Prospective randomised comparative study of visual foam sclerotherapy alone or in combination with ultrasound-guided foam sclerotherapy for treatment of superficial venous insufficiency: preliminary report.

OBJECTIVE: The aim of the study is to compare ultrasound-guided foam sclerotherapy (UGFS: injection of foam sclerosant under ultrasound guidance) of the great saphenous vein (GSV) combined with visual foam sclerotherapy (VFS: injection of foam sclerosant under visual control) for varicose tributary veins and VFS alone in the treatment of GSV reflux. DESIGN AND METHODS: A total of 133 limbs in 97 patients with GSV reflux were randomised to receive either VFS alone or VFS combined with UGFS. In both groups, 1% polidocanol foam was used. Assessments included duplex ultrasonography, evaluation of Venous Clinical Severity Scores (VCSS) and CEAP (clinical, etiologic, anatomic, and pathophysiologic) scores. Ultrasonographic inspection of the foam in the GSV was carried out during 5 min before compression was applied. The primary 'end' point of the study was obliteration of the GSV at 6 months. RESULTS: A total of 51 limbs in 48 patients were treated with UGFS + VFS and the remaining 52 limbs in 49 patients were treated with VFS alone. There were no significant inter-group differences in patient age, male: female ratio, height, weight, body mass index, CEAP clinical scores or VCSS. The GSV diameter was 6.0 ± 1.7 mm (median ± interquartile range) in the UGFS + VFS group and 5.7 ± 1.6 mm in the VFS group (p = 0.419). The mean injected volume of foam for varicose tributary veins was 4 ± 2 ml in the UGFS + VFS group and 6 ± 2 ml in the VFS group, a significantly higher amount of foam being used in the latter (p < 0.001). However, the mean total amount of foam was greater in limbs treated with UFGS + VFS than in those treated with VFS alone (p = 0.017). Ultrasonographic inspection revealed complete vasospasm of the GSV in 37 (72.5%) limbs in the UGFS + VFS group and 29 (55.8%) in the VFS group during sclerotherapy (p = 0.097). At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with UGFS + VFS and in 22 limbs (42.3%) treated with VFS. The difference between the two groups was not significant (p = 0.775). Reflux was absent in 30 limbs (58.8%) treated with UGFS + VFS and in 37 (71.2%) treated with VFS (p = 0.190). There was no inter-group difference in post-treatment VCSS (p = 0.223). CONCLUSIONS: These results show that UGFS + VFS and VFS are equally effective for the treatment of GSV reflux, despite the lower volume of foam used for VFS alone.

Foam sclerotherapy for spouting haemorrhage in patients with varicose veins.

The bleeding from various veins can be intense and may be mistaken for arterial haemorrhage. Several fatal cases are reported due to delay of treatment and inappropriate first aid. We describe five cases of haemorrhage from varicose veins that were treated with foam sclerotherapy. Polidocanol foam was injected in the various veins using ultrasound guidance. There was no recurrence of haemorrhage in any patient during the 17.4 months follow-up period. Foam sclerotherapy can be performed easily in an out-patient clinic setting. This method is an ideal therapy for haemorrhage from varicose veins because it mitigates problematic varicose veins.

Factors predicting development of post-thrombotic syndrome in patients with a first episode of deep vein thrombosis: preliminary report.

