Transcranial Color-Coded Duplex Ultrasound for Assessing Cerebrovascular Reserve in Intracranial Dissection with Aneurysm.

Intracranial artery dissection (IAD) is an uncommon cause of cerebral ischemia. It may lead to symptoms due to rupture of subadventitial aneurysms or thromboembolism from subintimal disruption. Severe stenosis may lead to reduced cerebrovascular reserve (CVR). While there are many methods of assessing CVR, we report a case of IAD with hemodynamic complications diagnosed by transcranial color-coded duplex (TCCD) ultrasonography. Our patient is a 38-year-old female who presented with a 2-month history of nausea, then feeling faint whenever she got up suddenly. On the day of admission, she had gotten up to walk, felt nauseous, and the left upper limb felt "funny," after which she lost consciousness. Clinical and neurological examination was normal. Brain magnetic resonance (MR) imaging was normal. MR angiogram and subsequent computed tomography (CT) angiogram showed flow attenuation in the M1 segment of the right middle cerebral artery (RMCA), with a possible flap. Catheter angiography was suggestive of a dissection with 2.7 mm pseudoaneurysm. TCCD showed very high velocities in the RMCA. The Breath-Holding Index (BHI) was 0.56, suggestive of reduced CVR in the RMCA territory. Acetazolamide-enhanced single-photon emission CT showed reduced right frontal CVR. She was given clopidogrel for secondary prevention, and has remained well. BHI as measured by TCCD is a new method for assessing CVR in patients with cerebral ischemia.

The Role of Liver-Directed Therapy in Metastatic Colorectal Cancer.

PURPOSE OF REVIEW: Colorectal cancer liver metastasis is a major clinical problem, and surgical resection is the only potentially curative treatment. We seek to discuss various liver-directed therapy modalities and explore their roles in the evolving realm of treatment strategies for metastatic colorectal cancer. RECENT FINDINGS: Clinical outcomes for patients with colorectal cancer liver metastases have improved as more patients undergo potentially curative resection and as the armamentarium of systemic treatment and liver-directed therapies continues to expand. Liver-directed therapies have been developed as adjuncts to improve resectability, employed in the adjuvant setting to potentially reduce local recurrence rates, and utilized in the palliative setting with the aim to improve overall survival. SUMMARY: Ongoing research is expected to validate the role of these evolving therapeutic options, and determine how best to sequence and when to apply these therapies.

Imaging of malignancies of the biliary tract- an update.

Malignancies of the biliary tract include cholangiocarcinoma, gallbladder cancers and carcinoma of the ampulla of Vater. Biliary tract adenocarcinomas are the second most common primary hepatobiliary cancer. Due to their slow growing nature, non-specific and late symptomatology, these malignancies are often diagnosed in advanced stages with poor prognosis. Apart from incidental discovery of gall bladder carcinoma upon cholecystectomy, early stage biliary tract cancers are now detected with computed tomography (CT) and magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). Accurate characterization and staging of these indolent cancers will determine outcome as majority of the patients' are inoperable at the time of presentation. Ultrasound is useful for initial evaluation of the biliary tract and gallbladder masses and in determining the next suitable modality for further evaluation. Multimodality imaging plays an integral role in the management of the biliary tract malignancies. The imaging techniques most useful are MRI with MRCP, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and positron emission tomography (PET). In this review we will discuss epidemiology and the role of imaging in detection, characterization and management of the biliary tract malignancies under the three broad categories of cholangiocarcinomas (intra- and extrahepatic), gallbladder cancers and ampullary carcinomas.

Thoracic endovascular aortic repair: a local single institution experience.

INTRODUCTION: The purpose of this retrospective study was to evaluate the short- to mid-term results of the endovascular repair of thoracic aortic disease and to present an overview of our experience with thoracic endovascular aortic repair (TEVAR) in our institution. MATERIALS AND METHODS: A retrospective review of all patients who were treated and underwent TEVAR in our institution between August 2004 and November 2009 was conducted. RESULTS: Technical success was achieved in 100% of the patients and the 30-day mortality rate was 0%. Perioperative endoleak was visualised at the end of the procedure in 4 patients. Secondary endoleak was observed in 2 patients. Mean hospital length of stay post-TEVAR was 15.4 days. Postoperative major complications were observed in 4 patients. The 30-day mortality rate was 0%, with 2 mortalities (11.1%) during the followup period. CONCLUSION: This study adds to the growing body of literature that support TEVAR as an effective procedure in the management of thoracic aortic diseases and reflects its feasibility in our population. Further technical advancement in stent grafts, careful selection of patients and standardised peri-procedural care would contribute to further improvements in clinical outcomes.

Catheter-induced aorto-coronary artery dissection: utility and appearance on CT coronary angiogram.

Aorto-coronary artery dissection (CCAD) is rare but potentially fatal complication of catheter coronary angiography. Management is dependent on the state of distal arterial flow and the extension of retrograde aortic dissection. This manuscript describes the use and appearance of CCAD on ECG-gated multi-detector CT coronary angiogram in the acute setting.

Health and developmental outcome of children following prenatal diagnosis of confined placental mosaicism.

OBJECTIVE: To determine the long-term health and development of a cohort of children in whom confined placental mosaicism (CPM) was diagnosed at prenatal diagnosis. METHODS: A retrospective cohort study was performed comparing 36 children in whom CPM had been diagnosed prenatally with 195 controls subjects in whom a normal karyotype had been detected prenatally. Data comprising birth information, health, health service utilisation, growth, development, behaviour, and the family were collected by a maternal questionnaire administered when the subjects were aged between 4 and 11 years. RESULTS: CPM cases did not differ from controls across a broad range of health measures and there were no major health problems or birth defects among the CPM group. No increase was detected in the incidence of intrauterine growth retardation (IUGR) among CPM cases; however, postnatal growth was reduced compared with controls (p = 0.047). Development and behaviour in CPM cases was similar to that of controls. CONCLUSIONS: The prenatal diagnosis of CPM is not associated with an increased risk of birth defects or developmental problems, but may be associated with decreased growth.