Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review

We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.

Multiple Infarcts after Intra-arterial Carboplatin Therapy

We report a case of multiple cerebral infarcts, which developed after intra-arterial(IA) carboplatin therapy in a patient with glioblastoma who had received surgery with conventional and intraoperative radiation therapy (IORT). A 31-year-old male patient presented with one-month history of worsening headaches and visual dimness. Seven years previously, he had been subjected to a subtotal resection of anaplastic astrocytoma in the right occipital lobe, followed by external radiation therapy with a total dose of 5580cGy. Carboplatin was given at an initial dose of 300mg/m2. Before and after the infusion of carboplatin, solumedrol(500mg/day) was given for seven days, with the dosage being gradually reduced over the next five days. In addition, 20% mannitol(100ml) was infused over a 15-minute period before chemotherapy, and the fluid volume of electrolyte was adjusted to maintain an optimal urine output. The patient underwent five cycles of IA carboplatin therapy. Careful attention should be given during IA carboplatin chemotherapy to patients who are also being treated with IORT.

Preoperative CT Assessement of Esophageal Carcinoma: Comparison between the Patients with and without Recurrence of Esophageal Carcinoma after Surgical Resection

PURPOSE: To determine whether preoperative CT is helpful in predicting the development of recurrent tumor following surgical resection in patients with esophageal cancer. MATERIALS AND METHODS: Thirty patients with esophageal cancer in whom preoperative CT of the chest had been performed were included in the study. All had undergone esophagectomy, esophagogastrostomy and lymph node dissection at our institution between 1995 and 1997. They were divided into two groups according to the development of tumor recurrence during the follow-up period of three years. Sixteen patients (group I) suffered tumor recurrence, while the other 14 (group II) remained tumor-free after surgery. In each group, a review of the preoperative CT scans indicated the length, thickness, location and margin of the tumor, and the presence or absence of lymphadenopathy in the mediastinum and/or upper abdomen. Differences in preoperative CT findings between the two groups were assessed by statistical testing. RESULTS: Lymphadenopathy of the mediastinum and/or upper abdomen was seen in 11 (69%) of 16 patients in group I and three (21%) of 14 in group II (p.05). In group I, five esophageal tumors were located in the middle esophagus and eleven in the lower esophagus. In group II, such tumor was located one in the upper esophagus, six in the middle esophagus, and seven in the lower esophagus (p>.05). CONCLUSION: Patients with preoperative CT findings of lymphadenopathy and/or an indistinct primary tumor margin are more likely to develop tumor recurrence following surgical resection than those without these findings.

What is the Best MR Sequence to Evaluate

PURPOSE: To determine the best MR sequence for evaluation of the anatomical structures of normal kidney. MATERIALS AND METHODS: Twenty normal volunteers (M:F=15:5) took part in this study, and for each, seven sequences were performed. The T1 weighted sequences were conventional spin echo T1 (Conv-SET1), turbo spin echo T1 (TSET1), and fast low angle shot (FLASH), while the T2 weighted sequences were turbo spin echo T2 (TSET2), half-Fourier acquisition single-shot turbo spin echo (HASTE), true-fast imaging with steady-state precession (True-FISP), and echoplanar imaging (EPI). The study involved quantitative and qualitative analysis. In quantitative analysis, CNRs between cortex and adjacent fat tissue, and between cortex and medulla were calculated from SNR (signal to noise ratio), and the CNRs of sequences were statistically compared. In quantative analysis, three radiologists collectively evaluated kidney outline, corticomedullary division, the renal vessels, the pelvis/ureter, and artifacts. For each sequence a grade was assigned, and for each parameter the grades were compared. RESULTS: Between cortex and adjacent fat, the highest CNR was shown by TSET1, followed by Conv-SET1,while among T2 sequences, the CNR shown by TSET2 was highest. Between cortex and medulla, the CNR demonstrated by the three T1 sequences showed no statistically significant difference. Among T2 sequences, however, HASTE showed the highest CNR, followed by EPI, and statistically, the findings for these two were significantly different from those of other T2 sequences. Among T1 sequences, FLASH provided the best kidney outline, though among T2-sequences there was no statistically significant difference. FLASH was also the best for cortico-medullary distinction, while for this purpose the best T2 sequence was HASTE. True-FISP was best for the evaluation of renal vessels, and HASTE for evaluating the pelvis and ureter. Artifacts were most prominent on Conv SET1. CONCLUSION: For evaluating the shape of the kidney, the best T2 sequence was TSET2, but the best T1 sequence could not be determined. For cortico-medullary differentiation, the best T1 sequence was FLASH and the best T2 sequence was HASTE. For the evaluation of renal vessels, True-FISP was best, and for the pelvis and ureter, HASTE. Artifacts were most prominent on Conv-SET1.

