RESUMEN
A 9.5-cm visceral artery aneurysm was found during a computed tomography (CT) scan performed for abdominal pain. Subsequent selective angiography showed the aneurysm arising from the second branch of the superior mesenteric artery (SMA). The celiac trunk was occluded at its origin and blood supply to the splenic artery was provided through the pancreatic-duodenal arcade. Two injections of 5.000 U of thrombin were delivered transcatheter to produce complete thrombosis. No major complications occurred. After 32 months the aneurysm decreased to 3.7 cm in diameter. Transcatheter thrombin injection seems to be a safe and durable option in the treatment of visceral aneurysms.
Asunto(s)
Aneurisma/terapia , Embolización Terapéutica , Trombina/administración & dosificación , Vísceras/irrigación sanguínea , Anciano , Aneurisma/diagnóstico , Femenino , HumanosRESUMEN
The Authors, reporting a recent case of small bowel lymphoma, review progress in diagnosis, methodology and therapeutical approach. They also stress the crucial role of surgery as diagnostic and therapeutic tool, sometimes curative in early stages, and however necessary for a proper staging and definition of these rare neoplasms of intestinal tube.
Asunto(s)
Neoplasias del Íleon , Fallo Hepático Agudo , Femenino , Humanos , Neoplasias del Íleon/clasificación , Neoplasias del Íleon/diagnóstico , Neoplasias del Íleon/epidemiología , Neoplasias del Íleon/etiología , Neoplasias del Íleon/cirugía , Fallo Hepático Agudo/clasificación , Fallo Hepático Agudo/diagnóstico , Fallo Hepático Agudo/etiología , Fallo Hepático Agudo/cirugía , Persona de Mediana EdadRESUMEN
Although the vestigial retrorectal cysts are still rare, the number of the observed ones is destined to increase, as methods by imaging become routinely used in the clinical practice. Once diagnosed, the removal of retrorectal lesions should be mandatory. Therefore, by reporting three clinical cases, the Authors propose notes of technique above the abdominal approach used for the surgical treatment of these retrorectal congenital neoformations. In their experience, the anterior route had no postoperative complications, short stay, no neurological consequences and good long-term results.
Asunto(s)
Quistes/cirugía , Neoplasias del Recto/cirugía , Región Sacrococcígea , Teratoma/cirugía , Abdomen , Adolescente , Adulto , Quistes/diagnóstico , Quistes/diagnóstico por imagen , Diagnóstico Diferencial , Femenino , Humanos , Imagen por Resonancia Magnética , Neoplasias del Recto/diagnóstico , Neoplasias del Recto/diagnóstico por imagen , Teratoma/diagnóstico , Teratoma/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
General surgeons are more and more frequently requested to prepare an operative exposure of the spine, in order to perform anterior maneuvers of removal and stabilization of the vertebral bodies. Since 1989 to date, in collaboration with the neurosurgical équipe of Prof. G. Cantore, Neurological Sciences Department, La Sapienza University of Rome, the Authors have collected 116 cases of vertebral diseases: among them, 48 involved the thoraco-lumbar junction of the spine (D12-L2). In this paper, Authors' aim is to state precisely the surgical technique of the anterior access to the thoraco-lumbar junction: attention has been focused on this tract of the column stating its anatomical complexity and the high invasivity of the procedures requested for its exposure. Therefore, such notes of technique have been elaborated to make safer the neurosurgical demolitive and reconstructive procedures and, most of all, to reduce the surgical trauma whenever it is possible.
Asunto(s)
Vértebras Lumbares , Enfermedades de la Columna Vertebral/cirugía , Fracturas de la Columna Vertebral/cirugía , Vértebras Torácicas , Adolescente , Adulto , Anciano , Cordoma/cirugía , Femenino , Estudios de Seguimiento , Humanos , Desplazamiento del Disco Intervertebral/cirugía , Masculino , Persona de Mediana Edad , Neurilemoma/cirugía , Neoplasias de la Columna Vertebral/cirugía , Factores de TiempoRESUMEN
The Authors report a very rare case of clear cell renal cancer associated with sarcoidosis, incidentally discovered in a 39 year-old man, admitted for a not correlated pathology (multiple left rib fractures due to automobile crash). Problems related to a proper assessment of sarcoidosis are discussed as well as potential arising of a neoplasm during the entire follow-up period: for that, it must always be complete and accurate.
