Prevalência de Doença Carotídea na Patologia Cérebro-Vascular Isquémica. O Papel do Eco-Doppler

BACKGROUND: Atherosclerotic carotid disease represents approximately 20% of the causes of ischemic stroke. Effective treatment options, such as endovascular or surgical revascularization procedures, are available. Doppler Ultrasound (DUS) is a non-invasive, inexpensive, routine exam used to evaluate the presence of internal carotid artery (ICA) stenosis. We retrospectively analysed the prevalence of severe atherosclerotic carotid disease in a population of patients with acute ischemic stroke/transitory ischemic attacks (TIAs), and the role of DUS in the detection of ICA stenosis and treatment decisions in these patients. METHODS: A total of 318 patients with ischemic stroke or TIAs was admitted to our stroke unit, and 260 patients were studied by DUS. ICA stenosis was evaluated by DUS according to peak systolic velocity. All DUS exams were performed by the same operator. ICA stenosis was further assessed in 43 patients by digital subtraction angiography (DSA) using NASCET criteria. RESULTS: Of the total 318 patients, 260 (82%) had DUS evaluation. Of the total 520 ICAs studied by DUS, degrees of ICA stenosis were: 0-29% n= 438 (84%); 30-49% n= 8 (2%); 50-69% n= 27 (5%); 70-89% n= 15 (3%); 90-99% n= 20 (4%); oclusão n= 14 (2%). Of the total 260 patients studied, 43 (16.5%) underwent DSA. Sensibility and specificity of DUS in the diagnosis of carotid stenosis over 70% were, respectively, 91% e 84%. Of the total 31 patients with significant carotid stenosis (70-99%), 23 (74%) underwent subsequent carotid revascularization procedures. DISCUSSION: DUS is an important screening test in our stroke unit, justifying its use as a routine exam for all patients with ischemic stroke/TIAs. Moreover, our results show the relevance of severe carotid disease in a population with acute ischemic stroke/TIAs (16.5%), with a total of 9% of patients being submitted to carotid revascularization procedures.

Origem Anómala da Artéria Coronária Esquerda a Partir da Artéria Pulmonar

OBJECTIVE: To assess the frequency and severity of the anomalous origin of the left coronary artery (ALCA) from the pulmonary artery (PA). DESIGN OF THE STUDY: Prospective study of case series between March 1991 and December 1994. SETTING: Referral-based Paediatric Cardiology Department of a Tertiary Care Center. PATIENTS AND METHODS: Five consecutive patients (pts) with anomalous origin of the LCA from the PA; there were three infants aged 4 months and two children one 8 year and one 9 year old. There were three girls and two boys. All pts had clinical and 2D-echo and Doppler investigation prior to cardiac catheterization (CC). Indication for CC was based in the association of symptoms and signs of myocarditis or dilated cardiomyopathy of acute or subacute onset and electrocardiographic (ECG) signs of ischemia in infants. In older patients (pts) diagnosis was suspected mainly from ECG. During CC in all pts, aortograms and when necessary selective coronary angiograms were performed. Surgical correction was performed in all children. In two pts stress exercise ECG and stress Thallium studies before and after surgery were performed. RESULTS: two pts had "adult" an three had "infantile" type of ALCA from the PA. CC was performed and diagnosis was confirmed at surgery in all cases. In one child, correct diagnosis was made by ECO prior to CC and in one case LCA to PA fistula was suspected on Colour-Doppler study. No complications were attributed to CC. Several types of surgery were performed: reimplantation of the ALCA from the PA to the aorta (three pts); tunnel connection of the aorta to the ALCA via the PA (one pt) and left internal mammary to LCA anastomosis (one pt). Two infants died intraoperatively due to extensive myocardial infarction and poor left ventricular function. All the three survivors are asymptomatic after a mean follow up of 34 months. Two oldest pts are currently in New York Heart Association functional class I with normal ECG and improved myocardial perfusion on Thallium scan despite almost total occlusion of LCA at the site of implantation in the aorta as diagnosed on coronary angiogram. CONCLUSIONS: ALCA from PA is associated with major morbidity and mortality. Diagnosis should be suspected in pts with unexplained myocardial ischemia on ECG and even more if it is associated to clinical signs of dilated cardiomyopathy or myocarditis. Careful assessment on ECO and pulsed Doppler and colour flow mapping should make the diagnosis in most cases. Although surgery can be performed based only on ECO diagnosis, we strongly advise for angiography in all cases as in our experience there are false negative diagnosis by ECO. Preoperative Thallium studies can be useful for the selection of the type of surgery as pts with very little viable myocardium will not survive the establishment of a direct systemic to coronary blood flow and may be candidates for heart transplantation.

