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PubMed1988

MR imaging of the aorta after surgery for aortic dissection.

MR imaging is known to be an effective technique for the noninvasive diagnosis of thoracic aortic disease, but it has not been used to monitor the appearance of the aorta or the fate of the false lumen after surgery for aortic dissection. This study describes our initial experience with postsurgical MR imaging of aortic dissection (nine type A and two type B) to evaluate prognostically important features, including the status of residual false lumen. The most notable findings were (1) aneurysmal dilatation beyond the interposed graft (11/11 cases), (2) residual intimal flap (10/11 cases) with at least partial patency of the false lumen (10/10 cases), and (3) origin of a visceral vessel from the false lumen in persistently dissected abdominal aorta (6/9 cases). Evaluation of residual false lumen by double-spin-echo-intensity and phase-display techniques showed evidence of slow blood flow with variable amounts of thrombus in eight of 10 cases. Differentiation between signal within the false lumen due to slow flow and signal due to thrombus was facilitated by phase display. MR imaging can be used for noninvasive monitoring of the aorta after surgical repair of aortic dissection. Since the false lumen usually remains patent after surgical repair, such follow-up of its status seems necessary for identifying potential complications of the original dissection and/or the therapy.

Adult↗

PubMed1995

Dissection of the carotid and vertebral arteries: imaging with MR angiography.

Arterial dissection occurs when an intimal tear allows blood to enter the arterial wall, potentially compromising the lumen and reducing blood flow. Carotid and vertebral artery dissections typically occur after major trauma, although they also can arise spontaneously or after trivial injury. Arterial dissection has been associated with a variety of factors, including hypertension, fibromuscular dysplasia, Marfan syndrome, cystic medial necrosis, oral contraceptives, drug abuse (sympathomimetics), and infection [1-8]. It is important to recognize arterial dissection early so that prompt treatment can be initiated to prevent ischemic complications [1]. In this essay, we illustrate the use of MR angiography in the diagnosis of carotid and vertebral artery dissection.

Adolescent↗

PubMed1995

Diagnosis of aortic dissection: value of helical CT with multiplanar reformation and three-dimensional rendering.

OBJECTIVE: Twenty-three patients with suspected aortic dissection were evaluated in this preliminary study of helical CT to determine the usefulness of axial sections, multiplanar reformation, and three-dimensional (3D) rendering in assessing the presence of dissection and the extent of intimal flap. MATERIALS AND METHODS: Patients were referred for helical CT scanning because of chest pain or an abnormal chest radiograph. Scans were performed during bolus injection of nonionic contrast material at 2.0-2.5 ml/sec using a mean scan delay of 47 sec. Axial scans with 5-mm collimation were obtained in all patients. They extended from the great vessels to the distal thoracic aorta just above the hiatus. Delayed nonhelical sections were obtained through the upper abdomen. Multiplanar reformations and 3D models were reconstructed from the helical data in 13 patients and were compared to axial sections in 7 patients who proved to have documented dissection. The efficacy of CT was determined using surgery, angiography, or clinical outcome to establish the diagnosis. RESULTS: Of the 23 patients studied, axial sections resulted in 15 true-negative, 7 true-positive, and 1 false-positive interpretation. In three of seven patients with dissection, it was difficult to determine the extent of the intimal flap on axial sections; multiplanar reformation or 3D views clarified the relevant anatomy in all 3 cases. Among the 3D display methods, ray-sum projection views were superior to surface model or maximum-intensity-projection views. CONCLUSION: If studies of larger numbers of patients confirm our preliminary findings, multiplanar reformation and 3D rendering of helical CT scans will be a valuable addition to axial display of CT studies used to detect aortic dissection and to determine the extent of the intimal flap.

Adult↗

PubMed2000

MR angiography for the long-term follow-up of dissecting aneurysms of the extracranial internal carotid artery.

OBJECTIVE: We used MR angiography to examine and follow up the changes of dissecting aneurysms of the extracranial internal carotid artery (ICA). MATERIALS AND METHODS: We retrospectively reviewed the records of 101 consecutive patients with dissecting aneurysms of the extracranial ICA. Twenty patients with 26 spontaneous dissecting aneurysms were followed up with MR angiography every 1-2 years (men, 16; women, four; age range, 28-67 years; mean age, 51 years). RESULTS: The mean duration of follow-up was 41 months (range, 10-93 months). At MR angiography follow-up, 20 aneurysms did not change, four decreased from their original size by 33-53% (mean, 43%), and two resolved. One patient had an asymptomatic recurrent dissecting aneurysm of the extracranial ICA. Clinically, no patient had a thromboembolic stroke or transient ischemic attack during the follow-up period. CONCLUSION: MR angiography revealed that dissecting aneurysms of the extracranial ICA remain stable, decrease in size, or resolve--but they do not increase in size.

