Obscured Segments of Ruptured Brain Arteriovenous Malformations: Insights from Their Visualization during Emergency Transarterial Embolization / 신경중재치료의학

A ruptured brain arteriovenous malformation (bAVM) presenting with a hematoma may have unseen parts of the shunts in diagnostic angiography in the acute phase, which may lead to innate incomplete evaluation for the whole angioarchitecture of the bAVM. Even though it is generally accepted that the nidus of a ruptured bAVM may be underestimated in angiography during the acute phase due to hematoma compression, documentation of the underestimated parts has not been described in the literature. The authors report 2 cases of ruptured bAVMs in which the obscured segments were cast with liquid embolic material, which suggests a potential presence of obscured segments in bAVMs.

Single Center Experience of the Balloon-Stent Technique for the Treatment of Unruptured Distal Internal Carotid Artery Aneurysms: Sharing a Simple and Reliable Tip to Use Scepter-Atlas Combination

Purpose@#The balloon-stent technique (BST) has certain strengths as an assisted technique for the treatment of complex aneurysms. After Atlas release, the BST can be executed without an exchange maneuver of the balloon to the stent-delivery catheter. The purpose of this article is to share our experience with the BST using the Scepter-Atlas combination. @*Materials and Methods@#Device inspection led us to a simple method to avoid failure in loading Atlas to the Scepter. From March 2018 to December 2019, 57 unruptured distal internal carotid artery (dICA) aneurysms were treated with coil embolization; among which, 25 aneurysms in 23 patients were treated with BST. Clinical and angiographic data were retrospectively collected and reviewed. @*Results@#The technical success rate of the Scepter-Atlas combination increased from 50% to 100% after careful inspection. BST angiographic results were comparable to the stent-assisted coil (SAC) group treated during the immediately post-embolization same period (modified Raymond-Roy classification [MRRC] 1 & 2 84% in BST, 96.3% in SAC) and during short-term follow-up (MRRC 1 & 2 95.8% in BST, 88.4% in SAC). A small number of patients showed periprocedural complications, but none had clinical consequences. @*Conclusion@#BST using the Scepter-Atlas combination can provide an effective and safe method for the treatment of dICA aneurysms. Scepters can be used as delivery catheters for Atlas.

The Relationship between Neural Foraminal Stenosis and Imaging Features of Lumbar Spine MRI in Patients Older Than 60 Years with Lumbar Radiculopathy

Purpose@#To investigate the MRI features associated with neural foraminal stenosis (NFS) in patients older than 60 years with lumbar (L) radiculopathy. @*Materials and Methods@#This study included 133 retrospectively selected patients older than 60 years with lumbar radiculopathy who had undergone a lumbar spine MRI (from January 2018 to April 2018). For L4/L5 and L5/sacral (S)1 levels, NFS was reviewed blindly by two radiologists. Spondylolisthesis, retrolisthesis, disc height loss, disc bulging/herniation/central canal stenosis, ligamentum flavum thickening, and facet hypertrophy were evaluated separately for the NFS and non-NFS groups, and they were compared using univariate and multivariate analyses. @*Results@#The univariate analysis revealed that disc height loss (p = 0.006) was associated with NFS for L4/L5. For L5/S1, both spondylolisthesis (p = 0.005) and facet hypertrophy (p = 0.006) were associated with NFS. The multivariate logistic analysis revealed that disc height loss was associated with NFS for L4/L5 [odds ratio (OR) = 4.272; 95% confidence interval (CI) 1.736– 10.514]. For L5/S1, spondylolisthesis (OR = 3.696; 95% CI 1.297–10.530) and facet hypertrophy (OR = 6.468; 95% CI 1.283–32.617) were associated with NFS. @*Conclusion@#Disc height loss was associated with NFS for L4/L5 and spondylolisthesis and facet hypertrophy were associated with NFS for L5/S1.

