Search Results (139)

Background/Purpose: Four patients independently reported episodes of seeing a dimly flickering overlay on an otherwise intact part of their binocular visual field. The aim of the study was to describe the clinical characteristics of this episodic phenomenon, which we call dim flicker. Methods: Retrospective chart review and patient evaluation of an animated reference simulation. Results: The patients described repeated episodes of a seeing a patch of rhythmically oscillating dim flicker overlaid on a circumscribed patch of their otherwise normal binocular visual field. The flicker was typically seen at low ambient light levels and disappeared in bright light or when one or both eyes were covered. Episodes lasted seconds to minutes. Some flicker patches crossed the vertical midline. The flicker was subjectively experienced as coming from one specific eye. Compared to a 7 Hz flicker simulation, patients reported differences in location, prominence, and frequency, with the latter ranging from 3 to 10 Hz. In three patients, the flicker was sometimes experienced during aerobic exercise and in two patients sometimes when they rose at night in the dark. In one patient, the flicker corresponded to an area of ischemic macular edema secondary to central retinal vein occlusion. There was no headache during or after the flicker. Associated maladies included retinal venous congestion, central serous chorioretinopathy, arterial hypertension, atrial fibrillation, and migraine with visual aura distinctly different from the dim flicker. Conclusions: Episodes of seeing an endogenous, rhythmically oscillating transparent overlay within a confined, non-expanding part of an otherwise intact binocular visual field appears to be a distinct nosological entity that can be associated with ocular and systemic vascular disease. Full article

Background/Objectives: The “bank-finger” or “spare-parts” principle offers an immediate reconstructive solution in mutilating hand injuries by repurposing viable tissues from non-salvageable digits to restore length, coverage, and function. Although described for decades, systematic evidence remains scarce. This study compared a single-center retrospective cohort with a systematic review of the specialized literature (2015–2025) to clarify the indications, reconstructive models, assessment of functional outcomes, and complication profiles associated with this technique. Methods: A retrospective analysis was performed on 35 adult patients treated for complex hand trauma between 2017 and 2024. It was compared with a systematic review of nine clinical studies identified across PubMed, Scopus, Embase, Web of Science, and Cochrane Library. Extracted variables included demographics, mechanisms of injury, type of tissues transferred, vascularization method, complications, and functional outcomes. Methodological quality was assessed using the Joanna Briggs Institute (JBI) criteria for case reports and case series. Results: Across 78 cases (43 from the literature and 35 institutional), vascularized fillet and osteo-cutaneous transfers constituted the predominant reconstructive approach, providing immediate skeletal stability and durable, sensate soft-tissue coverage. All flaps and grafts survived, and functional recovery was consistently favorable. In the retrospective cohort, standardized evaluation demonstrated excellent outcomes (mean DASH 14.6, MHQ 82.5, VAS 1.8). The overall complication rate remained below 10%, limited to transient venous congestion or mild postoperative stiffness. No infections, flap losses, or donor-site morbidity were reported. Conclusions: The bank-finger technique is a reliable, biologically efficient reconstructive strategy for acute mutilating hand trauma. When applied early and with appropriate tissue selection, it achieves outcomes comparable to conventional microsurgical options while avoiding additional donor-site morbidity. The present combined analysis highlights its reproducibility and underscores the need for prospective multicenter studies employing standardized functional metrics. Full article

