Retinal Vessel Phenotype in Patients with Nonarteritic Anterior Ischemic Optic Neuropathy

PURPOSE

The pathophysiology of nonarteritic anterior ischemic optic neuropathy (NAION) is not completely understood. Studies of the retinal vasculature phenotype in patients with NAION could help us to understand vascular abnormalities associated with the disease.

DESIGN

Retrospective case series with matched control subjects.

METHODS

Study population: 57 patients with NAION and 57 control subjects matched to NAION patients for sex, age, systemic hypertension, diabetes, and obstructive sleep apnea syndrome between September 2007 and July 2017.

MAIN OUTCOME MEASURES

All patients and control subjects underwent a complete ocular examination and 45° funduscopic color photographs. The widths of the 6 largest arteries in zone B (between 0.5 and 1 optic disc diameter from the optic disc), summarized by the central retinal artery equivalent (CRAE), the widths of the 6 largest veins in zone B, summarized by the central retinal vein equivalent (CRVE), the arteriole to venule ratio, tortuosity, and fractal dimension were measured on the 2 groups using Vessel Assessment and Measurement Platform for Images of the Retina, a software tool for efficient semiautomatic quantification of the retinal vasculature morphology in fundus camera images. The Wilcoxon signed-rank test and MacNemar χ² test for paired sample and generalized estimating equations for modeling the Vessel Assessment and Measurement Platform for Images of the Retina parameters as dependent variables were used.

RESULTS

CRVE and fractal dimension (D0a) were significantly higher in the NAION group when compared with the control group, whereas the arteriole to venule ratio and vascular tortuosity were significantly lower. Compared with control subjects, acute NAION yielded an increased CRAE value (174 ± 33 vs 160 ± 13 μm) while resolution NAION yielded a decreased CRAE value (152 ± 12 vs 156 ± 33 μm). Acute NAION yielded an increased CRVE value (244 ± 35 vs 210 ± 21 μm) while resolution NAION yielded an unchanged CRVE value. We found no difference between groups for age, refraction, optic disc diameter, CRAE, or fractal dimension.

CONCLUSIONS

Retinal vascular parameters were different in our sample between NAION and control patients, especially at the acute stage of the disease. Our results suggest a normalization of the same parameters at the resolution stage.

18FDG PET/CT & arterial inflammation: predicting cardiovascular events in lung cancer

BACKGROUND

18F-FDG PET/CT predicts cardiovascular disease. To analyze the predictive value of cardiovascular events from inflammation and arterial calcification in patients who underwent an 18F-FDG PET/CT for lung cancer.

METHODS

A retrospective study of 274 patients with primary lung neoplasia. We determined: (i) TBR (target-to-background ratio), and (ii) the calcium score, at eight common arterial segments. We took as arteriosclerosis, a TBR ≥1.6 and ≥15 Calcium Score sum. We registered cardiovascular risk factors, comorbidities, histology, stage, treatment, status at the last clinical review, cause of death and cardiovascular event during the follow-up.

RESULTS

The territory presenting the greatest uptake of 18F-FDG, was the thoracic aorta with an average of 1.77 (± 0.27 TBR) in the aortic arch, while the greatest degree of calcification was obtained in the abdominal aorta (52% with a Calcium Score ≥ 3). 24% of the patients presented a sum Calcium Score ≥15, and 17% a TBR ≥1.6. Patients with high TBR, (17%), had not a higher frequency of cardiovascular comorbidities beforehand, nor did they in the follow-up. However, those with a sum Calcium Score ≥15 (24%), were older, had more cardiovascular risk factors and ischemic events during follow-up. The calcium score, but not the TBR, predicted the emergence of a cardiovascular event (HR 4.9 IC95% 2.1-9.1, P < 0.05).

CONCLUSION

In our cohort, a high Calcium Score was an independent predictor for developing cardiovascular events.

The endocannabinoid system in canine Steroid-Responsive Meningitis-Arteritis and Intraspinal Spirocercosis

Endocannabinoids (ECs) are involved in immunomodulation, neuroprotection and control of inflammation in the central nervous system (CNS). Activation of cannabinoid type 2 receptors (CB2) is known to diminish the release of pro-inflammatory factors and enhance the secretion of anti-inflammatory cytokines. Furthermore, the endocannabinoid 2-arachidonoyl glycerol (2-AG) has been proved to induce the migration of eosinophils in a CB2 receptor-dependent manner in peripheral blood and activate neutrophils independent of CB activation in humans. The aim of the current study was to investigate the influence of the endocannabinoid system in two different CNS inflammatory diseases of the dog, i.e. Steroid-Responsive Meningitis-Arteritis (SRMA) and Intraspinal Spirocercosis (IS). The two main endocannabinoids, anandamide (AEA) and 2-AG, were quantified by mass spectrometry in CSF and serum samples of dogs affected with Steroid- Responsive Meningitis-Arteritis in the acute phase (SRMA A), SRMA under treatment with prednisolone (SRMA Tr), intraspinal Spirocercosis and healthy dogs. Moreover, expression of the CB2 receptor was evaluated in inflammatory lesions of SRMA and IS and compared to healthy controls using immunohistochemistry (IHC). Dogs with SRMA A showed significantly higher concentrations of total AG and AEA in serum in comparison to healthy controls and in CSF compared to SRMA Tr (p<0.05). Furthermore, dogs with IS displayed the highest ECs concentrations in CSF, being significantly higher than in CSF samples of dogs with SRMA A (p<0.05). CSF samples that demonstrated an eosinophilic pleocytosis had the highest levels of ECs, exceeding those with neutrophilic pleocytosis, suggesting that ECs have a major effect on migration of eosinophils in the CSF. Furthermore, CB2 receptor expression was found in glial cells in the spinal cord of healthy dogs, whereas in dogs with SRMA and IS, CB2 was strongly expressed not only in glial cells but also on the cellular surface of infiltrating leukocytes (i.e. neutrophils, eosinophils, lymphocytes, plasma cells, and macrophages) at lesion sites. The present study revealed an upregulated endocannabinoid system in dogs with inflammatory CNS diseases, highlighting the endocannabinoid system as a potential target for treatment of inflammatory CNS diseases.

