Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course and prognosis.

We reviewed the clinical and radiological findings of 93 consecutive patients with 111 extracranial internal carotid (ICAD) and vertebral artery (VAD) dissections and one concomitant intracranial VAD; 83% of the patients had unilateral and 17% multiple vessel dissections. The diagnosis was made by intra-arterial digital subtraction angiography in 92 patients and MR angiography in one. Follow-up angiography was performed in 77 cases (83%): of 49 initially stenotic arteries, 40 became completely or almost completely normal, while three showed slight improvement. Of 30 initially occluded arteries, nine had completely or partly recanalised. Of 12 pseudoaneurysms eight were unchanged at follow-up. The proximal vertebral artery was involved as often as the C1-C2 level. Recurrences were rare: a new dissection in another vessel was found in three patients. Kinking or coiling was found in 23% of the dissected internal carotid arteries.

Endovascular treatment of aortic aneurysms in Finland: the first four years' experience.

BACKGROUND AND AIMS: In this study the results of endovascular treatment of aortic aneurysms in Finland are presented and compared to the results of the Eurostar registry. MATERIAL AND METHODS: A total of 229 patients with aortic aneurysm were treated in five different Finnish centres during 1996-2000. The data of these patients were collected prospectively by surgeon or interventional radiologist involved. During the same period of time 2464 patients were registered in the Eurostar registry. RESULTS: The procedure was performed successfully in 97% of patients in Finland, and the 30-day mortality was 0,9%. A graft limb thrombosis was detected in 9% of the patients in Finland. A permanent primary endoleak at the first 30-day control was seen in 23 patients (10%). During the follow-up 17 secondary endoleaks (7%) were detected. A secondary intervention was necessary in 26% of the patients. Three patients (1.3%) had late rupture of the abdominal aortic aneurysm. CONCLUSIONS: According to the Finnish short-time results, endovascular treatment of aortic aneurysms is safe and associated with relatively low morbidity and mortality. The mid-term results are more disappointing with relatively many graft thromboses and endoleaks, and a frequent need of secondary interventions.

Treatment of renal cysts with single-session percutaneous drainage and ethanol sclerotherapy: long-term outcome.

OBJECTIVES: To evaluate the safety, efficacy, and long-term outcome of single-session ethanol sclerotherapy for non-neoplastic renal cysts. METHODS: In a prospective study, 32 patients with a simple renal cyst were treated with ultrasound-guided percutaneous aspiration, and no more than 100 mL sterile 99% ethanol was injected into the cyst. The procedure was performed under local anesthesia, and the patients were hospitalized overnight. The serum concentrations of alcohol immediately after the sclerotherapy and 1 hour later and the corresponding urine concentrations were measured. The mean follow-up period was 55 months (range 12 to 156). Control checkups were scheduled at 1, 3, 6, 9, and 12 months after the sclerotherapy. During the control visits, the patients underwent ultrasound measurement of the size of the cyst. The history concerning renal pain especially was evaluated by the urologist. The patients were asked if they did or did not have pain. The severity of pain was not evaluated. RESULTS: Sclerotherapy with ethanol was performed successfully in all 32 patients with a simple renal cyst. The cyst disappeared completely in 7 patients (22%). The mean size of all cysts decreased from 7.8 cm (range 3 to 16) to 1.7 cm (range 0 to 9; P <0.0001). Before the sclerotherapy, 24 patients had symptoms due to the cyst, and 18 of these (75%) were asymptomatic after the ethanol sclerotherapy. In 2 patients the pain decreased, 2 patients were without change, and in 2 patients the pain increased. There was no correlation between the size of the cyst and the intensity of pain. No major complications occurred. The serum concentration of alcohol varied from 0 to 0.30 g/L and that in urine from 0.04 to 0.27 g/L. CONCLUSIONS: Percutaneous aspiration and sclerotherapy with ethanol for simple renal cysts is simple, fast, safe, effective, and inexpensive. The results are comparable to those reported earlier. The treatment is without major complications. We propose sclerotherapy with 99% ethanol as the primary treatment of simple renal cyst. The treatment can be done in an outpatient clinic.

Developmental pathways of children with and without familial risk for dyslexia during the first years of life.