Asunto(s)
Adenocarcinoma de Células Claras/complicaciones , Adenocarcinoma de Células Claras/diagnóstico , Neoplasias Renales/complicaciones , Neoplasias Renales/diagnóstico , Sarcoidosis/complicaciones , Sarcoidosis/diagnóstico , Adulto , Diagnóstico Diferencial , Humanos , MasculinoRESUMEN
OBJECTIVE: Intestinal involvement is frequently observed in systemic sclerosis (SSc) and is associated with malnutrition and a decreased survival rate. Vascular lesions are claimed to underlie and precede these changes. The aim of this study was to establish whether a reduced mesenteric blood flow was present in SSc patients with no signs or symptoms of small bowel involvement. METHODS: Superior mesenteric artery (SMA) blood flow in the fasting state was measured by colour Doppler ultrasonography in 27 SSc patients and in 25 controls. The effect of a balanced liquid meal on mesenteric blood flow was measured in six matched patients and controls. RESULTS: In fasting SSc patients, there were reductions in mean SMA diameter (P<0.001), blood flow (213+/-92 vs 398+/-125 ml/min in controls, P<0.0001) and pulsatility index (3.49+/-1.0 vs 4.13+/-0.97 in controls, P<0.07). In both groups, the meal increased basal flow values and the differences between controls and patients in the fasting state were not significant. CONCLUSIONS: In the absence of symptoms of small bowel involvement, reversible SMA vasoconstriction is demonstrable in the fasting state in SSc patients.
Asunto(s)
Arteria Mesentérica Superior/fisiopatología , Esclerodermia Sistémica/fisiopatología , Ingestión de Alimentos/fisiología , Ayuno , Femenino , Humanos , Persona de Mediana Edad , Flujo Sanguíneo Regional/fisiología , Esclerodermia Sistémica/patología , Circulación Esplácnica/fisiología , Ultrasonografía Doppler , Vasoconstricción/fisiologíaRESUMEN
The Authors report their experience matured during the last decade in the Institute of III Surgical Clinic of the University "La Sapienza" in Rome, relatively to 174 patients operated of splenectomy of which 8 for not parassitair benign cystic pathology. After the nosologic organization of the varied types of cystics splenopaty is examined the different symptomatology and is discussed the different treatment.
Asunto(s)
Quistes , Enfermedades del Bazo , Adulto , Anciano , Quistes/diagnóstico , Quistes/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Bazo/diagnóstico , Enfermedades del Bazo/cirugíaRESUMEN
The Authors, reviewing their surgical experience with colo-rectal cancer in the last 13 years, conclude that, in the management of this condition, the routine use of traditional endoscopy will continue to have a crucial role in terms of prevention, cure and/or survival. It is possible that in the future present limits of endoscopic techniques will be seperated by routine use of endoscopic ultrasounds and virtual colonoscopy.
Asunto(s)
Colonografía Tomográfica Computarizada , Neoplasias Colorrectales/diagnóstico por imagen , Neoplasias Colorrectales/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The Authors examined the value of endoscopic ultrasounds in the tmanagement of colo-rectal lesions, particularly neoplastic ones, on the basis of their surgical experience, concluding that to date such technique cannot substitute traditional endoscopy, but surely can be a valid complementary tool for imaging diagnostics, expecially to study wall tumoral infiltration or extra-parietal relapses.
