Treatment of venous pulsatile tinnitus in younger women.

BACKGROUND: We present 7 cases of pulsatile tinnitus (PT) of venous origin in younger women seen over a period of 24 years and treated by Internal Jugular Bulb ligation. METHODS: All patients had a pulsatile bruit in one side of the neck that disappeared when gentle pressure over the internal jugular vein (IJV) caused it to collapse as seen in a duplex scan. Their computed tomography showed a dominant venous system with a high jugular bulb on the side of the bruit. RESULTS: The IJV was ligated under local anesthesia. Five patients in whom the ligation was done above the facial vein were cured. Two patients in whom the ligation was done below the facial vein experienced a decrease but not disappearance of the PT. CONCLUSIONS: Once other possible causes for PT have been discarded, ligation of the IJV above the facial vein cures this condition.

Experimental and clinical evidence supporting septectomy in the primary treatment of acute type B thoracic aortic dissection.

BACKGROUND: We reviewed the mechanics involved in the aneurysmal dilatation of the false lumen (FL) in type B aortic dissection and the experimental and clinical evidence supporting the proposition that the main agent for this dilatation is a differential of pressure between the false and true lumena. This difference in pressure is the consequence of a restricted outflow of the FL. Our aim was to study the relationship between the size of a septectomy that increases the outflow of the FL and its effect on the values of the differential of pressure. METHODS: A bench-top model of aortic dissection was used to determine the relationship between the area of the tears and the value of the pressure differential. A range of tear sizes was tested. RESULTS: The highest differential of pressure (6.77 mm Hg) was found with a single proximal tear. The addition of a distal tear decreases the pressure difference. The greater the sum of the areas of proximal and distal tears, the lower the pressure difference between true lumen and FL. This pressure difference approached zero, as the sum of the areas approached 250 mm(2). CONCLUSIONS: A septectomy of at least 250 mm(2), initiated from the distal tear to the proximal aorta of an area, should be part of the initial treatment of acute aortic dissection. Concomitant with it, the proximal tear should be occluded with either a bare stent or a stent graft.

Sources of error in the measurement of aortic diameter in computed tomography scans.

OBJECTIVE: This study was conducted to determine the differences in the diameter of the thoracic aorta when measured from electrocardiographic (ECG)-gated and nongated computed tomography (CT) angiography. Another aim was to define the difference in the aortic diameter when it is measured at peak systole and end diastole in ECG-gated scans. METHODS: The gated and nongated CT angiograms of 27 patients (mean age, 58 ± 16 standard deviation [SD] years) obtained on a 256-slice multidetector CT scanner were used. The transverse and anteroposterior diameters and the lumen areas were measured at 1, 4, and 8 cm below the origin of the left subclavian artery. RESULTS: There was a significant difference in the aortic measurements of diameter between gated and nongated scans found in samples taken at 1, 4, and 8 cm distal to the left subclavian artery (P < .0001). We found a considerable difference between the systolic and diastolic diameters (P < .0001). The maximum change in diameter between systole and diastole was 2.9 ± 0.9 (SD) mm (14.5%, P < .0001) at 1 cm, 5.4 mm (22.6%; median, 1.7 mm; P < .0001) at 4 cm, and 4.4 mm (16.9%; median, 1.3 mm; P < .0001) at 8 cm. There was a significant difference between the transverse and anteroposterior diameters in systole and diastole at all locations (P < .0001): The maximum change in diameter between transverse and anteroposterior diameters in systole was 5.4 ± 1.1 (SD) mm (15.7%, P < .0001) at 1 cm, 5.8 mm (19%; median, 1.4 mm; P < .0001) at 4 cm, and 5 mm (15%; median, 1.02 mm; P < .0001) at 8 cm. There was also a substantial difference between measuring the transverse diameter directly and deriving it from the lumen area (P < .0001). CONCLUSIONS: Our results showed an important difference between systolic and diastolic diameters measurements in ECG-gated scans. The standard protocol for measuring aortic diameters in gated scans of the thoracic aorta uses images at end diastole because the lack of wall motion at this time provides better resolution. This is likely to result in undersizing that, in some instances, may threaten stability and the proper seal of the stent graft. The dimensions of the aorta in a gated CT should be measured at peak systole rather than the conventional end diastole used today. Most medical centers use nongated CT or gated CT scans in end diastole to calculate sizes of endografts. In view of our findings, the latter method could result in potential complications.

Primary extracranial vertebral artery aneurysms.

