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PubMedDate not supplied

Squamous cell carcinoma of the head and neck treated with radiotherapy: does planned neck dissection reduce the change for successful surgical management of subsequent local recurrence?

For patients with squamous cell carcinoma of the head and neck whose primary lesion is managed with radiotherapy, radiotherapy alone or in combination with neck dissection may be used to treat clinically positive neck nodes. Although these two treatment options produce similar control rates for small mobile nodes, it is our impression that radiotherapy plus neck dissection is the preferred treatment for more advanced neck disease. The question that arises is whether the addition of a neck dissection after radiotherapy will decrease the likelihood of successful surgical management of a subsequent recurrence at the primary site. In an effort to answer this question, the records of 227 patients with squamous cell carcinoma of the head and neck were reviewed. All patients had clinically positive neck nodes and were treated with radiotherapy alone to the primary lesion. There was no apparent difference in the rate of disease control at the primary site or in the ability to manage patients successfully who developed a local recurrence when comparing patients initially treated with radiotherapy alone to those managed by radiotherapy and neck dissection. We conclude that postradiotherapy neck dissection does not decrease the likelihood of successfully managing a recurrence at the primary site.

Carcinoma, Squamous Cell↗

PubMed2006

Acute aortic dissection.

Acute aortic dissection is an uncommon but lethal cause of acute chest, back, and abdominal pain. Establishing a timely diagnosis is paramount, as mortality from acute aortic dissection rises by the hour. Physical findings are protean and may include acute aortic valve insufficiency, peripheral pulse deficits, a variety of neurologic deficits, or end-organ ischemia. The keys to establishing a timely diagnosis are maintaining a high index of suspicion and quickly obtaining a diagnostic study. CT angiography, magnetic resonance imaging, transesophageal echocardiography, and, to a lesser extent, aortography are all highly accurate imaging modalities. The choice of study should be driven by the clinical stability of the patient, the information required and the resources available at presentation. Proximal dissections are surgical emergencies, but distal dissections are generally treated medically. Endovascular stents are gaining favor for use in the repair of both acute and chronic distal dissections. Long-term outcome data for endovascular stenting are still limited, and it remains unclear when stenting should be favored over surgery or medical therapy.

Acute Disease↗

PubMed1989

Bilateral radical neck dissection: report of results in 55 patients.

Between 1952 and 1982, 55 patients underwent bilateral radical neck dissections at the National Cancer Institute. Of these, 17 patients had simultaneous (one-stage) bilateral dissections and 38 had nonsimultaneous (two-stage) dissections. In 37 patients both internal jugular veins were removed, while one vein was preserved in 18 patients. The operative mortality was 11.8% (2/17 patients) for simultaneous bilateral neck dissections and 2.6% (1/38 patients) for nonsimultaneous staged dissections. The overall operative mortality was 5.4%. Of the 18 patients in whom one jugular vein was preserved, six patients (33%) had postoperative facial edema and swelling, while of the 37 patients in which neither jugular vein was saved, 20 patients (54%) developed significant postoperative facial edema. The overall 2-year recurrence rate was 50%. The overall survival rates were 55% at 3 years and 39% at 5 years.

Adolescent↗

PubMed2003

Preliminary study of laser welding for aortic dissection in a porcine model using a diode laser with indocyanine green.

BACKGROUND AND OBJECTIVES: The objective of this study was to determine whether a dissected aorta could be welded by a diode laser with a solder using an in vitro porcine aortic dissection model. STUDY DESIGN/MATERIALS AND METHODS: Porcine aortic strips were dissected into two flaps and the dissected faces were immersed in a solution of indocyanine green. The two flaps were pressed at 0.2 kg/cm2 with contact between the two immersed faces. The pressed flaps were irradiated with a diode laser (810 nm) at intensities of 170-425 W/cm2 for 8 seconds. The welded flaps were studied by light microscopy and the adhesive strengths were measured. RESULTS: The irradiated flaps were successfully welded. The breaking stress, the maximum stress recorded in a stress-strain curve, increased with increase in irradiation intensity up to 396 W/cm2 (2.7 x 10(2) mmHg) and decreased when the intensity reached 425 W/cm2. In the specimen irradiated at 396 W/cm2, the welded faces showed continuous fusion of elastin layers, while some voids were seen between the welded faces in the specimen irradiated at 425 W/cm2. CONCLUSIONS: The dissected porcine aortas were successfully welded using a laser with solder. The results suggest that the welded aorta can bear physiological blood pressure.

Aortic Dissection↗

PubMedDate not supplied

Neck dissection: concepts, controversies, and technique.

