Efficacy of Combining Proximal Balloon Guiding Catheter and Distal Access Catheter in Thrombectomy with Stent Retriever for Anterior Circulation Ischemic Stroke

OBJECTIVE: We evaluated efficacy of combining proximal balloon guiding catheter (antegrade flow arrest) and distal access catheter (aspiration at the site of occlusion) in thrombectomy for anterior circulation ischemic stroke. METHODS: We retrospectively analyzed 116 patients who underwent mechanical thrombectomy with stent retriever. The patients were divided by the techniques adopted, the combined technique (proximal balloon guiding catheter and large bore distal access catheter) group (n=57, 49.1%) and the conventional (guiding catheter with stent retriever) technique group (n=59, 50.9%). We evaluated baseline characteristics (epidemiologic data, clinical and imaging characteristics) and procedure details (the number of retrieval attempts, procedure time), as well as angiographic (thrombolysis in cerebral infarction (TICI) score, distal thrombus migration) and clinical outcome (National Institutes of Health Stroke Scale at discharge, modified Rankin Scale [mRS] at 3 months) of them. RESULTS: The number of retrieval attempts was lower (p=0.002) and the first-pass successful reperfusion rate was higher (56.1% vs. 28.8%; p=0.003) in the combined technique group. And the rate of final result of TICI score 3 was higher (68.4% vs. 28.8%; p<0.01) and distal thrombus migration rate was also lower (15.8% vs. 40.7%; p=0.021) in the combined technique group. Early strong neurologic improvement (improvement of National Institutes of Health Stroke Scale ≥11 or National Institutes of Health Stroke Scale ≤1 at discharge) rate (57.9% vs. 36.2%; p=0.02) and favorable clinical outcome (mRS at 3 months ≤2) rate (59.6% vs. 33.9%; p=0.005) were also better in the combined technique group. CONCLUSION: The combined technique needs lesser attempts, decreases distal migration, increases TICI 3 reperfusion and achieves better clinical outcomes.

Efficacy of Combining Proximal Balloon Guiding Catheter and Distal Access Catheter in Thrombectomy with Stent Retriever for Anterior Circulation Ischemic Stroke

OBJECTIVE: We evaluated efficacy of combining proximal balloon guiding catheter (antegrade flow arrest) and distal access catheter (aspiration at the site of occlusion) in thrombectomy for anterior circulation ischemic stroke.METHODS: We retrospectively analyzed 116 patients who underwent mechanical thrombectomy with stent retriever. The patients were divided by the techniques adopted, the combined technique (proximal balloon guiding catheter and large bore distal access catheter) group (n=57, 49.1%) and the conventional (guiding catheter with stent retriever) technique group (n=59, 50.9%). We evaluated baseline characteristics (epidemiologic data, clinical and imaging characteristics) and procedure details (the number of retrieval attempts, procedure time), as well as angiographic (thrombolysis in cerebral infarction (TICI) score, distal thrombus migration) and clinical outcome (National Institutes of Health Stroke Scale at discharge, modified Rankin Scale [mRS] at 3 months) of them.RESULTS: The number of retrieval attempts was lower (p=0.002) and the first-pass successful reperfusion rate was higher (56.1% vs. 28.8%; p=0.003) in the combined technique group. And the rate of final result of TICI score 3 was higher (68.4% vs. 28.8%; p<0.01) and distal thrombus migration rate was also lower (15.8% vs. 40.7%; p=0.021) in the combined technique group. Early strong neurologic improvement (improvement of National Institutes of Health Stroke Scale ≥11 or National Institutes of Health Stroke Scale ≤1 at discharge) rate (57.9% vs. 36.2%; p=0.02) and favorable clinical outcome (mRS at 3 months ≤2) rate (59.6% vs. 33.9%; p=0.005) were also better in the combined technique group.CONCLUSION: The combined technique needs lesser attempts, decreases distal migration, increases TICI 3 reperfusion and achieves better clinical outcomes.

