Predictive Parameters in Patients Undergoing Percutaneous Hepatic Perfusion with Melphalan for Unresectable Liver Metastases from Uveal Melanoma: A Retrospective Pooled Analysis.

PURPOSE: The aim of this study was to identify positive predictors for survival in uveal melanoma (UM) patients treated with percutaneous hepatic perfusion with melphalan (M-PHP), by retrospectively pooling data from three centers. MATERIALS AND METHODS: Retrospective analysis including patients ([Formula: see text] 18 years) treated with M-PHP between February 2014 and December 2019 for unresectable liver-dominant or liver-only metastases from UM. Predictors for OS were assessed using uni- and multivariate analyses. Other study outcome measures were response rate, progression-free survival (PFS), liver progression-free survival (LPFS), overall survival (OS) and complications according to CTCAEv5.0. RESULTS: In total, 101 patients (47.5% males; median age 59.0 years) completed a minimum of one M-PHP. At a median follow-up time of 15.0 months, complete response (CR), partial response (PR), stable disease (SD) and progressive disease were seen in five (5.0%), 55 (54.5%), 30 (29.7%) and 11 (10.9%) patients, respectively, leading to a 89.1% disease control rate. Median PFS, LPFS and OS were 9.0, 11.0 and 20.0 months, respectively. Survival analyses stratified for radiological response demonstrated significant improved survival in patients with CR or PR and SD category. Treatment of the primary tumor with radiotherapy, ≥ 2 M-PHP and lactate dehydrogenase (LDH) < 248 U/L were correlated with improved OS. Thirty-day mortality was 1.1% (n = 2). Most common complication was hematological toxicity (self-limiting in most cases). CONCLUSION: M-PHP is safe and effective in patients with UM liver metastases. Achieving CR, PR or SD is associated with improved survival. Primary tumor treatment with radiotherapy, normal baseline LDH and > 1 M-PHP cycles are associated with improved OS.

Unresectable Hepatic Metastasis of Uveal Melanoma: Hepatic Chemosaturation with High-Dose Melphalan-Long-Term Overall Survival Negatively Correlates with Tumor Burden.

INTRODUCTION: Percutaneous hepatic perfusion with melphalan (PHP-M) for hepatic metastasis of uveal melanoma (LMUM) achieves high local response rates, but the individual clinical benefit is poorly defined. We aimed to determine cofactors of response and clinical outcomes including the probability of long-term (5-years) overall survival (OS) in PHP-M-treated patients with LMUM. Patients and Methods. We retrospectively reviewed clinicopathological, radiological, and outcome data of 19 patients with unresectable LMUM treated with 43 PHP-M (median 2 PHP-M) between 2014 and 2019. Tumor response and adverse events were evaluated using RECIST 1.1 and the Clavien-Dindo classification. Kaplan-Meier methods and Cox regression hazard proportional models were used. RESULTS: Of 19 patients, 10 (53%) achieved a partial response (PR) and 9 (47%) had stable disease (SD). There was no progressive disease (PD) and no adverse events exceeding Clavien-Dindo grade IV. Median OS was 16.7 months after the first PHP-M treatment and 26.4 months after initial diagnosis. Low hepatic tumor volume (median of 10 mL vs. 150 mL) was an independent predictor of favorable OS (hazard ratio (95% confidence interval): 0.190 (0.041, 0.893); p < 0.05), and female patients were at a lower risk compared with males (0.146 (0.017, 1.240)). Estimates of the overall survival were 0.213 (0.0449, 1) from first imaging (95% confidence interval) to 5 years and 0.793 (0.609, 1) and 0.604 (0.380, 0.960) for 1 and 2 years after chemosaturation, respectively. Discussion. PHP-M for nonresectable LMUV provides a safe and locally efficient liver-directed procedure that offers patients a chance for long-term OS, especially for patients with a low hepatic tumor burden.

