Aorto-oesophageal fistula after oesophageal stent placement in a patient with a Roux-en-Y gastric bypass.

A 43-year-old female patient suffered from persistent anastomotic leakage after Roux-en-Y gastric bypass for morbid obesity. Endoscopic stenting of the anastomotic leakage was performed. The patient presented with haematemesis 3 weeks later. An aorto-oesophageal fistula was diagnosed, most likely due to ulceration of the oesophageal stent. The fistula was closed with an endovascular covered aortic stent and a new gastrojejunostomy was created. One year after surgery, the patient is in good condition. Endoscopic stents are increasingly being used to treat anastomotic leakage in bariatric patients. An aorto-oesophageal fistula is a life-threatening complication of stent placement, early clinical recognition is essential. More data are needed on the complications of anastomotic stenting in bariatric patients.

Immune reconstitution inflammatory syndrome in natalizumab-associated PML.

OBJECTIVE: To study the outcome of patients with multiple sclerosis (MS) and with natalizumab-associated progressive multifocal leukoencephalopathy (PML) and immune reconstitution inflammatory syndrome (IRIS). METHODS: MedWatch reports from Biogen-Idec (manufacturer of natalizumab, Tysabri(®)) were reviewed which comprised all 42 cases of natalizumab-related PML cases since its reintroduction until March 2010. RESULTS: All except 2 patients with natalizumab-related PML were managed by discontinuation of natalizumab and plasmapheresis/immunoadsorption (PLEX/IA). Seventeen patients had contrast enhancement of PML lesions on neuroimaging at the time of diagnosis before withdrawal/removal of natalizumab (early-PML-IRIS) and 23 patients developed contrast enhancement only after withdrawal/removal of natalizumab (late-PML-IRIS). All patients developed IRIS. IRIS was defined as worsening of neurologic deficits during the immune reconstitution following discontinuation of natalizumab, corroborated by inflammatory changes on neuroimaging. Following PLEX/IA, JC viral load in CSF increased by >10 fold in those with early-PML-IRIS but <2 fold in late-PML-IRIS. IRIS developed earlier and was more severe in early-PML-IRIS (p < 0.05). At the last follow-up, all patients had worse EDSS scores but this was higher in patients with early-PML-IRIS compared to those with late-PML-IRIS (p > 0.05). Mortality was comparable between the 2 groups, 29.4 ± 11% vs 21.7 ± 8.8%. Corticosteroid therapy during IRIS was associated with better Expanded Disability Status Scale outcome, p < 0.05. CONCLUSION: Early immunologic rebound in natalizumab-associated PML has worse survival and neurologic outcome. PLEX/IA may accelerate IRIS and its impact on the final outcome is unclear. Corticosteroid therapy provides a modest benefit and needs to be systemically studied in a controlled manner in the management of natalizumab-associated PML-IRIS.

Hepatitis C seropositivity is not a risk factor for sensory neuropathy among patients with HIV.

BACKGROUND: Sensory neuropathy (SN) is common in patients with HIV. Hepatitis C (HCV) coinfection is often cited as an HIV-SN risk factor, but data to support this are lacking. This collaboration aimed to examine the association between HCV serostatus and SN risk among ambulatory HIV-positive patients. METHODS: Patients with HIV were assessed in cross-sectional studies in Baltimore, Jakarta, Johannesburg, Kuala Lumpur, Melbourne, and Sydney for SN (defined by both supportive symptoms and signs). HCV seropositivity was assessed as an SN risk using a chi(2) test, followed by logistic regression modeling to correct for treatment exposures and demographics. RESULTS: A total of 837 patients of African, Asian, and Caucasian descent were studied. HCV seroprevalence varied by site (Baltimore n = 104, 61% HCV+; Jakarta 96, 51%; Johannesburg 300, 1%; Kuala Lumpur 97, 10%; Melbourne 206, 16%; Sydney 34, 18%). HCV seropositivity was not associated with increased SN risk at any site, but was associated with reduced SN risk in Melbourne (p = 0.003). On multivariate analyses, the independent associations with SN were increasing age, height, and stavudine exposure. HCV seropositivity was not independently associated with an increased SN risk at any site, but associated independently with reduced SN risk in Baltimore (p = 0.04) and Melbourne (p = 0.06). CONCLUSIONS: Hepatitis C (HCV) seropositivity was not associated with increased sensory neuropathy risk among HIV-positive patients at any site. While we were unable to assess HCV RNA or liver damage, the data suggest that HCV coinfection is not a major contributor to HIV-SN. HCV = hepatitis C; SN = sensory neuropathy.

Simultaneous thromboses of multiple coronary arteries in acute myocardial infarction.

