No abstract

A series of 25 patients with aggressive meningeal tumors was studied to determine the efficacy of various management options. The median age of the patients was 52 years, with a range of 13 to 73 years. A marked male preponderance (64%) was noted. Twenty of 25 patients experienced recurrence during a median follow-up time of 47 months. Survival and freedom from recurrence varied with histological diagnosis. Recurrence was noted sooner in patients who had received partial resections on first presentation of tumor than in those who had received total resections at first presentation. Survival time was also shorter for patients who underwent partial resections at first presentation than for patients who underwent total resections. Patients' prognoses did not improve as a result of either chemotherapy or radiotherapy. Of six patients with extracranial metastases, the median time to metastasis was 102 months, with a 5-year metastasis-free rate of 85%. The most common sites of metastasis in these six patients were lung and bone. In each tumor type, histological features used in diagnosis and radiological features studied from computerized tomography and magnetic resonance imaging were evaluated, compared, and discussed. Of eight patients studied with an in vivo bromodeoxyuridine (BUdR) labeling index (LI), seven showed an LI of 1% or more. The authors support the incorporation of the BUdR LI into the diagnostic process to provide a better estimate of the potential for tumor recurrence.

Restenosis after carotid stenting is uncommon; however, patients with previous CEA or XRT are at increased risk. Restenotic lesions may be safely treated with further percutaneous interventions.

Background-Right atrial reentrant tachycardia resulting from lower loop reentry (LLR) around the inferior vena cava (IVC) has been described recently. However, all reported cases of LLR in the literature have negative flutter waves on the inferior surface ECG leads similar to that of counterclockwise typical atrial flutter around the tricuspid annulus (TA). Right atrial flutter with positive flutter waves in the inferior ECG leads has been assumed to rotate as a single reentrant activation wave front around the TA, and the role of LLR in those patients is not known. Methods and Results-Twelve consecutive patients with flutter wave morphology on surface ECG consistent with clockwise atrial flutter were studied. The endocardial activation pattern recorded from conventional multipolar electrode catheters was characteristic of clockwise atrial flutter around the TA. Entrainment pacing in all 12 patients and 3D activation sequence mapping in 7 patients, however, revealed clockwise LLR involving the lower right atrium around the IVC in 7 patients, figure-of-8 double-loop reentry around both the IVC and TA in 4, and single reentrant loop around the TA in 1. Linear radiofrequency ablation in the isthmus between the TA and IVC (TI isthmus) terminated the tachycardia in all patients. Conclusions-Surface ECG flutter wave morphology and limited recording intracardiac sites proved insufficient to delineate the precise mechanism of the TI isthmus-dependent clockwise right atrial flutters. Most right atrial flutters with positive flutter wave on surface ECG may be supported by a reentrant circuit around the IVC or a figure-of-8 double-loop reentry involving both the IVC and TA.

Major medical society guidelines recommend the measurement of fractional flow reserve (FFR) C oronary angiography has been well established as the initial invasive technique for evaluating coronary stenoses in patients with stable coronary artery disease (CAD), but its ability to determine the functional significance of an angiographically intermediate lesion is quite limited. Indeed, flow through a stenotic vessel is affected by multiple factors that cannot be measured by visual evaluation alone, such as flow entrance and exit angle, orifice shape, and degree of turbulence. Guidelines have recommended noninvasive functional tests before angiography.1 Nevertheless, only 44.5% of patients undergo stress testing in the 90 days before their elective percutaneous coronary intervention (PCI).2 Therefore, in many elective cases, the decision to stent is guided mainly by standard coronary angiographic findings. Indeed, 60.6% of PCIs in the American College of Cardiology National Cardiovascular Data Registry are performed ad hoc. Fractional flow reserve (FFR), defined as the pressure distal to a stenosis relative to the pressure proximal to that stenosis, enables the determination of flow impediment during maximal hyperemia and incorporates many lesion-specific variables, such as anatomic variability and the contribution of collateral vessels. The relative ease and safety of the test, as well as its documented sensitivity and specificity 4 (88% and 100%, respectively), make it ideal as objective documentation of the appropriateness of ad hoc PCI.The frequency of FFR use in daily practice is unknown. A recent study by Orvin and colleagues 5 showed that the operator's decision to stent was in discordance with FFR measurements in nearly 20% of cases. It is important to note that 83% of patients in Orvin's study had acute coronary syndrome (ACS), in which the clinical usefulness of FFR is less well established than in patients with stable CAD; in addition, interventionalists are generally more willing to perform PCI on ACS patients than on patients with stable CAD, even if their lesions are angiographically comparable. We performed a nationwide survey to determine how FFR is being applied by interventionalists in the United States to patients with stable CAD.

Malignancy is rare in intracranial meningiomas. Although the topic is widely discussed, there is little agreement in the literature as to the histological and radiological features that warrant the diagnosis of malignant meningioma. Three patients are described who had soft-tissue masses and underlying osteolytic lesions on computed tomography. All three patients also had a large intracranial component that proved to be a malignant meningioma. Rarely do meningiomas have all three of these features. We propose that a meningioma causing osteolysis and soft-tissue extension should be considered malignant until proven otherwise.

Malignancy is rare in intracranial meningiomas. Although the topic is widely discussed, there is little agreement in the literature as to the histological and radiological features that warrant the diagnosis of malignant meningioma. Three patients are described who had soft-tissue masses and underlying osteolytic lesions on computed tomography. All three patients also had a large intracranial component that proved to be a malignant meningioma. Rarely do meningiomas have all three of these features. We propose that a meningioma causing osteolysis and soft-tissue extension should be considered malignant until proven otherwise.

This case indicates that a combined endovascular and surgical approach may be a safe and effective option in the treatment of carotid-carotid bypass graft infection.