Outcomes of Mechanical Thrombectomy in Patients with Large Diffusion-Weighted Imaging Lesions

Objective@#: Despite many advancements in endovascular treatment, the benefits of mechanical thrombectomy (MT) in patients with large infarctions remain uncertain due to hemorrhagic complications. Therefore, we aimed to investigate the efficacy and safety of recanalization via MT within 6 hours after stroke in patients with large cerebral infarction volumes (>70 mL). @*Methods@#: We retrospectively reviewed the medical data of 30 patients with large lesions on initial diffusion-weighted imaging (>70 mL) who underwent MT at our institution within 6 hours after stroke onset. Baseline data, recanalization rate, and 3-month clinical outcomes were analyzed. Successful recanalization was defined as a modified treatment in cerebral ischemia score of 2b or 3. @*Results@#: The recanalization rate was 63.3%, and symptomatic intracerebral hemorrhage occurred in six patients (20%). The proportion of patients with modified Rankin Scale (mRS) scores of 0–3 was significantly higher in the recanalization group than in the non-recanalization group (47.4% vs. 9.1%, p=0.049). The mortality rate was higher in the non-recanalization group, this difference was not significant (15.8% vs. 36.4%, p=0.372). In the analysis of 3-month clinical outcomes, only successful recanalization was significantly associated with mRS scores of 0–3 (90% vs. 50%, p=0.049). The odds ratio of recanalization for favorable outcomes (mRS 0–3) was 9.00 (95% confidence interval, 0.95–84.90; p=0.055). @*Conclusion@#: Despite the risk of symptomatic intracerebral hemorrhage, successful recanalization via MT 6 hours after stroke may improve clinical outcomes in patients with large vessel occlusion.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: A literature review

Thanks to new generation devices, mechanical thrombectomy (MT) has substantially evolved and become the standard treatment for patients with acute occlusion of the internal carotid artery or proximal middle cerebral artery (MCA) (M1 segment). However, the role and benefit of MT in patients with distal MCA (M2 segment) occlusion remain unclear. Therefore, there is a need for further studies. To evaluate the efficacy and safety of MT for M2 occlusion, this article reviews the natural course of M2 occlusion, the evidence regarding MT for M2 segment occlusion, clinical outcomes of MT for M2 occlusion, and treatment outcomes according to device type.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: A literature review

Thanks to new generation devices, mechanical thrombectomy (MT) has substantially evolved and become the standard treatment for patients with acute occlusion of the internal carotid artery or proximal middle cerebral artery (MCA) (M1 segment). However, the role and benefit of MT in patients with distal MCA (M2 segment) occlusion remain unclear. Therefore, there is a need for further studies. To evaluate the efficacy and safety of MT for M2 occlusion, this article reviews the natural course of M2 occlusion, the evidence regarding MT for M2 segment occlusion, clinical outcomes of MT for M2 occlusion, and treatment outcomes according to device type.

Modified Suturing Techniques in Carotid Endarterectomy for Reducing the Cerebral Ischemic Time

Objective@#: Carotid endarterectomy (CEA) is an effective surgical procedure for treating symptomatic or asymptomatic patients with carotid stenosis. Many neurosurgeons use a shunt to reduce perioperative ischemic complications. However, the use of shunting is still controversial, and the shunt procedure can cause several complications. In our institution, we used two types of modified arteriotomy suture techniques instead of using a shunt. @*Methods@#: In technique 1, to prevent ischemic complications, we sutured a third of the arteriotomy site from both ends after removing the plaque. Afterward, the unsutured middle third was isolated from the arterial lumen by placing a curved Satinsky clamp. And then, we opened all the clamped carotid arteries before finishing the suture. In technique 2, we sutured the arteriotomy site at the common carotid artery (CCA). We then placed a curved Satinsky clamp crossing from the sutured site to the carotid bifurcation, isolating the unsutured site at the internal carotid artery (ICA). After placing the Satinsky clamp, the CCA and external carotid artery (ECA) were opened to allow blood flow from CCA to ECA. By opening the ECA, ECA collateral flow via ECA-ICA anastomoses could help to reduce cerebral ischemia. @*Results@#: The modified suture methods can reduce the cerebral ischemia directly (technique 1) or via using collaterals (technique 2). The modified arteriotomy suture techniques are simple, safe, and applicable to almost all cases of CEA. @*Conclusion@#: Two modified arteriotomy suture techniques could reduce perioperative ischemic complications by reducing the cerebral ischemic time.