BACKGROUND: Extracranial vertebral artery aneurysms are uncommon and are usually associated with trauma or dissection. Primary cervical vertebral aneurysms are even rarer and are not well described. The presentation and natural history are unknown and operative management can be difficult. Accessing aneurysms at the skull base can be difficult and, because the frail arteries are often afflicted with connective tissue abnormalities, direct repair can be particularly challenging. We describe the presentation and surgical management of patients with primary extracranial vertebral artery aneurysms. METHODS: In this study we performed a retrospective, multi-institutional review of patients with primary aneurysms within the extracranial vertebral artery. RESULTS: Between January 2000 and January 2011, 7 patients, aged 12-56 years, were noted to have 9 primary extracranial vertebral artery aneurysms. All had underlying connective tissue or another hereditary disorder, including Ehler-Danlos syndrome (n=3), Marfan's disease (n=2), neurofibromatosis (n=1), and an unspecified connective tissue abnormality (n=1). Eight of 9 aneurysms were managed operatively, including an attempted bypass that ultimately required vertebral ligation; the contralateral aneurysm on this patient has not been treated. Open interventions included vertebral bypass with vein, external carotid autograft, and vertebral transposition to the internal carotid artery. Special techniques were used for handling the anastomoses in patients with Ehler-Danlos syndrome. Although endovascular exclusion was not performed in isolation, 2 hybrid procedures were performed. There were no instances of perioperative stroke or death. CONCLUSIONS: Primary extracranial vertebral artery aneurysms are rare and occur in patients with hereditary disorders. Operative intervention is warranted in symptomatic patients. Exclusion and reconstruction may be performed with open and hybrid techniques with low morbidity and mortality.

Contemporary outcomes after distal vertebral reconstruction.

INTRODUCTION: Flow-limiting lesions or embolic phenomena can produce vertebrobasilar ischemia. This study aims to differentiate the pathophysiology of vertebral ischemia and examine contemporary outcomes after distal vertebral reconstruction. METHODS: Between February 2005 and November 2011, 41 consecutive distal vertebral artery (VA) reconstructions were performed in 34 patients, including bypass to the third portion of the VA (V3) at the C1-2 level (n = 24) or the C0-1 level (n = 7); transposition of the external carotid artery or its occipital branch onto V3 (n = 6); transposition of V3 onto the internal carotid artery (n = 3); and bypass from the ipsilateral subclavian artery to V3 (n = 1). Six patients required a concomitant carotid intervention, and nine patients required a partial resection of the C1 transverse process. Symptoms, present in 91% of patients, were attributed to a flow-limiting lesion in 16 (52%), to embolization in nine (29%), and to a mixed etiology in six (19%). RESULTS: Intraoperatively, five patients required graft revision or conversion of a transposition to a bypass, and two patients required vertebral ligation. Median blood loss was 260 mL. Median hospital length of stay was 1 day. Postoperatively, one patient (2%) required re-exploration for bleeding, a stroke occurred in one patient (2%), and cranial nerve injury occurred in three patients (7%). There were no perioperative deaths. Survival analysis showed that primary patency at 1, 2, and 5 years, respectively, was 74%, 74%, and 54%. Secondary patency was 80% at 1 year and remained so through the end of follow-up at 80 months. A statistically significant difference in patency was noted favoring arterial transposition over vertebral bypass of 100%, 100%, and 83% at 1, 2, and 5 years, respectively, vs 65%, 65%, and 39% (P = .018). Considering successful redo bypass grafting for late failure, 97% of patients demonstrated preserved patency at their last follow-up. There were two late deaths of unknown etiology and no late strokes. CONCLUSIONS: Distal VA reconstruction for flow-limiting or embolic lesions provides excellent stroke protection and symptomatic relief with acceptable perioperative risk in selected patients.

Determination of the elastic modulus of ascending thoracic aortic aneurysm at different ranges of pressure using uniaxial tensile testing.

OBJECTIVE: The purpose of this study is to provide measurements of the elastic modulus of the aortic wall of ascending thoracic aortic aneurysms for different ranges of pressure (physiologic, hypertensive). In addition, pre-failure stress, taken as the peak stress obtained before specimen failure, was recorded for each test. METHODS: Ninety-seven aortic samples freshly excised from 13 patients with ascending thoracic aortic aneurysms were obtained from greater and lesser curvatures and tested uniaxially in circumferential and longitudinal orientations. RESULTS: The maximum elastic moduli, overall, and particularly in the lesser curvature were significantly higher in the circumferential orientation (9.19 MPa) than in the longitudinal (3.13 MPa). Results of peak stress showed positive correlation with maximum elastic modulus and inverse correlation with tissue wall thickness. CONCLUSIONS: This study provides new data on the elastic modulus in the physiologic and hypertensive range that can be used in computational analysis and the design of bench-top models. The accuracy of computational analysis and bench-top models strongly depends on the knowledge of the elastic properties of the aortic wall. The mechanical properties presented in this study, with specific values for 2 locations (greater and lesser curvature) and 2 directions (circumferential, longitudinal), will increase our understanding of the mechanisms that precede rupture of an ascending aortic aneurysm.

Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation.

