Identification of Pelvic Congestion Syndrome Using Transvaginal Ultrasonography. A Useful Tool

The gold standard for the diagnosis of pelvic congestion syndrome (PCS) is venography (VG), although transvaginal ultrasound (TVU) might be a noninvasive, nonionizing alternative. Our aim is to determine whether TVU is an accurate and comparable diagnostic tool for PCS. An observational prospective study including 67 patients was carried out. A TVU was performed on patients, measuring pelvic venous vessels parameters. Subsequentially, a VG was performed, and results were compared for the test calibration of TVU. Out of the 67 patients included, only 51 completed the study and were distributed in two groups according to VG results: 39 patients belonging to the PCS group and 12 to the normal group. PCS patients had a larger venous plexus diameter (15.1 mm vs. 12 mm; p = 0.009) and higher rates of crossing veins in the myometrium (74.35% vs. 33.3%; p = 0.009), reverse or altered flow during Valsalva (58.9% vs. 25%; p = 0.04), and largest pelvic vein ≥ 8 mm (92.3% vs. 25%). The sensitivity and specificity of TVU were 92.3% (95% CI: 78.03–97.99%) and 75% (95% CI: 42.84–93.31%), respectively. In conclusion, transvaginal ultrasonography, with the described methodology, appears to be a promising tool for the diagnosis of PCS, with acceptable sensitivity and specificity.

Risk Factors for Pulmonary Cement Embolism (PCE) After Polymethylmethacrylate Augmentation: Analysis of 32 PCE Cases

Objective: Pulmonary cement embolism (PCE) is an underestimated but potentially fatal complication after cement augmentation. Although the treatment and follow-up of PCE have been reported in the literature, the risk factors for PCE are so far less investigated. This study aims to identify the preoperative and intraoperative risk factors for the development of PCE.Methods: A total of 1,373 patients treated with the polymethylmethacrylate (PMMA) augmentation technique were retrospectively included. Patients with PCE were divided into vertebral augmentation group and screw augmentation group. Possible risk factors were collected as follows: age, sex, bone mineral density, body mass index, diagnosis, comorbidity, surgical procedure, type of screw, augmented level, number of augmented vertebrae, fracture severity, presence of intravertebral cleft, cement volume, marked leakage in the paravertebral venous plexus, and periods of surgery. Binary logistic regression analyses were used to analyze independent risk factors for PCE.Results: PCE was identified in 32 patients, with an incidence rate of 2.33% (32 of 1,373). For patients who had undergone vertebral augmentation, marked leakage in the paravertebral venous plexus (odds ratio [OR], 0.012; 95% confidence interval [CI], 0.001–0.103; p = 0.000) and previous surgery (OR, 0.161; 95% CI, 0.042–0.610; p = 0.007) were independent risk factors for PCE. Regarding patients who had undergone screw augmentation, the marked leakage in the paravertebral venous plexus (OR, 0.042; 95% CI, 0.005–0.373; p = 0.004) was the main risk factor.Conclusion: Marked leakage in the paravertebral venous plexus and previous surgery were significant risk factors related to PCE. Paravertebral leakage and operator experience should be concerned when performing PMMA augmentation.

Spinal Epidural Lipomatosis Associated with Intrathecal Flow Voids: Demonstration of Engorged Veins Using Flat Panel Catheter Angiotomography

We present a case of a 54-year-old male with spinal epidural lipomatosis who had associated flow voids on magnetic resonance imaging with dilated intrathecal vessels. During spinal angiogram, 20s DynaCT (flat panel catheter angiotomography) was utilized to demonstrate the intrathecal engorged veins. Venous engorgement of epidural venous plexus has been previously described in epidural lipomatosis; however, dilated intrathecal perimedullary veins have not been demonstrated by imaging. We have described the utility of flat panel catheter angiotomography in understanding venous disorders in such patients.

Time-Resolved Magnetic Resonance Angiography for Follow-Up of Treated Dural and Epidural Spinal Arteriovenous Fistula

Background Spinal arteriovenous fistulas (AVFs) are uncommon vascular malformations of spinal dural and epidural vessels. Actually digital subtraction angiography (DSA) is the gold standard for diagnosis and follow-up. The aim of this study is to demonstrate the validity of the multiphasic magnetic resonance angiography (MRA) to identify recurrent/residual AVFs or their correct surgical and/or endovascular closure. Methods A retrospective cases series with perimedullary venous plexus congestion due to spinal dural or epidural AVF was performed at our center from April 2014 to September 2019. After 1 month from treatment, the patients were subjected to time-resolved MRA and DSA to demonstrate recurrence or correct closure of AVFs. Results We collected a series of 26 matched time-resolved MRA and DSA in 20 patients who underwent an endovascular and/or surgical procedure. In our series, we reported five cases of recurrence. Time-resolved MRA detected six cases of recurrence, with 100% sensitivity and 95% specificity (p < 0.001). We used DSA as the standard reference. Conclusion Time-resolved MRA is a valid tool in posttreatment follow-up to detect recurrent or residual AVFs. It has high sensitivity and specificity and may replace DSA.