OBJECTIVE: To investigate the indicative parameters reflecting the progression of post-thrombotic syndrome (PTS) in patients with a first episode of deep vein thrombosis (DVT). DESIGN AND METHODS: The patients' initial risk factors were assessed at presentation. Venous occlusion, and reflux and reflux parameters were evaluated at 6 months using venous duplex scanning. Near-infrared spectroscopy (NIRS) was also used to measure calf muscle deoxygenated haemoglobin levels at 6 months. Clinical manifestations were categorised using the clinical, etiologic, anatomic and pathophysiologic (CEAP) classification for chronic venous insufficiency (CVI), and the patients were divided into those having no PTS (C(0-3S),E(s),A(s,d,p),P(r,o)) and those having PTS (C(4-6S),E(s),A(s,d,p),P(r,o)). RESULTS: Of the 121 patients evaluated, 25 (21%) developed PTS with a mean follow-up period of 66 months. At initial presentation, ilio-femoral DVT (odds ratio (OR) 3.4, 95% confidence interval (CI) 1.4-8.6) was associated with development of PTS. At 6 months, venous occlusion combined with reflux (OR 4.4, 95% CI 2.9-20.7), peak reflux velocity >29.7 cm s(-1) (OR 13.7, 95% CI 4.1-45.7) and mean reflux velocity >8.6 cm s(-1) (OR 4.4, 95% CI 1.5-12.9) in the popliteal vein detected by duplex scanning were strong predictors of PTS. NIRS-derived retention index >3.5 was the strongest predictor of PTS at 6 months (OR 67.4, 95% CI 14.3-318.1). CONCLUSIONS: Ilio-femoral DVT is associated with the development of PTS at initial presentation. By contrast, occlusion and reflux, high reflux velocity in the popliteal vein and increased NIRS-derived retention index are important time-course predictors of PTS progression.

Advanced chronic venous insufficiency is associated with increased calf muscle deoxygenation.

OBJECTIVE: To determine the temporal relationship between changes in calf muscle deoxygenated haemoglobin (HHb) measured by near-infrared spectroscopy (NIRS) during light-intensity exercise and clinical stages of chronic venous insufficiency (CVI). DESIGN AND METHODS: Calf muscle HHb level was obtained in 168 limbs of 158 patients with various clinical stages of CVI. Clinical manifestations were categorised according to the CEAP classification (CEAP, clinical, etiological, anatomical and pathophysiological), and the patients were divided into two groups: early CVI (C(0-3),E(p)(,s),A(s)(,d,p),P(r)(,o)) and advanced CVI (C(4-6),E(p)(,s), A(s)(,d,p),P(r)(,o)). Calf venous blood-filling index (FI-HHb) was calculated on standing, then the calf venous ejection index (EI-HHb) was obtained after one tiptoe movement and the venous retention index (RI-HHb) after 10 tiptoe movements. RESULTS: A total of 116 limbs had early, and 52 had advanced CVI. FI and RI were significantly increased in patients with advanced CVI compared with those with early CVI (P = 0.003, 0.0001, respectively). Similarly, RI was significantly greater in patients who had superficial, combined with deep and/or perforator, insufficiency than in patients with superficial insufficiency alone (P = 0.002). RI showed the strongest correlation with duplex-derived peak reflux velocity in the popliteal vein (r = 0.78, P < 0.0001). Combination of an optimal cut-off point of 0.2 for FI and 2.9 for RI improved the ability to discriminate early from advanced CVI, with a sensitivity of 94% and a specificity of 86%. CONCLUSIONS: These results suggest that FI and RI, as measured by NIRS, may be promising parameters for discriminating early CVI from advanced CVI.

Prognostic impact of calf muscle near-infrared spectroscopy in patients with a first episode of deep vein thrombosis.

BACKGROUND: The risk factors that affect the development of post-thrombotic syndrome (PTS) are not fully recognized, and it is difficult to reliably predict which patients are likely to develop PTS in acute phase of deep vein thrombosis (DVT). AIMS: To investigate changes in calf muscle deoxygenated hemoglobin (HHb) levels after DVT, and to determine the indicative parameters reflecting the progression of PTS. METHODS: Seventy-six consecutive patients with a first episode of unilateral DVT were prospectively enrolled. Clinical manifestations were categorized according to the CEAP (Clinical, Etiologic, Anatomical, and Pathophysiologic) classification, and the patients were divided into no-PTS (C(0-3)E(s),A(s,d,p),P(r,o)) and PTS (C(4-6)E(s),A(s,d,p),P(r,o)) groups. Near-infrared spectroscopy (NIRS) was used to measure calf muscle HHb levels at 6 months after diagnosis of DVT. The calf venous blood filling index (HHbFI) was calculated on standing, and the venous ejection index and the venous retention index (HHbRI) were then obtained after exercise. All patients were followed up for more than 24 months after the diagnosis of DVT. RESULTS: Of 76 patients evaluated, 20 (26.3%) had PTS. The NIRS-derived HHbFI and HHbRI were significantly increased in patients who developed PTS in comparison with those who did not (P = 0.04 and P = 0.0001, respectively). HHbRI was significantly increased in patients with iliofemoral DVT in comparison with patients with calf DVT (P = 0.041). An optimal cut-off point of 2.9 for HHbRI showed the strongest ability to predict the development of PTS, with a sensitivity of 100% and a specificity of 82.1%. CONCLUSIONS: HHbRI as measured by NIRS is significantly increased in patients with iliofemoral DVT as compared with those with calf DVT. Furthermore, HHbRI > 2.9 is a strong predictor of the development of PTS at 6 months.