Organized Comprehensive Stroke Center is Associated with Reduced Mortality: Analysis of Consecutive Patients in a Single Hospital / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Organized inpatient stroke care is one of the most effective therapies for improving patient outcomes. Many stroke centers have been established to meet this need, however, there are limited data on the effectiveness of these organized comprehensive stroke center (CSC) in the real-world setting. Our aim is to determine whether inpatient care following the establishment of CSC lowers mortality of patients with acute ischemic stroke (AIS). METHODS: Based on a prospective stroke registry, we identified AIS patients hospitalized before and after the establishment of a CSC. We observed all-cause mortality within 30 days from time of admission. Logistic regression was used to determine whether the establishment of the CSC affects independently the 30-day all-cause mortality. RESULTS: A total of 3,117 consecutive patients with AIS were admitted within seven days after the onset of the symptoms. Unadjusted 30-day mortality was lower for patients admitted to our hospital after the establishment of the CSC than before (5.9% vs. 8.2%, P=0.012). Advanced age, female gender, previous coronary artery disease, non-smoking, stroke subtype, admission on a holiday, referral from other hospitals, high NIHSS on admission, and admission before the establishment of CSC were associated with increased 30-day stroke case fatality. After adjustment for these factors, stroke inpatient care subsequent to the establishment of the CSC was independently associated with lower 30-day mortality (OR, 0.57; 95% CI, 0.412-0.795). CONCLUSIONS: Patients treated after the establishment of a CSC had lower 30-mortality rates than ever before, even adjusting for the differences in the baseline characteristics. The present study reveals that organized stroke care in a CSC might improve the outcome after AIS.

Changes on Cognitive Function after Carotid Artery Stenting in Patients with Severe Carotid Artery Stenosis: A Prospective, 3 Months Follow-up Study

BACKGROUND: Carotid artery stenting (CAS) is emerging as an alternative to carotid endarterectomy for the treatment of carotid stenosis. The effects of CAS on cognitive function have not been fully addressed. The aim of this study was to assess the effect of carotid stenting on cognitive function from baseline to 3 months in patients with severe carotid artery stenosis through the use of a detailed neuropsychological test. METHODS: We recruited 28 patients with carotid artery stenosis (> or =70%) at baseline on a consecutive basis between February, 2009 and December, 2010. Twenty-two patients out of 28 cases, who had undergone CAS and follow-up neuropsychological evaluation after 3 months, were included in our analysis. Main cognitive outcome measures were the Seoul Neuropsychological Screening Battery-Dementia version (SNSB-D), which containing detailed cognitive tasks. We evaluated the baseline clinical characteristics and changes of cognitive outcome measures using SNSB-D in our cases from baseline to 3 months follow-up period, respectively. RESULTS: After a 3 month follow-up period, patients that underwent CAS showed significant improvement in cognitive function in total SNSB-D score compared to the baseline state of 18.1 points at 3 months (p<0.05). The other cognitive outcome measures showed significant improvements (p<0.05) in the task of confrontational naming, visual memory, and the scale of clinical dementia rating sum of box. CONCLUSION: We found that there might be a positive effect of carotid artery stenting on cognitive function from baseline to 3 months in patients with severe carotid artery stenosis.

Influence of Clinical and Anatomic Features on Treatment Decisions for Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study was to analyze the clinical and anatomic features involved in determining treatment modalities for anterior communicating artery (AcoA) aneurysms. METHODS: The authors retrospectively evaluated 112 AcoA aneurysms with pretreatment clinical features including age, Hunt and Hess grade, medical or neurological comorbidity, and anatomical features including aneurysm size, neck size, dome-to-neck ratio, vessel incorporation, multiple lobulation, and morphologic scoring system. Post-treatment clinical results were classified according to the Glasgow Outcome Scale, and anatomic results in coiled patients were classified according to the modified Raymond scale. Using multivariate logistic regression, the probabilities for decision making between surgical clipping and coil embolization were calculated. RESULTS: Sixty-seven patients (60%) were treated with surgical clipping and 45 patients (40%) with endovascular coil embolization. The clinical factor significantly associated with treatment decision was age (> or =65 vs. or =2), presence of vessel incorporation, multiple lobulation, and morphologic score (> or =2 vs. 65 years) had significantly higher odds of being treated with coil embolization relative to clipping (adjusted OR=3.78; 95% CI, 1.39-10.3; p=0.0093) and higher morphological score patients (> or =2) had a higher tendency toward surgical clipping than endovascular coil embolization (OR=0.23; 95% CI, 0.16-0.93; p=0.0039). CONCLUSION: The optimal decision for treating AcoA aneurysms cannot be determined by any single clinical or anatomic characteristics. All clinical and morphological features need to be considered, and a collaborative neurovascular team approach to AcoA aneurysms is essential.