Adult↗

PubMed2004

Number to treat analysis for planned neck dissection after organ preservation therapy with advanced neck disease.

OBJECTIVE: To perform a number to treat analysis for planned neck dissection after organ preservation protocols (OPPs) in N2-3 neck disease for head and neck cancer. METHODS: We performed a literature review from 1993 to the present and collected aggregate data to produce the following four variables: (1) percentage of N2-3 necks still harbouring cancer after radiotherapy in OPPs (C); (2) percentage of regional recurrence after planned neck dissection (P); (3) unsuccessful salvage rate in patients in whom a watch and wait strategy for neck disease was employed (S); and (4) the mortality rate of planned neck dissection (M). The number to treat can be estimated as 1/((C x S + C x M) - (P + M)) RESULTS: The number to treat in this analysis was 4.4. SUMMARY: In organ preservation therapy with N2-3 disease, one needs to perform 4.4 neck dissections to prevent one fatal regional recurrence. Although this calculation does have some inherent biases and errors, it may form the basis for an informed discussion with patients faced with the option of planned neck dissection.

Head and Neck Neoplasms↗

PubMed1984

Intracranial dissecting aneurysms of the posterior circulation. Report of six cases and review of the literature.

Dissecting aneurysms of the intracranial posterior circulation are unusual lesions that affect otherwise healthy young adults, are difficult to diagnose and manage, and carry a high morbidity and mortality rate. Headache in the suboccipital-posterior cervical region is the most common presenting symptom. The dissection usually occurs between the intima or internal elastic lamina and the media; subadventitial dissection does occur and accounts for the infrequent finding of subarachnoid hemorrhage. A deficit in the inner layers of the vessel is the proposed source of dissection. The angiographic features are inconsistent, although an irregularly narrowed arterial segment with proximal and/or distal dilatation are typical findings. Depending on the location of the dissection, the surgical options are: ligation, trapping, or reinforcement of exposed abnormal portions of the vessel. Anticoagulation therapy is not indicated in the management of this lesion.

Adolescent↗

PubMed1988

Traumatic dissections of the extracranial internal carotid artery.

Traumatic dissections of the extracranial internal carotid artery (ICA) in 18 patients aged 19 to 55 years were studied. All had suffered blunt head or neck injury of marked or moderate severity; motor-vehicle accidents were the leading cause of the injury. Delayed focal cerebral ischemic symptoms were the most common presenting symptoms. Less commonly noted was focal unilateral headache associated with oculosympathetic paresis or bruit. Following a head injury, the abrupt onset of focal cerebral symptoms after a lucid interval should raise the suspicion of arterial injury, particularly when computerized tomography fails to show abnormalities that would explain the evolving neurological deficits on the basis of direct trauma to the brain. Unilateral headaches, oculosympathetic palsy, and bruits also help in establishing the diagnosis. Focal cerebral ischemic symptoms may develop months or years after the initial trauma. These delayed symptoms are caused by embolization from a thrombus within a residual dissecting aneurysm. Common angiographic findings, in decreasing order of frequency, are: aneurysm, stenosis of the lumen, occlusion, intimal flap, distal branch occlusion (embolization), and slow ICA-to-middle cerebral artery flow. Although two patients died as the result of massive cerebral infarction and edema and some were left with severe neurological deficits, most made a good recovery. Residual dissecting aneurysms and occlusion seem to occur more frequently with traumatic dissections than with spontaneous dissections of the extracranial ICA.

Adult↗

PubMed1999

Serial angiography and endovascular treatment of dissecting aneurysms of the anterior cerebral and vertebral arteries. Case report.

This 47-year-old man was admitted to the hospital with disturbance of consciousness due to subarachnoid hemorrhage caused by a ruptured dissecting aneurysm of the left anterior cerebral artery (ACA). Conservative treatment resulted in improvement in the patient's consciousness; however, repeated rupture occurred during the chronic stage. Endovascular coil embolization of the parent artery was successful. Serial angiography demonstrated all stages in the development of the aneurysm. Follow-up angiography demonstrated an incidental dissecting aneurysm of the right vertebral artery. This aneurysm was also treated by endovascular embolization. No new neurological deficit appeared during or after the treatment. Multiple dissecting aneurysms are rare, especially those involving both supra- and infratentorial regions. A ruptured dissecting aneurysm of the ACA is also an uncommon vascular disorder. This case shows that rebleeding may occur, even during the chronic stage, and thus appropriate treatment for the prevention of subsequent bleeding is essential. Incidental dissecting aneurysms can be treated using the endovascular technique, but further study is necessary.