Anatomical features of the canine C2-C3 spinal cord vascular environment

OBJECTIVE Interarcuate branch (IAB) is a vascular structure, particularly developed in C2-3 intervertebral space, forming a dorsal bridge that connects ventral venous plexi in the vertebral canal. While precisely described in the human, the precise anatomical features of IABs have not been reported in the veterinary literature. The purpose of this study is to describe the features and relations of IABs in the C2-3 vertebral canal. ANIMALS 10 dogs were enrolled; 5 dogs for necropsy and 5 dogs for histology. PROCEDURES The ventral venous plexi in the cervical spine of 5 dogs were injected with latex and underwent vertebral canal dissection for visual assessment of the IAB. Two out of 5 dogs were injected with the addition of barium sulfate and underwent a CT scan. The C2-3 regions of 5 small-breed dogs were harvested for histological examinations. RESULTS IABs arose from the ventral venous plexus at the level of the intervertebral vein; they originated from 2 separate branches located caudally and cranially to the intervertebral foramen, forming a ventrodorsal triangle surrounding the spinal nerve root. No dorsal anastomosis was observed on the CT scan nor at dissection but were observed histologically. A cervical fibrous sheath was observed all around the vertebral canal. CLINICAL RELEVANCE IABs are voluminous venous structures at the C2-3 intervertebral space in dogs and found within a split of the cervical fibrous sheath, which is adherent to the interarcuate ligament and the ligamentum flavum. This anatomical description is paramount when planning an approach to the C2-3 intervertebral space.

Laryngeal varices: an atypical cause of globus

Laryngeal varices are rare and are usually associated with vocal cord trauma secondary to excessive use of voice. This report is the first documented case of laryngeal varices secondary to thyroid goitre. This is a report of an 83-year-old woman with a known retrosternal goitre chiefly with symptoms of globus. Retrosternal goitre was found to be compressing the pharyngeal venous plexus causing laryngeal venous structures bilaterally to be engorged along the aryepiglottic folds, arytenoids, posterior commissure and extending in to the postcricoid region. The presence of laryngeal varices carries a significant increased risk of haemorrhage. This case presents an atypical presentation of globus and the first reported case in the literature of laryngeal varices secondary to a thyroid goitre.

A Case Study on Effective Management of Abhayantra Arsha by Kshara Karma

Arshas being the most common grievous ailment and one of the eight most intractable disorders (Ashta Mahagada) explicited by Acharya Susruta & Vagbhata. Haemorrhoids are the dilatation of the anal and perianal venous plexus. The disturbance of Jatharagni is the most accepted cause of ano rectal problems, which further contributes to constipation. Constipation increases the back pressure into the haemorrhoidal veins to produce piles. Arsha requires a surgical technique in modern treatment, such as haemorrhoidectomy, rubber band ligation, and so on. Kshara is a caustic chemical, alkaline in nature, derived from medicinal plant ashes. The effect of Kshara karma is highly commended, it can replace the Shastra karma as it does the functions of Chedana, Bhedana, Lekhana karmas without using Shastras. Kshara karma can be utilised efficiently in individuals who are afraid of surgery as a complement for surgical operations. A 48years-old male patient presented with complaints of some mass coming out during defecation and bleeding while passing stool to the anorectal unit, OPD, National Institute of Ayurveda, deemed to be university Jaipur Rajasthan. The patient was treated successfully with Kshara karma application. The pile mass and per rectal haemorrhage was gone in 8 days and the patient was free of all symptoms within 18-20 days. The findings revealed that there are maximum advantages which are shared in this case study.

P.205 Association Between Vein of Galen Aneurysmal Malformation and Hirayama Disease: A Clue into Pathophysiology?

Background: Hirayama Disease (HD) is a rare disorder consisting of insidious onset of unilateral weakness and atrophy of the forearm and intrinsic hand muscles. Vein of Galen aneurysmal malformations (VGAMs) are rare congenital cerebral vascular malformations, consisting of high-flow arteriovenous shunting between a persistent median prosencephalic vein and arterial feeders. Methods: 14 years old boy known for VGAM presented with left-sided HD. His cervical MRI revealed enlarged epidural with anterior, left-ward displacement of the posterior dura and spinal cord. He underwent surgical treatment by laminotomies, along with tenting of an autologous duroplasty to the overlying laminae. Results: We decided to combine epidural venous plexus coagulation with posterior duraplasty and dural fixation using tenting suture which led to a favorable clinical outcome has not been previously proposed in the literature. We hypothesize that in this context, an abnormal vasculature could also predispose to posterior epidural venous plexus engorgement, anterior dural displacement in cervical flexion, and microvascular changes in the anterior spinal arterial circulation, leading to the progressive anterior horn cell ischemia that lead to the clinical phenotype of HD. Conclusions: The association between HD and VGAM in this patient may provide clues with regard to the pathophysiology of HD.