Endovascular Treatment and Microsurgical Treatment of Intracranial Aneurysms in the Elderly / 대한뇌혈관외과학회지

BACKGROUND: The prevalence of intracranial aneurysms in the elderly is increasing. However, most treatment strategies for the elderly is controversial and related research in the elderly has been insufficient. METHODS: Eighty-four patients > 65 years of age with intracranial aneurysms who received definitive treatment at our hospital between March 2007 and June 2010 were subjected to this study. Thirty-seven patients who had undergone endovascular treatment (EVT) were categorized into group I, while 47 patients who had undergone microsurgical treatment (MST) were categorized into group II. RESULTS: When the Glasgow Outcome Scale (GOS) score, which was independent to rupture, was evaluated at the time of discharge there was a trend of acquiring much better GOS scores (GOS> or =4) when the Hunt-Hess grade (HHG) is good (HHG< or =2) and the size of the aneurysm is small (<10 mm; p=0.001 [HHG] and p=0.000 [aneurysm size]). In the two groups in which EVT and MST were performed, the average values of the GOS scores by Student's t-test displayed a significant difference (4.54 [EVT] and 4.13 [MST], respectively, p=0.046). However, univariate and multivariate analyses were not statistically significant. CONCLUSION: If the clinical results are similar in the EVT and MST for intracranial aneurysms, then EVT is less invasive with less post-procedural complications would be considered with priority in elderly patients.

Clinical Analysis of Carotid Artery Stenting in Symptomatic High-Risk Patients : A Single Stroke Center Study / 대한뇌혈관외과학회지

OBJECTIVE: The early management of patients with acute symptoms due to carotid stenosis remains a subject of debate. Carotid endarterectomy (CEA) has been shown to reduce the risk of stroke in patients with symptomatic extracranial carotid artery stenosis. Carotid artery stenting (CAS) has recently emerged as an alternative to CEA for the primary and secondary prevention of stroke in patients who are at a high risk for complications from surgery. The aim of this study is to evaluate and analyze the clinical outcome of symptomatic high-risk patients with carotid stenosis that was treated with early CAS in a single stroke center. METHODS: From January 2008 to October 2009, we retrospectively analyzed 75 symptomatic high-risk carotid stenosis patients who had been admitted to the stroke center of our neurosurgical department and who were treated with early CAS. Twenty-five patients had transient ischemic attack (TIA) and 50 patients had minor or major stroke and all of them were at a high medical and surgical risk for carotid endarterectomy. They were treated with early CAS as soon as possible (treatment was done within 2 weeks from the onset of symptoms). RESULTS: At three months, 15 patients (20%) in the TIA and stroke group experienced an improvement in their initial neurologic deficit (a decreased modified Rankin scale greater than 2), while in 59 patients (78.4%) the deficit remained stable, and only one patient had a neurological impairment. CONCLUSION: Our data indicates that urgent assessment and early initiation of a combination of existing preventive treatments can reduce the risk of early recurrent stroke after TIA and minor or major stroke in the symptomatic high-risk patients with carotid stenosis.

Solitary Fibrous Tumor in Nasal Cavity: Surgical Treatment after Angiographic Embolization / 대한이비인후과학회지

The solitary fibrous tumor (SFT) is made of potential malignant spindle cells, a neoplasm of mesenchymal origin that is normally described as a thoracic lesion originating from pleural tissues. Recently, numerous extrapleural sites of the origins such as the following have been described: the liver, parapharyngeal space, sublingual gland, tongue, vulva, parotid gland, thyroid, larynx, nasal cavity and paranasal sinuses. The treatment of choice for SFTs is a complete surgical excision of the tumor. But, the possibility of profuse bleeding must be considered during resection and even during initial biopsies. This case report presents a case of an SFT in the nasal cavity of a 20-year-old male patient who was treated with surgical treatment after angiographic embolization.