Great saphenous vein sparing surgery by angioscopic valvuloplasty combined with axial transposition of a competent tributary vein--5-year follow-up.

OBJECTIVE: To evaluate the efficacy and haemodynamic effects of great saphenous vein (GSV) sparing surgery--valvuloplasty combined with axial transposition of a competent tributary vein (A-VACT). MATERIALS AND METHODS: Eighty-five limbs in 74 patients with isolated GSV incompetence were selected for GSV sparing surgery. After angiographic valvuloplasty, the competent tributary vein was exposed and cut 1.5 cm distal to its insertion point on the GSV. The transected vein was anastomosed end-to-side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Venous valve competence were screened by serial postoperative duplex examination, and venous haemodynamic changes were analyzed using venous filling index (VFI) measured by air plethysmograph pre- and postoperatively. The follow-up period was 5-years. RESULTS: Sixty-seven patients were included in whom 76 limbs were treated. There was a statistically significant reduction in the vein diameter at the SFJ after 5-years (0.83 S.D. 0.29 cm to 0.46 S.D. 0.12 cm, p=0.0002, Wilcoxon). Similarly, significant reduction was found in the GSV at the 5-year follow-up point (0.63 S.D. 0.19 cm to 0.39 S.D. 0.11 cm, p<0.0001, Wilcoxon). On the other hand, there was significant increase in the diameter of the competent tributary vein postoperatively (0.22 S.D. 0.13 cm to 0.31 S.D. 0.12 cm, p<0.0001, Wilcoxon). Duplex scanning demonstrated reflux at the SFJ in 12 limbs (16%). Similarly, in the GSV, venous reflux was found in 13 limbs (17%). Reflux in the transposed tributary vein was found in 20 limbs (26%). But only 7 limbs (9%) had minor varicose veins' recurrence. VFI remained normal during the follow-up examination. The preoperative VFI confirmed the presence of venous reflux, but there were significant improvement in the VFI values at all postoperative examinations. CONCLUSIONS: A-VACT procedure improves venous function, resolves varicose veins at 5-years follow-up as well as preserving the GSV for future grafting.

Presence of lower limb deep vein thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report.

OBJECTIVES: To investigate the presence of lower limb deep vein thrombosis (DVT) and prognosis in patients with symptomatic pulmonary embolism (PE). MATERIALS AND METHODS: A total of 203 consecutive referral patients with PE were included. The distribution of DVT was evaluated with compression ultrasound (CUS), and all patients were then followed for 12 months for investigation of recurrence of venous thromboembolism (VTE) and fatal events as adverse outcome. RESULTS: The mean age of the patients was 62.8 years, and 78 (38.4%) were males. DVT was found in 118 (58.1%) patients. Of these patients, 61 (30.0%) had proximal DVT. Multivariate analysis demonstrated that active cancer, inadequate anticoagulation, leg symptoms, male gender, presence of DVT, presence of proximal DVT, and previous DVT were independent risk factors for adverse outcome. A clinical risk score ranging from 0 to 10 points was generated on the basis of multivariate regression coefficients. Receiver operating characteristic curve analysis showed that an appropriate cut-off point for discriminating between the presence and the absence of an adverse event was 4. Using this category, 166 (81.8%) patients were classified as low risk and 37 (18.2%) as high risk for adverse outcome. The adverse event rates were 6.0% for the low-risk group and 59.5% for the high-risk group. CONCLUSIONS: This study has confirmed the clinical significance of surveillance CUS in patients with a first episode of PE. Furthermore, a simple risk score on the basis of available variables can identify patients at risk of an adverse outcome in patients with PE.