Chronic kidney disease (CKD) affects nearly 850 million people worldwide, and most patients with kidney failure are treated with kidney replacement therapy. Despite technological progress, venous congestion remains a major determinant of morbidity and mortality, and is often underdetected by conventional tools such as clinical evaluation, weight changes, blood pressure measurement, or bioimpedance. Point-of-care ultrasonography (PoCUS) has transformed this diagnostic landscape by providing real-time, physiology-based insights into both left- and right-sided filling pressures. In dialysis care, multiple or confluent B-lines and subtle pleural irregularities suggest elevated pulmonary capillary wedge pressure, while a dilated inferior vena cava (IVC) with reduced collapsibility and increased portal vein pulsatility indicate elevated right atrial pressures. Integrating these sonographic findings into a multiparametric assessment that also includes clinical assessment, bioimpedance, and biosensor feedback enhances diagnostic sensitivity and refines fluid management. Advanced practice nurses (APNs) trained in PoCUS can perform focused examinations of the lungs, IVC, portal venous system, arteriovenous access, and skeletal muscle, translating ultrasound findings into physiological interpretations that guide individualized ultrafiltration strategies and patient care. Nutritional ultrasound (NUS) further complements congestion assessment by quantifying muscle mass and quality, linking nutritional reserve and functional status with hemodynamic tolerance. The implementation of structured education, competency-based training, and standardized scanning protocols allows nurses to incorporate these techniques safely and reproducibly into daily dialysis workflows. By integrating PoCUS and NUS within interdisciplinary decision-making, nursing practice evolves from procedural to diagnostic, supporting early identification of congestion, protection of vascular access, and detection of malnutrition. This multiparametric, physiology-guided approach exemplifies the concept of precision nursing, where patient evaluation becomes continuous, individualized, and grounded in real-time pathophysiological insight. Full article

Background: Fontan-associated liver disease (FALD) is a progressive condition resulting from chronic hepatic venous congestion following the Fontan procedure for univentricular heart defects. As survival improves in these patients, recognition and management of FALD have become increasingly important. Objective: To describe the pathophysiological mechanisms, imaging findings, and diagnostic approach to FALD, with a focus on the role of ultrasonography, including contrast-enhanced ultrasound (CEUS). Methods: This narrative review explores the evolution of FALD through a multidisciplinary lens, integrating cardiovascular and hepatic imaging data. Particular attention is paid to Doppler ultrasound and CEUS, both in early parenchymal changes and in the differential diagnosis of potential complications such as hepatic nodules. Results: FALD is characterized by progressive fibrosis due to long-standing passive congestion, resulting in a wide spectrum of imaging findings. B-mode ultrasound reveals hepatomegaly, heterogeneous parenchyma, and gallbladder wall thickening. Doppler studies show altered hepatic venous flow patterns, while CEUS provides dynamic vascular evaluation, highlighting areas of altered perfusion. In advanced stages, hypo-vascular areas in the late phase may simulate malignant lesions, emphasizing the need for careful interpretation. The role of liver biopsy, though limited by invasiveness, remains crucial in selected cases. Surveillance strategies are not standardized but require close multidisciplinary follow-up. Conclusions: FALD presents complex diagnostic challenges requiring integrated imaging and clinical assessment. CEUS emerges as a valuable, non-invasive tool in characterizing hepatic congestion and guiding management. Increased awareness and standardized protocols are essential for early detection and tailored care in this growing patient population. Full article

Objectives: To study the associations of central retinal vein occlusion (CRVO) with glaucoma and cataract before and after the onset of CRVO. Methods: This study included 439 fundus photographically verified CRVO cases and a 5:1 set of 2195 registry-based age- and sex-matched control subjects without a record of CRVO. The study assessed rates of cataract and glaucoma before and after CRVO based on diagnoses, procedures, and prescriptions and analyzed their association with CRVO. Odds ratio (OR) and incidence rate ratio (IRR) estimates for 10 years prior to a subject’s first CRVO and incident comorbidity after CRVO were compared. Results: The median age at the time of presentation of 439 eligible patients with CRVO was 71 years (interquartile range 11 years). In the 10 years leading up to the incidence of CRVO, the ORs for glaucoma and cataract were 6.01 (95% confidence interval (CI95) 4.05 to 8.94) and 2.13 (CI95 1.45 to 3.12), respectively. During a mean follow-up of 5.7 years after CRVO, the incidence rate ratios for glaucoma and cataract were 16.7 (CI95 9.32–30.1) and 1.99 (CI95 1.39–2.84), respectively. Conclusions: Glaucoma and cataract occurred at elevated rates compared with the background population, both before and after the clinical presentation of CRVO. The results fit a disease model where retinal perfusion is compromised by chronic venous congestion, leading to glaucomatous retinal degeneration. Chronic venous congestion may subsequently convert to clinically manifest CRVO when retinal capillaries have been sufficiently weakened to produce hemorrhage, edema and vision loss. Full article