[Surgical treatment of a female patient with type III nonspecific aortoarteritis]

Described herein is a case report of a severe lesion of the arterial system in non-specific aortoarteritis: lesion of the aortic arch branches, thoracoabdominal segment of the aorta, abdominal aorta, visceral and renal arteries, thus underlining a multiple nature of the lesion of the aorta and its branches in the pathology concerned. Diagnosis of lesions of the aorta and its branches was made by means of multispiral computed tomography (MSCT), being the most informative method of examination in this cohort of patients, making it possible to accurately diagnose both the degree of the lesion and its extension, to choose an optimal surgical policy, to carry out dynamic follow up of the condition of the reconstructed arterial segments.

[Surgical treatment of a female patient with non-specific aortoarteritis]

Presented herein is a case report of successful surgical treatment of a female patient with non-specific aortoarteritis. In 2004 she was endured single-stage simultaneous autovenous ileorenal prosthetic repair on the right and autovenous aortorenal prosthetic reconstruction on the left for critical stenosis of the left renal artery and occlusion of the right one. In 2007 she underwent balloon dilatation of the aorta for abdominal aortic stenosis with a good favourable therapeutic outcome. In 2013 due to lesions of the aortic arch branches she was subjected to endarterectomy from the common carotid artery on the left, autovenous carotid-subclavian shunting on the right with a favourable outcome. Presented herein are the results of check-up multislice CT-angiography (MSCT) 9 years after operation on renal arteries. Multislice CT-angiography and duplex scanning of aortic arch branches made it possible to choose an optimal surgical policy in this woman. Simultaneous endarterectomy from the common carotid artery on the left with autovenous carotid-subclavian shunting on the right in a patient with non-specific aortoarteritis was used by us for the first time. This operation made it possible to restore patency of the carotid artery and to use it as a donor artery for carotid-subclavian shunting in order to eliminate vertebral subclavian steal syndrome.

Proinflammation: the key to arterial aging

Arterial aging is the major contributing factor to increases in the incidence and prevalence of cardiovascular disease, due mainly to the presence of chronic, low-grade, 'sterile' arterial inflammation. Inflammatory signaling driven by the angiotensin II cascade perpetrates adverse age-associated arterial structural and functional remodeling. The aged artery is characterized by endothelial disruption, enhanced vascular smooth muscle cell (VMSC) migration and proliferation, extracellular matrix (ECM) deposition, elastin fracture, and matrix calcification/amyloidosis/glycation. Importantly, the molecular mechanisms of arterial aging are also relevant to the pathogenesis of hypertension and atherosclerosis. Age-associated arterial proinflammation is to some extent mutable, and interventions to suppress or delay it may have the potential to ameliorate or retard age-associated arterial diseases.

Intravitreal triamcinolone injections in non-arteritic anterior ischemic optic neuropathy

BACKGROUND

In non-arteritic anterior ischemic optic neuropathy (NA-AION), no treatments have demonstrated to be effective in recovering visual loss in randomized clinical trials. Oral steroids have been evaluated, and small series of intravitreal triamcinolone acetonide (IVTA) injection in NA-AION have been reported. The purpose of our study was to report the visual outcome and morphological changes in response to a single IVTA injection as a treatment for patients with NA-AION.

PATIENTS AND METHODS

The charts of 36 patients with visual symptoms and optic disc swelling caused by NA-AION were evaluated. Twenty-one patients had received 4 mg IVTA and were compared with 15 non-treated patients. Visual acuity (VA), retinal nerve fiber layer thickness and static visual field were evaluated after 6 months.

RESULTS

VA improvement at 6 months is statistically better in the treated group than in the non-treated group (p = 0.0035). In the treated group, there was a significant inverse correlation between the delay of the injection and the visual acuity achieved at 6 months (p < 0.0083**, r = -0.56). A significant improvement of the visual field was noted in the injected group when compared with the non-treated group at 6 months (p < 0.0028).

DISCUSSION

In this retrospective study, patients receiving IVTA in the acute phase of NA-AION have better improvement of VA and visual field during the follow-up period of 6 months. However, only a large randomized controlled trial may enable to evaluate the benefits of IVTA Injections on visual outcome in NA-AION.

[Aortoarteritis in HBV-associated liver cirrhosis: diagnostics, therapeutic strategy, and prognosis]

A case of decompensated liver cirrhosis in a women with a long silent period of HBV infection is presented. The first manifestation was generalized vasculitis involving small and medium-size vessels and elastic-type arteries with the development of aortoarteritis. Proper interpretation of manifestations of viral liver cirrhosis allowed for immunosuppressive treatment in combination with effective antiviral drugs. As a result, aviremia, regression of vasculitis and portal hypertension along with considerable improvement of the prognosis were achieved.

Electrochemical impedance spectroscopy to characterize inflammatory atherosclerotic plaques

Despite advances in diagnosis and therapy, atherosclerotic cardiovascular disease remains the leading cause of morbidity and mortality in the Western world. Predicting metabolically active atherosclerotic lesions has remained an unmet clinical need. We hereby developed an electrochemical strategy to characterize the inflammatory states of high-risk atherosclerotic plaques. Using the concentric bipolar microelectrodes, we sought to demonstrate distinct Electrochemical Impedance Spectroscopic (EIS) measurements for unstable atherosclerotic plaques that harbored active lipids and inflammatory cells. Using equivalent circuits to simulate vessel impedance at the electrode-endoluminal tissue interface, we demonstrated specific electric elements to model working and counter electrode interfaces as well as the tissue impedance. Using explants of human coronary, carotid, and femoral arteries at various Stary stages of atherosclerotic lesions (n=15), we performed endoluminal EIS measurements (n=147) and validated with histology and immunohistochemistry. We computed the vascular tissue resistance using the equivalent circuit model and normalized the resistance to the lesion-free regions. Tissue resistance was significantly elevated in the oxLDL-rich thin-cap atheromas (1.57±0.40, n=14, p<0.001) and fatty streaks (1.36±0.28, n=33, p<0.001) as compared with lesion-free region (1.00±0.18, n=82) or oxLDL-absent fibrous atheromas (0.86±0.30, n=12). Tissue resistance was also elevated in the calcified core of fibrous atheroma (2.37±0.60, n=6, p<0.001). Despite presence of fibrous structures, tissue resistance between ox-LDL-absent fibroatheroma and the lesion-free regions was statistically insignificant (0.86±0.30, n=12, p>0.05). Hence, we demonstrate that the application of EIS strategy was sensitive to detect fibrous cap oxLDL-rich lesions and specific to distinguish oxLDL-absent fibroatheroma.

