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Diagnostic vascular angiography Prior to undertaking any intervention buy dapoxetine with visa, it is important to Magnetic resonance angiography have an accurate assessment of the extent and distribution of disease whether in the venous or purchase 90 mg dapoxetine mastercard, more commonly generic dapoxetine 30 mg with mastercard, the Magnetic resonance angiography is a very useful non- arterial system. In the past this could be obtained with invasive technique, which can demonstrate both arteries a diagnostic angiogram, though increasingly non-invasive and veins. Magnetic resonance angiography is particularly useful Arteriography for showing the aorta and its branches (Fig. Aneurysms and vas- but occasionally carbon dioxide) is injected through the cular malformations can also be detected in the intracranial catheter, which opacifes the target vessel. At the end of the procedure, the catheter injection of contrast, many thin sections can be obtained so Diagnostic Imaging, Seventh Edition. On the subtracted image (a) the bones and soft tissues are barely visible compared to the unsubtracted image (b). The angiogram shows a patent popliteal artery (thin arrow) with a short segment occlusion proximal to the trifurcation (curved arrow). Computed tomography angiography is particularly useful for visualizing the aorta and its branches for sus- pected aneurysms (Fig. Ultrasound of the arterial system Ultrasound has an important role to play in diagnosing Fig. A normal internal vessels, and is commonly the primary imaging modality carotid artery is seen on the left (arrowhead). The common, internal and external carotid arteries can be readily visualized in the neck. The location or size of any atheromatous plaques and the sever- Ultrasound venography ity of any luminal narrowing can be determined. With colour Doppler imaging, a stenosis in the artery can be Duplex ultrasound has now largely replaced contrast visualized and an occlusion will show as an absence of venography for the detection of venous thrombosis. Because a stenosis disrupts the normal fow pattern, a venous thrombosis, intraluminal echogenic material is analysis of the fow–velocity waveform can give further visible and the veins lose their normal compressibility; information regarding the degree of stenosis. Imaging of thrombus-free veins should be compressible by direct pres- the iliac vessels may be diffcult due to overlying bowel sure using the ultrasound transducer. Colour Doppler gas, but evaluation of the abdominal aorta is invariably scanning shows that there is a lack of spontaneous fow successful and can easily be performed during an outpa- in the affected veins. In practice, this is often not clinically signifcant as of contrast medium is injected into a vein on the arm or calf vein (i. The contrast is forced into the deep venous system of the upper limb by means of a tourniquet. Thrombi may be seen as flling defects in the opacifed veins, and Contrast venography any stenosis or occlusion in the central veins is well Contrast venography is routinely used for the evaluation demonstrated. Vascular and Interventional Radiology 475 under local anaesthesia, causing only relatively minor dis- comfort to the patient, allowing many procedures to be performed as ‘day cases’. Only the basic principles of the interventional techniques in widespread use will be described here. Angioplasty and stents Arterial stenoses and even occlusions may be traversed with a guidewire. A balloon catheter can be passed through the abnormal site, which has been previously determined by arteriography (Fig. This percuta- neous technique, which usually uses the femoral artery as an access route, has been widely employed in peripheral vascular disease and gives results as good as bypass surgery, particularly for iliac and superfcial femoral artery disease. Stents are balloon expandable or self-expanding metal cylinders that can be embedded in plastic and collapsed to enable them to be inserted through an artery or vein (Fig. As they ‘reinforce’ the vessel at the site of angioplasty, they have a more durable result. Stents are commonly used in the treatment of arterial stenosis and occlusion in coro- nary disease, in peripheral vascular disease, and in patients with mesenteric ischaemia secondary to atherosclerotic stenoses in the mesenteric arteries. Their role in the man- agement of renal artery stenosis is debatable following Fig. Reconstruction from many thin axial several recent trials, but is still indicated to treat patients sections following an intravenous injection of contrast with deteriorating renal function, fash pulmonary oedema demonstrating an aortic aneurysm (arrow). Due to the size of the Radiologists carry out various percutaneous techniques deployment system of these large stent grafts, they are under imaging control, including dilating stenoses, occlud- normally introduced through a femoral arteriotomy. Stents ing vessels, draining abscesses and other fuid collections, can also be introduced through the femoral vein and placed and obtaining biopsy samples. These procedures greatly across a stricture in the superior vena cava to overcome the assist and may modify surgery, or even replace it alto- distressing symptoms of superior vena caval obstruction, gether. They