Recurrent stenosis following carotid artery stenting treated with a drug-eluting balloon: a single-center retrospective analysis.

PURPOSE: Early in-stent restenosis after stent-protected angioplasty of the carotid artery (SPAC) is an infrequent, but potentially harmful condition for patients with carotid artery disease. METHODS: In our retrospective single-center analysis of 176 patients with carotid artery stenting between 2009 and 2015, using duplex ultrasound, we detected 9 patients with high-grade carotid artery in-stent restenosis. All restenosis patients were treated with a drug-eluting balloon (DEB) to prevent recurrent neointimal hyperplasia. One patient had bilateral carotid artery disease with bilateral in-stent restenosis, and 1 patient needed repeated DEB treatment 19 months after the first DEB intervention, so 11 DEB procedures, in total, were performed. RESULTS: The median time-interval between primary carotid artery stenting and first DEB-treatment was 9 months. In 3 of the 11 interventions, the DEB treatment was assisted by an additional stent. One repeat DEB treatment was necessary, and three DEB treatments were followed by a secondary stent. No peri-interventional complications (TIA, stroke, or death) were observed during or after DEB intervention. Therefore, in the entire group, the 1y event-free survival (EFS) was 100%, and the 2y/3y/5y EFS was 83%. CONCLUSION: DEB intervention seems to be an effective and safe treatment for patients with high-grade in-stent restenosis after SPAC.

Mechanical Recanalization following i.v. Thrombolysis: A Retrospective Analysis regarding Secondary Hemorrhagic Infarctions and Parenchymal Hematomas.

Introduction. In acute stroke by occlusion of the proximal medial cerebral artery (MCA) or the distal internal carotid artery, intravenous thrombolysis is an established treatment. Another option is mechanical recanalization. It remains unclear if the combination of both methods poses an additional bleeding risk. The aim of this retrospective analysis is to determine the proportion of hemorrhagic infarctions and parenchymal hematomas. Methods. Inclusion criteria were an occlusion of the carotid T or proximal MCA treated with full dose thrombolysis and mechanical recanalization. 31 patients were selected. Devices used were Trevo, Penumbra Aspiration system, Penumbra 3D Retriever, and Revive. The initial control by computed tomography was carried out with a mean delay to intervention of 10.9 hours (SD: 8.5 hours). Results. A slight hemorrhagic infarction (HI1) was observed in 2/31 patients, and a more severe HI2 occurred in two cases. A smaller parenchymal hematoma (PH1) was not seen and a space-occupying PH2 was seen in 2/31 cases. There was no significant difference in the probability of intracranial bleeding after successful (thrombolysis in cerebral infarctions 2b and 3) or unsuccessful recanalization. Conclusion. The proportion of intracranial bleeding using mechanical recanalization following intravenous thrombolysis appears comparable with reports using thrombolysis alone.

Altered skin flowmotion in hypertensive humans.

Essential hypertensive humans exhibit attenuated cutaneous nitric oxide (NO)-dependent vasodilation. Using spectral analysis (fast Fourier transformation) we aimed to characterize the skin flowmotion contained in the laser-Doppler flowmetry recordings during local heating-induced vasodilation before and after concurrent pharmacological inhibition of nitric oxide synthase (NOS) in hypertensive and age-matched normotensive men and women. We hypothesized that hypertensive subjects would have lower total power spectral densities (PSDs), specifically in the frequency intervals associated with intrinsic endothelial and neurogenic control of the microvasculature. Furthermore, we hypothesized that NOS inhibition would attenuate the endothelial frequency interval. Laser-Doppler flowmetry recordings during local heating experiments from 18 hypertensive (MAP: 108±2mmHg) and 18 normotensive (MAP: 88±2mmHg) men and women were analyzed. Within site NO-dependent vasodilation was assessed by perfusion of a non-specific NOS inhibitor (N(G)-nitro-l-arginine methyl ester; l-NAME) through intradermal microdialysis during the heating-induced plateau in skin blood flow. Local heating-induced vasodilation increased total PSD for all frequency intervals (all p<0.001). Hypertensives had a lower total PSD (p=0.03) and absolute neurogenic frequency intervals (p<0.01) compared to the normotensives. When normalized as a percentage of total PSD, hypertensives had reduced neurogenic (p<0.001) and augmented myogenic contributions (p=0.04) to the total spectrum. NOS inhibition decreased total PSD (p<0.001) for both groups, but hypertensives exhibited lower absolute endothelial (p<0.01), neurogenic (p<0.05), and total PSD (p<0.001) frequency intervals compared to normotensives. These data suggest that essential hypertension results in altered neurogenic and NOS-dependent control of skin flowmotion and support the use of spectral analysis as a non-invasive technique to study vasoreactivity.

