A Rare Case of Pulmonary Arteriovenous Malformation Caused by Hereditary Hemorrhagic Telangiectasia in a Hemodialysis Patient / 대한내과학회지

Hereditary hemorrhagic telangiectasia (HHT) is an uncommon autosomal dominant disorder resulting in vascular malformation, such as pulmonary arteriovenous malformation (PAVM). Here, we report a rare case of pulmonary arteriovenous malformation caused by HHT in a hemodialysis (HD) patient. A 34-year-old man receiving maintenance HD via radiocephalic arteriovenous fistula developed progressive dyspnea without definite pulmonary edema. His mother had been diagnosed with HHT. He had experienced multiple episodes of epistaxis and had been intermittently treated with blood transfusions because of severe anemia. Blood gas analysis showed hypoxia. Chest computed tomography revealed multiple dilated vessels of variable sizes, continuous with the pulmonary artery throughout both lung fields, consistent with PAVM. After treating pulmonary artery embolization at the largest PAVM, he recovered from his dyspnea symptoms and hypoxia.

A Rare Case of Pulmonary Arteriovenous Malformation Caused by Hereditary Hemorrhagic Telangiectasia in a Hemodialysis Patient / 대한내과학회지

Hereditary hemorrhagic telangiectasia (HHT) is an uncommon autosomal dominant disorder resulting in vascular malformation, such as pulmonary arteriovenous malformation (PAVM). Here, we report a rare case of pulmonary arteriovenous malformation caused by HHT in a hemodialysis (HD) patient. A 34-year-old man receiving maintenance HD via radiocephalic arteriovenous fistula developed progressive dyspnea without definite pulmonary edema. His mother had been diagnosed with HHT. He had experienced multiple episodes of epistaxis and had been intermittently treated with blood transfusions because of severe anemia. Blood gas analysis showed hypoxia. Chest computed tomography revealed multiple dilated vessels of variable sizes, continuous with the pulmonary artery throughout both lung fields, consistent with PAVM. After treating pulmonary artery embolization at the largest PAVM, he recovered from his dyspnea symptoms and hypoxia.

Technical and Clinical Considerations for Successful Management of Postoperative Bowel Perforation by Percutaneous Foley Catheter Placement

Purpose@#The aim of this study was to analyze several technical and clinical factors associated with the successful management of postoperative leakage by percutaneous Foley catheter placement. @*Materials and Methods@#Thirty-two patients were included in this retrospective study. Postoperative gastrointestinal leakage was diagnosed by computed tomography (CT) and the patients underwent percutaneous Foley catheter placement into the leakage site through Jackson-Pratt tubes or imaging-guided methods. Clinical success was defined as successful Foley catheter removal without symptom recurrence within 1 week and the risk factors for clinical failure were analyzed. @*Results@#In all patients, percutaneous Foley catheter placement was successfully achieved without complications. Foley catheter was placed at a median of 10 days (range, 1–68) after the confirmation of leakage on CT. Clinical success was achieved in 26 of the 32 patients (81%). Systemic comorbidity (p < 0.001) and failed oral intake (p = 0.015) were the statistically significant risk factors for clinical failure. @*Conclusion@#Percutaneous Foley catheter placement can be considered an effective approach for the management of postoperative bowel leakage. The presence of systemic comorbidity and successful oral diet after Foley catheter placement are significant factors for successful clinical recovery.

Technical and Clinical Considerations for Successful Management of Postoperative Bowel Perforation by Percutaneous Foley Catheter Placement

