[Flank pain caused by a renal artery dissection]. / Flankpijn door een nierarteriedissectie.

BACKGROUND: A spontaneous renal artery dissection is a very rare diagnosis. The clinical presentation can vary and its course can be atypical. There are no guidelines available regarding treatment; however, the options are a conservative (medication) or interventional (radiological or surgical) approach. CASE DESCRIPTION: A 45-year-old man presented to the emergency department with hypertensive urgency after earlier episodes of flank pain. The cause appeared to be a spontaneous bilateral renal artery dissection with infarction. After a multidisciplinary consultation, the decision was made to manage the patient conservatively since symptoms had subsided, blood pressure was acceptable and renal function remained stable. Eventually, kidney function restored to normal and CT images showed almost complete recovery of the previously damaged renal parenchyma. CONCLUSION: This case demonstrates that in the event of renal artery dissection, a conservative medication policy may be a good option in clinically stable patients with non-deteriorating renal function. Timely recognition and adequate follow-up are important to prevent serious complications, such as renal ischaemia or renal infarction that could necessitate a nephrectomy.

The effect of ultrasound on osteogenesis in the vertically distracted edentulous mandible: a double-blind trial.

Whether low intensity pulsed ultrasound therapy stimulates osteogenesis in mandibular distraction was investigated in a double-blind trial. Nine patients underwent a vertical mandibular distraction over a distance of 5.1+/-1.2mm. Ultrasound or placebo therapy was started daily from the first day of distraction. After 46+/-8.1 days consolidation, two endosseous implants were inserted and a transmandibular biopsy was taken. Ultrasonographs were taken regularly to follow osteogenesis inside the gap. There were no complications during the 44+/-7.1 months of follow-up. Microradiographic measurements of the biopsies revealed no differences in the area of mineralized tissue in the distraction gap. The cranially distracted bone segment appeared significantly more radiolucent than the caudal bone. Histological examination showed large lacunae inside the cranially distracted bone segment, filled with clusters of osteoclasts and surrounded by clear tetracycline double labels. Within the distraction gap, woven bone was present, with no apparent differences between the treatment groups. Ultrasonographic follow-up revealed that osteogenesis inside the distraction gap progresses from 4 to 20 weeks post distraction, with no differences between the ultrasound and the placebo groups. In summary, ultrasound treatment does not appear to stimulate bone formation in the severely resorbed vertical distracted mandible.

Multislice CT angiography in the selection of patients with ruptured intracranial aneurysms suitable for clipping or coiling.

INTRODUCTION: We sought to establish whether CT angiography (CTA) can be applied to the planning and performance of clipping or coiling in ruptured intracranial aneurysms without recourse to intraarterial digital subtraction angiography (IA-DSA). METHODS: Over the period April 2003 to January 2006 in all patients presenting with a subarachnoid haemorrhage CTA was performed primarily. If CTA demonstrated an aneurysm, coiling or clipping was undertaken. IA-DSA was limited to patients with negative or inconclusive CTA findings. We compared CTA images with findings at surgery or coiling in patients with positive CTA findings and in patients with negative and inconclusive findings in whom IA-DSA had been performed. RESULTS: In this study, 224 consecutive patients (mean age 52.7 years, 135 women) were included. In 133 patients (59%) CTA demonstrated an aneurysm, and CTA was followed directly by neurosurgical (n = 55) or endovascular treatment (n = 78). In 31 patients (14%) CTA findings were categorized as inconclusive, and in 60 (27%) CTA findings were negative. One patient received surgical treatment on the basis of false-positive CTA findings. In 17 patients in whom CTA findings were inconclusive, IA-DSA provided further diagnostic information required for correct patient selection for any therapy. Five ruptured aneurysms in patients with a nonperimesencephalic SAH were negative on CTA, and four of these were also false-negative on IA-DSA. On a patient basis the positive predictive value, negative predictive value, sensitivity, specificity and accuracy of CTA for symptomatic aneurysms were 99%, 90%, 96%, 98% and 96%, respectively. CONCLUSION: CTA should be used as the first diagnostic modality in the selection of patients for surgical or endovascular treatment of ruptured intracranial aneurysms. If CTA renders inconclusive results, IA-DSA should be performed. With negative CTA results the complementary value of IA-DSA is marginal. IA-DSA is not needed in patients with negative CTA and classic perimesencephalic SAH. Repeat IA-DSA or CTA should still be performed in patients with a nonperimesencephalic SAH.

Image guided surgery: new technology for surgery of soft tissue and bone sarcomas.

AIM: Providing the surgical oncologist with a new means of performing safe and radical sarcoma surgery with the help of image guidance technology. METHOD: Two patients with pelvic sarcomas were operated upon with the help of an intra-operative navigation system. The technology of image guided surgery is described in one patient with a retroperitoneal sarcoma invading the bony pelvis and another patient with a chondrosarcoma of the iliac crest. RESULTS: We show that this new procedure enables optimal radical surgical resection with minimal treatment related morbidity or loss of function. CONCLUSION: Image guided surgery is a new technical tool in sarcoma surgery.

[Acute renal failure, renal artery stenosis and angiotensin-converting enzyme (ACE) inhibitor]. / Akutt nyresvikt, nyrearteriestenose og angiotensinkonvertase (ACE)-hemmer.

BACKGROUND: Acute renal failure is a well-known complication in patients with renal artery stenosis during treatment with ACE inhibitor. Renal artery thrombosis after withdrawal of ACE inhibitor has not been reported previously. MATERIAL AND METHODS: We describe a patient with acute renal failure with an unexpected course. RESULTS: A 67-year-old man was admitted with acute anuric renal failure during treatment with hydrochlorothiazide and enalapril. His blood pressure was 165/60 mm Hg. Renal ultrasound was normal. After initial rehydration and dialysis, diuresis resumed until a sudden unexpected anuric renal failure recurred on day 12. Angiography disclosed bilateral renal artery occlusion. The right renal artery was successfully opened and a stenosis was blocked and stented, and brisk diuresis ensued. Two days later hypertension accelerated, and a new invasive procedure on day 24 succeeded in opening, blocking and stenting a proximal stenosis in the left artery; a mobile thrombus was located behind the stenosis and successfully treated with intraarterial thrombolysis. Blood pressure rapidly normalized, and serum creatinine was normal on visits 1.5 and 4 months later. INTERPRETATION: General aspects and prevention of acute renal failure during ACE inhibitor therapy are discussed. Acute renal thrombosis after withdrawal of ACE inhibitor in patients with stimulated renin angiotensin system and significant renal artery stenosis may be causally related to the antifibrinolytic effects of angiotensin II and aldosterone. Endovascular reconstruction of renal artery occlusion may completely restore the kidney function.