Unusual complication of total thyroidectomy: arteriovenous fistula.

We describe the case of a 29-year-old woman from the Chernobyl area, who moved to the Czech Republic 10 years after the Chernobyl nuclear disaster. She was evaluated for a large goiter. Fine-needle aspiration cytology indicated a diagnosis of a typical degenerated Hurthle cell adenoma. She underwent total thyroidectomy but a continual loud murmur was found 1 month after surgery. An arteriovenous (AV) fistula between the right thyrocervical trunk and the right jugular vein was proven angiographically. This fistula was successfully closed by artificial embolization performed by detachable Gianturco-Anderson-Wallace (GAW) coil. This is the first description of using such a procedure in order to close an AV fistula after thyroidectomy.

[Determination of ACTH in the inferior petrosal sinuses in the examination of patients with hypercortisolism]. / Prínos stanovení ACTH v sinus petrosi inferiores pri vysetrení pacientu s hyperkortizolismem.

BACKGROUND: Differential diagnosis of the etiology of ACTH-dependent hypercortisolism is very difficult in some cases. The uncertainty, whether there is a central or ectopic etiology, is also strengthened by the fact that even nuclear magnetic resonance (MR) sometimes does not prove the pituitary adenoma. A more precise differential diagnosis under these conditions has been made, over the last years, by selective determination of ACTH levels bilaterally in sinus petrosi inferiores (SPI) and by their comparison with the level in peripheral blood. The confirmation of central etiology makes a decision about neurosurgical intervention easier. This intervention, due to the present microsurgery technique, makes it possible to detect otherwise undetectable microadenoma and enables its selective excision with maintaining healthy hypophysis tissue and all its functions. METHODS AND RESULTS: In the last two years the authors indicated 11 patients (10 women, one man at the age of 17-54 years, mean age 33.5 year) with proved ACTH-dependent hypercortisolism to the determination of ACTH in SPI. Their CT or NMR examination did not prove a hypophysis tumour unequivocally. Only in one female patient the catheterization was not possible for anomalous vascular bed with aplasia of internal jugular vein on the left and hypoplasia of internal jugular vein on the right. In 8 patients the determination of the ratio of ACTH levels between SPI and periphery (7.78 +/- 1.54, mean +/- S.E.) has shown that even the basal levels indicated central etiology of hypercortisolism. This has been confirmed by the ratio of the values of ACTH after stimulation with corticotrophin releasing hormone (CRH). The diagnosis was confirmed in all patients by surgery, by histology and post-operation course. In two female patients the ratio of basal levels of ACTH, SPI/periphery did not prove useful for the diagnosis of the Cushing's disease. In the first patient the CRH stimulation was not yet performed routinely and the ratio of basal levels of ACTH, SPI/periphery gave a false negative result, as shown by the finding of adenoma of hypophysis during the operation. The operation was indicated on the basis of hormonal examinations and repeated MR with a finding of suspected microadenoma and the diagnosis was then confirmed by further clinical development. The determination of the levels of ACTH after CRH stimulation would give more precision in this case, as shown by analysis of the results of large cohorts in literature, which we perform at present as well. In the other patient the CRH stimulation test was done, changing the ratio from 1.1 to 5.7 and thus confirmed central etiology of the Cushing's syndrome. In agreement with literature this method did not contribute to lateral localization of the tumour. CONCLUSIONS: The determination of basal levels of ACTH in SPI and levels after CRH stimulation enables to differentiate between central and ectopic overproduction of ACTH in the ACTH-dependent Cushing's syndrome.

[Diagnosis of pulmonary embolism and monitoring of post-embolic changes in the vessels using pulmonary digital subtraction angiography]. / Diagnostika plicní embolie a sledování postembolizacních zmen na cévách pomocí plicní digitální subtrakcní angiografie.

The group comprises 48 patients where digital subtraction angiography revealed embolization of the lungs. Forty-four of the patients were examined on account of clinical suspicion of embolism of the lungs, in the remaining four the examination was made on account of other indications. In four instances of 48 patients where we diagnosed or suspected embolism of the lungs DSA was also used to follow up the effect of heparinization and anti-aggregation therapy in relatively extensive findings revealed during the first examination. Based on their experience, the authors summarize angiographic pictures into four morphological types: perfusion defect, localized thinning and reduction of peripheral arterioles, sudden discontinuation of lobar and segmental arteries ("cut-off") and intraluminal defects in the contrast filling of arteries. The authors evaluate objectively the advantages and disadvantages of DSA and compare in the discussion the course of the examination, as well as the results with classical angiography, with perfusion and ventilation scan and try to find the correct place in the algorithm of visualization methods when embolism of the lungs is suspected. Based on the assembled experience, DSA of the lungs can be used as the first diagnostic method or after screening perfusion scan, if the latter is available immediately after development of complaints, as the second method. The authors analyze also the reasons of the relatively less frequent and very often late indication of this examination in this country.