Single Center Experience of the Balloon-Stent Technique for the Treatment of Unruptured Distal Internal Carotid Artery Aneurysms: Sharing a Simple and Reliable Tip to Use Scepter-Atlas Combination

Purpose@#The balloon-stent technique (BST) has certain strengths as an assisted technique for the treatment of complex aneurysms. After Atlas release, the BST can be executed without an exchange maneuver of the balloon to the stent-delivery catheter. The purpose of this article is to share our experience with the BST using the Scepter-Atlas combination. @*Materials and Methods@#Device inspection led us to a simple method to avoid failure in loading Atlas to the Scepter. From March 2018 to December 2019, 57 unruptured distal internal carotid artery (dICA) aneurysms were treated with coil embolization; among which, 25 aneurysms in 23 patients were treated with BST. Clinical and angiographic data were retrospectively collected and reviewed. @*Results@#The technical success rate of the Scepter-Atlas combination increased from 50% to 100% after careful inspection. BST angiographic results were comparable to the stent-assisted coil (SAC) group treated during the immediately post-embolization same period (modified Raymond-Roy classification [MRRC] 1 & 2 84% in BST, 96.3% in SAC) and during short-term follow-up (MRRC 1 & 2 95.8% in BST, 88.4% in SAC). A small number of patients showed periprocedural complications, but none had clinical consequences. @*Conclusion@#BST using the Scepter-Atlas combination can provide an effective and safe method for the treatment of dICA aneurysms. Scepters can be used as delivery catheters for Atlas.

The Relationship between Neural Foraminal Stenosis and Imaging Features of Lumbar Spine MRI in Patients Older Than 60 Years with Lumbar Radiculopathy

Purpose@#To investigate the MRI features associated with neural foraminal stenosis (NFS) in patients older than 60 years with lumbar (L) radiculopathy. @*Materials and Methods@#This study included 133 retrospectively selected patients older than 60 years with lumbar radiculopathy who had undergone a lumbar spine MRI (from January 2018 to April 2018). For L4/L5 and L5/sacral (S)1 levels, NFS was reviewed blindly by two radiologists. Spondylolisthesis, retrolisthesis, disc height loss, disc bulging/herniation/central canal stenosis, ligamentum flavum thickening, and facet hypertrophy were evaluated separately for the NFS and non-NFS groups, and they were compared using univariate and multivariate analyses. @*Results@#The univariate analysis revealed that disc height loss (p = 0.006) was associated with NFS for L4/L5. For L5/S1, both spondylolisthesis (p = 0.005) and facet hypertrophy (p = 0.006) were associated with NFS. The multivariate logistic analysis revealed that disc height loss was associated with NFS for L4/L5 [odds ratio (OR) = 4.272; 95% confidence interval (CI) 1.736– 10.514]. For L5/S1, spondylolisthesis (OR = 3.696; 95% CI 1.297–10.530) and facet hypertrophy (OR = 6.468; 95% CI 1.283–32.617) were associated with NFS. @*Conclusion@#Disc height loss was associated with NFS for L4/L5 and spondylolisthesis and facet hypertrophy were associated with NFS for L5/S1.

Utility of sentinel lymph node biopsy in papillary thyroid microcarcinoma

Purpose@#There are many studies on sentinel lymph node (SLN) biopsy in thyroid carcinoma but SLN biopsy (SLNB) in papillary thyroid carcinoma (PTC) remains open to debate. Therefore in this retrospective study, the usefulness of SLNB in thyroid carcinoma patients who had micro-PTC without cervical lymphadenopathy was assessed. @*Methods@#SLNB was performed in 114 patients who were diagnosed with micro-PTC in a single lobe without palpable or ultrasound-detected lymph node at the tertiary center between January 2012 and December 2013. After SLNB, all patients underwent total thyroidectomy and central neck dissection or thyroid lobectomy and central neck dissection of the single side. @*Results@#SLNs were identified in 112 of 114 patients with 41 positive SLNs and 71 negative SLNs on intraoperative frozen sections. However, eight negative patients were found to be positive in the final pathology. Sentinel node identification rate and false negative value of SLNB were 98.2% and 11.3%, respectively. In the univariate analysis, higher lymph node metastasis was detected in men than in women. Higher detection number of SLN showed higher probability of lymph node metastasis. @*Conclusion@#SLNB may be helpful in papillary thyroid cancer, especially in male patients. Also, it is useful for the staging of nodal status and clearance of persistent disease.