Treatment of the Posterior Circulation Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Endovascular treatment is now accepted as an initial treatment modality, especially in cases of posterior circulation aneurysms. The purpose of this study was to review the treatment outcomes and to emphasize the necessity of maintaining the surgical ability for posterior circulation aneurysms. METHODS: During the past 10 years, 570 patients have been treated for cerebral aneurysms at our institute. Among these patients, 34 harbored posterior circulation aneurysms. From January 2004 to June 2008, 13 of the 34 patients were treated by endovascular coiling. We retrospectively reviewed the clinical outcome, cerebral angiograms, and other radiological imagings through a comparative study of the pre- and post-endovascular treatment periods. RESULTS: Overall, 9 (69.2%) of the pre-endovascular treatment period group and 20 (95.2%) of the endovascular treatment period group had good outcomes. The mean post-operative hospital days for these groups were 38.6 and 21.1, respectively. Patients in the endovascular treatment period group had shorter post-operative hospital periods and better outcomes than those in the pre-endovascular treatment period group. CONCLUSION: It is recommended that multimodality treatment involving microsurgical clipping and endovascular coiling is used to obtain better results in the treatment of posterior circulation aneurysms. These results suggest that although the trend toward endovascular treatment as the initial aneurysm therapy for posterior circulation aneurysms is also enhancing, it might be necessary to maintain the surgical ability for posterior circulation aneurysm.

A Case of Acute Colonic Pseudo-obstruction Treated by Percutaneous Endoscopic Colostomy / 대한소화기내시경학회지

Acute colonic pseudo-obstruction (Ogilvie's syndrome) results in massive colonic dilation without mechanical obstruction. In most cases, a conservative treatment with or without endoscopic decompression is efficient. Rarely, surgery has to be performed. A surgical treatment is associated with high morbidity and mortality. However, a percutaneous endoscopic colostomy could be an interesting alternative treatment. We report the case of a 88-year-old female with colonic pseudo-obstruction for which both the conservative and the colonoscopic treatments were unsuccessful. A percutaneous endoscopic colostomy was performed, and symptomatic improvement was observed. We have shown that percutaneous endoscopic colostomy is a safe and effective treatment for acute colonic pseudo- obstruct

A Case of Multiple Intraperitoneal Cysts from Ruptured Hepatic Hydatid Cysts / 대한소화기학회지

Hydatid disease is a parasitic infestation caused by the larval form of the cestode worms Echinococcus. In humans, the most commonly affected organs are liver and lung. Most cysts remain clinically silent and are diagnosed incidentally or when complications occur. The incidence of hydatid disease is high in the Middle East, Australia, East and South Africa and Central Europe. In Korea, hydatid disease is rare and has been reported in a few cases. We experienced a case of multiple intraperitoneal cysts from ruptured hepatic hydatid cysts in a 35-year old man. His complaint was palpable abdominal mass and discomfort. Abdominal ultrasound and CT scan revealed multiple hepatic and intraperitoneal cysts. The surgical findings showed multiple cysts and daughter cysts. The pathologic finding of resected cyst was the characteristic pattern of outer thick laminated membrane and inner thin germinal layer. Albendazole was administrated for prophylatic purpose.

Three Dimensional Volume Rendering Virtual Endoscopy of the Ossicles Using a Multi-Row Detector CT: Applications and Limitations