Inflammation is related to coronary flow reserve detected by positron emission tomography in asymptomatic male twins

OBJECTIVES

This study sought to examine the relationship between inflammation and coronary microvascular function in asymptomatic individuals using positron emission tomography (PET) and assessment of coronary flow reserve (CFR).

BACKGROUND

Coronary microvascular dysfunction is an early precursor of coronary artery disease (CAD) thought to result from endothelial cell activation and inflammation, but data are limited.

METHODS

We examined 268 asymptomatic male monozygotic and dizygotic twins. Plasma biomarkers of inflammation and endothelial cell activation included C-reactive protein (CRP), interleukin (IL)-6, white blood cell count (WBC), vascular cell adhesion molecule (VCAM)-1, and intercellular adhesion molecule (ICAM)-1. Blood flow quantitation was obtained with [¹³N] ammonia PET at rest and after adenosine stress. CFR was measured as the ratio of maximum flow to baseline flow at rest; abnormal CFR was defined as a ratio < 2.5. A summed stress score for visible perfusion defects was calculated.

RESULTS

In within-pair analyses, all biomarkers, except VCAM-1, were higher in twins with lower CFR than their brothers with higher CFR (p < 0.05). This was observed in the entire sample, as well as within pairs discordant for a CFR of <2.5. Associations persisted after adjusting for summed stress score and CAD risk factors. In contrast no biomarker, except IL-6, was related to the summed stress score of visible defects.

CONCLUSIONS

Even in asymptomatic subjects, a decrease in coronary microvascular function is accompanied by a systemic inflammatory response, independent of CAD risk factors. Our results, using a controlled twin design, highlight the importance of coronary microvascular function in the early phases of CAD.

Is vascular stiffness a target for therapy?

BACKGROUND

Early cardiovascular disease starts in the endothelium leading to functional changes in the vasculature. These changes can be depicted by assessment of arterial stiffness or elasticity. There are several techniques to assess arterial stiffness. Increased arterial stiffness or decreased arterial elasticity has been associated with cardiovascular risk factors. There is now evidence that small artery elasticity is a strong predictor for arterial hypertension. Moreover arterial elasticity provides extra prognostic information beyond arterial blood pressure measurement. Arterial stiffness attenuation may reflect the true reduction of arterial wall damage.

RESULTS

ACE-inhibitors, angiotensin II receptor blockers, aldosterone antagonists and calcium antagonists have favorable effects in improving arterial elasticity, while beta-blockers have an inverse effect. Diuretics have not been evaluated. Lipid lowering therapy, some antidiabetic therapy have shown to reduce arterial stiffness. Inflammatory and infectious diseases have been associated with vascular inflammation and consequently increase in arterial stiffness. The effect of anti-inflammatory agents and antiretroviral therapy on arterial stiffness is under investigation.

CONCLUSIONS

Measurement of arterial stiffness will not only be helpful in the detection of early vascular disease but also as a tool in the selection and follow-up monitoring of therapeutic strategies aimed at preventing or delaying progression of vascular disease.

[Surgical management of a hypertensive young adult suffering from nonspecific aortoarteritis accompanied by renal arterial lesions]

Presented herein is a successful outcome of stagewise surgical management of a young adult suffering from nonspecific aortoarteritis accompanied renal artery lesions. The patient was subjected to a stagewise intervention consisting of stenting of the renal arteries and an open operation, i.e. bilateral aortorenal bypass grafting performed with the synthetic stent B-Braun.

Nrf2 Gene Transfer Induces Antioxidant Enzymes and Suppresses Smooth Muscle Cell Growth In Vitro and Reduces Oxidative Stress in Rabbit Aorta In Vivo

Background— Reactive oxygen species (ROS) play a major role in vascular inflammation and pathophysiology of many vascular diseases such as atherosclerosis and injury-induced neointima formation after balloon angioplasty. Nuclear factor E2–related factor-2 (Nrf2) is a transcription factor orchestrating antioxidant and cytoprotective responses on oxidative and electrophilic stress, and it has been shown to have antiinflammatory effects in vascular cells in vitro. We therefore postulated that Nrf2 gene transfer would have salutary effects on vascular inflammation after angioplasty.

Methods and Results— Transduction of vascular smooth muscle cells (VSMCs) with Nrf2-expressing adenovirus increased the expression of several antioxidant enzymes including heme oxygenase-1 (HO-1) compared with β-galactosidase (AdLacZ)-transduced controls. Moreover, Nrf2 gene transfer also inhibited vascular smooth muscle cell (VSMC) proliferation, and the effect was partially reversed by the HO inhibitor Sn(IV) protoporphyrin. In vivo, adenoviral gene transfer effectively reduced oxidative stress determined by antibody staining against oxidized epitopes of LDL, as well as inhibited vascular inflammation assessed by the macrophage cell count and monocyte chemoattractant protein-1 (MCP-1) staining. However, the antiproliferative effects of Nrf2 in vivo were counterbalanced with diminished apoptosis in neointimal VSMCs, resulting in no change in neointimal hyperplasia.

Conclusions— Nrf2 gene transfer or Nrf2-inducing drugs may have therapeutic applications in vascular diseases in which inflammation and oxidative stress play a role. However, the contrasting growth inhibitory and antiapoptotic effects of Nrf2 need to be considered in pathological conditions in which SMC proliferation plays a critical role.

Restenosis after percutaneous angioplasty: the role of vascular inflammation

Restenosis after endovascular treatment of atherosclerotic lesions in the peripheral, cerebrovascular, and coronary circulation is the major drawback of this minimally invasive technique. Although certain advances have been made during recent years to improve patency rates after percutaneous angioplasty, restenosis remains a challenging clinical problem. Understanding factors that contribute to the pathophysiology of late lumen loss is an effective strategy to improving patients' postangioplasty outcome. Vascular inflammation after balloon angioplasty or stent implantation has been identified as a cornerstone of the restenotic process, and several markers of inflammation have been referred to as potential predictors of outcome. This article reviews recent findings on the issue of inflammation and restenosis after percutaneous angioplasty with special attention given to the role of inflammatory parameters as markers for the restenosis risk in the peripheral vessel area.