The various types of neck dissections are described. The indications for each type of neck dissection are discussed for patients with necks staged N0, N+, for the patient with an unknown primary and for the patient whose neck dissection is in conjunction with radiation. The technical aspects of modified neck dissections are addressed but not in great detail. The indications for the use of postoperative radiation are emphasized. The nodal groups at risk for metastases from various primary sites are identified and a terminology for neck dissection is suggested.

Humans↗

PubMed1997

Effect of embryonic donor age and dissection on the DARPP-32 content of cell suspensions used for intrastriatal transplantation.

The aim of this study was to determine in vitro the DARPP-32 content of donor cells used for striatal transplantation in vivo. The effect of selective embryonic dissection of the lateral ganglionic eminence (LGE) was compared with the standard dissection of the whole ganglionic eminence (WGE) at each of three embryonic ages (14, 15, and 16 days of gestation) in the rat. The resultant cell suspensions were cultured for up to 7 days and incubated with antibodies against DARPP-32, a marker of striatal medium spiny neurons; beta-tubulin III, a neuronal marker; GFAP, a marker of reactive astrocytes; and Gal-C, a marker of oligodendrocytes. LGE dissection gave rise to more DARPP-32 neurons compared to WGE; but this relationship was only observed in the younger embryos. When older (16 days gestation) embryos are used there is no difference in the yield of DARPP-32 cells obtained from LGE and WGE. LGE dissections were also observed to contain fewer glial cells. There was no beneficial effect of LGE over WGE on survival of striatal neurons in vitro. These results have important implications for the selection and dissection of fetal donor material used in clinical trials of intrastriatal transplantation as a potential treatment for Huntington's disease.

Animals↗

PubMed1983

Dissecting aneurysm of intracranial vertebral artery: case report and review of literature.

A spontaneous dissecting aneurysm of the intracranial portion of the dominant right vertebral artery presented as massive subarachnoid hemorrhage, excruciating headache, and respiratory arrest in a 57-year-old white man with a history of systemic hypertension. He died on the 3rd day. Postmortem examination revealed a dissecting hemorrhage extending for 2.1 cm along the artery; rupture of the intima, media, and adventitia could be demonstrated. The intramural accumulation of blood in the proximal segments appeared to be related to retrograde dissection within a media weakened by cystic degeneration. Accumulation of pools of mucoid ground substance was also demonstrated in other intracranial and extracranial arteries. Hemodynamic stresses due to arterial hypertension and physical exertion may have played a contributory role in the etiopathogenesis of this uncommon form of cerebrovascular accident. A comprehensive literature review permits a comparison of supratentorial and infratentorial dissecting aneurysms; vertebral and basilar artery dissections are presented in tabular form.

Age Factors↗

PubMed1990

Traumatic and spontaneous extracranial internal carotid artery dissections.

Seventy patients with spontaneous and 21 with traumatic extracranial internal carotid artery dissections were studied clinically and angiographically with mean follow-ups of 64 (spontaneous group) and 40 months (traumatic group). Sixty percent of the patients in the spontaneous group and 71% in the traumatic group also had follow-up angiograms. In traumatic dissections aneurysms were common, significantly fewer aneurysms resolved or became smaller and fewer stenoses resolved or improved, whereas more stenoses progressed to occlusion. Traumatic dissections were more likely to leave the patients with neurological deficits. A significantly higher percentage of the patients with spontaneous dissections were asymptomatic at follow-up compared with the traumatic group. Although both spontaneous and traumatic dissections of extracranial internal carotid arteries mostly carry a good prognosis, the outcome may be somewhat less favorable for the traumatic group.

Adolescent↗

PubMed1992

Dissection of cranial arteries in the neck: correlation of MRI and arteriography.

Retrospective correlation of MRI and angiographic findings in nine patients with suspected cervical vascular dissections revealed MRI evidence of vessel abnormalities in eight patients, seven of whom proved to have arterial dissections. One patient whose MRI showed no abnormalities also proved to have a dissection, shown by angiography. Two patients had associated pseudoaneurysms not demonstrated by MRI. Five dissections involved the carotid arteries and three the vertebral arteries. Seven of the nine patients had associated transient neurologic deficits, while two had permanent deficits. Frank infarction of the brain was demonstrated by MRI in five cases. MRI findings suggestive of dissection included: (1) increased signal from the entire vessel; (2) a border of increased signal surrounding the lumen, with luminal narrowing; (3) poor or absent visualization of the vessel; and (4) significant compromise of the vessel lumen by adjacent abnormal increased signal tissue.

Adult↗

PubMed1991

MRI in spontaneous dissection of vertebral and carotid arteries. 15 cases studied at 0.5 tesla.