Tricuspid atresia (TA) is a cyanotic congenital heart defect defined by agenesis of the tricuspid valve and resultant right ventricular hypoplasia, representing 1.4–2.9% of congenital heart disease. Survival depends on interatrial and interventricular shunts that permit systemic and pulmonary blood flow, with staged surgical palliation culminating in the Fontan procedure. While surgical advances have improved long-term outcomes, Fontan circulation remains a delicate physiology characterized by preload dependence, elevated pulmonary vascular resistance, chronic venous hypertension, and a prothrombotic state. These features predispose patients to arrhythmias, lymphatic complications, hepatic congestion, and progressive circulatory failure. For anesthesiologists, perioperative management of TA and Fontan patients is uniquely complex. Anesthetic considerations include meticulous preload optimization, modulation of systemic and pulmonary vascular resistance, and ventilatory strategies that minimize adverse effects on venous return. Additional challenges include the high risk of air embolism, individualized anticoagulation needs, and hemodynamic sensitivity to patient positioning. Preoperative evaluation with echocardiography and electrocardiography provides critical insight into anatomy and physiology, while intraoperative planning must emphasize goal-directed fluid management, careful agent selection, and tailored ventilation. Postoperatively, vigilant monitoring, effective pain control, and prevention of complications are essential. This review synthesizes classification systems, pathophysiology, and the evolution of surgical palliation, while emphasizing anesthetic principles for the perioperative care of patients with TA and Fontan circulation. As survival improves and the population of Fontan patients expands, a nuanced understanding of this physiology is essential for optimizing outcomes across cardiac and non-cardiac surgical settings. Full article

Background: Fluid accumulation syndrome (FAS) is a well-recognized predictor of adverse outcomes in critically ill patients, particularly in the context of sepsis and cardiorenal syndrome. However, extreme cases of fluid accumulation exceeding 60 L are rare and poorly described. We report a unique case of severe, multifactorial congestion and discuss the diagnostic and therapeutic challenges, including the role of bedside ultrasound and venous congestion assessment, as well as the importance of bioelectric impedance analysis (BIA) for patient monitoring and follow-up. Case Presentation: We describe the clinical course of a 51-year-old male with dilated cardiomyopathy and infectious endocarditis who underwent tricuspid valve surgery complicated by cardiogenic and septic shock. The patient developed progressive congestion despite maximal medical management. Serial BIA and venous excess ultrasound (VExUS) assessments were used to monitor venous congestion and guide renal replacement therapy (RRT). A targeted literature review was performed to contextualize this case within current evidence on FAS and Compartment Balance Disorder in Intensive Care Units (CBD-ICUs). Results: The patient accumulated over 68 L of positive fluid balance due to prolonged vasopressor support, multiorgan failure, nutritional and infectious complications. Continuous and then intermittent hemodiafiltration, guided by point-of-care ultrasound and BIA, allowed gradual decongestion. Renal function recovered, and ventilator support was weaned after 120 days in intensive care. The literature review highlighted the prognostic relevance of FAS and emerging tools such as BIA and VExUS for individualized fluid management. Conclusions: Extreme FAS may reflect a failure of systemic and compartmental fluid regulation in critically ill patients (CBD-ICU). VExUS-guided decongestion, BIA and early RRT may improve outcomes in complex scenarios of overlapping cardiorenal and septic syndromes. Full article