Comparisons of the developmental pathways of the first 5 years of life for children with (N = 107) and without (N = 93) familial risk for dyslexia observed in the Jyväskylä Longitudinal study of Dyslexia are reviewed. The earliest differences between groups were found at the ages of a few days and at 6 months in brain event-related potential responses to speech sounds and in head-turn responses (at 6 months), conditioned to reflect categorical perception of speech stimuli. The development of vocalization and motor behavior, based on parental report of the time of reaching significant milestones, or the growth of vocabulary (using the MacArthur Communicative Development Inventories) failed to reveal differences before age 2. Similarly, no group differences were found in cognitive and language development assessed by the Bayley Scales of Infant Development and the Reynell Developmental Language Scales before age 2.5. The earliest language measure that showed lower scores among the at-risk group was maximum sentence length at age 2. Early gross motor development had higher correlation to later language skills among the at-risk group rather than the control children. The most consistent predictor of differential development between groups was the onset of talking. Children who were identified as late talkers at age 2 were still delayed at the age 3.5 in most features of language-related skills-but only if they belonged to the group at familial risk for dyslexia. Several phonological and naming measures known to correlate with reading from preschool age differentiated the groups consistently from age 3.5. Our findings imply that a marked proportion of children at familial risk for dyslexia follow atypical neurodevelopmental paths. The signs listed previously comprise a pool of candidates for early predictors and precursors of dyslexia, which await validation.

Cost-effectiveness of Percutaneous Transluminal Angioplasty (PTA) Versus Vascular Surgery in Limb-threatening Ischaemia.

The purpose of this study was to analyze the cost and cost-effectiveness of femoropopliteal PTA compared to femoropopliteal bypass surgery in chronic critical ischaemia of the lower limb. A total of 772 patients were treated either by femoropopliteal PTA or vascular reconstruction in two of the three largest vascular centers in Finland 1991-1992. A subset of 124 cases with chronic critical leg ischaemia, which according to a retrospective independent analysis by a vascular surgeon and a radiologist could have been treated with either modality, were included in the study. Eighty-six of those were treated with PTA and 38 with surgery. The patients were followed up for to three years after treatment. Clinical outcomes were measured as change in the ABI (ankle-brachial pressure index) and avoidance of reoperation and amputation. The hospital costs covering all events from preoperative examinations to the three-year follow-up visit were identified by using hospital discharge register and accounting data. Cost-effectiveness was calculated as cost per reoperation-free year and year of leg saved. Surgery cases were found to have a more severe disease as indicated by lower distal pressures and longer occlusions and they also showed a slightly better clinical outcome, although the differences were not statistically significant. PTA costs were half of those of vascular surgery. The cost-effectiveness rates were significantly better for the PTA patients. PTA is a feasible and cost-effective procedure in chronic critical ischaemia of the lower limb and should be the treatment of choice in the subset of patients where both procedures are possible.

Patency and complications of percutaneously inserted metallic stents in malignant biliary obstruction.

PURPOSE: The aim of this study was to analyze the patency of percutaneously inserted metallic stents in malignant biliary obstruction and to evaluate all the complications associated with the stents and the reinterventions needed. MATERIALS AND METHODS: Thirty-nine patients with 42 malignant strictures were treated percutaneously with 55 metallic self-expandable stents. Forty-eight were Wallstents and seven were Memotherm stents. Twenty-five strictures were hilar, 16 were in the common bile duct, and one was in the hepaticojejunal anastomosis. The patients were followed until death and the mean follow-up was 6.4 months. RESULTS: Stent insertion was successful in 97% of the patients. Thirty percent had early complications (<30 days), and as many as 66% had late complications, including stent occlusions, which were seen in 10 patients. The patency rates of patients with cholangio-carcinoma were significantly lower than those of the patients with other diagnoses. There was also a tendency toward obstruction with less dilation of the stents, Y, T or tandem-style stent placement, an increasing number of stents, longer strictures, and hilar strictures. Thirty-one percent of the patients alive after the first 30 days had late reinterventions. CONCLUSIONS: Although metallic stents offer an alternative in the palliation of malignant bile duct obstruction, there seem to be numerous early and late complications.

Modulation of murine phenobarbital-inducible CYP2A5, CYP2B10 and CYP1A enzymes by inhibitors of protein kinases and phosphatases.