Aortic Dissection↗

PubMed2000

Arterial dissections of penetrating cerebral arteries causing hypertension-induced cerebral hemorrhage.

OBJECT: For the past 130 years, it has been believed that hypertension-induced cerebral hemorrhages are the result of ruptures of microaneurysms or ruptures of arteries that have degenerative changes. The majority of previous investigations have focused on autopsied brain. In this study, the authors attempted to verify the cause of hypertension-induced cerebral hemorrhage by using surgical specimens of the penetrating arteries responsible for the hemorrhages. METHODS: Between 1997 and 1999, the authors performed pathological studies in surgical specimens of lenticulostriate arteries that had been confirmed during microsurgery to be the cause of hypertension-induced hemorrhage of the putamen. Nineteen lenticulostriate arteries were collected from 12 patients. Fifteen of these arteries were verified as the pathological causes of hemorrhage. They included six arterial dissections, six arterial ruptures with substantial degenerative changes, and three arterial ruptures with few degenerative changes. The pathological findings in the lenticulostriate artery dissections were similar to those of typical arterial dissections in major cerebral arteries. CONCLUSIONS: To the best of the authors' knowledge, arterial dissections of lenticulostriate arteries have not been identified as a cause of hypertension-induced cerebral hemorrhages. When penetrating arteries are included as causative vessels, cerebral arterial dissections may be much more common than previously thought.

Aged↗

PubMed2002

Subarachnoid hemorrhage caused by a dissecting aneurysm of the internal carotid artery.

OBJECT: Subarachnoid hemorrhage (SAH) caused by the rupture of a dissecting aneurysm of the internal carotid artery (ICA) has been considered rare. Based on data from cooperatively collected cases, the clinical features of patients with dissecting aneurysms of the ICA who presented with SAH were examined. METHODS: Data from 18 patients with dissecting aneurysms of the ICA who presented with SAH diagnosed on the basis of clinical signs, neuroradiological findings, and intraoperative findings from 41 institutions were collected during a 5-year period between 1995 and 1999. The authors found that 0.3% of all cases of SAH and 3.1% of cases of SAH of unverified cause were attributable to a dissecting aneurysm of the ICA. Eleven patients (61%) were middle-aged women, and eight patients (44%) had hypertension. Rebleeding before admission was demonstrated in 13 patients (72%), and intraoperative bleeding was exhibited in half of the patients who underwent surgery during the acute stage. Postoperative growth of an aneurysm bulge or recurrent SAH was seen in five of 10 patients who had undergone wrapping or clipping of the aneurysm bulge in the acute phase. Trapping with or without bypass, which resulted in no postoperative recurrence, was performed in three patients in the acute stage and in two patients in the chronic stage. Twelve patients (67%) had a poor prognosis, primarily attributed to intraoperative bleeding and postoperative recurrence. CONCLUSIONS: Generally, dissecting aneurysms of the ICA are not thought of as frequent causes of SAH. Nonetheless. the presence of these aneurysms should be considered when dealing with SAH because they have a susceptibility to bleeding that can lead to a poor prognosis. Careful surgical planning is necessary to decrease intraoperative bleeding and to avoid postoperative recurrence.

Adult↗

PubMed2003

Multimodal treatment of ruptured dissecting aneurysms of the vertebral artery during the acute stage.

OBJECT: The goal of this study was to implement an algorithm for and assess the multimodal (endovascular and microsurgical) treatment of patients with ruptured dissecting aneurysms of the vertebral artery (VA) during the acute stage. METHODS: During a 4-year period, the authors treated 19 ruptured dissecting aneurysms of the VA during the acute stage, within 3 days after the hemorrhage. Factors guiding management decisions were tolerance of the test occlusion and the site of the dissection. The algorithm takes into account these factors to select among treatment options, that is, trapping of the VA with Guglielmi Detachable Coils (GDCs); trapping of the VA and revascularization of the posterior inferior cerebellar artery (PICA); trapping of the VA and VA-posterior cerebral artery (PCA) anastomosis; and trapping of the VA, VA-PCA anastomosis, and revascularization of the PICA. Of the 15 aneurysms without PICA involvement, 14 were treated by trapping of the VA with GDCs and one by trapping of the VA and a VA-PCA bypass. The other four aneurysms with PICA involvement were treated by VA trapping and PICA revascularization. There was no episode of recurrent hemorrhage or ischemia during the posttreatment follow-up period. Although lateral medullary syndrome developed as a permanent complication in one patient, a good recovery was made by the other 18 patients by 6 months after the ictus. CONCLUSIONS: The factors that determine the appropriate treatment for ruptured dissecting aneurysms of the VA are tolerance of a test occlusion and the site of dissection. Favorable patient outcomes can be achieved when this algorithm is used.