Asunto(s)
Colonoscopía/métodos , Neoplasias Colorrectales/diagnóstico por imagen , Neoplasias Colorrectales/cirugía , Endosonografía , Humanos , Valor Predictivo de las Pruebas , Sensibilidad y EspecificidadRESUMEN
An abnormal vascular status is present in the transplanted kidney. To define whether vascular factors might influence kidney function of the graft, the renal volume, blood flow and vascular resistance of a group of healthy subjects were compared with those of a group of well functioning renal transplants by color Doppler ultrasonography. Sixty healthy subjects and 75 well functioning cadaver renal transplant recipients were compared by color Doppler ultrasonography. Subsequently, 15 couples of donors and recipients of a living related renal graft were compared to observe the differences between the two organs of the same subject in a different environment. The variables studied were: the diameters and the volume of the kidney, renal blood flow and renal resistance index (RI). The group of cadaver renal transplant patients showed higher mean blood pressure (P = 0.009), higher serum creatinine levels (P = 0.0001) and lower endogenous creatinine clearance (P < 0.0001) than healthy controls. The length (P < 0.00001) and volume (P < 0.001) of the kidneys of cadaver transplanted patients were significantly greater than those of healthy subjects, while the length and volume of the living donors kidneys were identical to those of the recipients. RI, measured on renal vessels, showed lower values in healthy subjects and in kidney donors than in transplanted patients (P < 0.00001). Well functioning transplanted kidneys showed increased renal arterial RI. This non-immunologic factor did not appear to be detrimental with renal function in time, at least until 50 months after successful grafting.
Asunto(s)
Trasplante de Riñón/fisiología , Circulación Renal/fisiología , Resistencia Vascular , Adulto , Azatioprina/uso terapéutico , Presión Sanguínea , Cadáver , Ciclosporina/uso terapéutico , Femenino , Supervivencia de Injerto , Humanos , Inmunosupresores , Riñón/diagnóstico por imagen , Trasplante de Riñón/inmunología , Donadores Vivos , Masculino , Persona de Mediana Edad , Valores de Referencia , Flujo Sanguíneo Regional , Donantes de Tejidos , Resultado del Tratamiento , Ultrasonografía Doppler en ColorRESUMEN
BACKGROUND: We examined the most widely used echo-Doppler variables in healthy adults to define their normal distribution and variability in relation to age, sex, body surface area and the right and left kidney. METHODS: Ninety healthy subjects were selected, stratified for sex and age (range 20-65 years). We also examined 8 subjects with a congenital solitary kidney and 15 surgically nephrectomized patients. Variables studied were the diameters and volume of the kidneys, renal blood flow (RBF) and resistive index (RI) measured on the renal, interlobar and cortical arteries. RESULTS: The mean length was greater in the left kidney (p<0.01) and width in the right one (p<0.02). Volume was no different on the two sides. RBF showed an age-dependent reduction (p<0.0001), while interlobar (p<0.0001) and cortical (p<0.0001) RI showed a selective age-dependent increase. RI were higher in females and diameters, volume and RBF, after correction for body surface area, were not different in the two sexes. Cortical RI was lower than the interlobar and renal RI (p<0.0001). In the group with congenital single kidney, length, volume and RBF were all greater. In the mononephrectomized patients, length and volume were greater but RBF was the same as in a normal single kidney. CONCLUSIONS: The ultrasonographic and Doppler variables studied did not show any differences from normal distribution but they were influenced differently by some demographic parameters; however, the integrated use of these measurements offers precision and repeatibility, and could help evaluating diffuse or localized abnormalities.
Asunto(s)
Riñón/diagnóstico por imagen , Ultrasonografía Doppler en Color , Adulto , Anciano , Femenino , Humanos , Riñón/anomalías , Masculino , Persona de Mediana Edad , Valores de Referencia , Reproducibilidad de los ResultadosRESUMEN
The recent observation of a new HNPCC patient case induced the Authors to review their experience with the syndrome as well as to make an up to date of the problems related to diagnosis, surgical management, surveillance and genetic counselling for such patients with a lifelong high cancer risk. Patients with HNPCC and their first-degree relatives, whose risk of early colorectal carcinoma (especially in the proximal colon) as well as a variety of extracolonic cancers (particularly endometrium, ovary, stomach, small bowel, ureter and renal pelvis) is significantly higher then that of patients with sporadic carcinoma, should be properly managed with surgery and then with endoscopic examination (ideally all life long) starting--in unaffected individuals--at early age (25 years old). Problems related to genetic counselling are considered as well.