Multiple small-dose injections can reduce the passage of sclerosant foam into deep veins during foam sclerotherapy for varicose veins.

OBJECTIVE: To compare the proportion of foam sclerosant that enters deep veins between multiple injections of <0.5 ml foam per injection and a few injections of >0.5 ml foam per injection. DESIGN & METHODS: One hundred and seven patients with superficial venous incompetence were randomised to receive either multiple injections of <0.5 ml 1% polidocanol (POL) -foam (multiple injections) or a few injections of >0.5 ml 1% POL-foam per injection (few injections) for the treatment of varicose tributaries. All patients then received ultrasound-guided foam sclerotherapy for refluxing great saphenous vein (GSV) using 3% POL-foam. Only a single session was allowed per patient in order to standardise treatment. Qualitative ultrasonographic inspection of the foam was carried out during a 5-min period before compression was applied. Post-sclerotherapy surveillance was done at day 3, 2 weeks, 1 month, 3 months, and 6 months. RESULTS: Fifty-six limbs in 53 patients were treated with multiple injections and the remaining 56 limbs in 54 patients were treated with a few injections. There were no significant differences in age or male:female ratio between the groups. The mean volume of 1% POL-foam was 2.2 S.D. 0.6 ml (range: 0.7-4.0 ml) in the multiple injections group and 2.5 S.D. 0.6 ml (range: 1.0-4.0 ml) in the few injections group (p=0.003). The mean volume of 3% POL was 1.5 ml (range: 0.7-3.0 ml) and 1.4 ml (range: 0.7-3.0 ml), respectively (p=0.137). Ultrasonographic inspection immediately after sclerotherapy demonstrated that foam was distributed significantly more commonly in the deep veins of patients treated with a few injections (p=0.0003). Two (4%) of the patients treated with a few injections developed migraine during the procedure, but recovered quickly with no further complications. There was no significant difference in the success rate between the groups at 6 months (p=0.257). CONCLUSIONS: These findings suggest that multiple small-dose injections can reduce the amount of foam sclerosant and the risk of foam sclerosant entering the deep veins in patients with superficial venous insufficiency.

Successful management of giant ischial decubitus ulcers complicated with urethral disorder.

SUMMARY: We report a case of bilateral ischial pressure sores complicated with urethral fistula, caused by previous complete ischiectomy. Successful reconstruction was achieved after closure of the bladder neck. The large defect in the bilateral ischium and perineum was covered simultaneously with a free total plantar flap. The paucity of suitable recipient vessels for microvascular anastomoses was resolved by the creation of an arteriovenous loop, when the closure of bladder neck was performed in a supine position.

High peak reflux velocity in the proximal deep veins is a strong predictor of advanced post-thrombotic sequelae.