Apolipoprotein E3- and Nitric Oxide–Dependent Modulation of Endothelial Cell Inflammatory Responses

Objective— Although apolipoprotein E3 (apoE3) is known to be atheroprotective, its mechanisms of protection in endothelial cells remain unclear.

Methods and Results— Cultured human aortic endothelial cells were stimulated with tumor necrosis factor (TNF)-α in the presence of human recombinant apoE3 solubilized in dimyristoyl phosphatidylcholine liposomes. Using flow cytometry and real-time polymerase chain reaction, a significant increase of inflammatory cell adhesion proteins (vascular cell adhesion molecule-1 and E-Selectin), and MCP-1, interleukin-8, and intercellular adhesion molecule-1 gene expression was observed within 5 hours of TNF-α exposure, which was markedly attenuated in cells coincubated with apoE3. Treatment with apoE4 resulted in increased inflammatory gene expression relative to either TNF treatment alone or TNF + apoE3 treatment. NO synthase inhibition experiments demonstrated NO to be an active participant in the actions of both TNF and apoE. To clarify the role of NO, dose-response experiments were performed with 0.03 to 300 μmol/L DEA-NONOate. Using flow cytometry and real-time polymerase chain reaction, a modulatory role of NO in TNF-induced endothelial cell activation was observed.

Conclusions— These data suggest a role of vascular wall apoE3 to balance the intracellular redox state in injured endothelial cells via NO-dependent pathways.

Intravitreal triamcinolone acetonide for treatment of acute nonarteritic anterior ischemic optic neuropathy

PURPOSE

To report on the use of intravitreal triamcinolone acetonide as treatment for nonarteritic anterior ischemic optic neuropathy (NAION).

METHODS

The interventional clinical case series included three patients with acute NAION who received an intravitreal injection of about 20 mg triamcinolone acetonide.

RESULTS

At the end of follow-up at 3 months, 3.5 months and at 5 months after the injection, visual acuity had changed from 0.10 at baseline to 0.20 in the first patient, from 0.50 to 0.20 in the second patient, and from 0.16 to 0.20 in the third patient. One eye developed triamcinolone-induced ocular hypertension which was treated by topical antiglaucomatous medication.

CONCLUSIONS

The clinical courses of all three patients presented suggest that an intravitreal high-dosage injection of triamcinolone acetonide may not be markedly effective in increasing visual acuity after acute NAION.

Local inflammation, endothelial dysfunction and fibrinolysis in coronary heart disease

Prospective epidemiological studies have shown associations of circulating inflammatory markers with risk of CHD (coronary heart disease); however, these associations are modest after adjustment for confounding by established risk factors, and do not add significantly to the predictive value of current clinical risk scores. In contrast, experimental human studies of local arterial inflammation, such as the brachial artery infusion of TNF-alpha (tumour necrosis factor-alpha) model reported in this issue of Clinical Science by Robinson and co-workers, are of value in elucidating the pathophysiology of atherothrombosis.

Nonarteritic anterior ischemic optic neuropathy

PURPOSE OF REVIEW

Nonarteritic anterior ischemic optic neuropathy remains a disease that is poorly understood in many aspects. The clinical presentation may diverge significantly from the classic unilateral, painless, sudden vision loss affecting patients over the age of 50 years. This variability might make nonarteritic anterior ischemic optic neuropathy hard to differentiate from optic neuritis and arteritic ischemic optic neuropathy. The course of nonarteritic anterior ischemic optic neuropathy is also variable, often sequentially affecting the other eye.

RECENT FINDINGS

Visual recovery has been reported, but it is not the rule. Multiple risk factors have been proposed, including crowded disc, atherosclerosis, diabetes, hyperlipidemia, hypertension, hypotension, hemoconcentration, hemodilution, and hypercoagulable states. The optic nerve damage in nonarteritic anterior ischemic optic neuropathy appears to result from a perfusion insufficiency in the short posterior ciliary arteries leading to infarction of the retrolaminar portion of the optic disc. The underlying mechanisms are still unclear, however. Multiple medical and surgical treatment options have been investigated, including optic nerve sheath decompression, standard and megadose corticosteroids, levodopa, carbidopa, hyperbaric oxygen, and neuroprotective agents, but no proven effective treatment is currently available.

SUMMARY

Intense investigations in humans and animals are under way. Hopefully these studies will enhance our understanding of the risk factors and pathophysiology of nonarteritic anterior ischemic optic neuropathy and aid in developing new strategies for prevention and treatment.

Acute myocardial infarction with normal coronary arteries in a young man with the Behcet's disease

Behcet's disease (BD) is an inflammatory disorder of unknown origin, which usually presents with mucocutaneous, ocular, articular, vascular, gastrointestinal and central nervous system manifestations. Although cardiac involvement is not infrequent as a manifestation of Behcet's disease, coronary arteritis is very rarely reported. We suggest that the diagnosis of coronary arteritis should be considered in patients presenting acute myocardial infarction especially in young patients as underlying cause.

Angiotensin II AT1 receptor blockade decreases brain artery inflammation in a stress-prone rat strain

The spontaneously hypertensive rats (SHR) are a genetically hypertensive strain with vulnerability to brain ischemia and stress. In SHR, the brain Angiotensin II (Ang II) system is chronically stimulated, resulting in brain artery remodeling and inflammation. Pretreatment with Ang II AT(1) receptor antagonists protects from brain ischemia and prevents the hormonal and sympathoadrenal response to stress. In addition, the anti-inflammatory effects of AT(1) receptor antagonists are partially responsible for preventing the development of stress-induced gastric ulcers. We asked whether AT(1) receptor antagonists could exert anti-inflammatory effects in the brain vasculature as a mechanism for their protective effects against ischemia. As determined by immunohistochemistry, long-term inhibition of brain AT(1) receptors by peripheral administration of the AT(1) receptor antagonist candesartan (0.3 mg/kg/day for 28 days) normalized the pathologic remodeling, decreased expression of the intercellular adhesion molecule-1 and the number of associated macrophages, and normalized the endothelial nitric oxide synthase expression in cerebral vessels of SHR. The anti-inflammatory effects of AT(1) receptor antagonists may be an important mechanism for protection against ischemia and could participate in the anti-stress properties of this class of compounds.

