Bloqueo del ganglio estrellado como terapia de rescate en el vasoespasmo refractario tras hemorragia subaracnoidea / Stellate ganglion block as rescue therapy in refractory vasospasm after subarachnoid hemorrhage

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Computed tomography perfusion usefulness in early imaging diagnosis of herpes simplex virus encephalitis.

An early diagnosis is crucial in herpes simplex virus encephalitis patients in order to institute acyclovir therapy and reduce mortality rates. Magnetic resonance imaging (MRI) is considered the gold standard for evaluation of these patients, but is frequently not available in the emergency setting. We report the first case of a computed tomography (CT) perfusion study that helped to establish a prompt diagnosis revealing abnormal increase of blood flow in the affected temporoparietal cortex at an early stage.

The European Multiple System Atrophy-Study Group (EMSA-SG).

Introduction. The European Multiple System Atrophy-Study Group (EMSA-SG) is an academic network comprising 23 centers across Europe and Israel that has constituted itself already in January 1999. This international forum of established experts under the guidance of the University Hospital of Innsbruck as coordinating center is supported by the 5th framework program of the European Union since March 2001 (QLK6-CT-2000-00661). Objectives. Primary goals of the network include (1) a central Registry for European multiple system atrophy (MSA) patients, (2) a decentralized DNA Bank, (3) the development and validation of the novel Unified MSA Rating Scale (UMSARS), (4) the conduction of a Natural History Study (NHS), and (5) the planning or implementation of interventional therapeutic trials. Methods. The EMSA-SG Registry is a computerized data bank localized at the coordinating centre in Innsbruck collecting diagnostic and therapeutic data of MSA patients. Blood samples of patients and controls are recruited into the DNA Bank. The UMSARS is a novel specific rating instrument that has been developed and validated by the EMSA-SG. The NHS comprises assessments of basic anthropometric data as well as a range of scales including the UMSARS, Unified Parkinson's Disease Rating Scale (UPDRS), measures of global disability, Red Flag list, MMSE (Mini Mental State Examination), quality of live measures, i.e. EuroQoL 5D (EQ-5D) and Medical Outcome Study Short Form (SF-36) as well as the Beck Depression Inventory (BDI). In a subgroup of patients dysautonomic features are recorded in detail using the Queen Square Cardiovascular Autonomic Function Test Battery, the Composite Autonomic Symptom Scale (COMPASS) and measurements of residual urinary volume. Most of these measures are repeated at 6-monthly follow up visits for a total study period of 24 months. Surrogate markers of the disease progression are identified by the EMSA-SG using magnetic resonance and diffusion weighted imaging (MRI and DWI, respectively). Results. 412 patients have been recruited into the Registry so far. Probable MSA-P was the most common diagnosis (49% of cases). 507 patients donated DNA for research. 131 patients have been recruited into the NHS. There was a rapid deterioration of the motor disorder (in particular akinesia) by 26.1% of the UMSARS II, and - to a lesser degree - of activities of daily living by 16.8% of the UMSARS I in relation to the respective baseline scores. Motor progression was associated with low motor or global disability as well as low akinesia or cerebellar subscores at baseline. Mental function did not deteriorate during this short follow up period. Conclusion. For the first time, prospective data concerning disease progression are available. Such data about the natural history and prognosis of MSA as well as surrogate markers of disease process allow planning and implementation of multi-centre phase II/III neuroprotective intervention trials within the next years more effectively. Indeed, a trial on growth hormone in MSA has just been completed, and another on minocycline will be completed by the end of this year.

A comparative study of magnetic resonance cholangiography and direct cholangiography.

