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The treatment of complicated anterior cerebral artery aneurysms remains challenging. Here, the authors describe a case of ruptured complicated A3 aneurysm, which was treated with trapping and in-situ bypass. A 47-year-old man presented to the emergency department with severe headache and vomiting. Computed tomography illustrated acute intracerebral hemorrhage in the right frontal lobe. Digital subtraction angiography (DSA) confirmed a ruptured fusiform A3 aneurysm with lobulation and a daughter sac. Trapping of the ruptured fusiform A3 aneurysm and distal end-toside A4 anastomosis was performed. DSA on postoperative day 7 showed mild vasospasm to the afferent artery. However, 2 months later, DSA demonstrated that the antegrade flow through the anastomosis site had recovered. Thus, surgeons should be aware of the possibility of postsurgical vasospasm of anastomosed arteries, especially in cases of ruptured aneurysms.
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Objective@#Several particular morphological factors that contribute to the hemodynamics of the anterior communicating artery (ACoA) have been documented, but no study has investigated the role of the degree of anterior cerebral artery (ACA) rotation on the presence of ACoA aneurysms (ACoAAs). @*Methods@#A retrospective study of an institutional aneurysm database was performed; patients with ruptured or nonruptured ACoAAs were selected. Two sex- and age-matched control groups were identified: control Group A (nonaneurysms) and control Group B (middle cerebral artery aneurysms). Measurements of ACA rotation degree were obtained by using a three-dimensional imaging tool. @*Results@#From 2015 to 2020, 315 patients were identified: 105 in the ACoAA group, 105 in control Group A, and 105 in control Group B. The average age at the time of presentation was 64 years, and 52.4% were female. The ACA rotation degree of the ACoAA group was significantly higher than that of control Group A (p <0.01). The A1 ratio and the A1A2 ratio of the ACoAA group were greater than those of control Group A (p <0.01 and p <0.01, respectively). The ACA rotation degree correlated insignificantly with aneurysm size in ACoAA patients (p=0.78). The ACA rotation degree in the ACoAA group was also insignificantly different from that in control B (p=0.11). @*Conclusions@#The degree of ACA rotation was greater in the ACoAA group than in the nonaneurysm group, and it may serve as an imaging marker for ACoAA.
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Intracranial dural arteriovenous fistulas (DAVF) are abnormal connections between intracranial arterial and venous systems within the dural layers. Intracranial DAVFs are rare but can occur wherever dural components exist. The pathogenesis of DAVFs is controversial. Venous hypertension is considered as a main cause of clinical symptoms which are subclassified into asymptomatic, benign and aggressive manifestations. To date, several classification schemes have been proposed to stratify the natural course and risks of DAVFs. Currently, endovascular therapy is the main treatment modality. Moreover, the use of radiosurgery and radiotherapy has been limited. Open surgery is also selectively performed as a main treatment modality for specific types of DAVFs and an adjunctive modality for the endovascular approach. Herein, we present a review of the general perspectives of intracranial DAVFs with an emphasis on the role of surgery.
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Background@#Currently, there is no consensus on the treatment of psoriasis in Korean patients. @*Objective@#This study aimed to establish a consensus on the basic therapeutic principles for Korean patients with plaque psoriasis. @*Methods@#Using the modified Delphi method, a steering committee proposed 53 statements for the first Delphi round, which covered five subjects: (1) the goal of treatment and evaluation of disease severity, (2) topical therapy, (3) phototherapy, (4) conventional systemic therapy, and (5) biologic therapy. The panel of dermatologists scored the level of agreement for each statement on a ten-point scale with scores ranging from 1 (strongly disagree) to 10 (strongly agree). After discussing the results of the first round, the committee reformulated 41 statements. Finally, consensus was defined as more than 70% of the second round scores being ≥7. @*Results@#The panel participants strongly agreed that the ideal treatment goals for Korean patients with plaque psoriasis should include complete skin clearance and high dermatological quality of life. A strong consensus was also reached on the use of topical agents for psoriasis of any severity, the consideration of phototherapy before biologics therapy, the conventional systemic agents for moderate-to-severe psoriasis, and the recommendation of biologic for retractable psoriasis to conventional systemic therapy and phototherapy. @*Conclusion@#This modified Delphi panel established an expert consensus on the therapeutic approach for Korean patients with plaque psoriasis. This consensus may improve the treatment outcomes for psoriasis in Korea.