PURPOSE: This study was conducted to know the applications and limitations of three dimensional volume rendering virtual endoscopy of the ossicles using a multi-row detector CT. MATERIALS AND METHODS: This study examined 25 patients who underwent temporal bone CT using a 16-row detector CT as a result of hearing problems or trauma. The axial CT scan of the temporal bone was performed with a 0.6 mm collimation, and a reconstruction was carried out with a U70u Sharp of kernel value, a 1 mm thickness and 0.5-1.0 mm increments. After observing the ossicles in the axial and coronal images, virtual endoscopy was performed using a three dimensional volume rendering technique with a threshold value of -500 HU. The intra-operative otoendoscopy was performed in 12 ears, and was compared with the virtual endoscopy findings. RESULTS: Virtual endoscopy of the 29 ears without hearing problems demonstrated hypoplastic or an incomplete depiction of the stapes superstructures in 25 ears and a normal depiction in 4 ears. Virtual endoscopy of 21 ears with hearing problems demonstrated no ossicles in 1 ear, no malleus in 3 ears, a malleoincudal subluxation in 6 ears, a dysplastic incus in 5 ears, an incudostapedial subluxation in 9 ears, dysplastic stapes in 2 ears, a hypoplastic or incomplete depiction of the stapes in 16 ears and no stapes in 1 ear. In contrast to the intra-operative otoendoscopy, 8 out of 12 ears showed a hypoplastic or deformed stapes in the virtual endoscopy. CONCLUSION: Volume rendering virtual endoscopy using a multi-row detector CT is an excellent method for evaluation the ossicles in three dimension, even though the partial volume effect for the stapes superstructures needs to be considered.

A Case of Colonic Tuberculosis Presenting as Massive Bleeding / 대한소화기내시경학회지

Tuberculous involvement of the colon is an uncommon clinical entity. Other colonic disease which should be considered in the differential diagnosis include inflammatory bowel disease such as Crohn's disease, ulcerative colitis and colon cancer. Intestinal tuberculosis most frequently involves the ileocecal area. The common presenting symptoms are abdominal pain, fever, weight loss and malabsorption. Pathologically, tuberculous colitis may present as an ulcerative type, hypertrophic type or in combination. Massive bleeding is said to be very rare even in the ulcerative type because of an obliterative endarteritis. We report a case of colonic tuberculosis presenting with massive bleeding in 52-year-old man with alcoholic liver cirrhosis, which was diagnosed by colonoscopic biopsy and acid-fast stain.

A Case of Kaposi's Sarcoma Associated with Ulcerative Colitis / 대한소화기학회지

Kaposi's sarcoma is a rare and slowly progressive disease that primarily affects the skin but has an associated visceral involvement. It can occur in the HIV-positive patients or patients treated with immunosuppressants. However, it is extremely rare in the patients receiving the treatment for inflammatory bowel disease. We used corticosteroid for the treatment of ulcerative colitis in 60-year-old woman. Then, Kaposis's sarcoma occured in the skin and colon of the patient. Since she was HIV-negative, we believed that it was developed from the condition of corticosteroid-induced immunosuppression. We present a case of skin and colonic Kaposi's sarcoma in a HIV-negative woman following treatment with corticosteroid for ulcerative colitis.

A Case of Hepatocellular-cholangiocarcinoma Invading the Gallbladder / 대한간학회지

Metastasis of hepatocellular carcinoma occurs at a relatively late stage of the disease. Hematogenous and lymphatic metastases are the most common routes for dissemination of tumor cells. Hepatocellular carcinoma also extends into the adjacent portal vein and bile ducts. Since there is no peritoneum between the body of the gallbladder and the liver fossa, gallbladder cancer can easily cross the boundary. Gallbladder invasion of hepatocellular carcinoma, however, is quite rare. We report a case of hepatocellular- cholangiocarcinoma in a non-cirrhotic liver that invaded the gallbladder mimicking the gallbladder carcinoma complicated by cholecystitis and liver abscess.

A case of large cell neuroendocrine carcinoma of gallbladder presenting with pyogenic liver abscess / 대한내과학회지

Pyogenic liver abscess is a rare but highly lethal disease. The diagnosis and treatment of pyogenic liver abscess has been evolving owing to specific antibiotic therapy, ultrasonography, abdominal computed tomography with improved percutaneous and operative techniques. However, pyogenic liver abscess may present as a rapidly fatal outcome. These unfavorable results are mainly attributed to the increasing numbers of patients with malignant disease and biliary tract disease. Carcinoma of the gallbladder has remained an uniformly fatal neoplasm characterized by early metastasis and rapid fatal course. In early stage, the symptom is nonspecific and often mimics benign biliary tract disease. We experienced a case of the gallbladder carcinoma presenting with pyogenic liver abscess in a 78-year-old female patient. Surgical drainage and cholecystectomy were done. The microscopic finding of resected gallbladder revealed large cell neuroendocrine carcinoma of gallbladder.