Vasa Vasorum Densities in Human Carotid Atherosclerosis Is Associated with Plaque Development and Vulnerability

Objective@#: The extensive vasa vasorum network functions as a conduit for the entry of inflammatory cells or factors that promote the progression of angiogenesis and plaque formation. Therefore, we investigated the correlation between the carotid vasa vasorum activities and carotid plaque vulnerability using indocyanine green video angiography (ICG-VA) during carotid endarterectomy (CEA). @*Methods@#: Sixty-nine patients who underwent CEA were enrolled prospectively from September 2015 to December 2017. During CEA, a bolus of ICG was injected intravenously before and after resecting the atheroma. Additionally, we performed immunohistochemistry using CD68 (a surface marker of macrophages), CD117 (a surface marker of mast cells), and CD4 and CD8 (surface markers of T-cells) antibodies to analyze the resected plaque specimens. @*Results@#: The density of active vasa vasorum was observed in all patients using ICG-VA. The vasa vasorum externa (VVE) and interna (VVI) were seen in 11 (16%) and 57 patients (82.6%), respectively. Macroscopically, the VVE-type patterns were strongly associated with preoperative angiographic instability (81.8%, p=0.005) and carotid plaque vulnerability (90.9%, p=0.017). In contrast, the VVI-type patterns were weakly associated with angiographic instability (31.6%) and plaque vulnerability (49.1%). CD68-stained macrophages and CD117-stained mast cells were observed more frequently in unstable plaques than in stable plaques (p<0.0001, p=0.002, respectively). @*Conclusion@#: The early appearance of VVE, along with the presence of many microvessel channels that provided nutrients to the developing and expanding atheroma during ICG-VA, was strongly associated with unstable carotid plaques. The degree of infiltration of macrophages and mast cells is possibly related to the formation of unstable plaques.

Diagnostic Value of Thrombus Size on T2*-weighted Gradient Echo Imaging in Acute Middle Cerebral Artery Occlusion

OBJECTIVE: The T2*-weighted gradient echo image susceptibility vessel sign (GRE SVS) is a well-known indicator of intraluminal thrombi in acute cerebral infarction. The purpose of this study was to evaluate the relationships between thrombus size on GRE SVS and recanalization after intravenous administration of tissue plasminogen activator (IV-tPA). MATERIALS AND METHODS: Fifty five patients with GRE SVSs on the M1 were enrolled. Examination of magnetic resonance image (MRI), including diffusion weighted imaging and MR angiography, was performed within 20 minutes of admission. Thrombus size on GRE was calculated using the Picture Archiving and Communication System upon initial MRI. Recanalization was assessed with follow-up MRI or transfemoral cerebral angiography within 24 hours of treatment. RESULTS: The patient group consisted of 37 males and 18 females with an average age of 63.74 +/- 10.28 years (range: 43 - 77 years). The median NIHSS score was 13. Fifteen of these patients achieved recanalization (27.3%). The average thrombus cross-sectional area in the recanalization group was 38.54 +/- 20.27 mm2, and the corresponding size of the non-recanalization group was 53.38 +/- 24.77 mm2 (p = 0.043). In the receiver operator characteristic curve for thrombus cross-sectional area in relation to recanalization, the cut-off point was 47.28 mm2. The sensitivity at this cut-off point was 73.3%, the specificity was 60%, and the area under the curve was 0.687. CONCLUSION: Thrombus size on GRE is a simple diagnostic tool that can be easily measured, and thrombus size on GRE SVS was found to be associated with recanalization after IV-tPA.