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Background@#Discoid lupus erythematosus (DLE) with alopecia of the scalp can result in permanent hair loss. Therefore, it is important to evaluate skin lesions and establish appropriate treatment plans for scalp DLE with alopecia. @*Objective@#We aimed to investigate the dermoscopic features of scalp DLE with alopecia and to determine the correlation between dermoscopic findings and treatment efficacy. @*Methods@#Thirty-one patients histopathologically diagnosed with scalp DLE and alopecia were included. We reviewed clinical photographs and dermoscopic findings of the patients and evaluated their treatment responses. @*Results@#The most frequent dermoscopic features of DLE with alopecia were follicular keratotic plugs (96.8%), white scales (71.0%), telangiectatic vessels (67.7%), and pigmentation (64.5%); followed by absent follicular openings (48.4%), white structureless areas (35.5%), follicular red dots (16.1%), and perifollicular whitish halo (12.9%). After at least 6 months of treatment, hair regrowth was observed in 22 patients (71.0%). Dermoscopic findings showed that white structureless areas, perifollicular whitish halo, absent follicular openings (especially when the alopecic patch involved ＞25% of the scalp), and moderate to severe telangiectatic vessels were associated with absence of hair regrowth. @*Conclusion@#Dermoscopy is a promising tool for evaluating lesions and predicting therapeutic outcomes in scalp DLE with alopecia. It may contribute to the establishment of appropriate treatment plan by determining whether hair loss is reversible.
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Purpose@#In hormone receptor-positive, human epidermal growth factor receptor 2–negative metastatic breast cancer (HR+ HER2–MBC), the mainstay treatment options include cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) and everolimus (EVE) in combination with endocrine treatment. This study aims to compare the outcomes of the following treatment sequences: CDK4/6i followed by EVE and EVE followed by CDK4/6i. @*Materials and Methods@#Data from HR+ HER2– MBC patients treated between January 2014 and November 2020 with both CDK4/6i and EVE were retrospectively analyzed. @*Results@#Among the 88 patients included in the study, 51 received CDK4/6i before EVE (C→E group), and 37 received EVE before CDK4/6i (E→C group) with endocrine treatment. More patients in the E→C group had endocrine resistance (13.7% vs. 40.5%), experienced palliative chemotherapy (7.8% vs. 40.5%), and were heavily treated (treated as ≥ 3rd line, 5.9% vs. 40.5%). Median overall survival was 46.8 months in the C→E group and 38.9 months in the E→C group (p=0.151). Median composite progression-free survival (PFS), defined as the time from the start of the preceding regimen to disease progression on the following regimen or death, was 24.8 months in the C→E group vs. 21.8 months in the E→C group (p=0.681). Median PFS2/PFS1 ratio did not differ significantly between groups (0.5 in the C→E group, 0.6 in the E→C group; p=0.775). Ten patients (11.4%) discontinued EVE, and two patients (2.3%) discontinued CDK4/6i during treatment. @*Conclusion@#Although the CDK4/6i-based regimen should be considered as an earlier line of treatment, CDK4/6i- and EVE-based treatments can be valid options in circumstances where the other treatment had been already given.
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Purpose@#For liposarcoma (LPS), clinical course and proper treatment strategies have not been well-established. Recently, immune-checkpoint inhibitors have shown potential efficacy in LPS. We aimed to describe the clinical course of LPS and evaluate the clinical impact of programmed death-ligand 1 (PD-L1). @*Materials and Methods@#We reviewed all consecutive patients (n=332) who underwent curative-intent surgery for localized LPS at Asan Medical Center between 1989 and 2017. PD-L1 testing was performed in well-differentiated and dedifferentiated LPS. @*Results@#The median age was 56 years with males comprising 60.8%. Abdomen-pelvis (47.6%) and well-differentiated (37.7%) were the most frequent primary site and histologic subtype, respectively. During a median follow-up of 81.2 months, recurrence was observed in 135 (40.7%), and 86.7% (117/135) were loco-regional. Well-differentiated subtype (hazard ratio [HR], 0.38), abdomen-pelvis origin (HR, 2.43), tumor size larger than 5 cm (HR, 1.83), positive resection margin (HR, 2.58), and postoperative radiotherapy (HR, 0.36) were significantly related with recurrence-free survival as well as visceral involvement (HR, 1.84) and multifocality (HR, 3.79) in abdomen-pelvis LPS. PD-L1 was positive in 31.5% (23/73) and 51.3% (39/76) of well-differentiated and dedifferentiated LPS, respectively, but had no impact on survival outcomes. @*Conclusion@#Clinical course of LPS was heterogeneous according to histology and anatomic location. Clear resection margin was important to lower recurrence and postoperative radiotherapy might have additional benefit. A decent portion of well-differentiated and dedifferentiated LPS were positive for PD-L1, but its prognostic role was unclear. Further research is needed to determine clinical implications of PD-L1, especially for advanced-stage LPS with unmet needs for effective systemic treatment.