BACKGROUND: The presence of reflux in the femoral vein (FV) and popliteal vein (POPV) after acute deep vein thrombosis (DVT) is considered to contribute to the development of advanced post-thrombotic syndrome (PTS). However, a quantification of reflux has yet to be determined. The purpose of study was to determine the indicative parameters reflecting the progression of PTS. METHODS: Venous abnormalities were evaluated in 131 limbs out of 130 patients who completed a six-year follow-up after an acute DVT. Clinical manifestations were categorized according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification, and the patients were divided into two groups at a six-year follow-up point: group I, C(0-3)E(s),A(s,d,p),P(r,o), early chronic venous insufficiency (CVI); group II, C(4-6)E(s),A(s,d,p),P(r,o), advanced CVI. Venous segments were examined whether they were occluded or recanalized. The reflux parameters assessed were the diameter (cm), the reflux time (RT; s), the peak reflux velocity (PRV; cm s(-1)), and total refluxed volume, and these parameters were assessed especially in the FV and POPV at the two-year (early phase) and subsequent six-year (late phase) follow-up points after DVT. RESULTS: There were 98 limbs in group I and 33 in group II. The frequency of venous reflux was significantly higher in group II (<0.0001). In contrast, the proportion of occlusion did not differ between the groups (P = 0.138). The proportions of FV and POPV incompetence were significantly higher in group II (P < 0.0001 and P < 0.0001, respectively). In these veins, the RT did not improve the discrimination power between the two groups. In contrast, the PRV had significant discrimination power in these veins at both the two- and six-year follow-up points. In the superficial venous system, there were no significant differences in any of the determined parameters between the groups. In group II, 19 patients (58%), who had early symptoms of CVI at the two-year follow-up point, subsequently developed advanced symptoms of PTS. After calculating a suitable cutoff point using receiver operating characteristic curves analysis at the two-year follow-up point, multivariable analysis showed that a PRV of >25.4 cm s(-1) in the POPV was the strongest independent predictor of advanced CVI [odds ratio (OR) 60.32; 95% confidence interval (95CI) 43.1-1238.97, P < 0.0001]. Similarly, in the FV, a PRV of >24.5 cm s(-1) was found to be a strong predictor of advanced CVI (OR 25.77, 95CI 10.56-331.12, P < 0.0001). CONCLUSIONS: These findings suggest that the presence of a high PRV in the proximal deep veins is an independent predictor of advanced symptoms of PTS.

Quantification of venous reflux parameters using duplex scanning and air plethysmography.

OBJECTIVE: To compare different duplex- and air plethysmography (APG)-derived parameters between patients with relatively early and those with advanced chronic venous insufficiency (CVI), and to investigate the indicative parameters reflecting the progression of CVI. DESIGN: Prospective study at the University Hospital. PATIENTS: In total 686 limbs in 574 patients at various clinical stages of CVI were included. The clinical manifestations were categorized according to the CEAP (clinical, aetiologic, anatomic and pathophysiologic) classification, and the patients were divided into two groups: group I (C(1-3(E(P,S)A(S,D,P)P(R,O), relatively early stage of CVI) and group II (C(4-6)E(P,S)A(S,D,P)P(R,O), advanced CVI). The distribution of venous insufficiency including the sapheno-femoral junction (SFJ), great saphenous vein (GSV), sapheno-popliteal junction (SPJ), common femoral vein (CFV), femoral vein (FV), popliteal vein (POPV), thigh perforators (TPV) and calf perforators (CPV) was determined by duplex ultrasound. The main duplex-derived parameters assessed were the reflux time (RT; s), peak reflux velocity (PRV; cm/s) and peak reflux flow (PRF; mL/s). The venous reflux was assumed to be present if the duration of reflux was > or = 0.5 s. The data obtained by APG were on VV (mL), VFI (mL/s), EF (%) and RVF (%). RESULTS: There was no significant difference in overall superficial venous reflux between the groups (P = 0.331). The frequency of deep and perforating vein incompetence differed only when superficial reflux was included in group II. The VFI and RVF were significantly higher in secondary CVI than in primary CVI (P = 0.0001, 0.003, respectively). In the secondary CVI, patients with reflux and obstruction showed significantly higher RVF than those with reflux alone (P = 0.003). The RT did not improve the discrimination power between the groups. In contrast, the PRV had significant discrimination power at the SFJ (P < 0.0001) and SPJ (P = 0.022), and in the GSV (P < 0.0001), the FV (P = 0.017), and the POPV (P = 0.0003). The PRF was significantly higher in group II at the SFJ (P < 0.0001), in the GSV (P = 0.002), in the CFV (P = 0.011), in the FV (P = 0.027), and the POPV (P = 0.016). CONCLUSIONS: This present study has suggested the importance of superficial venous insufficiency in the development of advanced CVI. In the secondary CVI, obstruction affects the RVF alone. The PRV and PRF are better parameters than the RT for discrimination of clinical severity in both superficial and deep venous insufficiency, and should be used to quantify venous valvular insufficiency.