Alterations of the sympathovagal balance evaluated by heart rate variability in a rare case of adult Still's disease

We present a rare case of adult Still's disease with cardiac involvement (myocarditis and coronary arteritis). The autonomic nervous system function was evaluated by heart rate variability (HRV) analysis performed by 24-hour electrocardiographic recording during the acute phase of the disease and the remission (after 1 month and 1 year). The HRV parameters were studied in the time (standard deviation of all NN intervals-total power - SDNN, square root of the mean of the sum of the squares of the differences between adjacent NN - RMS-SD and HRV index) and frequency domains (low frequency, high frequency, and low frequency/high frequency). The results of the analysis of the HRV highlight that in the acute phase of the disease with cardiac involvement the autonomic nervous system is globally altered, with modifications of the sympathovagal balance, due to impairment of the parasympathetic component. This trend tends to persist in the short period (1 month), but seems to resolve completely within 1 year. An altered sympathovagal balance should be considered as a possible marker of vasculitis-related ischemia.

Early and late presentations of radiation arteritis

Radiotherapy (XRT) plays a prominent role in the therapy of a variety of malignancies. Improved survival for malignancies treated with XRT has produced a growing subset of patients who present several years later with arterial occlusive disease in the irradiated field. Establishing a presumptive diagnosis of radiation arteritis (RA) is based on clinical history and the arteriographic appearance of lesions. The lesions of RA often occur in atypical locations with adjacent arterial beds largely spared of atherosclerosis. The indications for intervention for RA do not differ significantly from atherosclerotic arterial lesions. In most cases, RA lesions do not merit treatment unless they become symptomatic. However, asymptomatic carotid artery lesions should be considered for intervention because they are particularly prone to progression and development of neurologic symptoms. Percutaneous and endovascular techniques are viable treatment options for lesions with favorable anatomy. Operative interventions often require extraanatomic approaches and autogenous conduits to optimize outcomes in irradiated fields.

Interaction of oxidative stress and inflammatory response in coronary plaque instability: important role of C-reactive protein

OBJECTIVE

C-reactive protein (CRP), a predictor of cardiovascular events, localizes in atherosclerotic arteries and exerts proinflammatory effects on vascular cells. Reactive oxygen species (ROS) have been implicated in atherogenesis and plaque instability.

METHODS AND RESULTS

Expressional pattern of CRP in directional coronary atherectomy specimens from 39 patients was examined. Characteristics of histological plaque instability and higher levels of serum CRP and fibrinogen were associated with the CRP immunoreactivity. In situ hybridization revealed the presence of CRP mRNA in coronary vasculature. Furthermore, the expression of CRP mRNA and protein was detected in cultured human coronary artery smooth muscle cells (CASMCs) by reverse transcriptase-polymerase chain reaction and Western blotting. In addition, CRP was frequently colocalized with p22phox, an essential component of NADH/NADPH oxidase, which is an important source of ROS in vasculature. Moreover, the incubation of cultured CASMCs with CRP resulted in the enhanced p22phox protein expression and in the generation of intracellular ROS.

CONCLUSIONS

The expression of CRP in coronary arteries was associated with histological and clinical features of vulnerable plaque, and it had a prooxidative effect on cultured CASMCs, suggesting that it might play a crucial role in plaque instability and in the pathogenesis of acute coronary syndrome via its prooxidative effect.

Southern Association for Vascular Surgery William J. von Leibig Award. Inflammation and intimal hyperplasia associated with experimental pulmonary embolism

OBJECTIVE

We tested the hypothesis that a venous thromboembolism to the pulmonary arterial system (pulmonary embolism [PE]) would cause an inflammatory response within the pulmonary arterial (PA) wall marked by elevated cytokines and chemokines and an influx of inflammatory cells.

METHODS

Experimental PE was induced in 70 rats and confirmed with angiography and O(2) saturation depression, and an additional 70 rats underwent sham operations. PA and lung tissue were removed at 3 hours and at 1, 2, 4, 6, 8, and 14 days (n = 10 per time point), were analyzed for proinflammatory cytokines and chemokines, and underwent histologic analysis. Data were analyzed with analysis of variance and the unpaired Student t test.

RESULTS

Average gross PE resolution was 40% at 2 days, 90% at 4 days, and 100% at 6 days. Only monocyte chemoattractant protein-1 levels were greater in affected PAs compared with sham PAs at 3 hours, 1 day, and 2 days (137 +/- 13 pg/mg protein, 285 +/- 40 pg/mg protein, and 249 +/- 36 pg/mg protein versus 101 +/- 6 pg/mg protein, 150 +/- 36 pg/mg protein, and 92 +/- 3 pg/mg protein; P <.01 for all). Keratinocyte-derived chemokine, tissue necrosis factor, interleukin-10, nitric oxide, P-selectin, and E-selectin levels were not elevated. Neutrophils infiltrated the PA wall beginning at 3 hours, peaked at 2 days (69.4 +/- 21.7 per five high-power fields; P <.01), and returned to baseline by 8 days after PE. Macrophages peaked at 1 day after PE (29.3 +/- 6.9; P <.01) and returned to baseline by 4 days after PE. PE also was associated with a significantly increased intima to media ratio (P <.05), apparent at 4 days after PE and persisting through 14 days.

CONCLUSION

PE is associated with an early influx of polymorphonuclears and macrophages and monocyte chemoattractant protein-1 elevation within the PA wall. These are temporally associated with thrombus resolution and intimal hyperplasia. These factors may mediate these two processes after PE. This offers targets for further study with the hopes of minimizing the pathophysiologic response to PE.

