Outcome prediction in traumatic brain injury: comparison of neurological status, CT findings, and blood levels of S100B and GFAP.

OBJECTIVE: To investigate the predictive value of early serum levels of S100B and glial fibrillary acidic protein (GFAP) in traumatic brain injury. METHODS: Sixty patients admitted within 24 h of trauma were included. Neurological status on admission (Glasgow Coma Scale), initial cranial computed tomography (CCT) studies (Marshall Computed Tomographic Classification), and outcome after 6 months (Glasgow Outcome Scale) were evaluated. S100B and GFAP levels were determined on admission and 24 h after trauma. RESULTS: Blood levels of S100B and GFAP were elevated following head trauma and quantitatively reflected the severity of trauma. S100B levels after 24 h and on admission were of higher predictive value than CCT findings or clinical examination. GFAP, but not S100B levels rapidly declined after trauma. CONCLUSIONS: Blood levels of S100B and GFAP indicate the severity of brain damage and are correlated with neurological prognosis after trauma. Both methods can yield additional prognostic information if combined with clinical and CCT findings.

[Also consider sinusitis in facial pain: wisdown tooth, tumor, acute parotitis]. / Auch das müssen Sie beim V. a. Sinusitis abklären: Weisheitszahn, Tumor, akute Parotitis.

In numerous cases of head and facial pain, the underlying causes are found to be ENT problems. The most common cause of pain affecting the forehead and mid-facial region is acute sinusitis, in which the sphenoidal sinus is more commonly affected than previously assumed. Pain in the oral-facial region is largely due to disorders of the masticatory apparatus, but inflammatory diseases of the oral mucosa, abscesses or the so-called Eagle syndrome may also be involved. An accurate history and a clinical examination often points the physician in the right direction. To establish an accurate diagnosis, endoscopy of the upper airways and digestive system, together with ultrasonography, are usually required, followed, where necessary, by a radiological and NMR work-up, and puncture or biopsy. Provided that an accurate diagnosis has been established and multidisciplinary cooperation is available, the therapeutic options are usually effective.

Popliteal artery stenting using flexible tantalum stents.

PURPOSE: To evaluate the safety and efficacy of stent therapy for the treatment of residual stenoses after percutaneous transluminal angioplasty (PTA) of popliteal stenoses and occlusions. METHODS: In a prospective single-center study, flexible tantalum stents were implanted in 32 popliteal arteries for the treatment of residual stenosis greater than 50% after PTA of stenoses (n = 17) or occlusions (n = 15) in the P1 (n = 16), the P2 (n = 13), or both P1 and P2 segment (n = 3). Follow-up patency was assessed by clinical examination, ankle-brachial index, and color Doppler sonography or angiography. RESULTS: Early stent thrombosis (10 days): 1 of 32 arteries (3%). 1-year and 2-year primary patency rate (PPR): 81% +/- 7.1% and 74% +/- 9.1%, respectively. 1-year PPRs for subgroups: stented stenoses versus stented occlusions: 88% +/- 7.8% vs 73% +/- 12.0%, p = 0.12; good lower limb runoff versus poor: 84.0% +/- 8.7% vs 76.0% +/- 12.4; p = 0.09; P1 versus P2: 77.3% +/- 9.8% vs 85.7% +/- 9.4%, p = 0.38. Recurrent PTA lesions treated with stents showed higher restenosis rate than de novo lesions. CONCLUSION: The results of stent therapy of residual popliteal stenosis after PTA are encouraging and warrant further investigation.

Flexible tantalum stents for the treatment of renovascular hypertension: a 10-year experience.