Oculomotor Nerve Schwannoma: A Case Report

Schwannomas account for about 8% of intracranial tumors and 90% are vestibular schwannomas. Oculomotor schwannoma without neurofibromatosis is extremely rare. A 41-year-old female presented with complaints of blurred vision, and the neurologic examination revealed afferent pupillary defect and decreased visual acuity of the left side. Brain magnetic resonance image showed an extra axial mass in the left superior orbital fissure. The patient underwent major surgery via the fronto-temporal approach. The tumor originated from the oculomotor nerve and was subtotally removed under microscopic surgery. The pathological findings confirmed the tumor as a schwannoma. After surgery, ptosis and medial gaze limitation of the left eye was detected, but the symptoms improved gradually.

Heterotopic Ossification after Cervical Arthroplasty with ProDisc-C: Time Course Radiographic Follow-up over 3 years

OBJECTIVE: Heterotopic ossification (HO) is a well-known complication after total hip replacement. But the occurrence rate by the time-course, clinical effect and risk factors of HO after total cervical disc replacement (TCDR) are not well described. The purpose of this study is to evaluate the occurrence rate by the time-course and risk factors for HO after TCDR with a ProDisc-C. METHODS: Thirty-two patients whom followed up more than one year after the TCDR are enrolled. Radiographic study was done at 12, 24 and 36 months after the TCDR and classified HO with McAfee classification. Segmental range of motion, preoperative existence of spondylosis, type of operation, disc space occupying ratio by artificial disc, surgical level are analyzed to identify the risk factors of HO. The visual analog scale and the neck disability index were evaluated preoperatively and at last follow-up time for clinical parameters. RESULTS: Eighteen patients (56%) showed HO at 12 months, 18 patients (86%) showed HO at 24 months and 6 patients (89%) showed HO at 36 months after the TCDR. Clinical significant HO(Grade 3 and 4) was shown in one patient (3%) at 12 months, 3 patients (14%) at 24 months and 5 patients (56%) at 36 months. Only post-operative follow-up period increases the risk of development clinical significant HO. All patients showed improvement of clinical parameters (p<0.005). CONCLUSION: Incidence of HO is getting higher as time course progress. However, there are no relation between clinical outcome and radiologic change of ROM and the grade of HO.

Ultrasonogram as a Diagnostic Modality in Thyroid Tumors / 대한내분비외과학회지

PURPOSE: To evaluate the usefulness of ultrasonogram as a preoperative diagnostic tool in thyroid nodular diseases, this study was carried out. METHODS: From January 1998 to December 1999, 51 patients who underwent thyroidectomy were analyzed retrospectively. We compared the finally histopathological results to ultrasonographical findings such as internal consistency, multiplicity of nodules, nodular ehogenicity, nodular capsule or margin, calcification of nodules. RESULTS: There were 47 females and 4 males with 25 benign tumor, 23 malignant tumor and 3 occult carcinoma in histopathological diagnosis. The solid tumors in ultrasonography carried a probability of malignancy as 66.7% (16/24 cases) whereas cystic or mixed tumors as 16.7% (1/6 cases) or 23.8% (5/21cases) (p=0.006). The single nodular diseases carried a high probability of malignancy as 50% (13/26cases) whereas multiple diseases as 28.6% (6/21 cases). The hypoechogenicity of thyroid nodular disease showed a probability of malignancy as 60% (9/15 cases) whereas mixed-echogenicity as 36.4% (4/11 cases). The nodules with poorly-defined margin in ultrasonographic findings showed higher probability of malignancy as 63.6% (7/11cases) than the nodules with well -defined margin as 26.5% (9/34 cases) (p=0.025). The nodules with calcification in ultrasonographic findings were represented to high probability of malignancy as 70.6% (12/17 cases) compared to those without calcification as 29.4% (10/34 cases) (p=0.005). The differency between ultrasonic and histopathological diagnosis was high in solid nodules (33%), 3~4 cm sized nodules (28.6%) and mixed echogenecity (27.3%) whereas low in complex nodules with cystic and solid nature (4.8%), 2~3 cm sized nodules (8.3%) and pooly defined margin (9.1%). The accuracies of sonography in differentiating malignacy from benign thyroid nodules were 7.1% of false positivity, 39.1% of false negativity, 60.9% of sensitivity, 92.9% of specificity and 78.4% of accuracy. CONCLUSION: Sonographic examination was relatively excellent test as a preoperative diagnostic tool in thyroid nodular diseases when detailed checklists were applied such as internal consistency, multiplicity of nodules, nodular ehogenicity, nodular capsule or margin and calcification of nodules.