Background/Objectives: Heart failure (HF) causes systemic and regional haemodynamic alterations that extend beyond the heart, profoundly affecting splanchnic circulation. Venous congestion is a hallmark of heart failure (HF) and a major determinant of clinical deterioration and multiorgan dysfunction. The splanchnic venous system—comprising the portal, hepatic, and renal veins—acts as a key reservoir for intravascular volume redistribution. Conventional ultrasound (US), using grayscale and Doppler imaging, offers a direct, non-invasive approach to visualize these haemodynamic changes. This review, Part 1 of a two-part series, summarizes the current evidence and clinical applications of conventional US for assessing splanchnic, cardiac and pulmonary vascular alterations in patients with HF. Methods: A systematic review was performed in PubMed, Embase, and the Cochrane Library up to current date, following PRISMA 2020 guidelines. Eligible studies included adult human investigations evaluating splanchnic vascular changes in HF using B-mode, color Doppler, or pulsed Doppler ultrasonography. Exclusion criteria were pediatric, animal, or non-English studies and non-standard imaging methods. Data on ultrasonographic parameters, haemodynamic correlations, and prognostic value were extracted and qualitatively synthesized; Results: A total of 148 eligible studies (n ≈ 7000 patients) demonstrated consistent associations between HF severity and alterations in splanchnic, cardiac and pulmonary flow. Findings included increased bowel wall thickness, portal vein dilation with elevated pulsatility, and monophasic or reversed hepatic vein waveforms, all correlating with higher right atrial pressure and adverse clinical outcomes. The integration of these parameters into the Venous Excess Ultrasound (VExUS) framework enhanced detection of systemic venous congestion, in addition to the study of the cardiac and pulmonary circulation. Conclusions: Conventional ultrasound assessment of splanchnic vasculature provides valuable, reproducible insight into systemic congestion in HF. Incorporating hepatic and portal Doppler indices into standard evaluation protocols may improve risk stratification, optimize decongestion therapy, and guide management. Further prospective randomized and outcome-driven studies are required before VExUS-based therapeutic thresholds can be universally recommended and define prognostic thresholds. Full article

The identification of brain clearance failure as a precursor to a large variety of neurodegenerative diseases has shifted fluid dynamics from a secondary to a tertiary target of brain health. The identification of the glymphatic system, detailing cerebrospinal fluid entry along perivascular spaces and exit via perivenous and meningeal lymphatic pathways, provided a challenge to previous diffusion models and established aquaporin-4–dependent astroglial polarity as a governing principle of solute transport. Multiple lines of evidence now support a coupled glymphatic–venous axis, wherein vasomotion, venous outflow, and lymphatic drainage are functionally interrelated. Failure of any axis will cascade and affect the entire axis, linking venous congestion, aquaporin-4 disassembly, and meningeal lymphatic failure to protein aggregation, neuroinflammation, edema, and intracranial hypertension. Specific lines of evidence from diffusion tensor imaging along vascular spaces, clearance MRI, and multi-omic biomarkers can provide a measure of transport. Therapeutic strategies are rapidly advancing from experimental strategies to translational approval, including behavioral optimization, closed-loop sleep stimulation, vascular and lymphatic therapies, focused ultrasound, pharmacological polarity recoupling, and regenerative bioengineering. Novel computational approaches, such as digital twin dynamic modeling and adaptive trial designs, suggest that clearance measures may serve as endpoints to be approved by the FDA. This review is intended to bridge relevant mechanistic and translational reviews, focusing on impaired clearance as an exploitable systems defect rather than an incapacitating secondary effect. Improving our understanding of the glymphatic-venous axis Injury may lead to future target strategies that advance cognitive resilience, alleviate disease burden, and improve quality of life. By clarifying the glymphatic–venous axis, we provide a mechanistic link between impaired interstitial clearance and the pathological accumulation of amyloid-β, tau, and α-synuclein in neurodegenerative diseases. The repair of aquaporin-4 polarity, venous compliance, and lymphatic drainage might therefore open new avenues for the diagnosis and treatment of Alzheimer’s and Parkinson’s disease, supplying both biomarkers of disease progression and new targets for early intervention. These translational implications not only locate clearance failure as an epiphenomenon of neurodegeneration but, more importantly, as a modifiable driver of the course of neurodegeneration. Full article