The aim of this study was to determine long-term success of flexible tantalum stents for the treatment of ostial and truncal renal artery stenosis. Since 1989, flexible tantalum stents (type Strecker) were implanted in 34 patients (36 arteries, 25 ostial lesions, 11 truncal lesions) with uncontrollable renovascular hypertension, 9 of them in association with renal insufficiency. Stents were placed unilaterally in 32 patients, and bilaterally in 2 patients for the treatment of renal artery stenosis. Thirty-five of 36 lesions were atherosclerotic, including 5 recurrencies after previous percutaneous transluminal renal angioplasty (PTRA). One patient had Takayasu arteritis. Stents were implanted after unsuccessful PTRA of 11 truncal and 23 ostial lesions, and as a primary procedure in 2 ostial lesions. Follow-up examinations included blood pressure measurement, determination of serum creatinine level, color duplex sonography, or angiography. The technical success rate was 92%. Technical failure included incorrect stent placement (1 of 36 lesions, 2.8 % ), and stent dislocation (2 of 36 lesions, 5.6 %), and two stents were retrieved percutaneously. In one case of Takayasu arteritis, residual stenosis of 40% was observed. After technically successful stent placement, 77% of patients became normotensive with or without medication. In the remaining patients there was partial improvement with blood pressure between 140 and 180 mmHg. Renal function improved in 76% of patients (completely in 3 of 8, 38%; and partially in 3 of 8, 38%). Primary patency rate including all stented lesions and initial technical failures was 82.4% +/- 6.8 (1 year) and 82.4% +/- 9.2 (3 years). After technically successful stent placement, patency rates were 89.9 +/- 5.6% (1 year), and 89.9 +/- 7.6% (3 years). For ostial lesions, primary patency rate was 87.9 +/- 6.7% (1 year) and 87.9 +/- 9.2% (3 years). Placement of flexible tantalum stents in renal arteries is technically demanding, especially in ostial lesions. Once placed successfully stent patency rate is excellent.

Improvement in claudication after angioplasty of distal ostial collateral stenosis in patients with long-segment occlusion of the femoral artery.

PURPOSE: To evaluate the angiographic and clinical effects of percutaneous transluminal angioplasty (PTA) of distal ostial collateral stenoses in patients with claudication and long-segment occlusion of the superficial femoral artery (SFA). METHODS: In ten patients (9 men, 1 woman) with stable intermittent claudication due to chronic long-segment occlusion of the SFA a high-grade stenosis of the distal collateral ostium of the deep femoral artery to the popliteal artery were dilated. PTA was performed using popliteal artery access. Claudication distances on the treadmill and ankle-brachial pressure indices (ABI) at rest were analyzed before, 1 week, and 14 weeks after PTA. RESULTS: Initial technical success was obtained in all patients. There were no significant periprocedural local complications. The initial mean claudication distance on the treadmill increased significantly from 107 +/- 65 m to 306 +/- 209 m (p < 0.01), the maximal claudication distance from 203 +/- 128 m to 392 +/- 167 m (p < 0.01). The mean ABI changed slightly but significantly (0.61 +/- 0.08 vs. 0.64 +/- 0.07; p < 0.05). Early follow-up after 14 weeks revealed no clinical deterioration. CONCLUSION: This new technique is considered helpful in patients with well-defined claudication and long-segment occlusion of the SFA.

CT-guided epidural/perineural injections in painful disorders of the lumbar spine: short- and extended-term results.

PURPOSE: Evaluation of short- and extended-term results of repeated epidural/perineural injections (EDT/PRT) of corticoids in painful afflictions of the lumbar spine. METHODS: Thirty-two patients who had persistent radicular or low back pain for more than 6 weeks were treated with CT-guided injection therapy. By EDT/PRT, 40 mg of triamcinolonacetonid was injected either periradicularly or by a direct intraspinal epidural method at intervals of 3 weeks. Altogether, 140 EDT/PRT were performed in 32 patients (mean 4.4, range 2-8). In nine patients partial facet joint denervation with 1-2 ml of 50% alcohol solution was combined with EDT/PRT to reduce low back pain. Before and after treatment and at follow-up (mean 9.6 months), treatment success was evaluated on a visual analog scale and by physical examination (good = >50% improvement, moderate = 20%-50%, no improvement = <20%). RESULTS: Short-term (end of therapy) good or moderate improvement was achieved in 91% of patients, extended-term (mean 9.6 months) in 56%. Regarding certain subgroups, those with disc herniations of the lumbar spine showed a better outcome with good or moderate improvement in 95% short-term and 69% extended-term than those with spinal stenosis who had 72% short-term and 28% long-term. CONCLUSION: Results indicate that CT-guided EDT/PRT in combination with partial facet joint denervation is a safe and effective outpatient treatment.