Adult↗

PubMed2000

Three-dimensional image and virtual dissection program of the brain made of Korean cadaver.

The three-dimensional (3D) structure of the brain needs to be understood for accurate diagnosis and treatment of brain diseases. The brain of a cadaver may not always be available for dissection when it is needed. To overcome this problem, we attempted to create a 3D image and virtual dissection program of the brain using a Korean cadaver. The brain extracted from a Korean male cadaver was embedded in gelatin solution. 130 MRI of the brain were taken and 130 serially-sectioned specimens were made. All of MRI and specimens were inputted into the computer, and 10 brain components were manually segmented. A 3D image and virtual dissection program of the brain was made. Various virtual dissection functions were established, such as 1) sectioning the 3D image of the brain at free angles to represent its plane as a real image, segmented image, and MRI, 2) identifying the brain components represented in the sectioned plane, and 3) rotating the 3D image of the whole brain or the selected brain components at free angles. The resulting virtual dissection program of the brain is helpful in better understanding the 3D location and shape of the brain components and it is expected to be used as a CD-title or through Internet as an educational tool for medical students and doctors.

Brain↗

PubMed1998

[Neck Dissection for salivary gland carcinoma].

Between 1986 and 1997, 18 patients with high-grade salivary gland malignancies were treated at our institution. Histologically, 7 of the 18 malignant tumors were adenoid cystic carcinomas. 4 were carcinoma in pleomorphic adenoma, 3 were undifferentiated carcinomas and 4 were others. For treatment of the neck, 11 patients underwent neck dissection, 1 received supraomohyoid neck dissection (SOMH) and 7 received no neck treatment. In our study, there was no difference according to local-regional control as to whether to use neck dissection or not. The result do not suggest that prophylactic total neck dissection for salivary gland carcinoma show an impressive degree of improvement in local-regional control. Total neck dissection should be performed when the neck is clinically positive for a tumor. Based on the above findings, we concluded that SOMH is feasible for submandibullar gland cancer without positive lymph nodes.

Adenocarcinoma↗

PubMed2005

[Usefulness and limitations in ultrasonography for diagnosing neck lymph node metastases in patients with hypopharyngeal squamous cell carcinoma: comparison with pathological findings following neck dissection].

We evaluated the usefulness and limitations in ultrasonography (US) for diagnosing neck lymph node metastases in patients with hypopharyngeal cancer by comparing the results of preoperative US examinations with postoperative pathological findings following neck dissection. Seventy-five previously untreated patients with hypopharyngeal squamous cell carcinoma underwent a curative procedure that included neck dissection. Preoperatively, all patients were examined by palpation, computed tomography (CT), and US. Postoperatively, all dissected neck lymph nodes were submitted for pathological examination. Results of pre-and postoperative examinations were then compared. US accuracy for each lymph node was 93.9%, while sensitivity was 78.0%, since hypopharyngeal cancer metastasizes early and easily to the neck lymph nodes, and it is difficult to detect small, pathologically positive nodes. Nine of 75 cases showed latent neck recurrence, and two of these were underestimated by US. The major cause for neck recurrence was considered to be the high rate of metastases in such cases, rather than a reduced dissection field. It is not rare to find very small, pathologically positive lymph nodes that US cannot detect in hypopharyngeal cancer. Efforts must therefore be expanded to improve the accuracy of US diagnosis. Care must also be taken when selecting cases for no or limited neck dissection.

Aged↗

PubMed2004

Association of painless acute aortic dissection with increased mortality.