Fifteen patients were observed between 1987 and 1990: there were six with angiographically confirmed vertebral artery dissection, and 9 with carotid artery dissection. Results showed concordance of MRI and angiographic findings, in all cases but one. The dissected portion consistently showed a semilunar hyperintensity narrowing the residual eccentric signal void of the lumen when the artery was not completely occluded. In one angiographically occluded vessel, MR detected a small signal void within the hyperintensity, indicating that the artery was not completely occluded. The length of the dissected portion was clearly demonstrated by MR. Follow up MR and angiographic studies confirmed the regression of the dissection, and also allowed examination of the cerebral parenchyma.

Aortic Dissection↗

PubMed1996

Transcatheter Inoue endovascular graft for treatment of canine aortic dissection.

We examined whether the Inoue endovascular graft could be used as a device for the treatment of aortic dissection. This graft consists of a cylinder made from a thin Dacron sheet suspended by several extra-flexible wire rings. Aortic dissections were experimentally created in 11 dogs. Using aortography and intravascular ultrasound imaging (IVUS), we selected the size of the graft diameter according to the diameter of the normal descending aorta (distal to aortic dissection) in 5 dogs (group I) and according to the diameter of the true lumen of the aorta within the aneurysm in 6 dogs (group II). The graft was deployed transfemorally through a 15-F long sheath into the aneurysm to close the entry site, immediately after creation of the aortic dissection. The entry was completely closed in all dogs after immediate implantation. All 5 dogs in group I died within 11 days (mean, 7 days) after graft deployment. However, all grafts in group II were tolerated very well and followed up for as long as 5 months. After the follow up, IVUS and aortography showed no rupture of the aortic aneurysmal wall and no migration, leakage, or damage to the graft in any of the 6 dogs. These 6 dogs were sacrificed and autopsy showed that the graft was covered by a thin, translucent, neointima, effectively recreating a new aortic lumen and completely closing the entry of the aneurysm. The Inoue endovascular graft proved to be effective in the long-term treatment of aortic dissection without surgery, when the size of the graft was selected according to the diameter of the true lumen of the aorta within the aneurysm.

Aortic Dissection↗

PubMed1997

Treatment of dissecting basilar artery aneurysm by flow reversal.

Dissecting aneurysm of the basilar artery is a rare but increasingly recognized entity, with a frequently fatal or morbid outcome. Unlike the well established proximal occlusion and trapping approaches to vertebral artery dissections, surgical intervention for basilar lesions has been limited to wrapping techniques for arterial wall reinforcement. We report a case of midbasilar dissecting aneurysm successfully treated by clipping the proximal basilar artery below the level of the anterior inferior cerebellar arteries, allowing retrograde flow via the posterior communicating arteries to provide continued basilar perfusion. With the growing recognition of basilar dissection and pseudoaneurysm formation there is a need for improved therapeutic options. We suggest that definitive treatment can be achieved using the principle of proximal occlusion and flow reversal, and review the pertinent literature on basilar artery dissection.

Aortic Dissection↗

PubMed1993

Surgical treatment of superior mesenteric artery dissecting aneurysm and simultaneous celiac artery compression.

Spontaneous dissections of visceral arteries are rare, but when they do occur, they most commonly involve the superior mesenteric artery (SMA). We present a case of intestinal ischemia caused by a spontaneous dissection of the SMA in a patient with simultaneous celiac artery occlusion. The patient was a 45-year-old woman who presented with intestinal angina of sudden onset. Arteriography revealed the classic findings of SMA dissection and occlusion of the celiac artery. The patient underwent repair of both visceral vessels and made a full recovery. The 18 previously reported cases of isolated, spontaneous dissection of the SMA are reviewed. No previous case has been associated with celiac compression syndrome. The reported experience with symptomatic dissections of the SMA would suggest that prompt surgical repair is indicated and yields excellent results.

Anastomosis, Surgical↗

PubMed1998

Successful operative treatment for acute triple-barreled aortic dissection in a patient with Marfan's syndrome: report of a case.

Triple-barreled aortic dissection is a rare form of aortic dissection associated with high mortality. We report herein the case of a 41-year-old woman with Marfan's syndrome who developed acute triple-barreled aortic dissection from a Stanford type B dissecting aneurysm. Successful graft replacement of the proximal third of the descending thoracic aorta was subsequently performed. To the best of our knowledge, this is the first case of successful operative treatment for an acute triple-barreled aortic dissection ever to be reported.

Adult↗

PubMed1986

Aortic dissection following coronary artery bypass surgery: diagnosis by CT.

We describe an unusual case of aortic dissection causing spinal cord infarction. The dissection arose from an intimal tear at the suture line of a coronary artery bypass graft. CT was used to diagnose the dissection and to demonstrate its extension to the aortoiliac bifurcation and innominate artery and its rupture into the left pleural cavity. The most common causes of intimal tears following cardiac bypass surgery are aortic cross-clamping, aortic cannulation, and injury during suturing of the graft to the aorta. An underlying disease of the aorta such as atherosclerosis, cystic medial necrosis, or aortitis is commonly present. CT is an accurate and safe means of detecting aortic dissections following cardiac surgery, and is also useful in assessing the extent of the dissection and identifying its rupture into the pleural or pericardial cavity.