Phenobarbital causes a multitude of effects in hepatocytes, including increased cell proliferation, inhibition of apoptosis and upregulation of xenobiotic and endobiotic metabolizing enzymes. In this study, the involvement of several protein kinase and phosphatase pathways on constitutive and phenobarbital-induced activities of CYP2A5, CYP2B10 and CYP1A1/2 in primary mouse hepatocytes was determined using well-defined chemical modulators of intracellular protein phosphorylation and desphosphorylation events. A 48-h treatment of the hepatocytes with 2-aminopurine, a nonspecific serine/threonine kinase inhibitor, elicited dose-dependent increases in both basal and phenobarbital-induced CYP2A5 catalytic activity (assayed as coumarin 7-hydroxylation), the maximal induction being 60-fold greater than the control value upon cotreatment with 1.5 mM phenobarbital and 10 mM 2-aminopurine. In contrast, phenobarbital induction of CYP2B10 (pentoxyresorufin O-deethylase) and CYP1A1/2 (ethoxyresorufin O-deethylase) activities were blocked by 2-aminopurine. Increases in CYP2A5 activity were also observed after exposure of the hepatocytes to other protein kinase inhibitors affecting the cell cycle, i.e. roscovitine, K-252a and rapamycin. Inhibitors of protein kinases A and C, as well as tyrosine kinases, did not appreciably affect CYP2A5 activity levels. The serine/threonine phosphatase inhibitors tautomycin, calyculin A and okadaic acid all reduced both basal and phenobarbital-induced CYP2A5, CYP2B10 and CYP1A1/2 activities. These results further strengthen the concept that hepatic CYP2A5 is regulated in a unique way compared with CYP2B10 and CYP1A.

Spontaneous subcapsular or perirenal haemorrhage caused by renal tumours. A urological emergency.

OBJECTIVE: Spontaneous perirenal haemorrhage is a rare abdominal emergency most commonly caused by solid renal tumours. The aim of this study was to evaluate the efficacy of different diagnostic methods and treatment modalities. MATERIAL AND METHODS: A total of 9 patients (5 women and 4 men) with spontaneous subcapsular or perirenal haemorrhage caused by renal tumours were treated at two Finnish central hospitals over a period of 20 years. RESULTS AND CONCLUSIONS: All the patients presented with flank pain, often severe and associated with a palpable mass and a reduced haemoglobin concentration. Ultrasonography was abnormal in all cases where it was used, but was able to show the tumour and haemorrhage correctly in only one case (13%). Computed tomography had a sensitivity of 71%. Seven patients underwent extrafascial nephrectomy (5 renal cell cancers, 1 malignant oncocytoma and 1 angiomyolipoma) and two with known tuberous sclerosis and bilateral renal angiomyolipomas were treated by superselective embolization. As these few cases were all individual and were collected over a long period of time, general statements about diagnosis and treatment must be approached critically. It may be concluded, however, that spontaneous perirenal haemorrhage is often a surgical emergency necessitating great efforts in terms of diagnosis and treatment. Computed tomography should be performed on all patients nowadays. If the bleeding is caused by a malignant tumour, extrafascial nephrectomy is the treatment of choice. For those with benign tumours selective embolization should be used.

Transcultural Patient Care Committee: actualizing concepts and developing skills.

This article describes activities of a Transcultural Patient Care Committee whose aim is to develop the knowledge and skills of medical center staff to provide culturally congruent care. The activities include staff development offerings, a transcultural patient care resource manual, and communication and assessment tools. These efforts have provided a foundation to assist staff with meeting the challenge of caring for multicultural patients.

Comparison of early deflation rate of detachable latex and silicone balloons and observations on persistent varicocele.