A case of synchronous triple primary cancer of non-Hodgkin's lymphoma associated with hepatocellular carcinoma and early gastric cancer / 대한내과학회지

In recent years, increasing numbers of cases of the double primary cancer with different site origins in an individual have been reported. However, the occurrence of more than two primary cancer is relatively rare. We have experienced a case of synchronous triple primary cancer of non-Hodgkin's lymphoma associated with hepatocellular carcinoma and early gastric cancer in 64 years old woman who has been suffered from hepatitis B antigen (+) liver cirrhosis.

A case of gastric variceal bleeding associated with pancreatic endocrine tumor in the pancreas tail / 대한내과학회지

Isolated obstruction of the splenic vein leads to segmental portal hypertension, which is mainly originated from pancreatic disease, such as chronic pancreatitis, pancreatic pseudocyst, pancreatic cancer. The clinical manifestation are devoid of ascites and encephalopathy, but presented with gastric variceal bleeding. We experienced 27-year-old male patient who complained of hematochezia and melena. After work-up with CT and angiography, we performed operation with the impression of pancreatic tumor associated with splenic vein occlusion. It resulted nonfunctioning pancreatic endocrine tumor. Often called islet cell tumor, pancreatic endocrine tumor has various names according to secreted hormones, such as insulinoma, Zollinger-Ellison syndrome and glucagonoma. It was classified as nonfunctioning tumor if there were any evidence of hormone secretion by radioimmunoassay and immunohistochemistry. Surgical excision and adjuvant medical therapy is the mainstay of therapy. We performed tumor resection and splenectomy for control of gastric variceal bleeding due to splenic vein occlusion.

Gastric Wall Thickening on Spiral CT after Subtotal Gastrectomy for Gastric Cancer: Comparision between Recurrent Cancer and Benign Thickening

PURPOSE: To determine the features revealed by two-phase spiral CT scanning useful for differential diagnosis between recurrent cancer and benign wall thickening in patients who have undergone subtotal gastrectomy for stomach cancer. MATERIALS AND METHODS: We retrospectively reviewed 25 cases in which wall thickening of more than 1 cm in the remnant stomach after subtotal gastrectomy was revealed by two-phase spiral CT scanning. All cases were confirmed: 11 were recurrent cancer, and in 14, benign wall thickening was demonstrated. We analyzed the CT findings including maximal thickness of the gastric wall, patterns of wall thickening, degree of contrast enhancement seen during the arterial and portal phases, and the presence of perigastric strands. Maximal wall thickness was classified as either more or less than 15 mm, and as either focal or diffuse. We also determined whether lymphadenopathy was present. RESULTS: Mean maximal gastric wall thickness was 18.4 mm in the recurrent cancer group ("group A") and 12.6 mm in the benign group ("group B") . The gastric wall was thicker than 15 mm in 10 of 11 group A cases and in 3 of 14 in group B; wall thickening was focal (n=3) or diffuse (n=8) in group A, and focal (n=13) or diffuse (n=1) in group B, while the enhancement patterns seen during the arterial and portal phase, respectively, were high/high (n=8), low/high (n=1) and low/low (n=2) in group A, and low/low (n=7), low/high (n=4), high/low (n=1) and high/high (n=2) in group B. Perigastric strands were observed in nine cases in group A, but in none in group B, while lymphadenopathy was combined with wall thickening in seven group A cases but in none of those in group B. CONCLUSION: In patients who have undergone subtotal gastrectomy for gastric cancer, two-phase spiral CT findings including maximal thickness of the gastric wall, patterns of wall thickening, degree of contrast enhancement seen during the arterial and portal phase, the presence of perigastric strands, and lymphadenopathy are useful for differential diagnosis between recurrent cancer and benign wall thickening.