Influence of inferior petrosal sinus drainage symmetry on detection of adenomas in Cushing's syndrome.

BACKGROUND: Asymmetric inferior petrosal sinuses (IPS) are not infrequently encountered during bilateral IPS sampling. There is little data on whether IPS symmetry influences success in predicting the adenoma side in patients with ACTH-dependent Cushing's syndrome (CS). OBJECTIVE: To assess the influence of IPS drainage patterns on detection of an adenoma in CS. METHODS: Retrospective single-center cohort analysis reviewing records of patients with CS and negative MRI findings who subsequently underwent BIPSS. RESULTS: BIPSS was performed in 38 patients with a mean age of 45±15 years. The overall technical success rate was 97% for bilateral cannulation. Asymmetric IPS were observed in 11 (39%) patients with Cushing's disease (CD). A side-to-side ACTH ratio was not significantly different between patients with symmetric outflow and those with asymmetric outflow at baseline (8.6±2.7 versus 16.4±6.0; P=0.45), but ratios were significantly different after ovine corticotropin-releasing hormone (oCRH) stimulation (6.0±2.5 versus 35.7±22.5; P=0.03). BIPSS correctly predicted the side of the adenoma in 25 (96%) patients with CD. Prediction was better when the venous outflow was symmetric (100%) rather than asymmetric (93%), although the difference was not significant (P=0.42). Remission from CS was achieved in 32 patients (87%), independent of the symmetry of IPS. CONCLUSIONS: Bearing in mind the sample size of this audit, asymmetric IPS at least do not seem to diminish the accuracy of diagnosis of ACTH-dependent CS, nor do they influence the clinical outcome.

Low-profile titanium mesh in the use of orbital reconstruction: A pilot study.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to share our clinical experience in the use and accuracy of a newly designed, low-profile titanium mesh (Modus OPS 1.5; Medartis, Basel, Switzerland) for primary internal orbital reconstruction. STUDY DESIGN: Observational study. METHODS: This study was conducted at the Department of Cranio-Maxillofacial Surgery at the University Hospital of Bern, Switzerland, starting November 2008. Patients were included who had a defect size of ≥2 cm(2) or fractures of more than one wall. The operations were performed within 14 days after trauma. To repair the orbital fracture, a newly designed titanium mesh was applied. The technical innovation in regard to these plates is the low-profile height of 0.25 mm along the border and 0.2 mm in the mesh area. Two different sizes of two different types of mesh are available for reconstruction. Preoperative computed tomography (CT) scans were obtained to assess the fracture size and location. A maxillofacial surgeon performed pre- and postoperative assessments (at 2 weeks, 12 weeks, and 6 months). Ophthalmologic assessments were performed preoperatively and 6 months after the operation. Postoperative CT scans were obtained within 12 weeks after the operation and the orbital volumes analyzed by a radiologist. RESULTS: Twenty-seven patients underwent surgery (11 female; average age, 55.2 years). Final postoperative ophthalmologic follow-up was obtained at a mean of 8.8 months (range, 4.0-20.1 months). Twenty-five patients (93%) had a successful treatment outcome without complications. In two patients, the plate was buckled in the posterior edge region and had to be replaced. Surgical revision was performed within 3 weeks after the first procedure. These patients showed good clinical and radiologic outcome after the second procedure. At the final assessment, none of the patients had experienced diplopia. Three patients showed slight enophthalmos (2-mm side difference), however, without any subjective functional or aesthetic concerns. According to the literature, an average orbital volume difference of up to 1.95 cm(3) is normal. In our study, radiologic volume assessment showed a side difference of ≥2 cm(3) in four patients, of which one patient presented with a clinically detectable enophthalmos. CONCLUSIONS: The newly designed, thin titanium mesh is a reliable and safe implant for the repair of orbital defects. Owing to insufficient intraoperative control, two plates showed buckling at the posterior border, which made a repair necessary. Awareness of this problem may avoid such complications in the future. However, it would seem reasonable to improve the stability of the mesh by increasing the profile height, to minimize potential complications.

Repair of orbital floor fractures using bioresorbable poly-L/DL-lactide plates.