[Diabetic angiopathy: the role of microvascular exploration in routine practice. Consequences of a new algorithm for care of the diabetic foot]

Diabetes mellitus is the chief medical cause of amputation. The risk of amputation is 15-fold higher in diabetic subjects and 5 out of 6 amputees are diabetic. There are three types of clinical presentation of diabetes-neurological, infectious and ischemic. In clinical practice, these three forms are often intertwined but the most frequent clinical sequence of events is neuropathy --> ulceration --> infection --> amputation. In this sequence, ischemia is not mentioned. The explanation is that the ischemic component of the diabetic foot is only recognized when ankle pulses are missing and when duplex scanning shows stenosis or occlusion of the main arterial trunks of the legs. This manner of diagnosing the ischemic component of diabetic foot is wrong as it fails to recognize the possibility of distal diabetic arteritis. Some experts in diabetology deny the existence of this arteritis which is obvious for those who measure systolic toe pressure. This distal arteritis is present in about 15% of all diabetic patients without trophic changes and in 35% of those with trophic changes. This foot arteritis is closely related to neuropathy. Toe pressure is not usually mentioned in text books or in consensus conferences concerning the diabetic foot. This is the main explanation for the calamitous number of amputations among diabetic patients. Nothing will change as long as physicians do not include toe pressure as a useful diagnostic tool in patients with diabetes. We present here a four-stage algorithm including toe pressure measurement for the management of the diabetic foot.

[Cerebral arteritis and psychic involution in children. A report of one case with a good response to treatment]

OBJECTIVE

To show the importance of the cerebral arteritis as etiology of the language and the intellectual involution in children.

CLINICAL CASE

A boy started to show psychic and language involution since 18 months of life to arrive to an autistic behavior. After showing normal results in all the studies performed in order to investigate the possible etiologies, cerebral arteriography was performed. Cerebral arteritis affecting especially the right opercular artery was disclosed. Oral nicardipine administration was follow-up of a complete recuperation.

CONCLUSIONS

Cerebral arteritis is very seldom managed as the cause of intellectual and/or language involution in children as it also occurs with the syndrome of acquired aphasia. However, this pathology has a good response not only to corticoids but also to calcium channel antagonists as it occurred in our patient.

Role of inflammation and metalloproteinases in plaque disruption and thrombosis

Numerous pathological, clinical, angiographic and angioscopic studies have demonstrated that acute coronary syndromes (unstable angina, acute myocardial infarction and ischemic sudden death) are most frequently the consequence of plaque disruption (plaque rupture or superficial plaque erosion) and consequent coronary thrombosis. Several serial angiographic studies have demonstrated that nearly 60-70% of acute coronary syndromes evolve from mildly to moderately obstructive atherosclerotic plaques. Coronary plaque disruption appears to be a function of both the composition of the plaque (plaque vulnerability ) as well as extrinsic triggers that may precipitate plaque disruption in a vulnerable plaque. Vulnerability for plaque disruption appears to be largely determined by the size of the lipid-rich atheromatous core, the thickness of the fibrous cap covering the core, and the presence of ongoing inflammation within and underneath the cap. Inflammatory cells may play a critical role in plaque disruption through the elaboration of matrix degrading metalloproteinases or MMPs (collagenases, gelatinases, stromelysins and matrilysin) and by inhibition of function and survival of matrix-synthesizing smooth muscle cells. Inflammatory cells may also play a critical role in triggering thrombosis following plaque disruption through the tissue factor pathway. In addition, stresses resulting from hemodynamic and mechanical forces may precipitate plaque disruption, particularly at points where the fibrous cap is weakest, such as at its shoulders. The degree of thrombosis following plaque disruption is determined by the thrombogenicity of the disrupted plaque, disturbed local rheology and systemic thrombotic-thrombolytic milieu. Surges in sympathetic activity provoked by sudden vigorous exercise, emotional stress -- including anger, or cold weather, may also trigger plaque disruption. These observations have led to the concept of plaque stabilization as a new clinical strategy for the prevention of acute coronary syndromes. Plaque stabilization can be achieved through pharmacologic and lifestyle-modifying interventions that reduce vulnerability to plaque disruption by altering plaque composition and/or inflammatory activity within the plaque.

Painful Horner syndrome due to arteritis of the internal carotid artery

A 44-year-old man presented with painful Horner syndrome: severe periorbital pain, ptosis, and miosis of his right eye, with intact facial sweating. Lymphadenitis at the right side of his neck preceded the symptoms. MRI and magnetic resonance angiography showed thickening of the right internal carotid artery, extending from the bifurcation to the cavernous sinus, without evidence for dissection. The patient was treated with corticosteroids with immediate improvement. Control MRI scanning was normal after 6 weeks. We conclude that the painful Horner syndrome was caused by a reactive arteritis of the right internal carotid artery.

Nonarteritic anterior ischemic optic neuropathy with macular edema: visual improvement and fluorescein angiographic characteristics

The objective of the study was to assess visual outcomes in patients who have nonarteritic anterior ischemic optic neuropathy (NAION) with macular edema (ME). Thirteen eyes (12 patients) with NAION and ME were observed for an average of 5.3 months after onset of visual loss. Intravenous fluorescein angiography was performed on 10 eyes. Fluorescein leakage was observed in 8 of 10 (80%) eyes. Leakage was nonfocal, minimal, and diffuse. Eleven of 13 (85%) eyes with ME improved. The average improvement was 2.3 Snellen lines. The presence of ME in patients with NAION may confer a better visual prognosis than reported in patients with NAION alone.

Early and late onset manifestations of cerebral vasculitis related to varicella zoster

Varicella-zoster associated cerebral vasculitis (VZCV) as a cause of cerebral infarction has hitherto been considered a rare condition. Ischemic stroke in previously healthy children has occurred during recovery from chickenpox or has been attributed to virus reactivation among immunosuppressed patients. The clinical, radiologic and immunologic findings in four children with VZCV will be reported. Clinical manifestations included sudden onset of hemiparesis, motor aphasia and disturbed consciousness in previously healthy children. Only one child had a history of chickenpox six weeks prior to the onset of stroke, whereas a latency period of up to four years between chickenpox and the onset of stroke was found in the other three children. Diagnosis of VZCV was confirmed repeatedly by demonstrating intrathecal production of varicella-zoster IgG antibodies in three children or a four-fold increase of varicella-zoster serum IgA-antibodies in one child. Intrathecal production of antibodies against other latent viruses and borreliosis could be excluded. PCR for varicella on CSF, performed in two patients, remained negative. No intrathecal production of varicella-zoster antibodies has been found in a control group of twenty clinically healthy children (age range from 2-18 years) with a previous varicella infection. During follow-up two children recovered completely whereas two children still suffer from serious neurological deficits. Immunological investigations, performed in three children, showed circulating immune-complexes with slightly lowered complement concentrations in two patients. In addition a lowered T-helper/T-suppressor cell ratio of unknown origin was found in three children. These immunological findings will be discussed in the light of the pathophysiology of VZCV.