Aortic Dissection↗

PubMed1997

Follow-up of aortic dissection: contribution of MR angiography for evaluation of the abdominal aorta and its branches.

Spin-echo MR is an established method to evaluate thoracic aortic dissections, but is not well suited to study the abdominal aorta. In this study we evaluated whether MR angiography could provide a complete examination of the abdominal aorta. In 28 patients (40 MR studies) with suspected (n = 6) or known (n = 34) aortic dissection, MR studies were performed. Thoracic aorta was evaluated with spin-echo and gradient-recalled-echo MR imaging. Axial two-dimensional time-of-flight MR angiography with thin overlapping slices was used to study the abdominal aorta. Intermediate and high signal intensity on MR angiography was interpreted as patent flow, and low signal was interpreted as thrombus. The presence of an intima flap and the re-entry site could be depicted in all MR studies. Thrombus in the false channel was seen in 8 studies. The origin of the abdominal visceral branches and their relation to the false-true channel could be depicted, except in 4 of 80 renal arteries studied. Extension of the dissection into the coeliac trunk was seen in 2 and in the superior mesenteric artery in 10 studies. Dilatation of the suprarenal abdominal aorta was seen in 20 studies, and of the infrarenal aorta in 9 studies. MR angiography provides valuable information about the abdominal aorta and its branches in patients with aortic dissection. This makes MR imaging appealing as the preferred imaging modality for the diagnosis and follow-up of aortic dissection.

Aortic Dissection↗

PubMed2001

Surgery for acute type A aortic dissection using retrograde cerebral perfusion.

OBJECTIVE: We reviewed the surgical management of acute type A aortic dissection between 1989 and 1998. METHODS: Subjects were 28 consecutive patients (mean age: 61.8 +/- 10.7 years) with acute type A aortic dissection were studied. The mean duration between aortic dissection onset and surgery was 17.5 +/- 17.0 hours. In surgery, aortic pathology and flow patterns in dissected aortic channels were evaluated using transesophageal and epiaortic echo. Simple, safe combination of profound hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis was used for brain protection. Hypothermic circulatory arrest was 46.9 +/- 24.8 minutes. Aortic repair consisted in ascending aortic replacement in 5 patients, with hemiarch repair in 17, and total arch repair in 6. Intimal tears were resected in all but 2 patients. Concomitantly resuspension of the aortic valve was done in 9 and aortic root replacement in 2. RESULTS: No operative (30-day) deaths occurred, although 2 died from unrelated hepatic failure during hospitalization or late-stage pancreatic cancer in the late stage. In cerebral sequellae, 1 patient suffered a stroke and 2 patients developed temporary neurologic dysfunction. CONCLUSION: Our experience demonstrated that the simplified conjunction of hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis, associated with real-time assessment by transesophageal and epiaortic echo, is safe and useful during emergency aortic repair for acute type A aortic dissection.

Acute Disease↗

PubMedDate not supplied

Thoracic aortic dissection or aneurysm: clinical presentation, diagnostic imaging and initial management in a tertiary referral centre.

Spontaneous thoracic aortic dissection carries a high mortality despite progress in diagnosis and treatment. Early and accurate diagnosis is paramount and dependent on clinical and diagnostic imaging skills. A retrospective review of 55 consecutive patients referred with suspected thoracic aortic dissection to a medical cardiology department was performed. Clinical follow up was complete to November 1995. Median age was 68 years (range 30-93), with 37 males, 18 females. Presenting complaints included interscapular chest pain in 23 (42 per cent), neurological deficit in 2 (4 per cent), and limb ischaemia in 8 (15 per cent). On examination 34 (62 per cent) patients had hypertension, 5 (9 per cent) a pulse deficit and 10 (18 per cent) aortic incompetence. Electrocardiography confirmed myocardial infarction in 1. Chest X-ray showed a widened mediastinum in 37 (67 per cent) patients. Dissection was confirmed in 35 (64 per cent) patients (13-DeBakey Type I, 6-Type II, 14-Type III); 10 had nondissecting aneurysm. Contrast aortography was equally sensitive (84 per cent) and more specific (100 per cent vs 80 per cent) than computed tomography for detection of dissection. Surgical repair was performed on 24 patients with concomitant coronary artery bypass grafting in 6. At follow up 33 patients were alive. Clinical diagnosis of thoracic aortic dissection or aneurysm may be difficult. Frequently more than one imaging modality may be required in order to provide all of the necessary information for optimal patient management.

Adult↗