64-year-old patient with an ischemic stroke in the territory of the left carotid artery with a decompressive craniectomy performed at more than 72 hours from the beginning. For each of the two cases, we analyzed the following parameters: neurologic status, Glasgow Coma Scale, aspect of the cerebral computed tomography before and after surgery, in-hospital complications and modified Rankin Scale at discharge. Outcomes: While the intervention was life-saving in both cases, the procedure had different functional outcomes. Conclusion: Decompressive craniectomy may be a life-saving procedure for patients with both hemorrhagic or ischemic strokes complicated with massive edema and increased intracranial pressure. When performed in the first 48 hours, especially in patients with ischemic stroke aged less than 60, it may also improve the functional outcome compared to conservative treatment.

Unruptured Giant Intracerebral Aneurysms: Serious Trouble Requiring Serious Treatment - Case Report and Literature Review.

Giant intracranial aneurysms (ICGA) represent 3 to 5% of all intracranial aneurysms in adults. They are defined as arterial dilatations, with more than 25 mm in diameter. Despite important advances in the research of endovascular techniques of treating giant intracranial aneurysms, the management of these vascular malformations still poses great difficulties for neurologists and interventional radiologists. In particular, these challenges arise from the difficult and modified cerebral anatomy of patients with ICGA. Choosing the best treatment for patients with ICGA involves not only finding the perfect balance between the potential risks and benefits of endovascular treatment, but also taking into consideration the patient's biological condition and associated diseases. The aim of this paper is to describe the decisional algorithm of treating patients with giant intracranial aneurysms and factors which could influence the choice of endovascular technique. We report a clinical case of a 63-year-old female with cardio-vascular risk factors (atrial fibrillation, high blood pressure), diagnosed with a symptomatic giant aneurysm of the right internal carotid artery and multiple cerebral micro-bleeds. Given the very large size of the aneurysm, its characteristics as well as patient's associated comorbidities, it was decided to exclude the ICA aneurysm from circulation by occluding the parent vessel (right internal carotid artery) by using endovascular techniques. Also, a review of the literature on the currently available endovascular methods for treating patients with giant intracranial aneurysms was performed in order to see the indications and possible long-term complications of each method. In selected cases, the risks of serious complications associated with occluding a large cervical-cerebral vessel (as the internal carotid artery) are far exceeded by the risk for rupture of giant aneurysms, which is fatal in many cases. Nevertheless, it is of utmost importance to mention that, although the use of endovascular methods leads to a significant increase in life expectancy, a severe decline in quality of life might be experienced by these patients.

Impact of controlled attenuation parameter on detecting fibrosis using liver stiffness measurement.

BACKGROUND: Liver fibrosis is often accompanied by steatosis, particularly in patients with non-alcoholic fatty liver disease (NAFLD), and its non-invasive characterisation is of utmost importance. Vibration-controlled transient elastography is the non-invasive method of choice; however, recent research suggests that steatosis may influence its diagnostic performance. Controlled Attenuation Parameter (CAP) added to transient elastography enables simultaneous assessment of steatosis and fibrosis. AIM: To determine how to use CAP in interpreting liver stiffness measurements. METHODS: This is a secondary analysis of data from an individual patient data meta-analysis on CAP. The main exclusion criteria for the current analysis were unknown aetiology, unreliable elastography measurement and data already used for the same research question. Aetiology-specific liver stiffness measurement cut-offs were determined and used to estimate positive and negative predictive values (PPV/NPV) with logistic regression as functions of CAP. RESULTS: Two thousand and fifty eight patients fulfilled the inclusion criteria (37% women, 18% NAFLD/NASH, 42% HBV, 40% HCV, 51% significant fibrosis ≥ F2). Youden optimised cut-offs were only sufficient for ruling out cirrhosis (NPV of 98%). With sensitivity and specificity-optimised cut-offs, NPV for ruling out significant fibrosis was moderate (70%) and could be improved slightly through consideration of CAP. PPV for significant fibrosis and cirrhosis were 68% and 55% respectively, despite specificity-optimised cut-offs for cirrhosis. CONCLUSIONS: Liver stiffness measurement values below aetiology-specific cut-offs are very useful for ruling out cirrhosis, and to a lesser extent for ruling out significant fibrosis. In the case of the latter, Controlled Attenuation Parameter can improve interpretation slightly. Even if cut-offs are very high, liver stiffness measurements are not very reliable for ruling in fibrosis or cirrhosis.