O Eco-Doppler na Dissecção da Aorta Abdominal

Apresenta-se um caso clínico de dissecção da aorta abdominal - tipo B - diagnosticada por eco-Doppler e tomografia axial computorizada (TC). Discute-se o interesse do eco-Doppler no diagnóstico de dissecção da aorta abdominal e na avaliação do envolvimento arterial visceral. É ainda um método útil no follow-up dos doentes com terapêutica conservadora.

Estudo Comparativo entre Dois Tipos de Eco-Contrastes: Echovist® e Levovist®, Avaliação da Permeabilidade Tubária em Infertilidade Feminina

Na propedêutica inicial do casal infértil, a realização da Sonossalpingografia (SoSG) contrastada através de dois tipos de ecocontrastes, Echovist® e Levovist®, durante a realização da ultra-sonografia ginecológica convencional pode, em casos seleccionados, substituir como exame de “screening” da permeabilidade tubária a Histerossalpingografia (HSG) e a Laparoscopia com cromotubação (LPC). Objectivos: Comparar os resultados da permeabilidade tubária através da SoSG contrastada com Echovist® ou com Levovist® e a HSG e determinar a sua acuidade em relação a LPC considerada “gold-standard”. Pacientes e métodos: Foram avaliadas prospectivamente 90 pacientes inférteis submetidas a SoSG em que se utilizou o contraste ecogénico Echovist® e 28 pacientes em que se utilizou o eco-realçador Levovist®. Para a HSG utilizou-se, em todas as pacientes, contraste iodado e hidrossolúvel Telebrix®. A observação da permeabilidade tubária teve sua avaliação final e sistemática pela LPC. Resultados: No estudo das trompas pelo Echovist® observamos permeabilidade em 67 pacientes (74,4%) e obstruções bilaterais em 23 das pacientes (25,6%) e pelo Levovist®, respectivamente, 22 (78,6%) e 6 pacientes (21,4%). Na comparação da avaliação da permeabilidade tubária entre a SoSG com Echovist® e LPC encontramos: especificidade € 91,3%, sensibilidade (S) 100%, falsos positivos (FP) 8,7%, falsos negativos (FN) 0%, valor preditivo positivo (VPP) 97,1%, valor preditivo negativo (VPN) 100% e Kappa de 96,5%, e entre a HSG e LPC, neste grupo Echovist® foram: E 100%, S 91,04%, FP 0%, FN 8,96%, VPP 100%, VPN 79,31% e Kappa de 88,6%. Na comparação da avaliação da permeabilidade tubária entre a SoSG com Levovist® e LPC encontramos: E 100%, S 100%, FP 0%, FN 0%, VPP 100%, VPN 100% e Kappa de 100%, e entre a HSG e LPC, no grupo Levovist® foram: E 100%, S 86,36%, FP 0%, FN 13,64%, VPP 100%, VPN 66,67% e Kappa de 82,2%. Conclusões: As Sonossalpingografias (SoSG) contrastadas utilizando-se como eco-realçadores o Echovist® ou o Levovist® podem ser consideradas exames complementares equivalentes na rotina da avaliação inicial do factor tubário por apresentarem, além do mesmo composto químico activo, alta sensibilidade, especificidade e concordância, ambos com acuidade superior à HSG quando comparados com a LPC.