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This single-institute, retrospective cohort study enrolled patients with human epidermal growth factor receptor 2-positive metastatic breast cancer treated with trastuzumab deruxtecan between August 2017 and January 2021 from four previous studies. Of 31 patients, 4 (12.9%) had interstitial lung disease (ILD). The dominant pattern observed on computed tomography was organizing pneumonia (100%), comprising subpleural consolidations in the lung periphery. However, no dominant distribution was observed in radiological lesions of the lungs. Of all the tested patients, lower lobe predominance was noted in 2 (50.0%) patients, upper lobe predominance in 1 (25.0%) patient, and diffused lobe distribution in 1 (25.0%) patient. All events were confined to the Common Terminology Criteria for Adverse Events grade 1 or 2 (100%). None of the patients died. Despite the small number of cases investigated, the incidence of trastuzumab deruxtecan-induced ILD in the Korean population was comparable to that previously reported.
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Objective@#Written exposure therapy (WET) is exposure therapy for post-traumatic stress disorder (PTSD). Compared to evidencebased treatments for PTSD, WET requires only five sessions, has a shorter session time, and no between-session assignments. The current study examined the efficacy of WET among Korean patients with PTSD due to various traumatic events on PTSD symptoms, depressive symptoms, and global functioning levels. @*Methods@#The study recruited 41 patients with a current primary diagnosis of PTSD in psychiatric outpatient clinics. Assessments were conducted at baseline, and at 6, 12, and 24 weeks following the first treatment session. @*Results@#In total, 25 patients started WET. Findings showed a significant reduction in the rate of PTSD diagnosis and symptom severity scores. Fourteen of 23 (60.9%) patients at 6 weeks, 15 of 22 (68.2%) patients at 12 weeks, and 14 of 18 (77.8%) patients at 24 weeks no longer met the diagnosis of PTSD. Depressive symptoms and global function scores also improved after WET. The dropout rate was 8% (n=2). @*Conclusion@#This study suggests the feasibility of implementing WET among various types of patients with PTSD in Korea and other Asian countries.
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Background@#Epidermal growth factor (EGF) stimulates wound healing in various skin conditions, and EGFcontaining formulations can promote wound regeneration and help reduce complications after laser treatment. @*Objective@#To evaluate the effect of EGF-containing ointment on wound regeneration after ablative laser treatment and laser-induced postinflammatory erythema (PIE) and hyperpigmentation (PIH). @*Methods@#Twenty-five patients who required treatment with ablative laser on both sides of the face were enrolled and underwent one session of laser treatment. Postoperatively, all patients were instructed to apply the EGFcontaining ointment on the randomly assigned-hemifacial side, while gentamicin cream was applied on the opposite side. Investigators’ global assessment (IGA), evaluating general wound condition, erythema, pigmentation, and scab shedding, and patient’s global assessment (PGA), evaluating patient satisfaction with clinical improvement, were both measured at 1 week and 4 weeks after treatment. Objective assessments, including melanin index (MI), erythema index (EI), skin hydration, and transepidermal water loss (TEWL), were measured before treatment and at 1 week and 4 weeks after treatment. @*Results@#The EGF-containing ointment showed better outcomes with IGA (1 week; p=0.02, 4 weeks; p=0.002) and PGA (1 week; p=0.04, 4 weeks; p=0.01) scores compared to gentamicin cream. Compared to gentamicin cream, treatment with EGF-containing ointment resulted in significantly lower EI (p=0.044) and MI (p=0.023), but skin hydration and TEWL between the two groups exhibited nonsignificant differences. @*Conclusion@#EGF-containing ointment could be an effective adjuvant option for wound regeneration after ablative laser treatment and minimizing laser-induced PIE and PIH in Asian patients.