Clinical and Imaging Findings of Neonatal Seizures Presenting as Diffuse Cerebral White Matter Abnormality on Diffusion-Weighted Imaging without any Structural or Metabolic Etiology

Purpose@#Some patients with neonatal seizures show diffuse, symmetric diffusion-restricted lesions in the cerebral white matter. The aim of this study was to describe clinical and imaging findings of patients with neonatal seizures who had diffuse, symmetric diffusion-restricted lesions without any structural or metabolic etiology. @*Materials and Methods@#A total of 56 neonates aged less than 1 week underwent brain magnetic resonance imaging (MRI) for evaluation of seizures from November 2008 to February 2017. After excluding 43 patients, 13 patients showed diffuse white matter abnormality on diffusion-weighted imaging. Initial and follow-up clinical and MRI findings were analyzed retro-spectively. @*Results@#All 13 patients were born at full term. Among the ten patients who underwent a stool test for viruses, six were positive for rotavirus and one for astrovirus. MRI revealed diffuse, symmetric diffusion-restricted lesions distributed along the cerebral white matter, thalami, and midbrain variably. @*Conclusion@#Diffuse, symmetric diffusion-restricted lesions involving the cerebral white matter can be seen in patients with neonatal seizures without any structural or metabolic etiology. Rotavirus is commonly but not exclusively detected in these patients. Nevertheless, viral infection-associated encephalopathy should be considered for patients with characteristic clinical and MRI findings.

Emphysematous Gastritis Worsened after Upper Endoscopy

Emphysematous gastritis is an infectious disease in which air is formed in the gastric wall by gas-forming organisms. It is infrequently reported but can be fatal without early diagnosis and treatment. The stomach is rarely infected because of the acidity of the gastric secretions and the rich blood supply. Treatment should be aimed at covering gram-negative organisms and anaerobes using broad-spectrum intravenous antibiotics, and occasional surgical management in order to enhance survival. Risk factors are those that lead to disrupted mucosal integrity, such as corrosive injury, and those that result in an immunosuppressed condition, including diabetes mellitus, chronic kidney disease, immunosuppressive drug use, and subsequent invasion by gas-forming organisms. We experienced a case of emphysematous gastritis that worsened after endoscopy. Aeration during upper endoscopy examination can cause barotrauma to the gastric wall with impairment of the mucosal barrier, resulting in the spread of gastric wall infection to the whole body. Therefore, we report this case and provide relevant literature review to suggest that early endoscopic evaluation can lead to exacerbation of emphysematous gastritis.

Acoustic radiation force impulse imaging of biopsy-proven Kikuchi disease: initial experiences for evaluating feasibility in pediatric patients

PURPOSE: This study evaluated the feasibility of acoustic radiation force impulse (ARFI) elastography and characterized the sonographic features of lymph nodes (LNs) with Kikuchi disease in pediatric patients. METHODS: Seventy-six cervical LN biopsies were performed for the diagnosis of cervical lymphadenopathy. ARFI imaging was performed, and the characteristic ultrasound features of the biopsied LNs and the contralateral LNs were analyzed. We also reviewed clinical and conventional ultrasonographic findings. RESULTS: On histology, 56 patients were diagnosed with Kikuchi disease. These LNs were large and elongated, with increased perinodal echogenicity and capsular thickening. In 38 of them, ARFI elastography was performed, and the median shear wave velocity (SWV) of the biopsied LNs with Kikuchi disease (2.19 m/sec; range, 1.45 to 4.57 m/sec) was higher than of the contralateral LNs (1.72 m/sec; range, 0.95 to 2.65 m/sec; P < 0.001). In patients with reactive hyperplasia, the mean SWV of the biopsied LNs (2.00 m/sec; range, 1.49 to 2.26 m/sec) was higher than that of the contralateral LNs (1.55 m/sec; range, 1.21 to 2.32 m/sec; P=0.031). CONCLUSION: The SWV of LNs with Kikuchi disease was significantly higher than that of the contralateral LNs. Morphologically, LNs with Kikuchi disease showed an enlarged, elongated, and oval shape, increased perinodal echogenicity, and capsular thickening. In addition to the conventional ultrasonographic findings, the application of ARFI is feasible even in pediatric patients for the evaluation of cervical lymphadenopathy.