Purpose@#The aim of this study was to analyze several technical and clinical factors associated with the successful management of postoperative leakage by percutaneous Foley catheter placement. @*Materials and Methods@#Thirty-two patients were included in this retrospective study. Postoperative gastrointestinal leakage was diagnosed by computed tomography (CT) and the patients underwent percutaneous Foley catheter placement into the leakage site through Jackson-Pratt tubes or imaging-guided methods. Clinical success was defined as successful Foley catheter removal without symptom recurrence within 1 week and the risk factors for clinical failure were analyzed. @*Results@#In all patients, percutaneous Foley catheter placement was successfully achieved without complications. Foley catheter was placed at a median of 10 days (range, 1–68) after the confirmation of leakage on CT. Clinical success was achieved in 26 of the 32 patients (81%). Systemic comorbidity (p < 0.001) and failed oral intake (p = 0.015) were the statistically significant risk factors for clinical failure. @*Conclusion@#Percutaneous Foley catheter placement can be considered an effective approach for the management of postoperative bowel leakage. The presence of systemic comorbidity and successful oral diet after Foley catheter placement are significant factors for successful clinical recovery.

Evaluation of Arterial Impairment after Experimental Gelatin Sponge Embolization in a Rabbit Renal Model

OBJECTIVE: Arterial stenosis is a major obstacle for subsequent interventional procedures. We hypothesized that the stenosis is caused by gelatin sponge embolization and performed an experimental study in a rabbit renal model. MATERIALS AND METHODS: A total of 24 rabbits were embolized with porcine gelatin sponge particles injected into the renal arteries. Four rabbits were sacrificed on 1 day, 4 days, 1 week, 2 weeks, 3 weeks, and 4 weeks after embolization. Microscopic evaluations were performed on hematoxylin-eosin and smooth muscle actin immunohistochemical stained sections. RESULTS: Gelatin sponge particles were mainly observed in the segmental and interlobar arteries. Transmural inflammation of the embolized arterial wall and mild thickening of the media were observed 1 week after embolization. Resorption of the gelatin sponge and organization of thrombus accompanied by foreign body reactions, were observed from 2 to 4 weeks after embolization. Microscopic images of the 3 weeks group showed vessel lumens filled mostly with organized thrombi, resulting in severe stenosis. Additionally, vessels showed a thickened intima that contained migrating smooth muscle cells and accompanying interruption of the internal elastic lamina. The migrating smooth muscle cells were distributed around the recanalized arterial lumen. CONCLUSION: Gelatin sponge embolization may induce arterial stenosis by causing organized thrombus and intimal hyperplasia, which consists of migrating smooth muscle cells and intimal collagen deposits.

DC Bead Transarterial Chemoembolization Is Effective in Hepatocellular Carcinoma Refractory to Conventional Transarteral Chemoembolization: A Pilot Study

BACKGROUND/AIMS: To determine if hepatocellular carcinoma refractory to conventional transarterial chemoembolization (TACE) responds to TACE with DC beads. METHODS: Between July 2008 to June 2010, 435 patients underwent TACE. Of these, 10 patients who had tumors refractory to conventional TACE and who thus were treated with TACE with DC beads were enrolled in this study. The treatment response after TACE with DC beads was evaluated according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) and the Response Evaluation Criteria in Cancer of the Liver (RECICL). RESULTS: Ten tumors were treated in 10 patients. Using the mRECIST and the RECICL, a complete response was observed in four (40%) of the tumors, and six tumors (60%) showed a partial response. Eight (80%) out of 10 HCCs showed delayed enhancement patterns upon angiography, and better responses were observed in these cases following DC bead treatment. The adverse effects of treatment with DC beads became tolerable. CONCLUSIONS: TACE with DC beads was effective for HCCs refractory to conventional TACE, and this treatment elicited a better response, especially when the tumors were small and showed a delayed enhancement pattern upon angiography.

Acute Adverse Reactions to Gadolinium-based Intravenous Contrast Agents for MRI : Retrospective Analysis Using Computed Reporting System