are carried out with the help of a variety which is usually caused by a malignant tumour in the of imaging modalities, notably fuoroscopy, angiography, mediastinum. Interventional radiology is usually performed vessel) in peripheral vessels of the lower limb can also be 476 Chapter 17 (a) (b) Fig. The covered stent (short arrows), acting as an endoskeleton, has excluded the aneurysm from the circulation by creating a seal proximally below the renal arteries (long arrows) and distally in the iliacs. In subintimal angioplasty, the catheter is passed into the subintimal plane of the vessel, not in the lumen of the vessel. The principle is to create a new lumen in the subintimal plane rather than re-open the native lumen. Arterial embolization is also the principle being to create a new channel through the of use in patients with tumours (e. Vascular occlusion has also been success- fully used in treating arteriovenous malformations in various organs, most notably the brain and the lungs (Fig. Embolization of aneurysms on the intracranial arter- Arteries can be occluded by introducing a variety of materi- ies is being increasingly undertaken, thus avoiding crani- als through a catheter selectively placed in the vessel. These techniques In some cases, metastatic liver lesions and certain other have been used primarily to control bleeding. They are cautery), freezing (cryotherapy) or injecting a noxious used in patients who are at risk of pulmonary embolism agent such as ethanol into the tumour. The size and location that cannot be managed satisfactorily with anticoagulation of the tumour help to determine which method may be or where anticoagulation is contraindicated. One of the most Percutaneous needle biopsy frequently used of these techniques is thermal ablation of hepatic metastases. Needle biopsy techniques are particularly useful for the non-operative confrmation of suspected malignancy. Most intrathoracic or intra-abdominal Arterial catheters can be accurately placed for the infusion sites can be sampled. With a fne aspiration needle (20–22 of cytotoxic or radioactive agents directly into malignant gauge), material can be obtained for cytology. Apart from a small pneumothorax with the vascular system, a technique known as thrombolysis. To obtain material for histological study a larger needle (14–18 gauge for soft tissues, 10–13 gauge for bone) is used. The Inferior vena cava flters larger needles require specifc approaches to avoid damage Inferior vena cava flters can be introduced percutaneously to intervening structures and require stricter indications through the femoral vein. The technique is suitable for most abdominal abscesses, Percutaneous drainage of abscesses and other fuid though the success with some forms of abscess is consider- collections ably greater than with others.
What are the nonreproductive abnormalities associated with Kallmann syn- drome apart from anosmia? A variety of nonreproductive abnormalities are associated with Kallmann syn- drome generic dapoxetine 60mg online. The neurological abnormalities include bimanual synkinesia (mirror movements) buy dapoxetine 30 mg cheap, neurosensory deafness order dapoxetine online from canada, cerebellar ataxia and oculomotor abnor- malities, and skeletal abnormalities which include clinodactyly, syndactyly, camptodactyly, and short fourth and ffth metacarpals and metatarsals. Other associations include cleft lip/palate, high-arched palate, ocular hypertelorism, dental agenesis, and unilateral renal agenesis. Non-suppressible involuntary movements accompanied with voluntary move- ments are known as synkinesia or mirror movement. Synkinesia is a physiolog- ical phenomenon during childhood due to incomplete brain myelination and can be associated with a variety of disorders like Kallmann syndrome, Klippel– Feil disease, corpus callosum agenesis, Joubert syndrome, stroke, and Parkinson’s disease. Synkinesia can be considered as a manifestation of midline defect in patients with Kallmann syndrome. Various theories have been proposed to explain the phenomenon of synkinesia and include partial failure of decussation of 7 Delayed Puberty 225 corticospinal fbers, lack of inter-hemispheric inhibition between the two motor cortices, and functional defects in motor planning and execution (Fig. Can clinical phenotype guide the selection of genetic testing for Kallmann syndrome? Although Kallmann syndrome can be associated with a wide variety of nonre- productive abnormalities, the presence of certain phenotypic characteristics points toward a specifc mutation. Kallmann syndrome is typically associated with tall stature due to delayed epiphyseal closure as a result of gonadal steroid defciency. A diagnosis of micropenis is inadvertently made in obese children, as penis is buried in surrounding fat, giving an impression of apparently small-sized 226 7 Delayed Puberty penis. Therefore, accurate measurement of stretched penile length should be done prior to subjecting a child for evaluation of micropenis. The normative data for stretched penile length at various ages and cutoff for the diagnosis of micropenis are given in the table below. The causes of micropenis include hypogonadotropic hypogonadism, hypergonadotropic hypogonadism, disorders of androgen biosynthesis and action, and isolated growth hormone defciency (Fig. During infancy, postnatal surge of testosterone as a consequence of mini-puberty contributes to penile growth. In addition, growth hormone also has a permissive role in penile growth during intrauterine and prepubertal period as evidenced by the presence of micropenis in newborns and children with growth hormone defciency. The frst-line investigations in a child presenting with delayed puberty include hemogram, renal and liver function tests, celiac serology, and thyroid function test. Hypoplasia/agenesis of olfactory bulb and/or olfactory sulci and non- visualization of olfactory tracts are the characteristic neuroimaging abnormalities in patients with Kallmann syndrome. In addition, corpus callo- sum agenesis and cerebellar abnormalities have also been described. Olfactory bulbs and tracts are best visualized by coronal images, whereas olfactory sulci in axial images (Fig. The mechanism of reversibility in patients with isolated hypogonadotropic hypogonadism remains elusive; however, various theories have been proposed to explain this phenomenon. His height was 156 cm (at 3rd percentile, with target height of 173 cm, 25th percentile) and he had a tes- ticular volume of 2 ml bilaterally, pubic hair Tanner stage P2, and no axillary hair. His bone age was 11 years, and rou- tine investigations, thyroid function tests, and celiac serology were normal. However, on prospective follow-up, if the child does not enter into puberty by the age of 18 years, the diagnosis of isolated hypogonadotropic hypogonadism is almost certain. The fnal adult height is usu- ally within the target height range and fertility is normal. A 15-year-old boy presented with poor development of secondary sexual char- acteristics and short stature. This is because of poor spine growth due to delay in exposure to gonadal steroids. The commonly used regi- men is testosterone enanthate or cypionate 50–100 mg intramuscularly every 236 7 Delayed Puberty month for a period of 3 months. With this therapy, there is an increase in testicu- lar volume by 3–4 ml in 6–9 months, progressive appearance of secondary sexual characteristics, and acceleration of growth velocity from 4 cm/year to 9–10 cm/year. If testicu- lar enlargement does not occur within 3 months after discontinuation of testos- terone therapy, another short course of testosterone may be administered. Normal puberty is a slow and progressive process which is completed over a period of 2–5 years; therefore, pubertal development should be accomplished slowly over a period of 2–5 years. Normal pubertal development is orchestrated by synergistic actions of gonado- tropins. Exogenous testosterone therapy leads to gynecomastia due to aromatization of testosterone to estradiol in adipose tis- sues. Circulating estradiol levels may not necessarily be elevated in all patients because local aromatase activity in the breast tissue also contributes to gynecomastia. The index patient developed gynecomastia after initiation of testosterone therapy. Testosterone-mediated gynecomastia is frequently painful because of rapid enlargement of breast. Treatment strategies include reduction in either dose and/or frequency of testosterone administration or use of selec- tive estrogen receptor modulators/aromatase inhibitors. Selective estrogen receptor modulators like tamoxifen have been widely used in the treatment of peripubertal gynecomastia and are most effective in those with recent-onset gynecomastia. There are anecdotal case reports regarding use of aromatase inhibitors like anastrozole for the treatment of testosterone-mediated gyne- comastia. Although the most common agent used to induce virilization is testosterone, it does not initiate spermatogenesis. However, it is not clear whether to initiate combined gonadotropin therapy, at induction of puberty or when fertility is desired. It has been shown that early use of combined therapy (at 15–20 years) is more effective for initiation of spermatogenesis, as compared to its use in older subjects (at 25–30 years). Various formulations of testosterone are available including oral, intramuscular, transdermal, buccal, and nasal spray; however, 240 7 Delayed Puberty intramuscular preparations of testosterone like enanthate, propionate, or cypi- onate are preferred for induction of puberty because of the vast experience with their use. Therapy is initiated at a dose of 50–100 mg monthly, and the dose is gradually increased by 50 mg, every six months. Therapy is initiated at a low dose to minimize the risk of priapism, aggressive behavior, and acne and to prevent premature closure of epiphysis. Once a dose of 100–150 mg is reached, the frequency of administration can be increased to fortnightly. The adult replacement dose of testosterone is 200–250 mg intramuscularly every 2–3 weeks. After initiation of therapy, boys should be monitored for growth and progression of pubertal development. Monitoring of serum testosterone levels is not recommended during induction of puberty because of wide variation in reference range of serum testosterone during pubertal development in healthy boys. However, monitoring of serum testosterone should be performed once the adult replacement dose is initiated, with a target to maintain serum testosterone in the mid-normal adult range.
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