Comparison of manual compression release with distal pneumatic cuff maneuver in the ultrasonic evaluation of superficial venous insufficiency.

BACKGROUND: Venous reflux can be elicited either manually or by pneumatic tourniquet, and previous studies did not indicate any significant difference between these manoeuvres in patients with superficial venous insufficiency (SVI). PURPOSE: To investigate if two methods correlate in patients with CVI. MATERIALS AND METHODS: Venous reflux was studied in 94 venous segments of 57 limbs in 52 consecutive patients with SVI. Limbs were divided into two groups: group I (CEAP C2-C3) and group II (CEAP C4-C6). A colour duplex scanner was used to determine quantitative venous reflux at the sapheno-femoral junction (SFJ), at the sapheno-popliteal junction (SPJ), and in the greater saphenous vein in the thigh (GSV). Patients received both manual compression and cuff deflation method in eliciting venous reflux. The parameters assessed were the duration of reflux (second) and the peak reflux velocity (cm/s). STATISTICS: Paired t-test was used to evaluate differences between the two methods. Statistical significance was recorded when the p-value was <0.05. Bland and Altman plot was also used to assess the agreement of the same measurement. RESULTS: There were 58 venous segments in group I and 36 in group II. In group I, there were no significant differences in the duration of reflux at the SFJ, SPJ, and in the GSV. On the contrary, peak reflux velocity was found to be significantly higher at the SFJ and in the GSV (p=0.022 and 0.006, respectively). In group II, there was no significant difference in the duration of reflux at the SFJ and SPJ between the two methods. On the contrary, manual compression maneuver produced significantly higher peak reflux velocity than at the SFJ and in the GSV (p=0.023 and 0.002, respectively). Bland and Altman plot analysis, manual compression method displayed a relatively good agreement with cuff deflation manoeuvre both in group I and group II. In contrast, concerning the peak reflux velocity, relative wide limits of agreement were found between the two methods. CONCLUSIONS: Unlike previously published reports, our results lead to apparent discrepancies in the quantitative evaluation of venous reflux using different methodology.

The utility of quantitative calf muscle near-infrared spectroscopy in the follow-up of acute deep vein thrombosis.

BACKGROUND: To investigate patterns of venous insufficiency and changes in calf muscle deoxygenated hemoglobin (HHb) levels after an acute deep vein thrombosis (DVT). METHODS: A total of 78 limbs with an acute DVT involving 156 anatomic segments were evaluated with duplex scanning and near-infrared spectroscopy (NIRS) at 1, 3, 6 and 12 months. Venous segments were examined whether they were occluded, partially recanalized, and totally recanalized, and the development of venous reflux was noted. The NIRS was used to measure calf muscle HHb levels. Calf venous blood filling index (HHbFI) was calculated on standing, then the calf venous ejection index (HHbEI), and the venous retention index (HHbRI) were obtained after exercise. RESULTS: The segments investigated were the common femoral vein (CFV; 38 segments), femoral vein (FV; 37), popliteal vein (POPV; 44), and calf veins (CV; 37). At 1 year, thrombi had fully resolved in 67% of the segments, 27% remained partially recanalized, 6% were occluded. The venous occlusion was predominant in the FV (24%) at 1 year. On the contrary, rapid recanalization was obtained in CV than proximal veins at each examination (P < 0.01). Venous reflux was predominant in POPV (55%), followed by FV (19%), and no reflux was found in CV. At 1 year, the HHbFI in POPV reflux patients was significantly higher than those with resolution (0.19 +/- 0.14, 0.11 +/- 0.05 microm s, P = 0.009, respectively). Similarly, there was a significant difference in the HHbRI between the two groups (3.08 +/- 1.91, 1.42 +/- 1.56, P = 0.002, respectively). In patients with FV occlusion, the value of HHbRI was significantly higher than those with complete resolution (2.59 +/- 1.50, 1.42 +/- 1.56, P = 0.011, respectively). CONCLUSIONS: The lower extremity venous segments show different proportions of occlusion, partial recanalization, and total recanalization. The CV shows more rapid recanalization than proximal veins. The NIRS-derived HHbFI and HHbRI could be promising parameters as the overall venous function in the follow-up of acute DVT. These findings might be very helpful for physician in detecting patients who require much longer follow-up studies.