EFSUMB Statement on Medical Student Education in Ultrasound [long version].

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we report EFSUMB policy statements on medical student education in ultrasound that in a short version is already published in Ultraschall in der Medizin 1.

Fast nanoscale addressability of nitrogen-vacancy spins via coupling to a dynamic ferromagnetic vortex.

The core of a ferromagnetic vortex domain creates a strong, localized magnetic field, which can be manipulated on nanosecond timescales, providing a platform for addressing and controlling individual nitrogen-vacancy centre spins in diamond at room temperature, with nanometre-scale resolution. Here, we show that the ferromagnetic vortex can be driven into proximity with a nitrogen-vacancy defect using small applied magnetic fields, inducing significant nitrogen-vacancy spin splitting. We also find that the magnetic field gradient produced by the vortex is sufficient to address spins separated by nanometre-length scales. By applying a microwave-frequency magnetic field, we drive both the vortex and the nitrogen-vacancy spins, resulting in enhanced coherent rotation of the spin state. Finally, we demonstrate that by driving the vortex on fast timescales, sequential addressing and coherent manipulation of spins is possible on ∼100 ns timescales.

EFSUMB statement on medical student education in ultrasound [short version].

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we summarise EFSUMB policy statements on medical student education in ultrasound.

Point Shear Wave Elastography by Acoustic Radiation Force Impulse Quantification in Comparison to Transient Elastography for the Noninvasive Assessment of Liver Fibrosis in Chronic Hepatitis C: A Prospective International Multicenter Study.

PURPOSE: The aim of the present prospective European multicenter study was to demonstrate the non-inferiority of point shear wave elastography (pSWE) compared to transient elastography (TE) for the assessment of liver fibrosis in patients with chronic hepatitis C. MATERIALS AND METHODS: 241 patients with chronic hepatitis C were prospectively enrolled at 7 European study sites and received pSWE, TE and blood tests. Liver biopsy was performed with histological staging by a central pathologist. In addition, for inclusion of cirrhotic patients, a maximum of 10 % of patients with overt liver cirrhosis confirmed by imaging methods were allowed by protocol (n = 24). RESULTS: Owing to slower than expected recruitment due to a reduction of liver biopsies, the study was closed after 4 years before the target enrollment of 433 patients with 235 patients in the 'intention to diagnose' analysis and 182 patients in the 'per protocol' analysis. Therefore, the non-inferiority margin was enhanced to 0.075 but non-inferiority of pSWE could not be proven. However, Paired comparison of the diagnostic accuracy of pSWE and TE revealed no significant difference between the two methods in the 'intention to diagnose' and 'per protocol' analysis (0.81 vs. 0.85 for F ≥ 2, p = 0.15; 0.88 vs. 0.92 for F ≥ 3, p = 0.11; 0.89 vs. 0.94 for F = 4, p = 0.19). Measurement failure was significantly higher for TE than for pSWE (p = 0.030). CONCLUSION: Non-inferiority of pSWE compared to TE could not be shown. However, the diagnostic accuracy of pSWE and TE was comparable for the noninvasive staging of liver fibrosis in patients with chronic hepatitis C.

Chronic pancreatitis with hemosuccus pancreaticus. The diagnostic contribution of computed tomography and contrast enhanced ultrasonography--case report.