PURPOSE: To determine the frequency of and time until spontaneous deflation of detachable embolization balloons made of different materials and the correlation between persisting or recurrent varicocele and the spontaneous deflation of the balloons. MATERIALS AND METHODS: Forty-five patients with clinically detected left-sided varicocele underwent embolization with 78 silicone and 22 latex balloons. The minimum follow-up time was 3 months and the follow-up consisted of clinical examination, color duplex ultrasonography, and plain radiography of the balloons. Those patients who were suspected of having recurrent varicoceles underwent control venography to assess the internal spermatic vein. RESULTS: All of the latex balloons and 10% of the silicone balloons deflated spontaneously during the follow-up. The average time until deflation was 5.1 months for latex and 9.9 months for silicone balloons. Persistence of varicocele, attributed to perfusion through a previously occluded portion of the internal spermatic vein, occurred in two of 11 (18%) recurrences. Nine of 11 (72%) recurrences were due to bypassing collaterals past the site of detachable balloon placement. CONCLUSIONS: Latex balloons seem to predispose more to persisting/recurrent varicocele than silicone balloons. Early deflation of the balloons explained two (18%) of the 11 persisting or recurrent varicoceles. A combination of a sclerosing agent with balloon embolization of the internal spermatic vein is recommended.

Intracranial arterial dissection.

We review the angiographic and CT findings, precipitating factors and clinical features in nine patients with ten intracranial arterial dissections. The internal carotid artery was involved in five cases, the vertebral artery in four and the posterior inferior cerebellar artery in one. Angiography revealed irregular stenosis in four cases, irregular stenosis and a pseudoaneurysm in two, irregular stenosis and irregular dilatation in one, arterial occlusion in two and a pseudoaneurysm in one. CT demonstrated an infarct in four cases, a dense middle cerebral artery in two and subarachnoid haemorrhage in one. A possible precipitating factor was identified in five cases. Six patients recovered well, while three had persisting neurological deficits.

Duplex ultrasound in the subclavian steal syndrome.

PURPOSE: The effect of subclavian steal on the contralateral vertebral flow and its possible effect on carotid flow were studied and the US results were compared to the angiographic findings. MATERIAL AND METHODS: The study consisted of the records of 74 patients with a duplex Doppler finding of subclavian steal syndrome. Of these, 48 patients had had both angiography and US of the neck arteries and were selected for comparison. For a comparison of the US flow values, a control series of 48 was selected from our carotid archive and consisted of patients without subclavian steal who had also been examined with both US and angiography. RESULTS: Of the 48 patients, 44 had a subclavian steal syndrome at angiography, 31 on the left side and 13 on the right. Of the 44, 21 patients had subclavian occlusion, and 23 stenosis. In 84% of the subclavian occlusions, US showed a complete systodiastolic steal and in 16% a partial systolic steal, while the corresponding findings for subclavian stenoses were 17% and 83%. Of the 48 cases, 4 were not real subclavian steals: 2 had vertebral occlusion (1 with a 90% subclavian diameter stenosis) on the side of retrograde flow at US and a steal through the vertebral and collateral arteries to the spinal arteries; and 2 had a 70% diameter stenosis of the subclavian artery and to-and-fro flow in the vertebral artery at angiography. In the 21 cases of complete steals, the subclavian diameter stenosis was 97 +/- 8% at angiography, and in the 23 partial steals, it was 85 +/- 10%. There was a significant increase in contralateral vertebral and common carotid flow in the cases with retrograde vertebral flow compared to the vertebral and common carotid flow of the control subjects. The retrograde flow values, the ipsilateral vertebral lumen diameter, and the flow values in the common carotid arteries were higher in complete steals and subclavian occlusions than in partial steals. CONCLUSION: A complete vertebral steal at US correlated well with subclavian occlusion and a partial steal suggested stenosis of the subclavian artery. There were also flow changes in the contralateral vertebral artery and the common carotid arteries that compensated for the steal. Retrograde vertebral flow at US was sometimes associated with vertebral occlusion in subclavian stenosis without a true subclavian steal.

Non-prosthetic surgery in the treatment of erectile dysfunction. A retrospective study of 45 impotent patients in the University of Oulu.