Asunto(s)
Neoplasias Colorrectales Hereditarias sin Poliposis/cirugía , Adulto , Neoplasias Colorrectales Hereditarias sin Poliposis/diagnóstico , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/mortalidad , Femenino , Asesoramiento Genético , Humanos , Masculino , Persona de Mediana Edad , Linaje , Factores de RiesgoRESUMEN
The Authors report their three year experience with five patients suffering from gastric leiomyoma, each with different anatomical and clinical characteristics. The Authors have performed a research of the different diagnostics, clinical and therapeutic problems of these rare tumors that sometimes are asymptomatic in spite of the large size they reach, but more frequently they present with haemorrhagic symptoms which tend to point to other more frequent pathological conditions. Diagnosis can only be suspected, but cannot be reached without a histological examination, also if the classifications of these tumors have been argument of many changes, particularly by the light of the recent diagnostics possibilities offered by ultrastructural and immunohistochemical examination.
Asunto(s)
Leiomioma/diagnóstico , Neoplasias Gástricas/diagnóstico , Adulto , Anciano , Femenino , Humanos , Leiomioma/cirugía , Masculino , Persona de Mediana Edad , Neoplasias Gástricas/cirugíaRESUMEN
OBJECTIVE: To evaluate the prevalence and the clinical evolution of patients with an initial diagnosis of indeterminate colitis. DESIGN: Retrospective, observational study. SETTING: Fifteen gastrointestinal units in northern Italy. PARTICIPANTS: Patients with an initial diagnosis of indeterminate colitis seen between 1988 and 1993. INTERVENTIONS: Patients were traced through a common database and centres were requested to update their clinical follow-up. MAIN OUTCOME MEASURES: Frequency of patients with an initial diagnosis of indeterminate colitis among those with IBD; rate of patients who subsequently had a definite diagnosis of either Crohn's disease or ulcerative colitis. RESULTS: Fifty out of 1113 IBD patients (4.6%) had been diagnosed as having indeterminate colitis. During follow-up, 37 patients (72.5%) had a definite diagnosis of either Crohn's disease or ulcerative colitis. The cumulative probability of having a definite diagnosis of either ulcerative colitis or Crohn's disease was 80% 8 years after the first one (i.e. the first diagnosis). The probability of having a diagnosis of Crohn's disease was increased in patients with fever at onset, segmental endoscopic lesions or extra-intestinal complications and in current smokers. The probability of having a diagnosis of ulcerative colitis was increased in patients who had not undergone appendectomy before diagnosis. CONCLUSIONS: In our area, indeterminate colitis accounts for about 5% of initial diagnoses of IBD. In about 80% of patients, a diagnosis of either ulcerative colitis or Crohn's disease is made within 8 years. Several clinical and demographic features can help in identifying those patients more likely to have a subsequent diagnosis of Crohn's disease and those more likely to have a subsequent diagnosis of ulcerative colitis.
Asunto(s)
Colitis Ulcerosa/diagnóstico , Colitis Ulcerosa/epidemiología , Enfermedad de Crohn/diagnóstico , Enfermedad de Crohn/epidemiología , Adolescente , Adulto , Anciano , Niño , Demografía , Diagnóstico Diferencial , Progresión de la Enfermedad , Femenino , Humanos , Italia , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , FumarRESUMEN
Aim of the study was to asses the differences in size and hemodynamics in the normal kidney and well-functioning renal graft by color Doppler ultrasonography (CDU). Sixty healthy subjects, 75 well-functioning cadaver renal transplant recipients, 15 couples of living donors and related graft recipients were compared by CDU. Renal diameters, volume, renal blood flow (RBF) and renal resistance index (RI) were the variables studied. Cadaveric transplants, living donors and related recipients had a longer kidney (p<0.00001) and greater volume (p<0.001) than normal native kidneys. This was not associated with any significant increase in RBF. RI was lower in healthy subjects and in kidney donors than in transplant recipients (p<0.00001). Transplanted kidneys had a higher arterial RI but apparently normal function.