[Anomalies of the basilar and vertebral arteries that are of practical importance]. / Beitrag zu praktisch wichtigen Anomalien der A. basilaris und A. vertebralis.

Anomalies of vertebrobasilar vessels arise as early embryonal developmental deteriorations. The majority of them concerns the position, origin and shape of the vertebral and/or basilar arteries. In three patients, reported here, the aberrations were found occasionally and contributed in no way to the clinical symptomatology. In the first patient, a fenestration of A. basilaris was found with a fork-like division on its periphery. In the second patient we noted a doubled proximal origin of the vertebral artery. One artery arose from A. subclavia sinistra, the second one from the aortic arch. Both joined thereafter the common vertebral stem at the level of C4. In the third patient, A. vertebralis originated from the aortal arch, and, at the level of the thyroid, A. thyreoidea inferior originated from it. Attention is drawn to the practical importance of such variations as a possible source of diagnostic errors during cerebral arteriography.

[Digital subtraction angiography in intracranial vascular malformations]. / Digitální subtrakcní angiografie u nitrolebních cévních malformací.

From a total number of 350 DSA examinations in the cervicocranial region intracranial vascular malformations were detected in 14 patients, i.e. in 4%. In six instances an aneurysm was involved, six times arteriovenous and twice a venous malformation. Using digital subtraction angiography, it is usually possible to diagnose by the intravenous or intraaortal route major findings, however, in the majority the finding serves only for orientation. For a more detailed diagnosis, in particular of small findings and findings before operation, a selective examination is more suitable.

[Anomalous branching of the inferior thyroid artery from the left vertebral artery]. / Anomální odstup arteria thyreoidea inferior z levé vertebrální tepny.

In a 53 years old woman hospitalized for a suddenly developed picture of vascular insufficiency in the verterobrobasillary vascular bed the authors detected an anomalous division of the left vertebral artery from aortic arch. Moreover, at the level of thyroid gland there was the division of inferior thyroid artery from the vertebral artery. We express the opinion that the finding did not participate in the clinical symptomatology.

Digital subtraction angiography in cerebrovascular diseases. Correlation of DSA with clinical findings. / Digitální subtrakcní angiografie u cévních onemocnení mozku. Korelace DSA a klinického nálezu.

Digital subtraction angiography (DSA) was performed in 100 patients with cerebrovascular diseases. The results of angiographic examination were compared with clinical findings on admission to and on discharge from hospital. The statistical evaluation was made on computers. Processing of anamnestic data revealed in the patients a large number of risk factors and other diseases, on average 3.68 per man and 3.96 per woman. 71% of the patients were examined on account of a relapse of some cerebrovascular disease. No relationship was found between the degree of the neurological deficit and clinical units on the angiographic finding. Clinically assumed arterial stenosis or occlusion was confirmed by DSA in 44.4%. On the other hand, in 57.9% of 38 affected subjects a stenotizing or obliterating process of the extracranial portion of the internal carotid was diagnosed in the absence of previous clinical suspicion. Of 76 patients with arteriosclerotic change in 56.6% the extracranial portion of the internal carotid was affected, incl. its bifurcation. Of 38 patients with stenosis or occlusion in 36.8% the affection was bilateral. Nine patients were indicated for operation, in another four endarterectomy of the internal carotid was done previously. DSA is a very useful examination method in patients with arteriosclerotic changes of the cerebral and cerebellar arteries. The risk for patients is, as compared with classical angiography, reduced while the obtained information on anatomical changes of the arterial wall is sufficient.

[The role of digital subtraction angiography in the diagnosis of pulmonary anomalies]. / Uloha digitální subtrakcní angiografie (DSA) pri diagnostice anomálií plic.