The purpose of this retrospective study was to assess the outcomes of the patients with total erectile impotence who have undergone non-prosthetic surgery in our hospital and to make a decision concerning the continuation of this treatment modality. The study series consisted of 45 operated patients, 21 of whom had undergone venous leakage surgery and 24 revascularization of the penis. The follow-up time was at least 12 months. The outcome of venous surgery after 6 months was initially good in 16 patients (76%) but declined in such a way that 12 months after the operation it was good only in 6/21 patients (29%). Despite this, 11/21 patients were capable of intercourse after a prostaglandin E1 injection 1 year from the operation. Altogether 17/21 patients (81%) benefited from venous surgery after 12 months. The outcome of arterial surgery was good in 11/24 patients (46%) 12 months after the operation. A moderate outcome was obtained in another 8/24 patients (33%), who were capable of intercourse after a prostaglandin E1 injection. Minor complications occurred in 20% of the venous surgery patients; 25% of the patients with arterial surgery had complications and half of these were severe, resulting in glans hypervascularization. Our findings indicate that non-prosthetic surgery continues to have an established position in the treatment of severe impotence when all conservative treatment modalities have been used.

Percutaneous cholecystostomy in acute cholecystitis in high-risk patients: an analysis of 69 patients.

BACKGROUND: Optimal treatment of acute cholecystitis in high-risk patients with acute cholecystitis continues to be a difficult therapeutic problem. With the development of more advanced radiological imaging techniques, percutaneous cholecystostomy (PCS) has been presented as an effective treatment alternative in critically ill patients. This paper reports our experiences of percutaneous cholecystostomy in the treatment of acute cholecystitis in a well defined high-risk patient group. METHODS: The data concerning 69 high-risk patients with acute cholecystitis treated by percutaneous cholecystostomy in Oulu University Hospital and Kokkola Central Hospital were analyzed. RESULTS: Ultrasound showed gallbladder stones in 71% (49/69) of the patients and 29% of them presented with acalculous cholecystitis. After PCS, pain diminished in 94% (61/65), fever in 90% (35/39), CRP values in 87% (53/61) and leucocyte count in 84% (46/55) of the patients. Before PCS, the CRP value was 132+/-106 mg/l and after PCS 79+/-73 mg/l (P = 0.001) and corresponding leucocyte counts were 14.7+/-5.0 and 9.3+/-3.2 (P = 0.001), respectively. The antegrade cholecystocholangiography was performed in 29 patients after PCS, and common bile duct stones were detected in 8 patients; these stones were treated by endoscopic papillotomy. Complications after PCS occurred in 17 patients (26%), but only two patients required emergency laparotomy. Mortality was 19% (13/69). Acute cholecystitis alone was the cause of death in only three patients. Mostly, fatal outcome was caused by the serious underlying diseases. CONCLUSION: According to our results, PCS should be the method of choice in high-risk patients with acute cholecystitis.

Superselective intra-arterial chemotherapy with mitomycin C in hepatic metastases from colorectal cancer.

BACKGROUND: Mitomycin C has been found clinically useful in the treatment of colorectal cancer when administered via the hepatic artery. In a prospective therapeutic trial, we studied the effect of superselective intra-arterial chemotherapy with mitomycin C in patients with hepatic metastases from colorectal cancer. METHODS: Forty-six patients with hepatic metastases from colorectal cancer received intra-arterial chemotherapy with mitomycin C (SIAC) between 1981 and 1991. The results of a 5-year follow-up were compared with 46 control patients standardized by sex, age, and tumor distribution. RESULTS: The overall response rate to intra-arterial chemotherapy was 20%. The median survival time for responders was 26 months and that for nonresponders 12 months (P < 0.003). The median survival period after intra-arterial chemotherapy was 15 months, compared with 9 months in controls (P < 0.004). The cumulative 5-year survival rate was 6% for patients treated by SIAC and 5% for controls. Cessation of chemotherapy was necessary in 39 of the 46 patients: in 28 because of tumor progression, in 9 because of toxicity, in 1 because of catheterization difficulties, and in 1 because of patient refusal. CONCLUSIONS: Superselective intra-arterial mitomycin C therapy had a poor effect on hepatic metastases from colorectal cancer because of the low response and long-term survival rates.

Preoperative embolization in the management of neck paragangliomas.