Hemosuccus pancreaticus is defined as upper gastrointestinal hemorrhage from the ampulla of Vater via the pancreatic duct. It is a rare disease, with non-specific presentation, challenging to diagnose and difficult to treat, with high mortality rates in untreated patients with massive bleeding. Given the intermittent nature of the bleeding, delays in diagnosis frequently occur. Timely diagnosis and treatment seem to result in markedly reduced mortality, therefore we emphasize the diagnostic contribution of imaging techniques by presenting the case of a patient with chronic pancreatitis in whom computed tomography established the diagnosis of blood in the Wirsung duct and contrast-enhanced ultrasound brought its added value by excluding the active bleeding.

Contrast-enhanced ultrasound (CEUS) for the evaluation of focal liver lesions - a prospective multicenter study of its usefulness in clinical practice.

PURPOSE: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs) and for diagnosing different FLL types. MATERIAL AND METHODS: CEUS performed in 14 Romanian centers was prospectively collected between February 2011 and June 2012. The inclusion criteria were: age > 18 years; patients diagnosed with 1 - 3 de novo FLLs on B-mode ultrasound; reference method (computed tomography (CT), magnetic resonance imaging (MRI) or biopsy) available; patient's informed consent. FLL lesions were characterized during CEUS according to the European Federation of Societies for Ultrasound in Medicine and Biology guidelines. For statistical analysis, indeterminate FLLs at CEUS were rated as false classifications. RESULTS: A total number of 536 cases were included in the final analysis, 344 malignant lesions (64.2 %) and 192 benign lesions (35.8 %). The reference method was: CT/MRI - 379 cases (70.7 %), pathological exam - 150 cases (27.9 %) and aspiration of liver abscesses - 7 cases (1.4 %). CEUS was conclusive in 89.3 % and inconclusive in 10.7 % of cases. To differentiate between malignant and benign FLLs, CEUS had 85.7 % sensitivity, 85.9 % specificity, 91.6 % positive predictive value, 77.1 % negative predictive value and 85.8 % accuracy. The CEUS accuracy for differentiation between malignant and benign liver lesions was similar in tumors with diameter ≤ 2 cm and those with diameter > 2 cm. CONCLUSION: CEUS represents a useful method in clinical practice for differentiating between malignant and benign FLLs detected on standard ultrasonography, and the results of this study are in concordance with previous multicenter studies: DEGUM (Germany) and STIC (France).

Thrombophlebitis of the lateral chest wall (Mondor's disease).

Mondor's disease is a rare condition, which involves the thrombophlebitis of the superficial veins of the breast and anterior chest wall. A 37-year-old woman presented with sudden onset of local pain and edema on her right chest wall, accompanied by a longitudinal retraction of the skin during arm abduction in the area. Clinical, histological and ultrasonographic findings confirmed Mondor's disease and the treatment was symptomatic, using pain relievers and warm compresses. The symptomatology remitted within 2 weeks of therapy. Mondor's disease is a rare condition where ultrasound complements the clinical evaluation and allows the characterization of certain abnormalities, which correlated with functional biochemical data and other procedures may substitute the need of biopsy.

The combined role of intravenous contrast enhanced ultrasound (CEUS) and computed tomography (CT) in liver abscess diagnosis.

BACKGROUND AND AIMS: Through this study, we intend to review the main aspects regarding the contrast enhanced ultrasound evaluation of liver abscesses, pursuing a comparative analysis between the medical literature and our own experience. MATERIAL AND METHODS: From June 2008 until December 2010 we have evaluated in our department a consecutive series of 11 patients with liver abscesses (7 males, 63.63%) all between the ages of 45 and 74. All the patients displayed a clinical and biological picture leading to an inflammatory process. The imaging diagnosis was made after confronting the results of the contrast enhanced ultrasound with those of the computed tomography. RESULTS: In 10 out of 11 patients that were part of the study, we have assessed 14 liver abscesses. A single patient showed spread lesions inside both liver lobes, and they were assessed as hepatic micro abscesses. Three of the patients showed multiple right lobe lesions, 7 patients showed single lesions and one patient showed disseminated lesions within both lobes. We examined six mature lesions, 4 lesions with incomplete necrosis and 4 immature lesions, with no necrosis. The particular aspect of mycotic microabscesses is mentioned at the conventional ultrasound and at the CEUS as well. CONCLUSION: Various types of hepatic abscesses have different imaging findings, and typical CT and CEUS findings can suggest the diagnosis.