BACKGROUND: The operating room is a high-risk setting for occupational sharps injuries and bloodborne pathogen exposure. The requirement to provide safety-engineered devices, mandated by the Needlestick Safety and Prevention Act of 2000, has received scant attention in surgical settings. STUDY DESIGN: We analyzed percutaneous injury surveillance data from 87 hospitals in the United States from 1993 through 2006, comparing injury rates in surgical and nonsurgical settings before and after passage of the law. We identified devices and circumstances associated with injuries among surgical team members. RESULTS: Of 31,324 total sharps injuries, 7,186 were to surgical personnel. After the legislation, injury rates in nonsurgical settings dropped 31.6%, but increased 6.5% in surgical settings. Most injuries were caused by suture needles (43.4%), scalpel blades (17%), and syringes (12%). Three-quarters of injuries occurred during use or passing of devices. Surgeons and residents were most often original users of the injury-causing devices; nurses and surgical technicians were typically injured by devices originally used by others. CONCLUSIONS: Despite legislation and advances in sharps safety technology, surgical injuries continued to increase during the period that nonsurgical injuries decreased significantly. Hospitals should comply with requirements for the adoption of safer surgical technologies, and promote policies and practices shown to substantially reduce blood exposures to surgeons, their coworkers, and patients. Although decisions affecting the safety of the surgical team lie primarily in the surgeon's hands, there are also roles for administrators, educators, and policy makers.

Two case presentations and surgical management of Bow Hunter's syndrome associated with bony abnormalities of the C7 vertebra.

Bow Hunter's syndrome is a condition in which patients experience vertebrobasilar symptoms on head turn. It may be a consequence of intrinsic factors such as atherosclerosis, or it may be secondary to mechanical compression. Most commonly, this occurs at the level of C2 or above. We present two rare cases of Bow Hunter's syndrome secondary to mechanical compression at the level of C7. Discussed are the anatomic conditions leading to this syndrome in these two patients, the methodology for confirming the diagnosis, and the successful management by partial resection of the transverse processes compressing the vertebral arteries.

Synchronous carotid body and thoracic paraganglioma associated with a germline SDHC mutation.

Paraganglionic tumors are rare. A germline mutation responsible for a familial pattern of paragangliomas (PGLs) has been identified on the genes encoding for the subunits of succinate dehydrogenase (SDH). Manifestations of those with a succinate dehydrogenase subunit C (SDHC) germline mutation have been almost exclusively reported as single head and neck paragangliomas (HNPGLs). We present a 32-year-old man with a familial SDHC mutation who manifests synchronous PGLs of the carotid body and the thoracic aortopulmonary window. To our knowledge, this is the first report of such a presentation for this mutation.

The spectrum of arterial compression at the thoracic outlet.

OBJECTIVE: In the absence of ischemic events, arterial pathology at the thoracic outlet (TO) is rarely identified because findings of chronic arterial pathology may be masked by symptoms of neurogenic compression. This study describes the clinical presentations and significance of arterial compression at the TO. METHODS: This was a retrospective analysis of the clinical records and imaging studies of 41 patients with objective findings of arterial compression at the TO. Sixteen were diagnosed from 1990 to 2003, during which 284 patients underwent surgery for TO decompression with selective arterial imaging; 25 were diagnosed from 2003 to 2009, and 62 underwent TO surgical decompressions. RESULTS: Subclavian artery stenosis, with or without poststenotic dilatation (PSD), was found in 26 patients (63%), subclavian artery aneurysms in 12 (29%), chronic subclavian occlusion in 1(2.4%), and axillary artery compression in 2 (5%). Chronic symptoms difficult to discern from neurogenic compression were present in 27 patients (66%; 24 had subclavian stenoses or PSD, or both, 1 had subclavian occlusion, and 2 had axillary artery compression); 13 (32%) presented with acute ischemia (11 had aneurysms and 2 had PSDs), and 1 asymptomatic patient had a subclavian aneurysm. Osteoarticular anomalies were found in 27 patients (66%), including 19 cervical ribs, 4 first rib anomalies, and 4 clavicular or first rib fractures, or both. Among 27 patients with subclavian aneurysms or PSD, 21 (78%) had a bone anomaly. Arterial pathology was deemed significant in 30 patients (73%) and mild or moderate in 11 (21%). Symptoms in 23 of these patients were compatible with neurogenic compression without clinical suspicion of arterial pathology, but 13 (56%) harbored a significant arterial anomaly. CONCLUSIONS: The incidence of arterial pathology secondary to compression at the TO may be underestimated, and in the absence of obvious ischemia, significant arterial pathology may not be suspected. Two-thirds of patients with arterial compression have associated bone anomalies. Therefore, routine arterial imaging seems advisable for patients evaluated for TO syndrome in the presence of a bone anomaly at the TO or an examination that shows an arterial abnormality. In the absence of these signs, however, arterial pathology may be overlooked in patients with symptoms suggestive of neurogenic compression. Further study is needed to elucidate the incidence, natural history, and clinical relevance of arterial compression and PSD at the TO.