Surgery of neck paragangliomas carries inherent risks of excessive blood loss and cranial nerve injury. Preoperative embolization has been used to lessen the morbidity of surgery. We sought to characterize our experience with preoperative embolization by evaluating safety, efficacy, and surgical data. During a period of 22 years (1974 to 1996), 19 consecutive patients with 27 histopathologically confirmed neck paragangliomas were surgically treated at the Oulu University Hospital. All patients underwent preoperative arteriography and 17 patients had cervical ultrasonography (US). Eleven patients with 15 tumors were operated on without embolization and nine patients with 12 tumors were preoperatively embolized with 150- to 250-microm polyvinyl alcohol (PVA) particles. The mean blood loss during surgery in the nonembolized group was 1374 mL (range, 100 to 4500 mL) and the mean operation time was 4 hours and 48 minutes (range, 1.5 to 9 hours). In the embolized group the mean blood loss was significantly less (588 mL; range, 100 to 1800 mL; P = 0.04) and the mean operation time shorter (3 hours 24 minutes; range, 2 to 5 hours; P = 0.05). No embolic complications were recorded after the embolization. We conclude that preoperative embolization of neck paragangliomas 3 cm or greater in diameter with PVA particles is safe. Embolization to minimize operative bleeding facilitates surgery, shortens the operation time, and lessens the surgical risks.

Isolated dissecting aneurysm of the left posterior inferior cerebellar artery: endovascular treatment with a Guglielmi detachable coil.

An isolated progressive dissecting aneurysm of the left posterior inferior cerebellar artery (PICA) associated with a persistent trigeminal artery was successfully treated by endovascular occlusion of the proximal PICA with a Guglielmi detachable coil.

Transarterial embolization of a direct carotid cavernous fistula with Guglielmi detachable coils.

Four patients underwent transarterial embolization of a carotid-cavernous fistula with Guglielmi detachable coils; in three cases as the initial form of treatment and in one case after treatment via transarterial balloon embolization failed. The fistulas were 2 to 3 mm in diameter on pretreatment angiograms. Complete obliteration was achieved in two patients; in the other two, minimal residual flow remained immediately after embolization but disappeared by follow-up angiography. One to four coils were used to occlude the fistulas. The internal carotid artery remained patent in all patients, and there were no complications.

Insulin-like growth factors and their binding proteins in the venous effluents of ovary and adrenal gland in severely hyperandrogenic women.

Insulin and insulin-like growth factors (IGF) are thought to play an important role in the pathogenesis of excessive androgen production. To explore this question further we measured the concentrations of IGF-I and -II and their binding proteins (IGFBP-1 and-3) in adrenal and ovarian vein samples of severely hyperandrogenic women (serum testosterone > 5 nmol/l) collected as part of their diagnostic work-up. The concentration of IGF-II was slightly but not significantly higher in the ovarian vein than in the adrenal and peripheral veins. The concentrations of IGF-I and IGFBP were identical in both the adrenal and ovarian veins and did not differ from those in the peripheral circulation. The concentration of IGFBP-1 was negatively correlated (r = -0.60, P > 0.05) with insulin and IGFBP-3 showed a strong positive correlation with IGF-1 (r = 0.90, P > 0.01). These results indicate that neither the ovary nor the adrenal gland contributes significantly to the circulating pool of IGF or their binding proteins in severely hyperandrogenic subjects. Hyperinsulinaemia is associated with low circulating IGFBP-1 concentrations and IGFBP-3 seems to be an excellent indicator of the peripheral IGF-I concentration. The concentrations of IGF-I suggested decreased somatotrophic activity in these obese, hyperinsulinaemic subjects.

Is varicocele treatment useful?

The effect of the treatment of varicocele on symptoms and fertility was followed up in 66 patients for an average of 27 months (range 6-84 months). The patients had been treated either surgically (n = 45) or with embolization (n = 21). The mean duration of the inpatient periods and sick leaves were significantly shorter among the patients treated with embolization than among the surgical patients (2.4 vs 3.3 days and 4.8 vs 21.3 days, respectively). Scrotal problems disappeared either completely or almost completely in 73% of the patients treated for symptoms (n = 40). The number of spermatozoa increased significantly (from 6.7 mill/ml to 27.4 mill/ml) in the patients with infertility after the treatment of varicocele. Pregnancy started in 31% of the couples with infertility problems. A spontaneous abortion occurred in two cases, and six couples (23%) had a child of their own. It could be concluded that the treatment of varicocele is useful regardless of whether it is given for symptoms or infertility. It is also indicated for the patients with infertility problems who have a low number of spermatozoa and disturbed spermatozoan motility in sperm analysis.