OBJECTIVE: Magnetic resonance cholangiopancreatography (MRCP) is a rapidly developing method for the noninvasive assessment of the biliary tree and pancreatic duct that obviates the need for contrast medium. We describe our experience with this new diagnostic imaging method in patients with obstruction of the biliary tree. We assessed both the location and cause of obstruction, and compared the results with direct cholangiography. METHODS: Between 1997 and 1998, 81 patients underwent MRCP at our facility. Two different image acquisition protocols (half-Fourier acquisition single-shot turbo spin-echo -HASTE- and rapid acquisition with relaxation enhancement -RARE-) for T2-weighted turbo spin echo sequences as well as cross-sectional fast multiplanar gradient-echo pulse (T1-weighted FL2D) and T2-weighted fast spin echo (T2 TSE) sequences were used. All patients underwent direct (either percutaneous or endoscopic retrograde) cholangiography or surgery for confirmation and/or treatment. The images obtained with MRCP were evaluated by two radiologists with expertise in biliary tree imaging who were unaware of the patient's clinical characteristics, and their diagnostic interpretations were compared with the findings obtained upon surgery or direct cholangiography. RESULTS: The sensitivity and specificity of MRCP in ruling out pathologies and detecting the presence of dilatation of the biliary tree were 100%. In assessing the level of the obstruction, sensitivity and specificity varied with location (intrahepatic/hilar, suprapancreatic, intrapancreatic or ampullary). Sensitivity in these locations was 100, 92, 69 and 86%, respectively, whereas specificity was 100, 94, 92 and 91%, respectively. In determining the cause of the obstruction, the results were variable depending on the cause: choledocholithiasis (sensitivity, 89%; specificity, 90%) malignant obstruction (sensitivity, 92%; specificity, 88%), benign stricture (sensitivity, 63%; specificity, 90%), and chronic pancreatitis (sensitivity, 50%; specificity, 99%). CONCLUSIONS: MRCP offered high diagnostic accuracy in the assessment of the occurrence and location of biliary obstruction. Sensitivity and specificity in establishing the cause varied, and were highest for choledocholithiasis and malignant obstruction. MRCP may be used instead of ERCP, which may then be reserved for patients who are likely to require surgery.

Valoración actual de la colangiografia por resonancia magnética. Estudio comparativo con la colangiografía directa / A comparative study of magnetic resonance cholangiography and direct cholangiography

Objetivo: la colangiopancreatografía por resonancia magnética (CPRM) es una técnica en rápido desarrollo que permite valorar la vía biliar y pancreática de forma no invasiva sin necesidad de administrar contraste. Describimos nuestra experiencia en la utilización de este nuevo método de imagen en el diagnóstico de la obstrucción de la vía biliar, de su localización y de su causa comparándolo con la conlangiografía directa. Material y métodos: durante el período 1997-1998 se estudiaron en nuestro Servicio 81 pacientes con CPRM mediante dos formas distintas de adquisición de imágenes turbo spin echo en T2 (HASTE y RARE), junto a secuencias T1 F12D y T2 TSE transversas de abdomen. Todos ellos tuvieron confirmación diagnóstica posterior mediante colangiografía directa (retrógrada endoscópica o percutánea) o cirugía. Las imágenes de CPRM fueron evaluadas de forma ciega por dos radiólogos expertos en imagen de la vía biliar y su impresión diagnóstica comparada con el resultado de las pruebas confirmatorias. Resultados: la sensibilidad y especificidad de la CPRM para descartar patología y para detectar la presencia de dilatación de la vía biliar fueron del 100 por ciento. Para localizar el nivel de obstrucción, dependiendo de la localización; intrahepática/hiiar, suprapancreática, intrapancreática y ampular la sensibilidad fue del 100, 92, 69 y 86 por ciento y la especificidad del 100, 94, 92 y 91 por ciento, respectivamente. Para definir la causa de la obstrucción los resultados dependieron de las distintas etiologías: coledocolitiasis (S: 89 por ciento; E:90 por ciento), obstrucción maligna (S: 92 por ciento; E:88 por ciento), estenosis inflamatoria (S: 63; E:90 por ciento) y pancreatitis crónica (S: 50 por ciento; E:99 por ciento). Conclusiones: la CPRM posee una alta fiabilidad diagnóstica para evaluar la presencia y el nivel de obstrucción maligna. Puede utilizarse en el lugar de la CPRE diagnóstica, quedando esta última técnica reservada para cuando se tenga una alta sospecha de que será necesario realizar un procedimiento terapéutico (AU)

[The association of pelvic injuries with urethral ruptures]. / Asociación de los traumatismos pélvicos con las roturas de uretra.

INTRODUCTION: Pelvic trauma is associated in a high rate of patients with posterior urethral injuries. Blood at the urethral meatus or the inability to void are suspicious of urethral damage, but their absence do not exclude it. The attempt to pass a urethral catheter can worse a previous injury. METHOD: Retrospective study of 565 pelvic trauma along the last 5 years in the Hospital Valdecilla of Santander. We asses the urethral injury according Colapinto and McCallum classification and their relationship with the pelvic trauma, their outcome and diagnosis methodology. RESULTS: There was 60 urethral injuries among 565 pelvic trauma (10.61%); 15 (25%) grade I were associated with trauma of the posterior ring of the pelvis; 17 (28.3%) grade II were associated in 12 cases with fractures of the anterior ring and in 5 cases with severe fractures of the posterior ring; 28 (46.66%) grade III were associated in 26 cases with fractures of the anterior ring and 2 fracture-luxation of the posterior one. Against the suggest of avoiding the attempt of passing a urethral catheter, nearly all patients had suffered and attempt before the urologist were asked for. The deferred combined urethrography was the best method of urethral evaluation.