OBJECTIVE: To evaluate the clinical characteristics and outcomes of patients with painless acute aortic dissection (AAD). PATIENTS AND METHODS: For this study conducted from 1997 to 2001, we searched the International Registry of Acute Aortic Dissection to identify patients with painless AAD (group 1). Their clinical features and in-hospital events were compared with patients who had painful AAD (group 2). RESULTS: Of the 977 patients in the database, 63 (6.4%) had painless AAD, and 914 (93.6%) had painful AAD. Patients in group 1 were older than those in group 2 (mean +/- SD age, 66.6 +/- 13.3 vs 61.9 +/- 14.1 years; P = .01). Type A dissection (involving the ascendIng aorta or the arch) was more frequent in group 1 (74.6% vs 60.9%; P = .03). Syncope (33.9% vs 11.7%; P < .001), congestive heart failure (19.7% vs 3.9%; P < .001), and stroke (11.3% vs 4.7%; P = .03) were more frequent presenting signs in group 1. Diabetes (10.2% vs 4.0%; P = .04), aortic aneurysm (29.5% vs 13.1%; P < .001), and prior cardiovascular surgery (48.1% vs 19.7%; P < .001) were also more common in group 1. In-hospital mortality was higher in group 1 (33.3% vs 23.2%; P = .05), especially due to type B dissection (limited to the descending aorta) (43.8% vs 10.4%; P < .001), and the prevalence of aortic rupture was higher among patients with type B dissection in group 1 (18.8% vs 5.9%; P = .04). CONCLUSION: Patients with painless AAD had syncope, congestive heart failure, or stroke. Compared with patients who have painful AAD, patients who have painless AAD have higher mortality, especially when AAD is type B.

Acute Disease↗

PubMedDate not supplied

Acute aortic dissection in a patient with Marfan's syndrome complicated by gestational hypertension.

OBJECTIVE: To present a case of aortic dissection in a pregnant woman with Marfan's syndrome. CLINICAL FEATURES: A 34-year-old woman with Marfan's syndrome developed gestational hypertension and Type III aortic dissection during the third trimester. The diagnosis was confirmed by computed tomography and aortography. OUTCOME: Although the dissection progressed, the woman was treated successfully. Elective caesarean section was performed. At follow-up the dissection had healed. CONCLUSION: Marfan's syndrome introduces a high risk of aortic dissection during pregnancy and the treatment chosen is crucial. As dilatation of the aorta is progressive, patients with Marfan's syndrome should be followed up closely and offered prophylactic surgery if necessary.

Adult↗

PubMed1999

[Surgical management for acute aortic dissection with organ ischemia].

In a series of one hundred and one cases of surgical treatment for acute aortic dissection between January 1986 and September 1997, we evaluated 29 cases presenting with organ ischemia. These consisted of 23 cases of acute type A dissection (type A) and 6 cases of type B dissection (type B). Organ ischemia was diagnosed by (1) aortography, (2) a retrospective review of the history and (3) physical examination or laboratory data. The 23 surgical cases of acute type A dissection consisted of, coronary ischemia 8 cases, cerebral and spinal cord ischemia 9 cases, intestinal ischemia 3 cases, lower extremities ischemia 10 cases, and plural organs ischemia 8 cases. In the 6 cases of acute type B, we noted 4 intestinal ischemias and 2 lower extremities ischemias. The operative mortality rates when subdivided according to ischemic organ were: coronary ischemia 50%, cerebral and spinal cord ischemia 11%, intestinal ischemia type A 33%, type B 50%, and lower extremities ischemia type A 33%, type B 0%. The operative mortality rates, especially for patients presenting with acute myocardial infarction or intestinal ischemia, were relatively high. In cases of acute aortic dissection when organ ischemia occurred, we believed that it was necessary to perform early thoracic aortic repair and reconstruction of the ischemic organ.

Acute Disease↗

PubMed1999

[Ischemic complications in aortic dissection--percutaneous treatment with balloon fenestration and stent implantation].

PURPOSE: To describe principles and results of percutaneous treatment of ischemic complications of aortic dissection. MATERIALS AND METHODS: In five cases (four patients) aortic dissection was clinically complicated by renal (n = 4), iliofemoral (n = 2) or mesenterial ischemia (n = 1). After evaluation by means of computed tomography, angiography, and manometry, treatment consisted of balloon fenestration of the intimal flap, stent placement or both. RESULTS: Eleven of 25 vascular beds were classified as ischemic. Treatment consisted of 11 balloon fenestration procedures in 3 patients, in one case supported by stent placement across the dissection membrane. Stents were placed in five renal arteries, one stent was placed in the true lumen of the aorta. One iliac artery was treated with balloon dilatation. One renal artery dissection became symptomatic after balloon fenestration and was treated successfully by stent placement. In all cases ischemia was resolved by endovascular treatment. All patients had persistent relief of symptoms. Mean follow-up time is 5.8 months. CONCLUSION: Ischemic complications of aortic dissection can be effectively and safely treated with stent placement and balloon fenestration.

Adult↗