The authors evaluate the importance of pulmonary digital subtraction angiography (DSA) in anomalies of pulmonary tissue, the bronchial tree and vascular pulmonary malformations. In a group of eight patients, comprising unilateral pulmonary hypoplasia, pulmonary cysts, vascular malformations and pulmonary sequestrations, they analyze the asset of DSA and the place of this method in the diagnostic algorithm. Reduction of the invasive and risky character of the examination, lower costs, the possibility of immediate evaluation and subsequent processing of the picture and modification of the length of the record is one of the main advantages, as compared with classical angiography.

[Dilation of stenoses of the oral part of the esophagus in the Kelly-Paterson syndrome (Plummer-Vinson)]. / Dilatace zúzení orální cásti jícnu u syndromu Kelly-Paterson (Plummer-Vinson).

The dilatation of oesophagus oral portion in the Kelly-Paterson (Plummer Vinson) syndrome was made in two female patients at the age of 58 and 81 years. For the extreme stenosis (2 and 3 mm) of the lumen the dilatation was first performed by the Grüntzig Catheter and after extension above 5 mm special oesophageal catheters with a balloon of 15 mm diameter (Cook) were used. The dilatation proved successful in both patients. The dilatation in the K.-P. syndrome must be performed with care beginning with catheters of small diameter and narrow end with a step-wise slow filling of the balloon. A good anesthesia of upper respiratory pathways and swallowing passages is required.

DSA diagnosis of pulmonary embolization from intracardial thrombus in a patient with permanent pacing catheter.

Pulmonary embolization in patients with implanted pacemakers is rare and an intracardiac thrombus attached to the distal end of a newly implanted ventricular endocardial electrode following removal of a previously implanted lead is a curiosity. We have documented such a case by digital subtraction angiography, a minimally invasive procedure that demonstrates both an intracardiac thrombus and secondary pulmonary embolization in a single procedure, which also allows simplified follow-up evaluation following therapy.

[An unusual entrapment syndrome diagnosed early]. / Neobvyklý, casne diagnostikovaný entrapment syndrom.

The authors describe the case of a 32-year-old man with intermittent claudications. Large abnormal muscular structures were found in the popliteal regions, incl. a secondary pterygium on the right. On both limbs these muscles arrested by their pressure during contraction the blood flow in the popliteal artery and caused its temporary lateral deviation. The described sings (abnormally large muscles, pterygium, deviation to the their side) differentiate this entrapment syndrome from known patterns of the latter. The syndrome was diagnosed in time before the artery was morphologically altered. The surgical treatment involved an extensive resection of the abnormal muscles and revision of the artery.

[Experience with dilatation of tight esophageal stenoses using a balloon catheter]. / Zkusenosti s dilatací tesných jícnových stenóz balónkovými katétry.

The dilatation of oesophageal stenoses with balloon catheters was made in 38 patients with 44 stenoses of different origin. The most frequent stenosis was localized in oesophagogastric or oesophagocolic anastomosis after oesophagectomy, postcorrosive stenoses an those after reflux oesophagitis. The stenoses were mostly of filiform type, the diameter being 1-3 mm (79%) less frequently 4-7 mm (21%). It became possible to dilate 37 stenoses up to 10 to 20 mm, four stenoses to 22 mm. In only three cases the stenosis was dilated to less than 10 mm. In six patients it proved necessary to repeat the dilatation within one to six-month intervals. The dilatation failed to give positive in one case.

[The significance of digital subtraction angiography in diseases of the lungs and mediastinum]. / Význam digitální subtrakcní angiografie (DSA) u onemocnení plic a mediastina.

The authors present their first experience with lung DSA in a group of 75 patients. The examination was most frequently performed by instilling a contrast medium into central, less frequently into peripheral veins. The most frequent indications included tumorous lung diseases and mediastinal tumours before an operation treatment, a suspected pulmonary embolism, lung and vascular malformation. Intravenous DSA proved to be also useful in the evaluation of pathological changes of thoracic aorta.

[Dilatation technic in esophageal stenoses using a balloon catheter]. / K technice dilatace jícnových stenóz balónkovými katétry.

In dilating oesophageal stenoses by balloon catheters it becomes necessary to adapt the technique of the intervention to the type and degree of stenosis and condition of the patient. The dilatation may be successfully performed even in very narrow postinflammation, postoperation and postcorrosion stenoses. The dilatation is usually performed for the period of 30 minutes, the shortest period between interventions being twice in a week, being followed by weekly or several weeks intervals. In a careful application of the balloon catheters transnasally or transorally it becomes possible to decrease the unpleasant feelings of the patient and possible complications to a minimum.