[Clinical symptoms, treatment and outcome of EHEC and EHEC-HUS patients treated as in-patients]. / Klinische Symptomatik, Therapie und Verlauf Stationär Behandelter EHEC/EHEC-HUS Patienten.

BACKGROUND AND OBJECTIVE: From May to June 2011 an outbreak of Shiga-toxin-producing Escherichia coli (EHEC) infections occurred in northern Germany leading to a great number of patients with hemolytic-uremic syndrome (HUS). A monocentric case series from Hamburg is described. MATERIAL AND METHODS: All patients at that time presenting with acute diarrhoea at the Asklepios Clinic Barmbek in Hamburg were proved for EHEC infections. Clinical data of EHEC and EHEC-HUS patients treated as in-patients as well as stool analysis and laboratory results were documented. RESULTS: In total, 117 patients suspicious to have EHEC infection were treated as in-patients. In 68 patients an EHEC infection (n = 36) or HUS (n = 32) could be confirmed. Additional infections with other diarrhoea-causative organism could be revealed in 23 of these 68 patients (34 %). The median age of the HUS patients was 44 years being significantly lower compared to the age of EHEC patients without HUS (51 years, p = 0,04). In the group of HUS patients there were significantly more women (26/32 vs. 21/36, p = 0.03). 19 patients with HUS dialysis was necessary. In total, a number of 248 plasma separations were required. 18 patients developed severe neuro-psychiatric symptoms. One patient died. CONCLUSION: This monocentric case series describes one of the so far largest published series of mostly young and female patients with EHEC and EHEC-HUS.

Contrast-enhanced magnetic resonance angiography in stroke diagnostics: additional information compared with time-of-flight magnetic resonance angiography?

PURPOSE: The aim of this study was a comparison of the diagnostic value of time-of-flight magnetic resonance angiography (TOF-MRA) and contrast-enhanced (CE) MRA in the setting of acute stroke MRI. The hypothesis was that CE-MRA has at least the same diagnostic value as the commonly used TOF-MRA. MATERIALS AND METHODS: A total of 66 stroke patients underwent MRI up to 24 h after symptom onset and again after 3­6 days. Primary slices and maximum intensity projections (MIP) of both techniques were evaluated separately and in combination by two readers in consensus. The quality of imaging and degree of vascular pathologies were evaluated. RESULTS: Out of 109 examinations 105 could be evaluated. There were no significant differences in imaging quality in normal vascular segments. For arterial segments distal to an occlusion CE-MRA allowed better visualization of vessels than TOF-MRA. A combined evaluation of both techniques allowed a significantly better assessment than evaluation of images by one technique alone. In contrast to TOF-MRA, CE-MRA included extracranial segments. CONCLUSION: CE-MRA and TOF-MRA do not differ regarding the evaluation of normal intracranial vessels. CE-MRA provides the advantage of good visualization of vessels distal to occluded segments. Furthermore CE-MRA allows visualization of extracranial vessels and faster image acquisition. TOF-MRA can be equivalently used if the administration of contrast agents is not possible.