Background: Postoperative free flap monitoring, traditionally performed by surgical residents, has shifted toward nurse-led models due to global workforce constraints. While this practice is widespread, its implementation is fragmented, creating a “standardization gap” between successful outcomes and reproducible protocols. This scoping review aimed to comprehensively map all available evidence on nurse involvement in free flap monitoring and synthesize the findings into an evidence-based framework for implementation. Methods: A scoping review was conducted following PRISMA-ScR guidelines. A comprehensive search of PubMed, CINAHL, and the Cochrane Library was performed without date or language restrictions. Data from included studies were charted and synthesized narratively to identify key themes related to protocols, education, and clinical outcomes. Results: Twelve studies met the inclusion criteria. The evidence demonstrates that well-structured, nurse-led monitoring protocols achieve high flap success rates (≥94%), comparable to physician-intensive models. Three major themes emerged from the analysis: (1) the equivalence of clinical outcomes under nurse-led care; (2) the role of technology as an enabler for objective assessment and anxiety reduction; and (3) a persistent “standardization gap” due to significant variation in protocols and training across institutions. A critical knowledge deficit among nurses regarding venous congestion was also identified as a key target for educational interventions. Conclusions: Nurse-led free flap monitoring is a safe and effective model of care. Successful implementation hinges on a framework built upon three pillars: standardized education, clear and actionable protocols, and the standardized integration of technology. This review provides the first comprehensive roadmap to bridge the existing standardization gap and offers a foundation for developing international best-practice guidelines. Full article

Background: The nipple–areolar complex (NAC) necrosis is a rare yet significant complication following breast reduction surgery, primarily linked to compromised vascularization of the NAC, particularly in nipple-sparing techniques. While multiple therapeutic strategies have been described in the postoperative setting, their application remains limited in clinical practice. Case series: We report on three patients that developed early NAC venous distress following bilateral breast reduction. Following discussion of therapeutic options—ranging from conventional methods such as scarification and local heparin therapy to off-label pharmacologic treatment—all three patients received oral sildenafil citrate (20 mg every 6 h), after excluding contraindications and obtaining informed consent. In two patients, sildenafil alone was sufficient to restore venous outflow and salvage the NAC. In one case, adjunct scarification and heparin therapy were necessary due to partial response. No arterial damage or major adverse effects related to sildenafil were observed during the postoperative period. Conclusions: This small series supports the potential use of off-label sildenafil citrate as a valuable, non-invasive pharmacologic option for treating postoperative areolar venous congestion. Its favorable safety profile, widespread hospital availability, and mechanism of enhancing microvascular circulation make it a promising adjunct in managing this complication. Further studies are warranted to standardize its use and determine its place within a broader postoperative management spectrum of compromised vascularization in breast surgery. Full article

Background: Orthostatic hypotension (OH) is identified by a significant decrease in blood pressure upon standing from a seated or supine position. A reduction in systolic blood pressure of 20 mmHg within three minutes of standing meets the criteria for clinical diagnosis. We hypothesized that venous outflow obstruction from jugular valvular dysfunction or extrinsic compression of the left brachiocephalic vein may cause OH. Improving venous return and reducing venous congestion of the autonomic pathways through endovascular intervention could alleviate symptoms. Methods: This retrospective review included six male patients (aged 63–87) with medically refractory OH who underwent venograms revealing jugular, brachiocephalic, or subclavian vein stenosis. Patients were treated with balloon angioplasty and/or stenting. Blood pressure was measured in supine, seated, and standing positions before and immediately after the procedure, with multiple readings per position (total n = 117 for supine-standing comparisons). Statistical analysis used Welch’s t-test to compare pre- and post-procedural systolic blood pressure disparities. Results: The patients showed improved post-procedural blood pressure and reduced OH symptoms. The average supine-standing systolic disparity decreased from 38.68 mmHg preoperatively to 24.61 mmHg postoperatively (p = 0.024). The seated-standing disparity was insignificant, possibly due to autonomic compensation. Patients also reported relief from associated symptoms like headaches, tinnitus, and vertigo. Conclusions: These findings suggest venous outflow obstruction may contribute to OH, and venoplasty/stenting can mitigate symptoms, potentially reducing reliance on medications with adverse effects. Further studies should explore the role of Venous Outflow Obstruction Disorders in neurological conditions. Full article