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Objective@#This study aimed to evaluate the accuracy of the assessment of medical directors for indirect medical oversight on prehospital care. @*Methods@#Medical directors assessed the same prehospital care run sheets with six cases of cardiac arrest, four cases of withholding or interruption of cardiopulmonary resuscitation (CPR) and six cases of severe trauma patients. Demographics of the medical directors and the accuracy of their assessment for the prehospital care run sheets were investigated. @*Results@#Board certified emergency physician was 14 of the total 21 medical directors (58%). Eleven medical directors were educated for the medical director course of the Korean council of emergency medical services physicians. The accuracy of the assessment of the medical directors was 50% in the assessment of electrocardiogram using an automated external defibrillator (AED) in cardiac arrest. Pulse check, respiration check, AED monitoring and the reason of interruption for CPR were lower than 60% for withholding or interruption of CPR. The lowest accurate assessment of medical directors was the appropriate treatment for trauma, with 36.5% in severe trauma. @*Conclusion@#Lower accuracy in some assessments of the medical directors for indirect medical oversight on prehospital care was identified. Education and quality control are needed for medical directors to provide high-quality indirect medical oversight.
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Objective@#: Biodegradable poly-L-lactic acid (PLLA) with a highly biocompatible surface via tantalum (Ta) ion implantation can be an innovative solution for the problems associated with current biodegradable stents. The purpose of this study is to develop a Ta-implanted PLLA stent for clinical use and to investigate its biological performance capabilities. @*Methods@#: A series of in vitro and in vivo tests were used to assess the biological performance of bare and Ta-implanted PLLA stents. The re-endothelialization ability and thrombogenicity were examined through in vitro endothelial cell and platelet adhesion tests. An in vivo swine model was used to evaluate the effects of Ta ion implantation on subacute restenosis and thrombosis. Angiographic and histologic evaluations were conducted at one, two and three months post-treatment. @*Results@#: The Ta-implanted PLLA stent was successfully fabricated, exhibiting a smooth surface morphology and modified layer integration. After Ta ion implantation, the surface properties were more favorable for rapid endothelialization and for less platelet attachment compared to the bare PLLA stent. In an in vivo animal test, follow-up angiography showed no evidence of in-stent stenosis in either group. In a microscopic histologic examination, luminal thrombus formation was significantly suppressed in the Ta-implanted PLLA stent group according to the 2-month follow-up assessment (21.2% vs. 63.9%, p=0.005). Cells positive for CD 68, a marker for the monocyte lineage, were less frequently identified around the Ta-implanted PLLA stent in the 1-month follow-up assessments. @*Conclusion@#: The use of a Ta-implanted PLLA stent appears to promote re-endothelialization and anti-thrombogenicity.
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Objective@#Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating cerebrovascular event; patients are routinely admitted to the intensive care unit (ICU) for initial management. Because complications may be delayed, unplanned ICU readmissions can occur. Therefore, in this study we evaluate the rate of and factors associated with readmission after aSAH and identify if readmission is associated with poor clinical outcomes. @*Methods@#We retrospectively reviewed the medical records of all patients receiving surgical or endovascular treatment for aSAH and admitted to the ICU between January 2008 and December 2019. We categorized patients by readmission and analyzed their clinical parameters. @*Results@#Of the 345 patients who transferred to ward-level care after an initial ICU stay (Group 2), 27 (7.3%) were readmitted to the ICU (Group 1). History of hypertension (HTN), initial Glasgow Coma Scale (GCS) score, modified Fisher grade, and vasospasm therapy during first ICU stay were significantly different between the groups. The most common reason for readmission was delayed cerebral ischemia (DCI; 70.3%; OR 5.545; 95% CI 1.25−24.52; p=0.024). Comorbid HTN (OR 5.311; 95% CI 1.75−16.12; p=0.03) and vasospasm therapy during first ICU stay (OR 7.234; 95% CI 2.41−21.7; p＜0.01) also were associated with readmission. Readmitted patients had longer hospital stay and lower GCS scores at discharge (p＜0.01). @*Conclusions@#DCI was the most common cause of ICU readmission in patients with aSAH. Readmission may indicate clinical deterioration, and patients who are at a high risk for DCI should be monitored to prevent readmission.