Cerebellar glioblastoma genetically defined as a secondary one.

We report here the case of a 29-year-old woman with cerebellar glioblastma. In the present case, tumor lesions were observed in each cerebellar hemisphere. The left-side lesion was diagnosed as glioblastoma, and the right-side lesion as malignant astrocytoma by histopathology. Immunohistochemistry revealed that the tumor cells of the left-side lesion was positive for p53, whereas epidermal growth factor receptors (EGFR) were negative in tumor cells from both sides. Genetic alterations were investigated using a genome DNA microarray (GenoSensor Array 300), which has led us to define this tumor as a secondary glioblastoma. The clinical presentation and genetic findings of this relatively rare entity are discussed.

Vertical-torsional oscillations and dissociated bilateral horizontal gaze palsy in a patient with a pontine cavernous angioma.

We report the case of a 16 year old girl with vertical-torsional oscillations. She had a 4 year history of bilateral horizontal gaze palsy caused by a cavernous angioma in the medial part of the dorsal pons. She presented with vertical oscillopsia that had worsened during the past 3 months. Unilateral three dimensional eye movements and bilateral horizontal eye movements were recorded using a magnetic search coil method and direct current electro-oculography, respectively. She had vertical-torsional oscillations (average frequency: 3.0 Hz) leaving vertical saccades and pursuits intact. The average amplitudes of the vertical and torsional components were 2.0 degrees and 0.6 degrees , respectively. Her horizontal rapid eye movements were severely impaired; however, her horizontal pursuits and slow phases of vestibulo-ocular reflex were only partially impaired (gain<0.3, oculomotor range<+/-9 degrees ). Convergence and divergence were intact. Lesions involving the medial part of the dorsal pons and bilateral paramedian pontine reticular formation can induce vertical and torsional oscillations without disruption of vertical rapid eye movements.

Ovarian fibrosarcoma producing multiple cytokines.

A case of ovarian fibrosarcoma producing multiple cytokines is presented. The tumor occurred in the left ovary of a Japanese woman with epigastralgia, remittent fever, leukocytosis and slight thrombocytosis with moderate increase of mast cells in bone marrow, but lack of hormonal abnormality. The resected tumor of the ovary was well encapsulated and it was composed of spindle-shaped tumor cells and scattered tubules with marked mast cell infiltration. The tumor recurred in the pelvic cavity 14 months later, accompanied by similar signs and symptoms as occurred with the primary tumor. Serum levels of interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha were elevated. The recurrent tumor showed similar histological findings to those of the primary tumor, except for lack of tubules. Tumor cells revealed a focally positive immunoreaction for vimentin, IL-6 and TNF-alpha and alpha-inhibin. Reverse transcription-polymerase chain reaction using total RNA obtained from the recurrent tumor demonstrated mRNA expression of IL-6, IL-10, TNF-alpha and stem cell factor. This is a rare case of ovarian fibrosarcoma producing multiple cytokines, resulting in atypical clinical findings.

[Intermittent administration of 5-FU and isovorin to patients with advanced and recurrent colon cancer].

We attempted a new regimen of intermittent administration of 5-FU and low-dose Isovorin (F.I) to four patients with advanced and recurrent colon cancer. A partial response (PR) was achieved in two of four patients who had evaluable lesions for this treatment. We observed few side effects among these patients. Only one patient among four showed grade 1 neuropathy after two administrations of this chemotherapy. However, after a two-week pause in administration, the neuropathy disappeared and we could continue the therapy. This patient with multiple liver metastases achieved a partial response. Other patients had no side effects such as bone marrow suppression or digestive symptoms. This intermittent F.I treatment might be an effective and promising therapy with few side effects even for patients with poorer conditions.