Background and Objectives: Severe complications associated with cervical hyperextension during general anesthesia have been reported. The question is whether some of the cerebral/spinal ischemic complications could be partially related to the position itself. Cerebral oximetric monitoring, combined with optic nerve sheath diameter and cognitive function in non-anesthetized healthy volunteers, should provide more extensive information about the effects of cervical hyperextension, independent of anesthesia. Materials and Methods: 51 healthy volunteers with no vertebrobasilar abnormalities completed the study and were included in statistical analysis. Primary outcomes were cervical blood flow and cerebral relative hemoglobin change. The secondary outcomes were optic nerve sheath diameter and cognitive function assessment. After baseline Doppler ultrasonography of the cervical vessels, Mini-Mental State Examination, Montreal Cognitive Assessment, and optic nerve sheath diameter measurements at T0, volunteers underwent cervical hyperextension > 30°, with assessments repeated at the first and 30th minutes (T1, T30). Relative total, oxi-, and deoxyhemoglobin changes were assessed every 5 min. Results: Peak systolic velocities in the jugular veins at T1 and T30 were significantly lower than those at baseline (p1 and p2 < 0.001). After hyperextension, deoxyhemoglobin changes significantly increased at T1 and T30 (p1 < 0.001). The optic nerve sheath diameter increased at T30 compared to the baseline (p < 0.001). Cognitive scores improved at T30 (p = 0.044 and p < 0.001, respectively). Conclusions: Cervical hyperextension causes a significant increase in relative total and deoxyhemoglobin changes, which are related to acute cerebral congestion by severely impairing cerebral venous flow. A significant change in optic nerve sheath diameter indirectly indicates increased intracranial pressure. Full article

Dural arteriovenous fistulas (dAVFs) are a heterogeneous group of intracranial vascular anomalies characterized by abnormal arteriovenous shunting within the dura mater. While they are often considered acquired lesions—associated with trauma, surgery, venous sinus stenosis, or thrombosis—their precise etiology remains unclear in many cases. The clinical presentation of dAVFs varies widely depending on location and venous drainage patterns. Benign forms may manifest as pulsatile tinnitus or headache, whereas lesions with retrograde venous drainage and cortical venous reflux are considered aggressive and carry a heightened risk of hemorrhage and progressive neurological decline. Multiple classification systems, primarily based on angioarchitecture and venous outflow characteristics, have been developed to stratify risk and guide treatment strategies, as these features largely determine the natural history and clinical course of dAVFs. Endovascular embolization, microsurgical disconnection, and stereotactic radiosurgery (SRS) represent the mainstays of treatment, aiming to prevent hemorrhage or rebleeding and to alleviate symptoms related to venous congestion. Over the past two decades, advances in endovascular techniques have driven a paradigm shift in management, positioning embolization as the first-line therapy for most dAVFs. This review begins with a comprehensive overview of dAVF pathogenesis, classification systems, and angioarchitecture. It then focuses on the endovascular management of dAVFs, offering a detailed appraisal of current and emerging techniques, key technical considerations, and lesion-specific treatment strategies. Finally, we discuss the role of microsurgery and SRS. Full article

Background: Reconstruction of distal forearm and hand soft tissue defects remains a complex surgical challenge due to the functional and aesthetic significance of the region. Several flap options have been established such as the posterior interosseous artery flap (PIA) or temporalis fascia flap (TFF), yet the anterolateral thigh flap (ALT) has gained increasing attention for its versatility and favorable risk profile. Methods: We retrospectively analyzed 12 patients (7 males, 5 females; mean age 51.8 years) who underwent free microvascular ALT reconstruction for distal forearm and hand defects between May 2020 and May 2025. Etiologies included infection, chemical burns, explosion injuries, and traffic accidents. The mean defect size was 75.4 cm², and the average operative time was 217 min. Secondary flap thinning was performed in eight cases. In one patient without available recipient veins, a pedicle vein was anastomosed using a coupler device anchored into a cortical window of the distal radius to establish venous outflow via the bone marrow. Results: All flaps demonstrated complete survival with successful integration. Minor complications included transient venous congestion in one case and superficial wound dehiscence in four cases. Functional outcomes were favorable, with postoperative hand function rated as very good in 10 of 12 patients at follow-up. The bone-anchored venous anastomosis provided effective venous drainage in the salvage case. Conclusions: The free microvascular ALT is a reliable and highly adaptable method for distal forearm and hand reconstruction. It provides excellent soft tissue coverage, allows for secondary contouring, and achieves both functional and aesthetic goals. Furthermore, intraosseous venous anastomosis using a coupler device might represent a novel adjunct that may expand reconstructive options in cases with absent or unusable recipient veins. Full article