PURPOSE: To assess the frequency and severity of acute adverse reactions to intravenous administration of gadolinium-based contrast agents using computerized reporting system at a single large academic institution. MATERIALS AND METHODS: We assessed data from electronic hospital information system from October 2008 to December 2010. Reactions were classified as mild, moderate, or severe. We compared the frequency of adverse reactions among three contrast agents (Gd-BT-DO3A, Gd-DTPA and Gd-EOB-DTPA). RESULTS: The total number of administrated contrast agents was 33,600, and the number of administration of Gd-BT-DO3A, Gd-DTPA and Gd-EOB-DTPA were 20,824 (62%), 10,417 (31%) and 2,359 (7%), respectively. Total 39 adverse reactions were reported accounting for 0.1161% of all administrations. The incidences of adverse reactions were 0.1248% (26/39, 67%) for Gd-BT-DO3A, 0.0768% (8/39, 21%) for Gd-DTPA, and 0.2120% (5/39, 13%) for Gd-EOB-DTPA. The difference of frequencies of adverse reaction among three contrast agents was not significant. Most cases of the adverse effect were mild (35/39, 89.7%). Moderate and severe adverse reactions were encountered in two patients, respectively. CONCLUSION: Among Koreans, adverse effects were rare, and especially, moderate to severe adverse reactions were much rarer. There was no difference among the frequencies of adverse reactions caused by three different contrast agents.

Fat-Containing Lesions in Vertebrae and Spinal Canal: A Pictorial Review

The recent development of image techniques, including computed tomography and magnetic resonance imaging, plays an important role in the diagnosis and treatment of spinal disease. A variety of lesions in the spine may contain fat tissue, and these lesions have the possibility of being benign or malignancy. The principle of treatment varies depending on the characteristics of the lesions. The purpose of this pictorial assay is to document the radiologic findings to help physicians make the correct diagnosis, to confirm the characteristics and the extent of the lesion, to anticipate the prognosis and to select and decide upon the therapeutic method when a fat-containing lesion is located in the spinal vertebrae and/or spinal canal.

Fat-Containing Lesions in Vertebrae and Spinal Canal: A Pictorial Review

The recent development of image techniques, including computed tomography and magnetic resonance imaging, plays an important role in the diagnosis and treatment of spinal disease. A variety of lesions in the spine may contain fat tissue, and these lesions have the possibility of being benign or malignancy. The principle of treatment varies depending on the characteristics of the lesions. The purpose of this pictorial assay is to document the radiologic findings to help physicians make the correct diagnosis, to confirm the characteristics and the extent of the lesion, to anticipate the prognosis and to select and decide upon the therapeutic method when a fat-containing lesion is located in the spinal vertebrae and/or spinal canal.

Polyvinyl Alcohol Embolization Adjuvant to Oily Chemoembolization in Advanced Hepatocellular Carcinoma with Arterioportal Shunts

OBJECTIVE: To assess the feasibility and safety of polyvinyl alcohol (PVA) embolization adjuvant to transarterial oily chemoembolization (P-TACE) in advanced hepatocellular carcinoma (HCC) with arterioportal shunts (APS). MATERIALS AND METHODS: Nineteen patients who underwent PVA embolization for APS before a routine chemoembolization (TACE) procedure were retrospectively reviewed. 10 of these 19 patients underwent follow-up TACE or P-TACE after P-TACE (Group A), but nine patients underwent only initial P-TACE because of progression of HCC and/or underlying liver cirrhosis (Group B). Hepatic function tests, APS grades, and portal flow directions were evaluated before and after P-TACE sessions. Complications after procedures and survival days were also evaluated. RESULTS: In group A, APS grade was improved in eight patients and five of six patients with hepatofugal flow showed restored hepatopetal flow postoperatively. No immediate complication was developed in either group. Transient hepatic insufficiency developed in eight (42.1%) of 19 patients after P-TACE, and seven (87.5%) of these eight recovered within two weeks under conservative care. The mean and median survival time all study subjects was 280 days and 162 days. CONCLUSION: P-TACE is feasible and safe in advanced HCC patients with APS.

Intrasellar Schwannoma: A Case Report

Schwannomas usually arise from sensory nerves, and most often from the vestibular component of the acoustic nerve. Intrasellar and parasellar schwannomas are exceedingly rare. It is difficult to distinguish them from typical pituitary macroadenomas because of their clinical and radiological resemblance. In this report, we present an unusual case of an intrasellar schwannoma with a suprasellar extension that radiographically simulated a pituitary macroadenoma.