Quantitative contrast-enhanced harmonic endoscopic ultrasonography for the discrimination of solid pancreatic masses.

PURPOSE: Contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) for the assessment of microcirculation and the delineation of pancreatic tumors in order to characterize and stage them has only recently become available for commercial use, and few reports have been published. The purpose of the study was the qualitative and quantitative digital image analysis of pancreatic adenocarcinomas using conventional endoscopic ultrasonography (EUS) and CEH-EUS and the evaluation of whether contrast medium injection modified adenocarcinoma staging and patient management. MATERIALS AND METHODS: In each of 30 prospectively examined patients with suspected pancreatic solid lesions, CEH-EUS was performed using the same quantity of the contrast agent SonoVue and a low mechanical index (0.3 - 0.4), followed by EUS-FNA. The histology, based on EUS-FNA or surgery and 9 months of follow-up, was: pancreatic adenocarcinoma (n = 15), pseudotumoral chronic pancreatitis (n = 12), neuroendocrine tumor (n = 1), common bile duct tumor (n = 1), lymph node metastases of gastric cancer (n = 1). The quantitative analysis was based on histograms obtained from each CEH-EUS video recording. RESULTS: CEH-EUS showed a hypoenhanced pattern in 14 cases of adenocarcinoma and in 10 cases of chronic pancreatitis. The index of the contrast uptake ratio was significantly lower in adenocarcinoma than in mass-forming chronic pancreatitis. A cut-off uptake ratio index value of 0.17 for diagnosing adenocarcinoma corresponded to an AUC (CI 95%) of 0.86 (0.67 - 1.00) with a sensitivity of 80%, a specificity of 91.7%, a positive predictive value of 92.8%, and a negative predictive value of 78%. The size of the pancreatic mass was assessed significantly more effectively by CEH-EUS but adenocarcinoma staging was not modified. CONCLUSION: The majority of cases of both pancreatic adenocarcinoma and chronic pancreatitis were hypoenhanced and visual discrimination was not possible. This is the first study about CEH-EUS for the quantitative assessment of uptake after contrast injection which has shown that it can aid differentiation between benign and malignant masses but cannot replace EUS-FNA. Neither tumor stage nor therapeutic management have changed after contrast medium injection during CEH-EUS.

Liver biopsy versus noninvasive methods--fibroscan and fibrotest in the diagnosis of non-alcoholic fatty liver disease: a review of the literature.

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing in general population so it is impossible to perform liver biopsy in such a large number of patients to identify those with advanced fibrosis or non-alcoholic steatohepatitis. Liver biopsy has a potential sampling error, it is invasive and prone to complications, so it is no longer considered as mandatory as first line screening tools for chronic liver disease. The development of non-invasive biomarkers, FibroTest-ActiTest in 2001 and more recently FibroMax, as well as transient elastography (TE) has changed the management of chronic liver disease. The aim of this review is to summarize the advantages and limits of the available non-invasive biomarkers of liver fibrosis, in comparison with liver biopsy in NAFLD patients.

Risk of asymptomatic and symptomatic gallstones in moderately obese women: a longitudinal follow-up study.