Recurrent Abdominal Pains: A Field Survey of 1,783 School Children in Seoul

PURPOSE: We investigated the occurrence rate of recurrent abdominal pain (RAP) in general population of elementary school children, accompanied symptoms, symptom-aggravating factors such as emotional stresses, food and personality characters, which time of day the pain develops and whether they visited hospital for RAP. METHODS: From 1995. 4.27. to 1995. 5. 12. questionnaires were given to the parents of 1,783 elementary school children in Seoul. The qestions were as follow; 1) Have your child ever experienced abdominal pain more than 3 months and more than 3 times? 2) Were there any accompanied symptoms? 3) Does emotional stress encrease or induce the abdominal pain of your child? 4) Which time of day does the abdominal pain occur? 5) Have your child visited hospital for the RAP? 6)How is your child's personality and emotional characters? 7) Which foods induce or aggravate the abdominal pain? 8) Does your child with RAP like meat foods or vegetable foods? 9) If you think an emotional stressful factor for RAP, do you have such factors in the environment of your child? RESULTS: 1) Among the 1,783 children, 296 children had RAP (16.6%), boys 143 (15.4%), girl 153 (7.9%). The distribution of school grade of the children with RAP were in the order of the 2nd. grade (23.5%), 5th. grade (19.6%), 4th grade (15.8%), 6th. grade (15.0%), 1st. grade (14.3%), and 3rd.grade (11.9). 2) Symptoms which were accompained with abdominal pain was poor appetite (35.1%), diarrhea (31.8%), headache (27.1%), constipation (21.7%) vomiting (18.4%), urinary symptoms (11.1%) and 73 children (24.4%) had no accompanied symptom. 3) In 181 children (60.5% of RAP children), abdominal pain was induced or aggravated by emotional or psychologic stress. 4) In 130 children (43.5% of RAP children) abdominal pain occurred at postprandial time, in 80 children (28.6%) before meal, and in 70 children (23.4) early morning or night time. 5) Main personality characteristics of children with RAP were poor self confidences (111, 37.1%), strong desires for sucess (104,34.8%), and compulsivenesses (55,18.4%). 6) 135 children with RAP (45.2%) visited doctor due to RAP 7) Foods which induced or aggravated the abdominal symptoms were dairy food (56 children,19.4% of RAP children), greasy food (50,17.3%), wheat (29,10%), pork (21,7.3%) and in 165 children with RAP (57.1) foods had no relation with the abdominal pain. 8) 218 children with RAP (75.4%) liked meat foods (75.4%), and 73 children (25.3%) vegetable foods. 9) Specific emotional stresses of children with RAP which were described by the parents were school problems in 41 children (14.2%), divorces of parents in 3 children (1.4%). CONCLUSIONS: RAP in school children were more frequent than previously reported. We suspected organic causes for the RAP in many children who developed abdominal pain at night time, who had some accompanied symptoms, whose symptoms had no relation with emotional stresses or foods. Further active investigations in children with RAP are needed to elucidate the role of associated disorders.

Pituitary Stalk Transection Syndrome / 대한내분비학회지

We experienced one case of severe pituitary dwarfism in a 16 years old male boy that magnetic resonance image(MRI) revealed transection of the pituitary stalk with the ectopic location of posterior pituitary gland and hypoplastic anterior pituitary gland. The serum growth horrnone(GH) response to clonidine and L-dopa revealed severe GH deficiency. The patient revealed normal response in TSH, prolactin and LH, FSH to TRH and LHRH respectively. So far, the primary cause of idiopathic pituitary dwarfism in many patients was due to hypoxic injury to hypothalmus by perinatal insults. In this patients, there was no history of perinatal insults and postnatal head trauma. We report a case of severe dwarfism due to hypogenesis of anterior pituitary gland.