Migration of a Slipped Aneurysmal Clip from the Intracranium into the Spinal Canal: Case Report

Very rarely, clips used for the ligation of intracranial aneurysms become detached and subsequently migrate into the spinal canal, causing lumbar pain or radiculopathy by compressing nerve roots or inducing inflammatory processes in their newly established location. However, it is easy to overlook the migration of the clip, because there may be either no noticeable symptoms, or a herniated disk may be mistakenly diagnosed as being the source of the present symptoms. Herein, the authors report a case in which an aneurysmal clip migrated into the spinal cord.

Airway Obstruction in Rheumatoid Arthritis: CT Manifestations, Correlated with Pulmonary Function Testing

In the present study, the signs of airflow obstruction on inspiratory and expiratory CT scans in 45 patients with rheumatoid arthritis were investigated. Radiologic findings were evaluated and correlated with the clinical data, which included rheumatoid factors and pulmonary function tests results. A lung biopsy was performed in five patients. The pattern of CT findings was as follows: infiltrative (n=15), obstructive (n=12), mixed (infiltrative and obstructive; n=10), other complicating diseases (n=7), and normal (n=1). The rheumatologic factor between patients with bronchial wall thickenings and patients without thickenings was significantly different (p=0.009). The forced expiratory flow rate between 25% and 75% of the vital capacity (FEF25-75%) was significantly more reduced in patients with interlobular septal thickenings than in patients without these thickenings. The patients with mosaic attenuation had significantly lower mean values of FEF25-75% (p=0.001) and a lower peak expiratory flow (p=0.003) than patients without mosaic attenuation. On expiratory scans, the mean air-trapping score was 21%. These air-trapping scores were found to be well correlated with FEV1/FVC (r=0.230, p=0.0452), and FEF25-75% (r=-0.63, p= 0.05). It is widely known that a relatively higher percentage of mosaic attenuation with air-trapping and a good correlation between these and functional values contribute to the detection of early airway obstruction in patients with rheumatoid arthritis, and even in patients with infiltrative lung disease only.

Muscle Mass in the Calf as a Presenting Symptom of Sarcoidosis / 대한류마티스학회지

Sarcoidosis is a multisystemic granulomatous disease of unknown cause. Lung, skin, eye, liver and lymph nodes are commonly affected. But the nodular type of muscular sarcoidosis is rare. The nodular type can be presented with a soft tissue mass that may be confused with a tumor. Magnetic resonance imaging and muscle biopsy are useful methods for early diagnosis. Optimal management of nodular sarcoidosis is not well known, but surgical excision or corticosteroid may be considered as an initial management. We report a case of nodular muscular sarcoidosis as an initial manifestation of sarcoidosis in a 56-year-old woman who was treated with corticosteroid therapy after surgical excision.

Gastrosplenic Fistula Complicated in a Patient with Non- Hodgkin's Lymphoma / Journal of the Korean Cancer Association, 대한암학회지

Reported cases of gastrosplenic fistulas are extremely rare in the literature. Malignancy is the primary cause in 50% of patients, followed by perforated peptic ulcer (40%). Fistulas can cause spleen rupture and potential bleeding that threaten the life of the patient. Lymphoma is the most common cause of malignancy complicated with gastrosplenic fistula. Most gastrosplenic fistulae caused by lymphoma eventually close following chemotherapy, although splenectomy should be performed to avoid further complications. We experienced a case of non-Hodgkin's lymphoma complicated with gastrosplenic fistula in a 21 year-old man. He was admitted to our hospital because of LUQ mass. On the abdominal CT, a splenic mass with central necrosis and gas was discovered. The biopsy specimen of the stomach and spleen displayed diffuse, large B cell type non-Hodgkin's lymphoma. After one cycle of CHOP chemotherapy, the LUQ mass was markedly regressed although the gastrosplenic fistula was still present on the follow-up CT. The fistula was treated by splenectomy and a partial resection of gastric fundus. Follow-up chemotherapy was continued after surgery.