[Cardiovascular manifestations of Horton disease: an underestimated disease in cardiology]

Horton's disease is a giant cell arteritis well known for its presentation as temporal arteritis. It is, in fact, a systemic disease which affects over 1% of the general populations after 50 years of age. With the exception of the risk of blindness by occlusion of the ophthalmic artery, the cardiovascular manifestations of Horton's disease are not well known and probably underestimated by clinicians. The main complications are involvement of the large arteries, especially the thoracic aorta and subclavian and axillary arteries, the femoro-popliteal axis and supra-aortic arterial vessels. During the initial phase of the disease, extension of arteritis to the carotid and vertebral arteries is of particular concern because of the risk of cerebral infarction. The coronary arteries, myocardium, pericardium of pulmonary arteries may also be affected by the inflammatory process. In the long-term, Horton's disease may be complicated by aneurysms, dissection of parietal rupture of the thoracic aorta. Treatment is based on steroid therapy, sometimes associated with antiplatelet agents or anticoagulants during the initial phase of treatment. Long-term follow-up is justified because of the risk of late aortic complications.

Chronic and recovered cases of sheep-associated malignant catarrhal fever in cattle

Malignant catarrhal fever (MCF) is traditionally regarded as a disease with a short clinical course, low morbidity and high case fatality rate. Owing to the limitations of the assays used for laboratory diagnosis. It was difficult in characterise the clinical spectrum of sheep-associated MCF, particularly when the cattle recovered from an MCF-like clinical syndrome. Over a period of three years, 11 cattle that survived MCF for up to two-and-a-half years were identified on four premises. A clinical diagnosis of MCF was confirmed by the detection of ovine herpesvirus-2 DNA in peripheral blood leucocytes using a polymerase chain reaction (PCR) assay that detects a specific 238 base-pair fragment of viral genomic DNA. Of the 11 cattle examined, six recovered clinically with the exception of bilateral corneal oedema with stromal keratitis (four animals) and unilateral perforating keratitis (one animal). The 10 animals available for postmortem examination had disseminated subacute to chronic arteriopathy. Recovery was associated with the resolution of the acute lymphoid panarteritis that characterises the acute phase of MCF, and with the development of generalised chronic obliterative arteriosclerosis. Bilateral leucomata were due in part to the focal destruction of corneal endothelium secondary to acute endothelialitis. Formalin-fixed tissues and/or unfixed lymphoid cells from all 11 cattle were positive for sheep-associated MCF by PCR. These observations indicate that recovery and chronic disease are a significant part of the clinical spectrum of MCF and that such cases occur with some frequency in the area studied. The affected cattle remain persistently infected by the putative sheep-associated MCF gammaherpesvirus.

Rare vasculitic syndromes

Vasculitis can and does occur in childhood. Apart from the common vasculitides (Henoch-Schönlein purpura, hypersensitivity angiitis and Kawasaki disease) there are a number of important but comparatively rare disorders affecting children. These include macroscopic and microscopic polyarteritis, cutaneous polyarteritis, Wegener's granulomatosis, Churg-Strauss syndrome, primary angiitis of the central nervous system, hypocomplimentaemic urticarial vasculitis, vasculitis associated with various connective tissue disorders, Takayasu's disease and vasculitis associated with conditions such as Behcet's syndrome, familial Mediterranean fever and Cogan's syndrome. Distinguishing these conditions from other disorders is often difficult and requires clinical acumen and appropriate investigative procedures. With modern therapeutic agents it is possible to implement appropriate therapy but in spite of this, there remains a not inconsequential morbidity and mortality.

Application of HELP in nonarteritic anterior ischemic optic neuropathy: a prospective, randomized, controlled study

BACKGROUND

Heparin-induced extracorporeal LDL/fibrinogen precipitation (HELP) eliminates selectively fibrinogen, LDL, cholesterol, triglycerides and LP(a) from blood plasma using extracorporeal circulation. The reduction of fibrinogen and LDL by about 50% after only one procedure immediately improves the hemorheological situation.

METHOD

In a prospective, randomized, controlled study over a period of 3 months, 40 patients with nonarteritic ischemic optic neuropathy (NAION) were randomly assigned to either HELP or hemodilution therapy to determine the efficacy of these two treatments on visual acuity and fields.

RESULTS

After transformation of the Snellen acuity into logMAR units the statistical analysis did not show a significant difference between the two groups (P = 0.48). An increase of the visual acuity by two or more lines was obtained in 9 patients (47.4%) of the HELP group, 10 (52.6%) remained stable and none got worse. In the hemodilution group, visual acuity increased in patients (33.4%), 9 (42.8%) remained stable and 5 (23.8%) experienced a decrease. The calculated mean sensitivity of visual fields at baseline improved statistically significantly (P < 0.01) in the HELP group from 6.83 +/- 4.52 dB to 8.27 +/- 4.89 dB, but did not change significantly in the hemodilution group (6.25 +/- 4.12 dB to 6.12 +/- 3.92 dB).

CONCLUSION

The HELP system seems to be safe and more effective than hemodilution in improving the hemorheological and the functional situation in NAION and could be a promising regimen in the treatment of NAION.

Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results

OBJECTIVE

To evaluate the efficacy and safety of percutaneous transluminal renal angioplasty (PTRA) in children.

METHODS

We performed aortography and attempted PTRA in 35 consecutive children (age 5 to 14 years, mean 10.8 +/- 2.5 years) with severe hypertension having > or = 75% renal artery stenosis (RAS).