Simultaneous thrombotic occlusion of multiple coronary arteries in acute myocardial infarction is a well-recognised phenomenon. Studies have reported diffuse destabilisation of atherosclerotic plaques in patients with acute myocardial infarction, leading to the concept of "pan-coronaritis". The putative mechanism is attributed to a systemic thrombophilic and inflammatory state. We report the occurrence of this phenomenon in two middle-aged male patients.

Incidence of enhancement of the trigeminal nerve on MRI in patients with multiple sclerosis.

The purpose of this study is to review the incidence of contrast enhancement of the trigeminal nerve on magnetic resonance imaging (MRI) in a large cohort of patients with multiple sclerosis (MS). MRI scans of 851 MS patients participating in a phase III clinical trial were reviewed for the presence of gadolinium enhancement on postcontrast T1-weighted images. If enhancement was present, it was documented whether this involved only the proximal or also the distal part of the fifth nerve, and whether the abnormality was unilateral or bilateral. In 24 (2.8%) patients, enhancement of the trigeminal nerve was observed, and was bilateral in 16 (66.7%) of those. In 19 (79.2%) patients with abnormal nerves, enhancement extended to the distal part of the trigeminal nerve (into Meckel's cave). The results of this study indicate a high, probably clinically silent, incidence of trigeminal nerve demyelination in MS and frequent involvement of the peripheral type of myelin in MS.

Isotropic 3D fast FLAIR imaging of the brain in multiple sclerosis patients: initial experience.

The application of image registration and subtraction to detect change in multiple sclerosis (MS) disease burden on serial MR scans benefits from the use of isotropic voxels. An optimised 3D fast fluid-attenuated inversion recovery (FLAIR) sequence with 1.2- and 1.8-mm cubic voxels was compared with a 2D T2 SE sequence using standard 3-mm slices. Three-dimensional fast FLAIR and T2 SE series were obtained in 20 MS patients and 15 controls. Whole brain acquisition times for the 1.2- and 1.8-mm FLAIR were 21 and 10.5 min, respectively, for the interleaved T2 SE 16 min. Brain lesions were marked in consensus by two radiologists and the CNR was calculated in ten lesions. The mean number of lesions detected with the 1.2-mm FLAIR sequence was 115 +/- 76, compared with 85 +/- 59 for the T2 SE series ( p<0.001). The 1.8-mm FLAIR detected only 73 +/- 46 lesions. The CNR of the 1.2-mm FLAIR was significantly better than the T2 SE ( p<0.01), but not as good as the 1.8-mm FLAIR. In conclusion, isotropic 3D fast FLAIR using 1.2-mm cubic voxels is superior to the 2D T2 SE in the detection of brain lesions in MS patients. The isotropic 1.8-mm FLAIR is faster and has better contrast characteristics but lacks sensitivity.

Improved interobserver agreement for visual detection of active T2 lesions on serial MR scans in multiple sclerosis using image registration.

The aim of this study was to analyse the effect of image registration on interobserver agreement in the visual detection of active multiple sclerosis (MS) lesions from serial magnetic resonance (MR) scans. T2W spin-echo MR scans (3-mm slices) of 16 MS patients participating in a treatment trial were selected. For each patient, two pairs of scans were used: an original (i. e., non-registered) and a registered pair. For the original pair, baseline and month 6 were used, and for the registered pair month 3 and 9. For registration an automatic matching algorithm based on Mutual Information was used. Six observers identified active lesions on both original and registered scans. Kappa values were calculated to assess interobserver agreement. Reslicing caused a slight blurring of the images, but near perfect registration. The kappa value of 0.35 +/- 0.07 for new lesions on original images improved to 0.62 (+/- 0.06) by registration (p = 0.004). For enlarging lesions on original images it was extremely poor (kappa 0.11 +/- 0.05), and did not benefit much by registration (kappa 0.20 +/- 0.11). Thus, image registration improved interobserver agreement for visual detection of new lesions. For enlarging lesions, registration improved agreement but still not to a satisfactory level.

MR venography of multiple sclerosis.

BACKGROUND AND PURPOSE: The distribution of multiple sclerosis (MS) lesions in the brain follows a specific pattern, with most lesions in the periventricular regions and in the deep white matter; histopathologic studies have shown a perivenous distribution. The aim of this study was to illustrate these distribution patterns in vivo using high-resolution MR venography. METHODS: Seventeen MS patients underwent MR imaging at 1.5 T. Venographic studies were obtained with a 3D gradient-echo technique. MS lesions were identified on T2-weighted images, and their shape, orientation, and location were compared with the venous anatomy on the venograms. RESULTS: The use of contrast material facilitated the visualization of small veins and increased the number of veins seen. A total of 95 MS lesions could be identified on both the T2-weighted series and the venograms; a central vein was visible in all 43 periventricular lesions and in all but one of the 52 focal deep white matter lesions. The typical ovoid shape and orientation of the long axis of the MS lesions correlated well with the course of these veins. CONCLUSION: With MR venography, the perivenous distribution of MS lesions in the brain can be visualized in vivo. The venous anatomy defines the typical form and orientation of these lesions.