Management of renal artery pseudoaneurysm after partial nephrectomy.

PURPOSE: Nephron sparing surgery has been established as a standard treatment for renal masses smaller than 4 cm in diameter. The benefit of nephron sparing surgery may be hampered by new types of complications. In particular, postoperative gross hematuria due to the formation of renal artery pseudoaneurysm (RAP) can lead to clinical significant hemorrhage. We retrospectively investigated the occurrence of postoperative RAP in our own consecutive series of open/laparoscopic partial nephrectomies requiring transarterial angioembolization. METHODS: Open partial nephrectomy (OPN) was performed in 289 patients, and laparoscopic partial nephrectomy (LPN) in 40 patients. Six patients (1.82%) developed postoperative clinical symptomatic, persistent gross hematuria from RAP. Patient files were evaluated for preoperative, operative and postoperative data. RESULTS: First symptom presentation was observed at a median of 12.5 days (range 6-36) after surgery. Symptoms were flank pain, gross hematuria, dizziness/syncope and/or fever. Median postoperative blood transfusion rate was 3 units (range 0-8). RAP was proven with angiography in all patients. RAP was sufficiently occluded in all patients by using microcoils in a supraselective approach. Median follow-up was 23 months (range 10-37) without any episodes of hemorrhage/flank pain in each patient. CONCLUSIONS: RAP is a rare, but typical complication after partial nephrectomy. The clinical symptoms present with delay. Angiography identifies the origin of the bleeding and provides successful minimally invasive treatment.

[Central positional vertigo due to cerebellar nodular infarction]. / Lagerungsschwindel bei zerebellärem Nodulusinfarkt.

Nodular infarctions are a rare cause of vertigo and may imitate vestibular neuritis. We report on two patients with acute positional vertigo due to nodular infarction, a clinical presentation is not reported so far. High-resolution MR imaging using thin slices is required to identify isolated nodular infarctions.

[Neurolymphomatosis. Subacute sensorimotor polyneuropathy as a first sign of non-Hodgkin's B cell lymphoma]. / Neurolymphomatose. Subakute sensomotorische Polyneuropathie als Erstmanifestation eines Non-Hodgkin-B-Zell-Lymphoms.

We report on a 65-year-old patient with subacute painful sensorimotor polyneuropathy with distal leg muscle palsy and initially presenting with bilateral leg edema. Electrophysiologic testing showed an axonal lesion pattern with acute denervation. Nerve biopsy demonstrated neurolymphomatosis as an initial manifestation of a non-Hodgkin's B cell lymphoma.

Micro-Raman spectroscopy study of colloidal crystal films of polystyrene-gold composites.

Monolayers and multilayers of polystyrene (PS)-gold composite films prepared by two different deposition methods have been investigated by atomic force microscopy (AFM), scanning electron microscopy (SEM), X-ray diffraction (XRD), and confocal Raman microspectroscopy. The intensity of the 1001 cm(-1) ring breathing mode of PS is used to evaluate the degree of ordering of monolayers and multilayers within a colloidal crystal. The depth profiling capability of confocal Raman microscopy is used to probe the regions inside the fractures in multilayered films. The intensity profile of the 1001 cm(-1) peak revealed the presence of fractures of different shapes with some PS microspheres at the bottom of the fracture. A strong increase in the Raman intensity (by 10(3) times) has been observed when probing the regions where Au nanoparticles are concentrated in aggregates of different shapes. This enhancement is attributed to the surface plasmons generated by the periodic structure of the gold nanoparticles.

Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses.