Use of recombinant human erythropoietin (EPO-alfa) in a mother alloimmunized to the Js(b) antigen.

Erythropoietin (EPO) is a glycoprotein hormone and the principal regulator of erythropoiesis in the fetus, newborn, and adult. EPO-alfa is erythropoietin manufactured by recombinant human DNA technology (rhEPO). After counseling, a pregnant woman with anti-Js(b) in her serum was started on rhEPO (600 U/Kg, biweekly) to prevent anemia secondary to serial donations of her blood for fetal transfusions. After a total of 25 rhEPO infusions and autologous donation of 8 units of whole blood, maternal hemoglobin prior to the elective cesarean section at 37 weeks was 11.3 gm/dL. Serum EPO concentration was determined in paired maternal and fetal blood samples, before ultrasound guided intravascular transfusions, in this alloimmunized Js(b)-negative and another Rh(D) alloimmunized pregnancy to determine possible correlations between maternal and fetal serum EPO. rhEPO prevented anemia in a patient who donated 8 units of blood from 18-37 weeks of pregnancy without inducing adverse biological effects such as hypertension or thrombotic complications in the placenta. Data presented in this study suggest that EPO does not cross the human placenta.

Low-molecular-weight heparin (reviparin) reduces the incidence of femoropopliteal in-stent stenosis: preliminary results of an ongoing study.

PURPOSE: To examine the efficacy of the low-molecular-weight heparin, reviparin, for prevention of femoropopliteal stent restenosis. METHODS: Forty-two patients who had implantation of flexible tantalum stents for the treatment of stenosis (n = 24) or occlusion (n = 18) of the femoral (n = 27) or popliteal (n = 15) arteries were included in this study protocol. An intraarterial bolus of 5000 IU heparin was given before percutaneous transluminal angioplasty (PTA), and in the case of stent implantation due to unsuccessful PTA, an additional dose of reviparin (3500 anti-factor Xa IU) was given. Postprocedurally, 10,500 anti-factor Xa IU of reviparin were administered intravenously over 24 hr, followed by 3500 anti-factor Xa IU subcutaneously twice a day for 23 days. Oral aspirin (100 mg/day) was prescribed for the long term. Follow-up criteria (maximum follow-up 37 months) were clinical symptoms, Doppler ankle arm indices, color and duplex sonography, and angiography for suspicion of restenosis. RESULTS: Early stent thromboses were not observed. Overall primary patency rate (PPR) was 88% +/- 6.0% (1 year) and 74% +/- 10.1% (2 years). Major hemorrhagic complications have not occurred. CONCLUSION: Reviparin administered in a high dose over a period of 24 days is a safe medication regimen and provides excellent patency rates after stent implantation.

Femoropopliteal artery stent placement: evaluation of long-term success.

PURPOSE: To evaluate the long-term success of femoropopliteal artery stent placement after technical failure of balloon angioplasty and to determine potential factors predictive of stent failure. MATERIALS AND METHODS: In 80 patients, flexible tantalum stents were implanted for treatment of residual stenosis greater than 30% after balloon angioplasty of femoropopliteal artery stenoses (n = 33) or occlusions (n = 47). Follow-up examinations were performed at 1-72 months to evaluate early and late stent failure according to risk factors such as lesion type, anatomic location, stent length, runoff quality, and restenosis after balloon angioplasty. RESULTS: Early stent thrombosis occurred within 10 days after stent placement in four (5%) patients; the frequency was higher (P < .01) in stents longer than 4 cm (14%) versus that in stents 4 cm or shorter (2%). For all stents, the 2-year primary patency rate was 51% and the 3-year rate was 48%. The 2-year primary patency rate was significantly better (P < .05) for shorter stents (59%) versus that for longer stents (30%) and for treated stenoses (73%) versus treated occlusions (33%). Multivariate analysis revealed that lesion type and lesion length were the most reliable factors predictive of stent failure. CONCLUSION: Successful stent therapy does not seem to depend on the type of stent used but rather on lesion type, lesion length, and other predisposing factors.

S-100 protein plasma levels after aneurysmal subarachnoid haemorrhage.