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Background@#Riehl’s melanosis of the face and neck has been reported in middle-aged women who have darker skin types. Recently, cases of Riehl’s melanosis have been on the rise in Korea, which might reflect the increased use of various cosmetic products and procedures. @*Objective@#This study was designed to analyze the clinicopathological characteristics and treatment outcomes of Riehl’s melanosis in Korean patients. @*Methods@#We closely observed 80 patients with Riehl’s melanosis diagnosed in Asan Medical Center and Hanyang University Medical Center between 2005 and 2015. A skin biopsy was analyzed in 51 patients, and a patch test was carried out in 16 patients. @*Results@#Patients with chronic Riehl’s melanosis (＞12 months) had an increased frequency of previous laser treatments. Patients with acute Riehl’s melanosis (＜3 months) reported a previous history of dry skin, itching, or irritation as a result of the use of hair dye. Patients older than 50 years, with darker skin type, and with a longer disease duration (＞12 months) had poor response rates. Chronic Riehl’s melanosis may be preceded by repeated irritation of barrier-compromised skin, and acute Riehl’s melanosis seems to be an allergic form of Riehl’s melanosis. @*Conclusion@#Riehl’s melanosis has different clinical manifestations according to disease duration and different treatment responses based on disease duration.
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Congenital melanocytic nevus is a hamartoma derived from the neural crest that is present at birth. Regression following surgical excision with an apparent halo phenomenon through suture lines has never been reported. A nine-year-old boy presented with a solitary symmetric, oval-shaped, blackish pigmented patch on his right forearm.He reported increasing size of the lesion with no other subjective symptoms. Histological examination of the first excisional biopsy revealed congenital melanocytic nevus, and serial excisions were planned. Interestingly, at the second visit at 18 months after the first biopsy, the size of the congenital melanocytic nevus was reduced with a peripheral whitish halo. Linear regression through suture lines and a peripheral halo was observed after the second and third serial excisions. The mechanism of the halo phenomenon remains elusive but is suggested theorized to be caused by destruction of melanocytes by immune responses of autoantibodies or cytotoxic T cells.
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Background@#Isotretinoin is a gold standard treatment for moderate to severe acne vulgaris but is associated with cheilitis. Though moisturizing agents or petrolatum have been suggested, uncomfortable isotretinoin-induced cheilitis can disrupt treatment of acne patients. Topical tacrolimus has been used in atopic dermatitis with good safety and efficacy; however, there is no study of application of topical tacrolimus in cheilitis induced by isotretinoin. @*Objective@#In this study, we aimed to describe the efficacy of topical tacrolimus 0.1% ointment on cheilitis associated with isotretinoin therapy using isotretinoin cheilitis grading scale (ICGS), investigator global assessment (IGA), and patient global assessment (PGA). We also observed the side effects of topical tacrolimus ointment. @*Methods@#Fifty acne vulgaris patients with isotretinoin-induced cheilitis were randomly allocated to either topical tacrolimus or petrolatum treatment using permuted-block randomization. Patients were followed-up at 4 and 8 weeks, at which cheilitis lesions were photographed and evaluated with ICGS, IGA, and PGA. @*Results@#Compared to petrolatum group, tacrolimus group had greater responses to treatment as measured by mean values of ICGS, IGA, PGA at follow-up visits. Also, the ICGS decrease was larger in the tacrolimus group compared with the petrolatum group even according to isotretinoin dose. @*Conclusion@#Topical tacrolimus ointment had superior efficacy in treating cheilitis induced by isotretinoin compared to petrolatum. Erythema, fissures, scales, and commissures all showed better response to tacrolimus ointment. Topical tacrolimus ointment can be administered as an effective strategy in treatment of cheilitis as a complication of isotretinoin therapy and can improve compliance of acne patients.