Linomide in the treatment of multiple sclerosis: MRI results from prematurely terminated phase-III trials.

Due to an unexpected increase in serious cardiovascular events in MS patients treated with Linomide, a synthetic immunomodulator, two phase-III multinational relapsing remitting (RR) and secondary progressive (SP) MS trials had to be discontinued. MRI results of 413 patients who participated for at least 3 months were analysed. Patients received placebo, 2.5 or 5 mg Linomide. Scans were performed at pre-enrolment, month 3 and termination. The number and volume of enhancing lesions (ELV), and the number of active scans were evaluated. At month 3, the decrease in the number of enhancing lesions in the placebo group was 11%, compared with 15% in the 2.5 mg group (P=0.027) and 23% in the 5 mg group (P=0.057). Using the percentage of active scans as outcome parameter, the odds ratio for improvement between placebo and 2.5 mg group was 1.62 (P=0.14); between placebo and 5 mg Linomide group 3.58 (P=0.003). At termination, a rebound effect was noted in the 2.5 mg group (P=0.01). Analysis of the ELV showed no significant difference between placebo and treatment groups. Although Linomide has unacceptable side effects, it seems to have a modest effect on MS disease activity, as measured by MRI. Multiple Sclerosis (2000) 6, 99 - 104

Female pelvic floor: endovaginal MR imaging of normal anatomy.

PURPOSE: To demonstrate the anatomy of the female pelvic floor with endovaginal magnetic resonance (MR) imaging. MATERIALS AND METHODS: Ten healthy nulliparous volunteers (age, 22-26 years) underwent MR imaging with an endovaginal coil. Findings on endovaginal MR images in the volunteers were correlated with findings on endovaginal MR images and cross-sectional anatomic slices obtained in three cadavers. RESULTS: The endovaginal coil was well tolerated by all volunteers. Pelvic floor structures such as the pelvic diaphragm and the urogenital diaphragm were well depicted. Previously undescribed urethral supporting structures--the periurethral and paraurethral ligaments--were visualized. The zonal anatomy of the urethra was clearly visible. The endovaginal MR imaging findings in the volunteers correlated with the endovaginal MR findings and gross anatomy in the cadavers. CONCLUSION: Endovaginal MR imaging clearly demonstrates the anatomy of the female pelvic floor and urethra.

Magnetic resonance imaging of the female pelvic floor and urethra: body coil versus endovaginal coil.

The anatomy of the female pelvic floor and urethra is complex. With the introduction of MRI, the discussion about the normal anatomy of this area has not diminished. The use of a body coil may be contributary to this. In the present study images obtained with an endovaginal coil are compared with those of a quadrature body coil series to study the possible advantage of endovaginal imaging. Axial and radial T2-w TSE images at a 1.0-T machine were obtained in seven healthy volunteers. The pelvic floor structures as well as the levator ani muscle and the urogenital diaphragm are excellently demonstrated with the endovaginal coil. Also, the urethrovaginal sphincter could be recognized in six volunteers, but only in three with the body coil. In six volunteers a new ligamentous structure, the urethropelvic sling, connecting the urethra to the levator ani muscle and contributing to the supporting mechanism of the urethra is shown with the endovaginal coil. The zonal anatomy of the urethra is excellently shown with the endovaginal coil. The urethral length could only be accurately measured with this coil and ranged from 3.1 to 3.6 cm. Compared with the body coil, endovaginal MRI is excellent in demonstrating the anatomy of the pelvic floor and urethra.

Critical limb ischemia after accidental subcutaneous infusion of sulprostone.

A 34-year-old patient was treated with constant intravenous infusion of sulprostone because of postpartum hemorrhage from a hypotonic uterus. The arm in which sulprostone had been infused was painful 23 h after infusion. A day later, the arm was found to be blueish, edematous and extremely painful as a result of arterial spasm. The vasospasm was probably caused by accidental subcutaneous infusion of sulprostone as a result of a displaced intravenous catheter. A diagnosis of critical limb ischemia was made. Treatment with the prostacyclin-analogue iloprost resulted in full recovery. Critical limb ischemia as a serious complication of sulprostone has not been previously reported.