We investigated the level of S-100 protein in blood as an indicator of brain damage in 71 patients suffering from subarachnoid haemorrhage (SAH) due to ruptured aneurysms. Concentrations of S-100 protein were determined by micro-titre based immunofluorometic assay detecting predominantly S-100b on blood samples obtained 24 hours, 3 days and 7 days after onset of symptoms in patients with SAH and from 120 healthy control subjects. Neurological status was assessed using the Hunt and Hess (HH) scale on admission and by the Glasgow Outcome Scale (GOS) 6 months later. Mean concentrations of S-100 protein in blood were significantly (p < 0.0001) higher in patients 24 hours (0.263 +/- 0.387 microgram/l), 3 days (0.192 +/- 0.288 microgram/l) and 7 days (0.256 +/- 0.442 microgram/l) after onset of SAH symptoms compared to controls (0.050 +/- 0.081 microgram/l). More severe neurological symptoms (higher HH scale scores) on admission correlated with higher S-100 levels on admission (R = 0.70) and Day 3 (R = 0.66) (p < 0.0001). Worse outcome (lower GOS score) 6 months after SAH was also associated with higher plasma concentration of S-100 in the first week after SAH. In summary, this study showed that in patients with SAH due to ruptured aneurysm, S-100 protein levels correlate with early neurological deficit and are as sensitive as HH scores in predicting neurological outcome (GOS scores). Measurement of S-100 protein in blood is a reliable non-invasive method and may be clinically useful to screen for and monitor progression of central nervous system diseases of various origins.

Early gestational glucose screening and gestational diabetes.

OBJECTIVE: The purpose of this study was to determine the benefit of early glucose screening prior to 24 weeks' gestation in detecting gestational diabetes. STUDY DESIGN: A retrospective analysis of 329 patients who received both early and complete prenatal care at the University of Illinois was performed. A 50-g, 1-hour glucose screen was performed at the first prenatal visit. An abnormal glucose screen, defined as blood sugar > 135 mg/dL, was followed by a 100-g, 3-hour glucose tolerance test. Gestational diabetes was defined as the presence of two or more abnormal values on the three-hour test. This protocol was repeated again at 28 weeks in all patients except those diagnosed as diabetic by having abnormal early three-hour tests. Data collected included maternal age, race, gravidity, presence of risk factors, pregnancy weight gain at glucose testing and delivery, neonatal birth weight and trauma. Data were analyzed using analysis of variance and chi 2 testing, with P < .05 considered significant. RESULTS: Gestational diabetes was diagnosed in 20 (6.1%) of the study patients. Eight (40%) of the gestational diabetics in the study population were detected with the early screening protocol. Factors associated with early detection of glucose intolerance included maternal age > 30 years (P < .001), black race (P < .001) and the presence of risk factors (P < .0001). Poor pregnancy weight gain was associated with the late development of glucose intolerance (P < .001). Gestational diabetes was subsequently diagnosed in 16% (6/38) of those patients who had, on early testing, an elevated one-hour glucose screen and negative three-hour glucose tolerance test when testing was repeated in the third trimester. CONCLUSION: Early gestational glucose screening may be beneficial in detecting gestational diabetes in patients over 30 years old who are black or who have risk factors for diabetes. Consideration should be given to repeat glucose testing in the early third trimester in patients with false positive early one-hour screening tests.

[Aortitis and development of an aneurysm after PTA of distal aortic stenosis]. / Aortitis und Entstehung eines Aneurysmas nach PTA einer distalen Aortenstenose.

A 43-year-old woman was admitted with peripheral arterial occlusive disease (PAD), pelvis-type. The angiography showed a high-grade stenosis of the aortal bifurcation. A percutaneous transluminal angioplasty (PTA) in "kissing-balloon-technique" was performed. After 7 days the patient developed a sepsis with distinct back-pain. The ultrasound-B-scan and CT-scan of the abdomen showed the development of an infrarenal aortic aneurysm during a period of 29 days. Bacterial infection of the aorta was considered to be the reason of development of the aneurysm occurred. Immediate antibiotic therapy got the patient afebrile after 14 days. We implanted an aortobiiliacal Dacron graft 2 weeks later. The follow-up time was without complications except for two thrombotic occlusions of the graft after 4 and 19 months. Thrombectomy was carried out in both cases without complications.