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Atherectomy has become a promising treatment option for peripheral artery disease caused by diabetes mellitus or end-stage renal disease. Atherectomy refers to the removal of atheromatous tissue by mechanical method, resulting in an enlarged lumen of the treated blood vessel. Based on this method, the term is limited to the percutaneous minimally invasive approach, and there are currently two types of atherectomy devices available in Korea. The increased prevalence of atherectomy has led to the concept of “vascular preparation” and a new treatment concept of “leave nothing behind.” Various studies have proven the safety and effectiveness of atherectomy; however, there are some limitations. We need to remain focused on patient selection and subsequent large-scale research.
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Objective@#: The fate of partially thrombosed intracranial aneurysms (PTIAs) is not well known after endovascular treatment. The authors aimed to analyze the treatment outcomes of PTIAs. @*Methods@#: We retrospectively reviewed the medical records of 27 PTIAs treated with endovascular intervention between January 1999 and March 2018. Twenty-one aneurysms were treated with intraluminal embolization (ILE), and six were treated with parent artery occlusion (PAO) with or without bypass surgery. Radiological results, clinical outcomes and risk factors for major recurrence were assessed. @*Results@#: The initial clinical status was similar in both groups; however, the last status was better in the ILE group than in the PAO group (p=0.049). Neurological deterioration resulted from mass effect in one case and rupture in one after ILE, and mass effect in two and perforator infarction in one after PAO. Twenty cases (94.2%) in the ILE group initially achieved complete occlusion or residual neck status. However, 13 cases (61.9%) showed major recurrence, the major causes of which included coil migration or compaction. Seven cases (33.3%) ultimately achieved residual sac status after repeat treatment. In the PAO group, all initially showed complete occlusion or a residual neck, and just one case ultimately had a residual sac. Two cases showed major recurrence, the cause of which was incomplete PAO. Aneurysm wall calcification was the only significantly protective factor against major recurrence (odds ratio, 36.12; 95% confidence interval, 1.85 to 705.18; p=0.018). @*Conclusion@#: Complete PAO of PTIAs is the best option if treatment-related complications can be minimized. Simple fluoroscopy is a useful imaging modality because of the recurrence pattern.
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Purpose@#The tumor-infiltrating lymphocytes (TILs) expression in breast cancer is a positive prognostic marker for certain breast cancer subtypes. We evaluated the efficacy of dual antihuman epidermal growth factor receptor 2 (HER2) blockade in HER2-positive breast cancer and hypothesized that high TILs tumors are associated with better outcomes. @*Methods@#A total of 176 patients who were treated with neoadjuvant docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) between December 2015 and December 2018 were reviewed. They were grouped based on a cut-off value of the stromal TILs grade (≤ 20% TILs, > 20% TILs). @*Results@#In total, 107 patients (60.8%) achieved pathological complete response (pCR).Hormone receptor (HR)-negativity (p = 0.001) and a high TILs grade (p = 0.022) were independent predictors of pCR. Among the HR-negative patients, high TILs tumors were significantly associated with pCR (p = 0.035). @*Conclusion@#HR status and the TILs grade are significantly correlated with pCR in dual anti-HER2 neoadjuvant therapy. The evaluation of the TILs at baseline may be beneficial for predicting pCR in HER2-positive breast cancer.
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Objective@#Written exposure therapy (WET) is exposure therapy for post-traumatic stress disorder (PTSD). Compared to evidencebased treatments for PTSD, WET requires only five sessions, has a shorter session time, and no between-session assignments. The current study examined the efficacy of WET among Korean patients with PTSD due to various traumatic events on PTSD symptoms, depressive symptoms, and global functioning levels. @*Methods@#The study recruited 41 patients with a current primary diagnosis of PTSD in psychiatric outpatient clinics. Assessments were conducted at baseline, and at 6, 12, and 24 weeks following the first treatment session. @*Results@#In total, 25 patients started WET. Findings showed a significant reduction in the rate of PTSD diagnosis and symptom severity scores. Fourteen of 23 (60.9%) patients at 6 weeks, 15 of 22 (68.2%) patients at 12 weeks, and 14 of 18 (77.8%) patients at 24 weeks no longer met the diagnosis of PTSD. Depressive symptoms and global function scores also improved after WET. The dropout rate was 8% (n=2). @*Conclusion@#This study suggests the feasibility of implementing WET among various types of patients with PTSD in Korea and other Asian countries.