RESULTS

The stenosis was caused by aortoarteritis in 31 (88.6%) cases and by juvenile idiopathic fibromuscular disease (FMD) in four (11.4%) cases. Twenty-seven (77.1%) patients, including three having RAS of solitary functioning kidney with total occlusion of contralateral renal artery, had bilateral RAS and eight (22.9%) had unilateral RAS. PTRA was technically successful in 54 (91.5%) of 59 stenotic lesions in 31 (88.6%) of 35 patients. Both aortoarteritis and FMD patients had significant decrease in RAS after PTRA. One patient had acute reocclusion of one renal artery after bilateral PTRA, which could be successfully opened by reangioplasty. Postangioplasty angiographic restudy performed in 18 patients at 4 to 72 months (mean 23.1 +/- 27.9 months) after successful angioplasty showed restenosis in 8 (25.8%) of 31 lesions initially dilated and de novo lesions of aorta in two patients. All seven restenotic renal artery lesions attempted and both stenosis of aorta were successfully dilated. Twenty-nine of 31 patients with successful PTRA have been followed up from 4 to 108 months (mean 41.0 +/- 29.3 months). Mean systolic blood pressure decreased from 185.1 +/- 27.4 to 120.6 +/- 19.2 mm Hg and mean diastolic blood pressure decreased from 118.4 +/- 13.2 to 84.6 +/- 10.4 mm Hg after PTRA. Twenty seven (93.1%) of these 29 patients had benefical blood pressure response. Seventeen (58.6%) patients improved, 10 (34.5%) were cured, although 2 (6.9%) patients failed to respond to PTRA. Blood pressure response was better in FMD as compared to aortoarteritis group. Patients with unilateral RAS, discrete stenosis, and post-PTRA stenosis < or = 20% also identified good blood pressure response.

CONCLUSION

Aortoarteritis is the most common cause of renovascular hypertension in South Asian children. PTRA is safe and highly effective and therefore should be the treatment of choice in pediatric renovascular hypertension.

Recurrent aortic valve prosthesis dehiscence secondary to aortoarteritis: three case reports and literature review

We report three young Chinese male patients who underwent aortic valve replacement for severe aortic regurgitation of subacute onset, complicated by recurrent dehiscence of the aortic valve prosthesis, due to aortitis. One of the three patients underwent aortic valve replacement three times and progression of the prosthesis dehiscence was arrested with the use of corticosteroids. A review of the literature on the prognosis and treatment of aortoarteritis with particular reference to the management of recurrent valvular dehiscence is discussed.

Effect of levodopa and carbidopa on recovery of visual function in patients with nonarteritic anterior ischemic optic neuropathy of longer than six months' duration

PURPOSE

We conducted a pilot clinical trial to determine the efficacy of levodopa in promoting visual recovery in eyes with nonarteritic anterior ischemic optic neuropathy of greater than six months' duration.

METHODS

This prospective, randomized, double-masked, placebo-controlled clinical trial involved 20 subjects with nonarteritic anterior ischemic optic neuropathy of 30 months' mean duration. Subjects were randomly assigned to receive either low-dose levodopa and carbidopa or a placebo for three weeks. At 12 weeks after the baseline visit, the levodopa group then was provided a higher, conventional dose of levodopa and carbidopa for three more weeks. Change in visual function was monitored at four, 12, 16, and 24 weeks after the baseline visit.

RESULTS

At 12 weeks after the baseline visit, the levodopa group experienced a significant (P = .016) mean difference in improvement of visual acuity of 5.9 letters from the placebo group. At 24 weeks after the baseline visit, a significant treatment effect (P = .036) for visual acuity was still evident; the levodopa group had a mean gain in improvement of 7.5 letters difference from baseline from the placebo group. Three subjects in the levodopa group experienced a doubling of the visual angle as denoted by a gain of at least 15 letters. Significant improvement was not observed for color vision (P = .82) or mean deviation of visual field loss (P = .82).

CONCLUSION

The study found significant improvement of visual acuity among subjects receiving levodopa and carbidopa despite long-standing visual loss from nonarteritic anterior ischemic neuropathy. Confirmation of our results is awaited from larger population studies and with a longer follow-up time interval regarding the efficacy of levodopa in reversing visual loss in this disease.

Multimodality evoked potentials in aortoarteritis

Brainstem auditory evoked potentials (BAEPs) have been used to detect early and even asymptomatic brain ischemia. There is a need to detect subclinical brain and/or spinal cord ischemia in patients with aortoarteritis so that ischemic deficits can be prevented by early intervention. We studied multimodality (Visual evoked potentials--VEPs, Somatosensory evoked potentials--SEPs and BAEPs) evoked potentials (EPs) in 10 neurologically asymptomatic subjects with aortoarteritis. EP latencies were normal in all the patients studied. The possible value of EP latencies in detection of early brain and/or spinal cord ischemia in patients with aortoarteritis is discussed.

[Drug evaluation methods in lower limb arteriopathy]

The prevalence and severity of chronic vascular leg disease explains the necessity to clarify methods for assessing it. Today the methods are both clinical and paraclinical. Clinically, they are based on the Fontaine and Leriche classification and appearance of ischaemic pain. Paraclinically, they are measuring distal blood pressure, artery output, micro-circulation, rheology, and tissular metabolism. But this approach must be also global, assessing coronary and carotid disease. Trials methodology includes a first step of explanatory studies by paraclinical ways and lastly pragmatic efficacy and tolerability studies. We recommend an accurate selection of patients and a stratification. The disease must be stable and the treatment and diet too. The trials should be randomised vs placebo. In conclusion we propose a multiparametric classification of the disease.

The arteritides

This article reviews the histopathological, clinical and immunological features of the arteritides. Based on these criteria, a classification scheme is proposed that includes infectious and non-infectious causes. Included in the non-infectious arteritides are: hypersensitivity vasculitis including serum sickness. Henoch-Schönlein purpura, mixed cryoglobulinaemia, hypocomplementaemia, drug and malignancy-associated vasculitis; arteritides of small and medium-sized arteries including polyarteritis nodosa, Kawasaki's disease, Wegener's granulomatosis, Churg-Strauss syndrome, necrotizing sarcoid granulomatosis, thromboangiitis obliterans (Buerger's disease) and localized forms of arteritis; arteritides involving large, medium and small-sized arteries which includes giant cell (temporal) arteritis, Takayasu's disease and arteritis of collagen-vascular disease (rheumatoid arthritis, rheumatic fever, Behçet's disease, Sjörgren's syndrome, systemic lupus erythematosis and systemic sclerosis.