Superior Mesenteric Artery Syndrome: Clinical, Endoscopic, and Radiological Findings.

BACKGROUND: The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and weight loss. Studies to determine the optimal methods of diagnosis and treatment are required. AIMS AND METHODS: This study aims at analyzing the clinical presentation, diagnosis, and management of SMA syndrome. Ten cases of SMA syndrome out of 2074 esophagogastroduodenoscopies were suspected. A contrast-enhanced computed tomography (CECT) scan was performed to confirm the diagnosis. After, a gastroenterologist and a nutritionist personalized the therapy. Furthermore, we compared the demographical, clinical, endoscopic, and radiological parameters of these cases with a control group consisting of 10 cases out of 2380 EGDS of initially suspected (but not radiologically confirmed) SMA over a follow-up 2-year period (2015-2016). RESULTS: The prevalence of SMA syndrome was 0.005%. Median age and body mass index were 23.5 years and 21.5 kg/m2, respectively. Symptoms developed between 6 and 24 months. Median aortomesenteric angle and aorta-SMA distance were 22 and 6 mm, respectively. All patients improved on conservative treatment. In our series, a marked (>5 kg) weight loss (p = 0.006) and a long-standing presentation (more than six months in 80% of patients) (p = 0.002) are significantly related to a diagnosis of confirmed SMA syndrome at CECT after an endoscopic suspicion. A "resembling postprandial distress syndrome dyspepsia" presentation may be helpful to the endoscopist in suspecting a latent SMA syndrome (p = 0.02). The narrowing of both the aortomesenteric angle (p = 0.001) and the aortomesenteric distance (p < 0.001) was significantly associated with the diagnosis of SMA after an endoscopic suspicion; however, the narrowing of the aortomesenteric distance seemed to be more accurate, rather than the narrowing of the aortomesenteric angle. CONCLUSION: SMA syndrome represents a diagnostic and therapeutic challenge. Our results show the following findings: the importance of the endoscopic suspicion of SMA syndrome; the preponderance of a long-standing and chronic onset; a female preponderance; the importance of the nutritional counseling for the treatment; no need of surgical intervention; and better diagnostic accuracy of the narrowing of the aorta-SMA distance. Larger prospective studies are needed to clarify the best diagnosis and management of the SMA syndrome.

Prolonged Cerebrospinal Fluid Neurofilament Light Chain Increase in Patients with Post-Traumatic Disorders of Consciousness.

The mechanisms involved in secondary brain injury after the acute phase of severe traumatic brain injury (TBI) are largely unknown. Ongoing axonal degeneration, consequent to the initial trauma, may lead to secondary brain injury. To test this hypothesis, we evaluated the cerebrospinal fluid (CSF) level of neurofilament light chain (NF-L), a proposed marker of axonal degeneration, in 10 patients who developed a severe disorder of consciousness after a TBI, including 7 in a minimally conscious state and 3 with unresponsive wakefulness syndrome (time since brain injury, 309 ± 169 days). CSF NF-L level was measured with a commercially available NF-L enzyme-linked immunosorbent assay. CSF NF-L level was very high in all 10 patients, ranging from 2.4- to 60.5-fold the upper normal limit (median value, 4458 pg/mL; range, 695-23,000). Moreover, NF-L level was significantly higher after a severe TBI than in a reference group of 9 patients with probable Alzheimer's disease, a population with elevated levels of CSF NF-L attributed to neuronal degeneration (median value, 1173 pg/mL; range, 670-3643; p < 0.01). CSF NF-L level was correlated with time post-TBI (p = 0.04). These results demonstrate prolonged secondary brain injury, suggesting that patients exhibit ongoing axonal degeneration up to 19 months after a severe TBI.

EEG epileptiform abnormalities at admission to a rehabilitation department predict the risk of seizures in disorders of consciousness following a coma.

BACKGROUND: Seizures affect about a quarter of patients with disorders of consciousness (DOC) after a coma. AIMS: We investigated whether the presence of epileptiform abnormalities (EAs) in the electroencephalogram (EEG) of patients with DOC may predict the occurrence of seizures. Moreover, we evaluated whether EAs have a prognostic role in these patients. METHODS: This was a retrospective single-center cohort study of patients hospitalized between January 2005 and December 2014 in a rehabilitation department (mean time from acute brain injury: 46.1 days). We analyzed 30-minute EEGs at admittance for 112 patients with unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS), then compared occurrence of seizures over the following three months across patients with absent, unilateral, and bilateral EAs (generalized or bilateral independent). Outcomes at three months were assessed in the same groups using the Coma Recovery Scale Revised. RESULTS: Epileptiform abnormalities were observed in 38 patients (33.9%). Of these, 25 were unilateral, and 13 were bilateral. Seizures occurred in 84.6% of patients with bilateral EAs, which was significantly higher than in patients without EAs (10.8%, p<0.001) or with unilateral EAs (24%, p=0.001). The presence of EAs was not related to etiology or different DOC and did not significantly affect outcomes at three months. CONCLUSIONS: Patients with EAs at admission to a rehabilitation department have an increased risk of seizures. Specifically, most patients with bilateral EAs had seizures within the following 3 months. Evaluation of EAs in EEGs of patients with DOC may give valuable information in the management of antiepileptic drug treatment.