BACKGROUND AND PURPOSE: The diagnosis of cerebral venous and sinus thrombosis (CVST) as a rare but important cause of stroke is challenging. We aimed to investigate the diagnostic value of multidetector-row CT angiography (MDCTA) as a fast and cost-effective imaging tool in diagnosing CVST. MATERIALS AND METHODS: Nineteen patients who presented with clinical symptoms of a possible CVST were included. All patients had received both MDCTA and MR imaging with venous MR-angiography. Three blinded readers were asked to identify the cerebral sinuses and veins in MDCTA and to evaluate the presence of CVST in MDCTA. Consensus reading with interpretation of the MR imaging served to establish the definite diagnosis. RESULTS: The consensus reading revealed CVST in 10 of the 19 patients. With MDCTA, the venous sinuses could be identified in 99.2% and the cerebral veins in 87.6% of cases. The sensitivity and specificity of MDCTA for the diagnosis of CVST were 100%. CONCLUSION: Our study demonstrates that MDCTA provides excellent sensitivity and specificity for the diagnosis of CVST. Further studies are needed to evaluate the diagnostic potential of MDCTA in specific subsets of the general entity of CVST such as cortical venous thrombosis, thrombosis of the cavernous sinus, and thrombosis of the internal cerebral veins.

[Gadolinium enhancement of the cauda equina following ischemia of the lumbar cord]. / Kontrastmittelaufnahme der Cauda equina nach Ischämie im Conus medullaris.

Enhancement of the cauda equina is a well-recognized finding, in particular in patients with inflammatory diseases of the peripheral nervous system. However, we report an unusual case of a woman with an ischemic lesion in the lumbar intumescence who developed enhancement of the cauda equina 18 days after disease onset. Seventy-six days after the onset of illness, contrast uptake was no longer detectable. Severe injury to the motor neurons in the lumbar intumescence was evident clinically and electromyographically. We propose that the enhancement of the cauda equina was due to blood-nerve barrier disruption during Wallerian degeneration following ischemic injury to the motor neurons of the lumbar cord.

[Value of electron beam tomography (EBT)]. / Wertigkeit der Elektronenstrahl-Computertomographie (EBT) -- II. Nichtkardiale Anwendungen und Strahlenexposition.

Electron beam tomography (EBT) has been scientifically evaluated to a much lesser degree for non-cardiac indications than for cardiac purposes. Therefore, four groups of investigators in Berlin (2), Mannheim and Munchen, which were supported by the Deutsche Forschungsgemeinschaft (DFG), included applications outside the heart in their evaluation of EBT technology. EBT has proven useful to look for pulmonary embolism and to assess other vessels (aorta, aortic branches, and intracranial arteries). Imaging of the lung parenchyma benefits from its intrinsic high contrast and from the fast data acquisition of EBT. Limited photon efficiency, higher radiation exposure, increased noise levels and other artifacts, however, markedly reduce the value of EBT for imaging of low contrast objects compared to conventional spiral CT and multislice CT (MSCT), compromising, in particular, the morphologic depiction of parenchymal abdominal organs and the brain. Consequently, scientific studies to further evaluate EBT for scanning of the brain and parenchymal abdominal organs were not pursued. Radiation exposure for non-cardiac EBT studies is up to three times higher than that for respective spiral CT studies, and in children EBT can only be advocated in select cases. Radiation exposure for the various prospectively triggered cardiac examination protocols of EBT is lower than that for conventional coronary angiography. Radiation exposure in cardiac multislice CT exceeds severalfold that of EBT, but the dose efficiency of EBT and MSCT are similar due to higher spatial resolution and less image noise of MSCT. In addition, modifications of MSCT (ECG pulsing) can further reduce radiation exposure to the level of EBT. Technical improvements of the EBT successor scanner "e-Speed" enable faster data acquisition at higher spatial resolution. Within comparative studies, the "e-Speed" will have to prove its value and competitiveness, particularly in comparison with multislice CT. After profound scientific assessment in a multicenter evaluation supported by the Deutsche Forschungsgemeinschaft (DFG) and regardless of the specific suitability of electron beam tomography for various cardiac and some non-cardiac indications, the investigators unanimously find the electron beam tomograph Evolution C150 XP not suitable as a whole body CT scanner.