Obesity is a rather documented risk factor for the formation of gallstones (GS) in women. The magnitude of the increased risk and the rates of GS occurrence, however, have not been well quantified, except for two studies on the risk of symptomatic stones in obese women. We analyzed the incidence of GS in 157 moderately obese women (body mass index, 31.4 +/- 3.6 kg/ m2) followed up prospectively by ultrasound for 2-6 yr (mean 3.95 yr). Women with morbid obesity (body mass index > 40 kg/m2) were excluded from the study, as well as patients having diseases with lithogenic risk. All the enrolled women had normal cholecystosonogram results at the beginning of the study. Age, family history of GS or obesity, parity, age of obesity onset, hyperlipoproteinemia type, plasma cholesterol (total, HDL, LDL), and triglycerides were assessed. The Student's t, the Mann-Whitney rank sum and the Fisher's exact tests were used, as well as the multiple logistic regression for the multivariate analysis. During the survey, 16 of 157 women (10.2%) developed GS. GS were asymptomatic in 11 persons (68.8%). The cumulative incidence of both asymptomatic and symptomatic GS was 2.6 cases/100 obese women.year. During the follow-up, most of the detected GS were asymptomatic, and this explains the higher GS incidence rate found compared with that previously calculated for symptomatic GS. The following risk factors were associated with GS formation: age (p = 0.002), family history of GS (p = 0.011), early obesity onset (p = 0.003), and hyperlipoproteinemia type IV (p = 0.011). A high risk class might be thus identified among obese women, offering a more realistic approach for the primary prophylaxis of GS.

Ultrasonographic study of gall-bladder emptying in obese patients.

In order to assess gall-bladder (GB) motility in obese patients, we measured by ultrasound the GB fasting volume (FV) in 45 women (23 obese, 22 controls) and 43 men (21 obese, 22 controls). The FV was larger in obese women (45.9 +/- 21.6 cm3) than in controls (26.6 +/- 10.7 cm3) (P less than 0.001), and also in obese men (39.2 +/- 20.2 vs. 23.8 +/- 9.9 cm3) (P less than 0.01). In obese women, GB FV correlated with relative body weight. No correlation was found between GB volume and age in obese subjects. In controls, but not in obese subjects, the GB ejection fraction was significantly greater in men (65.3 +/- 19.9%) than in women (51.3 +/- 9.0%) (P less than 0.02). Gall-bladder contraction was not decreased in obese subjects vs. controls, suggesting that GB hypocontractility is not a lithogenic risk factor in obesity. The observation that GB emptying does not correlate with body weight represents another argument that obesity does not impair GB contraction.

[Echographic differential diagnosis in oculo-orbital tumors]. / Diagnostic diferential ecografic în unele tumori oculo-orbitare.

Within the period October 1987-September 1990, the authors submit 130 patients to clinical examination and ultrasonography the latter performed by adapting commercially available ultrasonograph type Bruel and Kjaer 3405 and Shimasonic. Among the investigated individuals, 25 exhibited oculo-orbital tumours of various types. The cases are assessed considering the following for establishing the diagnosis: clinical examination, ultrasonography, fluorescein angiography, radiotracer and morphopathological examinations. Besides the use an adapted device, the authors propose a simple and fast morphopathological method: the fixation in formaldehyde solution as long as 48 hours.

[Ultrasound studies of the portal vein system in liver tumors]. / Sonographische Untersuchungen des Pfortadersystems bei Lebertumoren.

The study was carried out on a group of 21 patients with liver tumours (20 of them primary) and thrombosis of the portal venous system. Thrombosis in the left portal vein system was found in 10 patients, in the portal vein stem in 9 patients and in the portal confluence in 2 patients. In 15 patients thrombosis developed in the presence of a multicentric liver neoplasm. Proaf of the presence of a thrombus on the main portal trunk in patients with documented liver tumour contraindicates surgical or non-surgical therapeutic manoeuvres. If a thrombus is incidentally found in the portal venous system, a careful search for a tumour in the portal vein systems is imperative. In case of any suspicious modification, fine needle-aspiration should be performed.