Prevalence of asymptomatic lower limb venous thrombosis in infertile women with thrombophilic disorders.

OBJECTIVE: We sought to assess the prevalence of asymptomatic venous thrombosis in infertile women with thrombophilic disorders (TDs). METHODS AND RESULTS: A total of 73 infertile women with TDs underwent duplex ultrasound scan to evaluate superficial and deep venous circulation of lower limbs. A control group of 35 infertile women without TDs was included. A single TD was found in 13 (17.8%) subjects, and 40 (54.8%) women presented a combined defect (more than three alterations). No residual mural thrombosis (RT) was noted in any deep veins. We found RT in 48 (65.8%) patients of TD group, while no RT was found in the control group (p < 0.0001). None of the clinical and prothrombotic factors were predictors of RT (all p > 0.20), and frequency of TD did not correlate with multi-vessel RT (p = 0.252). CONCLUSIONS: No signs of deep vein thrombosis but high prevalence of superficial RT is present in infertile women with TDs. Further studies are needed to assess the prognostic value of our findings.

Early carotid atherosclerosis in women: results of an ultrasonographic study measuring carotid artery intima-media thickness.

Ultrasonography (US) is a useful diagnostic tool in detecting early vascular diseases in women and is particularly relevant in the elderly population. Increased carotid artery intima-media thickness (IMT) is a predictive marker of onset of atherosclerosis and is associated with vascular events. The objective of the present study was to determine carotid artery IMT in asymptomatic women of different age classes and to correlate the results with metabolic and coagulative parameters, age, and menopause. A total of 1200 women age 29-73 years selected from the electoral list of the city of Catania, Italy consented to participate in the US study to determine IMT. The percentage of IMT values exceeding an IMT cutoff value of < 1.3 mm observed in our study groups was significant. Correlations were observed between IMT and total cholesterol (r = .157), high-density lipoprotein (HDL) cholesterol (r = .87), low-density lipoprotein (LDL) cholesterol (r = .149), and fibrinogen (r = .140) values. Increased ultrasonographic markers showing onset of carotid artery remodeling can be observed in asymptomatic women of all ages. Some cardiovascular risk factors are linked to the initial stages of atherosclerosis. We recommend US screening in healthy populations to identify subjects who could develop vascular disease.

Ultrasound diagnosis of carotid artery lesions in a population of asymptomatic subjects presenting atherosclerosis risk factors.

Carotid artery atherosclerosis, age, family history, smoking, arterial hypertension, diabetes mellitus, and dyslipidemia represent risk factors of cerebrovascular events (stroke and transient ischemic attack). Hence, preventive treatment is vital for patients presenting these factors. Seven hundred and sixty-six patients (348 men and 418 women; age range 30-80 years) who were asymptomatic and attending a vascular unit for routine ultrasound (US) screening of the carotid arteries and with risk factors, intima-media thickness (IMT) of carotid artery > 1.3 mm, IMT associated with findings of atherosclerotic plaque creating stenosis > 20%, < or = 50%, and carotid plaque creating stenosis > 50% were considered. For patients with diabetes and hyperlipemia (35.8%)--or with hypertension, diabetes, and hyperlipemia (34.8%)--a higher prevalence of IMT > 1.3 mm was found. Higher prevalence of atherosclerotic plaque > 50% varied between 14.2% (in cases with diabetes mellitus and dyslipidemia) and 29.6% (in cases presenting 4 concomitant risk factors). Direct correlation was found between different risk factors and US findings. Our US findings revealed both a high incidence of carotid atherosclerosis, and that single and multiple correlation between US diagnosis of vascular damage and risk factors further enhanced risk. The study results confirmed the significance of vascular risk factors in patients with carotid artery atherosclerosis, and underlined the diagnostic validity of US.

High circulating levels of cytokines (IL-6 and TNFalpha), adhesion molecules (VCAM-1 and ICAM-1) and selectins in patients with peripheral arterial disease at rest and after a treadmill test.

Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis that is associated with systemic inflammation. The aim of our study was to assess whether plasma markers of inflammation increased after exercise in patients with PAD. The study was conducted on two groups of 20 subjects each: one group (mean age 68.4 +/- 5.09 years) was affected by PAD with claudication, while the other group consisted of healthy controls (66.9 +/- 6.1 years). Concentrations of interleukin 6 (IL-6) and tumor necrosis factor alpha (TNFalpha) were determined in plasma, in supernatants and in cells stimulated with 1 mg lipopolysaccharide in all patients. E-selectin (ES), L-selectin (LS) and P-selectin (PS) concentrations and plasma concentrations of VCAM-1 and ICAM-1 were also determined. All determinations were performed in patients at rest and after the treadmill exercise. Resting values of soluble mediators were greater in PAD patients than in controls. They increased in both groups after the treadmill test, even if post-treadmill concentrations were significantly higher in PAD patients (PAD p < 0.001 or 0.0001, controls p < 0.05 or 0.001). These results confirm that white blood cell activation is characteristic of systemic atherosclerosis and that these inflammation markers increase in conditions of hemodynamic stress.