Maffucci's Syndrome Associated with Chondrosarcoma and Aneurysm: Case Report

Maffucci syndrome is a rare congenital non-inherited condition characterized by multiple enchondromas and cutaneous hemangiomas. It is associated with increased risk of malignancy, including chondrosarcomas, and because of generalized mesodermal dysplasia, aneurysms can develop. We present a case of Maffucci syndrome associated with intracranial chondrosarcoma and aneurysm.

Arachnoid Cyst in Cavernous Sinus: Case Report

Arachnoid cyst of the cavernous sinus is very rare. When present, its anatomic location frequently gives rise to cranial nerve palsy. We report a case of arachnoid cyst of the cavernous sinus in a 38-year-old man with impaired eyeball movement and diplopia.

Retroperitoneal Malignant Mesenchymoma: A Case of Mesenchymal Mixed Tumor with Osteosarcoma, Leiomyosarcoma, Liposarcoma and Fibrosarcoma

Malignant mesenchymoma is an interesting but very rare tumor in which malignant differentiation has occurred twice or more. We report a case of retroperitoneal malignant mesenchymoma consisting of osteosarcoma, leiomyosarcoma, liposarcoma and fibrosarcoma. Abdominal CT showed a large retroperitoneal mass with two separate and distinct parts, namely an area of prominent calcification and one of clearly enhancing solid components. The mass contained histologically distinct tumorous components with no histologic admixure at the interfaces. The densely calcified nodule corresponded to osteosarcoma, and the noncalcified clearly enhancing nodules to leiomyosarcoma, liposarcoma and fibrosarcoma.

Cavernous Hemangioma of the Cavernous Sinus: A Case Report

Intracranial extra-axial cavernous hemangioma of the cavernous sinus is a very rare vascular malformation. It usually appears as a round non-encapsulated mass with well-defined borders, mimicking meningioma. We describe a case of cavernous hemangioma of the cavernous sinus, including the radiologic imaging findings, and also review the literature.

Determination of the Activity of Pulmonary Tuberculosis: the Utility of High-Resolution Computed Tomography

PURPOSE: To evaluate the utility of high-resolution computed tomography(HRCT), as used to determine the activity of tuberculosis, and to analyze the HRCT findings in active and in inactive tuberculosis. MATERIALS AND METHODS: We analyzed the HRCT findings of 100 patients (54 men, 46 women; average age, 54 years) who according to the results of chest radiography had pulmonary tuberculosis of undetermined activity. We assessed HRCT findings such as the presence of a entrilobular, macro-, or micronodule; consolidation, ground-glass opacity, cavity, interlobular septal thickening, irregular linear opacities, bronchial wall thickening, bronchovascular bundle distortion, bronchiectasis, atelectasis, and pericicatrical emphysema. We compared the ratio of the area of nodule and consolidation to that of whole lung, and compared the findings between active and inactive tuberculosis. RESULTS: Eleven of 100 patients were excluded because the final diagnosis was other than tuberculosis. In 59 patients, the presence of active pulmonary tuberculosis was proven by positive sputum smear and/or culture for Mycobacterium tuberculosis. On the basis of the negative results of these tests, pulmonary tuberculosis was found to be inactive in 30 patients; serial chest radiographs indicated that their condition remained stable over a 6-month period. For HRCT, sensitivity was 96.6%, specificity 56.7%, positive predictive value 81.4%, negative predictive value 89.5%, and accuracy 83.1%. For active tuberculosis, the presence of centrilobular nodules, tree-in-bud, macronodules, cavity within the nodule, and consolidations was statistically significant, while for inactive tuberculosis, that of irregular linear opacities, micronodules, bronchiectasis, and cicatrization atelectasis was similarly significant. The CT score for the area of nodules and consolidations was higher in active than in inactive tuberculosis, but only the nodule score showed statistical significance. CONCLUSION: HRCT can be a useful diagnostic tool for evaluating the activity of pulmonary tuberculosis