OBJECTIVE: To assess the long-term clinical and radiologic findings after insertion of a bioresorbable polylactide plates P(L/DL)LA 70/30 implant (PolyMax) in the repair of orbital floor and wall defects, with special focus on stability and clinical signs of foreign-body reaction. METHODS: Forty-six patients who had orbital blowout fractures with at least 1.5-cm(2) bone defects in 1 or 2 walls were included in this retrospective study. Each defect was reconstructed within 2 weeks of injury using a triangle form plate of polylactide. Computed tomography (CT) was performed before the operation and 1 year postoperatively. In 17 patients, additional CT was performed within 2 to 3 years postoperatively. Clinical assessments were performed preoperatively and at 3-, 6-, and 12-month intervals postoperatively. RESULTS: None of the patients showed clinical foreign-body reactions. There was no evidence of infection. Diplopia was seen in 6 patients 3 months postoperatively but normalized in 5 patients at 6 months. Mild enophthalmos was seen in 2 patients postoperatively at 1 year. No sagging of the reconstructed area was found on CT. CONCLUSIONS: The P(L/DL)LA 70/30 implant is a well-tolerated, reliable material in orbital repair of relatively large defects. The bioresorbable plate leaves a stable bridge of healed bone or soft tissue after complete degradation.

Venous thromboembolism and occult malignancy: simultaneous detection during pulmonary CT angiography with CT venography.

OBJECTIVE: We explored the potential for patients with proven venous thromboembolism or pulmonary embolism (PE) to have occult malignancies detected during the same CT examination. To verify this, we compared the presence of occult malignancies identified on pulmonary artery CT angiography (CTA) and CT venography (CTV) when venous thromboembolism (VTE) was present. SUBJECTS AND METHODS: Pulmonary artery CTA combined with CTV was performed on a 16-MDCT scanner on 186 adult patients suspected of having pulmonary embolism without any known malignancies. CTV was performed from the diaphragm to the knee 180 seconds after CTA. Two radiologists evaluated the presence of VTE, that is PE or deep venous thrombosis (DVT), and tumor lesions on both examinations in consensus. The malignant nature of the possibly identified tumors was confirmed by pathologic examination. RESULTS: VTE was found in 49 patients (26%). Malignant tumors were detected in 24 patients (13%). Eleven patients with malignant tumors had VTE (46% of patients with malignant tumors; 22% with VTE and 6% of all patients). There was correlation with presence of malignancies between both and DVT and DVT associated with PE but not between presence of malignancies and PE only. Patients with DVT and those with DVT associated with PE had a risk ratio of 3.2 and 3.3, respectively, for having a malignant tumor discovered simultaneously. CONCLUSION: A high number of malignant tumors can be incidentally discovered on pulmonary artery CTA, even more so with additional CTV. Radiologists should scrutinize scans to pick up unknown malignancies, especially in patients with identified VTE.

Disorders of paravertebral lumbar muscles: from pathology to cross-sectional imaging.

Paravertebral lumbar muscles are important for spine stabilization and mobility. They may be abnormal in several disorders that may be associated with pain or functional impairment. Special attention should be paid to the paravertebral muscles during imaging, so that a possible muscular disease is not overlooked, especially in patients with low back pain. This article reviews such imaging abnormalities.

Effects of probucol versus aspirin and versus brachytherapy on restenosis after femoropopliteal angioplasty: the PAB randomized multicenter trial.

PURPOSE: To evaluate the effect of probucol and/or of endovascular brachytherapy (EVBT) on restenosis after percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries. METHODS: A total of 335 patients (206 men; mean age 72+/-9 years) with intermittent claudication were randomized according to a 2x2 factorial design to 1 of the 4 groups: probucol, placebo, EVBT, and EVBT+probucol. Probucol (1 g/d) or placebo were given in double-blinded fashion 1 month before and for 6 months after PTA. Gamma irradiation (192Iridium, 14 Gy, 5-mm reference depth) was randomly applied in an unblinded manner from a noncentered endoluminal catheter. All patients received aspirin (100 mg/d). Primary endpoint was restenosis (>50% diameter reduction) detected by duplex ultrasound 6 months after PTA. Secondary endpoints included clinical and hemodynamic assessment. RESULTS: Restenosis in patients undergoing EVBT was 17% (23/133) versus 35% (50/142) in patients without EVBT (p<0.001); in patients treated with probucol versus placebo, the rates were 23% (31/135) and 30% (43/140, p<0.001). Three quarters (77%, 102/133) of patients were free of claudication after EVBT therapy versus 61% (87/142) without EVBT (p<0.05). Need for target vessel revascularization was 6% (8/133) with EVBT versus 14% (20/142) without EVBT (p<0.01). Late thrombotic occlusions occurred in 4% (6/133), exclusively in patients treated with EVBT after stent implantation. CONCLUSIONS: Endovascular brachytherapy significantly reduces restenosis, improves symptoms, and reduces reinterventions after PTA of femoropopliteal arteries. Probucol reduces restenosis but has no additive effect when combined with brachytherapy.