Asunto(s)
Hemodinámica/fisiología , Trasplante de Riñón , Riñón/diagnóstico por imagen , Ultrasonografía Doppler en Color , Adulto , Cadáver , Femenino , Humanos , Riñón/anatomía & histología , Riñón/irrigación sanguínea , Masculino , Persona de Mediana Edad , Circulación Renal/fisiología , Donantes de TejidosRESUMEN
Urological vascular complications (UVC) are largely secondary to percutaneous procedures that are nowadays extensevely used by the urologists and the nephrologists. The major frequency of UVC is observed after the renal biopsy, in a percentage varying from 7 to 17% in different series; UVC are less frequent after a nephrostomic procedure (near 1-3%). UVC consist of artero-venous fistulas (AVF) and pseudoaneurysms (PA), that generally cause haemorrhage, particularly macroscopic hematuria. In the vast majority of cases hematuria resolves spontaneously or with conservative therapy but, in the 4 to 9% of patients persists and requires an adequate therapy, often in emergency. Interventional radiology permits an effective and timely treatment of the lesions, using the techniques of transcatheter embolization that are greatly improved in the last 20 years and that present rate of technical success greater than 80%. Moreover radiological embolization shows a low incidence of complications and lower hospitalization cost with respect to surgical treatment. Herein we describe the different techniques of embolization, the indications and the results as appears from the literature and the personal experience. The latter is based on a series of 31 procedures performed in 26 patients, with a rate of technical and clinical success of 93.5%.
Asunto(s)
Aneurisma Falso/terapia , Angiografía de Substracción Digital/métodos , Fístula Arteriovenosa/terapia , Embolización Terapéutica/métodos , Riñón/diagnóstico por imagen , Radiografía Intervencional/métodos , Adolescente , Adulto , Anciano , Aneurisma Falso/diagnóstico por imagen , Fístula Arteriovenosa/diagnóstico por imagen , Cateterismo/efectos adversos , Niño , Femenino , Hemorragia , Humanos , Riñón/patología , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Percutaneous transluminal renal angioplasty (PTRA) alone or in combination with stent implantation, is increasingly used as an alternative technique to surgical revascularization for treatment of renal artery stenosis (RAS) wich may cause hypertension or jeopardize renal function. Herein we report the results obtained with 305 PTRAs performed in 242 hypertensive patients, 144 of whom had atherosclerotic RAS, 69 fibromuscolar dysplasia, 15 Ras in transplanted kidneys, 6 restenosis in surgically revascularized kidneys, 4 Takayasu arteritis and 4 neurofibromatosis. Stents were implanted in 68 cases, mostly in atherosclerotic stenoses. The technical success was achieved in 261 arteries (85.6%), with 33 failures (10.8%) and 11 (3.6%) procedures not completed for anatomical reasons. PTRA related complications were observed in 23 cases (7.5%), but no fatalities occurred. An overall benefit on blood pressure control was observed in 41% of patients with atherosclerotic RAS and in 68% of those with fibromuscolar dysplasia. It appears that independently from the ethiology PTRA is technically effective in correcting RAS; yet the position of PTRA with respect to that of medical or surgical treatment needs to be better delineated through randomized, controlled studies aimed at comparing the clinical efficacies of these different approaches.
Asunto(s)
Angioplastia de Balón/métodos , Radiografía Intervencional/métodos , Obstrucción de la Arteria Renal/terapia , Adulto , Anciano , Arteriosclerosis/terapia , Femenino , Humanos , Hipertensión Renal/terapia , Riñón/irrigación sanguínea , Riñón/diagnóstico por imagen , Trasplante de Riñón , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional , Obstrucción de la Arteria Renal/diagnóstico por imagen , Stents , Resultado del TratamientoRESUMEN
The Authors, on the basis of their experience with neoplastic colorectal pathology and after a review of the Literature, report a reappraisal of the problems related to colorectal multiple carcinomas. They emphasize the importance of routine preoperative pancolonoscopy for the identification of possible synchronous tumors (both benign and malignant) and periodic endoscopic follow-up (ideally a life-long one) for the detection and removal of all adenomatous polyps as well as early stage metachronous carcinomas, especially for patients with HNPCC. Besides, they stress the importance of sensibilization of the population about the heritability of colorectal carcinomas.