The Study of Operative Indications of Blunt Hepatic Trauma

PURPOSE: Nonoperative management is currently considered a treatment modality in 50 to 80% of patients with blunt liver injury. Nevertheless 10 to 50% of patients need operative management, and the criteria for operative management have not established. The purpose of this study is to find criteria for operative management of patients with blunt liver injury. METHODS: The records of 117 patients who experienced blunt hepatic injury from January 1992 to April 1999 were reviewed retrospectively with respect to hemodynamic stability, transfusion requirement, injury severity score, liver injury grade, amount of blood in the peritoneal cavity, and pooling of contrast material on computerized tomography (CT). RESULTS: Among the 117 patients, 29 patients (25%) were treated operatively (Group 1) and 88 patients (75%) were treated nonoperatively (Group 2). The initial systolic blood pressure in Group 1 was significantly lower than that of Group 2 (74.4+/-30.3 mmHg vs 107.1+/-27.2 mmHg, p<0.001). The amounts of transfusion for hemodynamic stability were 2.1 units in Group 1 and 0.4 units in Group 2 (p<0.001). The injury Severity score of Group 1 was significantly higher than that of Group 2 (20.8 +/- 11.0 vs 10.7+/-6.8, p=0.03). The mean injury grade was 3.7+/-0.1 for Group 1 and 2.4+/-1.0 for Group 2, which was a statistically significant difference was seen (p<0.001). The amount of hemoperitoneum in Group 1 was significantly higher than that of Group 2 (p<0.001). The pooling of contrast material on CT was detected in 3 cases in Group 1. CONCLUSION: We can establish the following criteria for operative management: operative management is necessary for hemodynamic instability during resusci tation, positive peritoneal irritation signs, and presence of pooling of contrast material on CT. In cases above grade IV, above 500 mL of hemoperitoneum on CT, or above 2 units of blood transfusion during resuscitation, close observation in an intensive care unit is necessary. If abnormality develops during observation, prompt operative management is mandatory.

Profound hypothermia and cardiopulmonary bypass in the treatment of recurrent giant angioblastic meningioma case report

Hypothermia and cardiopulmonary bypass has rarely been used for difficult lesions of the brain such as giant aneurysms and hemangioblastoma of the brainstem. We report a case of huge recurrent angioblastic meningioma operated under the profound hypothermia and cardiopulmonary bypass. We reviewed the complications related to hypothermia and cardiopulmonary bypass for brain lesions.

Transcervical interruption of ectopic pregnancy

The diagnostic possibility and the incidence of ectopic pregnancy are increasing due to several factor. Furthermore, radioimmunoassay of serum β-HCG and US make it possible to diagnose early before the tubal rupture. A conventional surgical approach has been considered as a choice of treatments. Until recent years, however, surgery may have considerable risk of infertility and sugical hazard. In view of the natural tendency of some ectopic pregnancies to terminate in tubal abortion or complete resorption, we tried to cure ectopic pregnancy with nonsurgical transcervical intervention. Five of 8 patients with unruptured tubal pregnancies, it was possible to inject PGF2a into the tubes or gestational sac. 4 of them were ended up with satisfactory reduction of serum β-HCG level and improvement of symptoms & signs. In only one patient, β-HCG level remained a high level continuously, so salpingectomy was done. As a result, we consider that fluoroscopy-guided transcervical interventional procedure is a useful treatment modality for early unruptured ectopic pregnancy.

Transcervical interruption of ectopic pregnancy

The diagnostic possibility and the incidence of ectopic pregnancy are increasing due to several factor. Furthermore, radioimmunoassay of serum β-HCG and US make it possible to diagnose early before the tubal rupture. A conventional surgical approach has been considered as a choice of treatments. Until recent years, however, surgery may have considerable risk of infertility and sugical hazard. In view of the natural tendency of some ectopic pregnancies to terminate in tubal abortion or complete resorption, we tried to cure ectopic pregnancy with nonsurgical transcervical intervention. Five of 8 patients with unruptured tubal pregnancies, it was possible to inject PGF2a into the tubes or gestational sac. 4 of them were ended up with satisfactory reduction of serum β-HCG level and improvement of symptoms & signs. In only one patient, β-HCG level remained a high level continuously, so salpingectomy was done. As a result, we consider that fluoroscopy-guided transcervical interventional procedure is a useful treatment modality for early unruptured ectopic pregnancy.