Asunto(s)
Adenocarcinoma , Neoplasias Colorrectales , Neoplasias Primarias Múltiples , Neoplasias Primarias Secundarias , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Adenocarcinoma Mucinoso/mortalidad , Adenocarcinoma Mucinoso/patología , Adenocarcinoma Mucinoso/cirugía , Adenoma/patología , Adenoma Velloso/patología , Adulto , Anciano , Anciano de 80 o más Años , Colectomía , Colon/patología , Pólipos del Colon/patología , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/cirugía , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Hepáticas/secundario , Masculino , Persona de Mediana Edad , Neoplasias Primarias Múltiples/mortalidad , Neoplasias Primarias Múltiples/patología , Neoplasias Primarias Múltiples/cirugía , Neoplasias Primarias Secundarias/mortalidad , Neoplasias Primarias Secundarias/patología , Neoplasias Primarias Secundarias/cirugía , Pronóstico , Recto/patología , Factores de TiempoRESUMEN
The usefulness in cirrhotic patients of hemodynamic measurements by Doppler ultrasonography (US) is still not defined. We investigated the relationships between Doppler measurements and the severity of ascites. Portal blood flow velocity and volume, and hepatic and renal arterial resistance indexes (RI) were measured in 57 cirrhotic patients (19 without ascites, 28 with responsive ascites, and 10 with refractory ascites) and 15 healthy controls. The renal arterial RI were obtained for the main renal artery, interlobar vessels, and cortical vessels. Cirrhotic patients had decreased portal blood flow and an increased congestion index (CI). Only the CI was correlated to the severity of ascites, showing that it is also a reliable measure of the severity of portal hypertension in patients with ascites. The hepatic and renal artery RI were increased in cirrhotic patients, and the two values were correlated (r = .68; P = .00001). The RI of renal interlobar and cortical vessels were higher in patients with refractory ascites than in patients without ascites (P < .02 and P < .009), and correlated with sodium excretion rate (r = -.45; P < .003), the renin-aldosterone system, and creatinine clearance (r = -.62; P < .0002). The RI decreased from the hilum of the kidney to the outer parenchyma in healthy subjects and patients with responsive ascites, but this difference disappeared in patients with refractory ascites. This indicates that the degree of renal vasoconstriction varies in different areas according to the severity of the ascites. Cortical vessels are involved mainly in patients with refractory ascites, suggesting that the intrarenal blood flow distribution in cirrhosis tends to preserve the cortical area and that severe cortical ischemia is a feature of refractory ascites.
Asunto(s)
Ascitis/complicaciones , Corteza Renal/irrigación sanguínea , Cirrosis Hepática/complicaciones , Cirrosis Hepática/fisiopatología , Ultrasonografía Doppler en Color , Adulto , Anciano , Ascitis/terapia , Velocidad del Flujo Sanguíneo , Creatinina/sangre , Femenino , Humanos , Hígado/irrigación sanguínea , Cirrosis Hepática/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Natriuresis , Vena Porta/fisiopatología , Renina/sangre , Resistencia Vascular , VasoconstricciónRESUMEN
OBJECTIVE: To investigate the effect of iloprost, a stable prostacycline analog, on kidney blood flow in patients with systemic sclerosis (SSc), using color flow Doppler sonography. METHODS: The acute effect of the drug was studied in 10 patients with SSc with elevated resistance index (RI) levels (all RI values reported are multiplied by 100). Iloprost was administered intravenously (2 ng/kg/min for a period of 8 h). To study the effects of chronic drug administration, 16 patients with SSc were randomly assigned to 2 groups of 8 cases each. The first group was treated with 9 infusions of iloprost in 6 mo. The second group was treated with slow release nifedipine (40 mg/day) for 6 mo. RESULTS: Interlobar artery RI (median 67 vs 61; p = 0.02) and cortical vessel RI (median 65 vs 54; p = 0.001) were reduced after acute treatment. In chronic drug administration, RI values were not modified by nifedipine, while iloprost reduced the RI of the interlobar (median 69 vs 61; p < 0.03) and cortical arteries (median 66 vs 58: p < 0.01). CONCLUSION: Our findings suggest iloprost might be useful for treatment of scleroderma renal vasospasm.