A Rare Case of Syphilitic Myelitis of the Spinal Cord

Neurosyphilis is an infection of the brain or spinal cord that is caused by the bacterium Treponema pallidum. Syphilitic myelitis, which involves the spinal cord, is a very rare form of neurosyphilis seen in patients with syphilis. It requires differentiation from other diseases of the spinal cord, including idiopathic transverse myelitis and spinal cord infarction. Herein, we describe the presentation and diagnosis of syphilitic myelitis in a 43-year-old woman, based on a flip-flop sign and candle guttering appearance depicted in magnetic resonance imaging and laboratory tests.

A Rare Case of Extrahepatic Left Hepatic Duct Diverticulum: Case Report with Literature Review / 대한췌담도학회지

Hepatic duct diverticulum is a rare form of choledochal cyst that does not fit into the most widely used Todani classification system. Because of its rarity, it may be difficult for clinicians to diagnose and treat it. Here, we present a case of left hepatic diverticulum in a 57-year-old woman with epigastric pain. At presentation, there were mild elevations in the liver function tests. Computed tomography and magnetic resonance cholangiopancreatography showed diverticulum-like cystic lesion with sludge ball near the confluence portion of both intrahepatic bile duct, but the origin of the lesion could not be identified. The clinical impression was type II choledochal cyst. Surgical excision was planned due to recurrent abdominal pain. The operative findings revealed diverticulum arising from left hepatic duct. Histopathology confirmed the lesion to be diverticulum lined by biliary epithelium. The patient had no postoperative complication and no further symptoms since the operation.

Gastric Tuberculosis Presenting as a Subepithelial Mass: A Rare Cause of Gastrointestinal Bleeding / 대한소화기학회지

Gastric tuberculosis accounts for approximately 2% of all cases of gastrointestinal tuberculosis. Diagnosis of gastric tuberculosis is challenging because it can present with various clinical, endoscopic, and radiologic features. Tuberculosis manifesting as a gastric subepithelial tumor is exceedingly rare; only several dozen cases have been reported. A 30-year-old male visited emergency room of our hospital with hematemesis and melena. Abdominal CT revealed a 2.5 cm mass in the gastric antrum, and endoscopy revealed a subepithelial mass with a visible vessel at its center on gastric antrum. Primary gastric tuberculosis was diagnosed by surgical wedge resection. We report a rare case of gastric tuberculosis mimicking a subepithelial tumor with acute gastric ulcer bleeding.

A Rare Manifestation of Solitary Primary Bone Lymphoma of the Finger: a Case Report

Primary extranodal bone lymphoma involving the peripheral extremities is extremely rare. Here, we report a definitive case of diffuse large B-cell lymphoma involving the phalangeal bone of the 3rd finger. Systemic evaluation revealed the lesion as the only site of lymphoma involvement.

Feasibility, Safety, and Follow-up Angiographic Results of Endovascular Treatment for Non-Selected Ruptured Intracranial Aneurysms Under Local Anesthesia with Conscious Sedation

BACKGROUND: At most centers, general anesthesia (GA) has been preferred for endovascular treatment (EVT) of ruptured intracranial aneurysms (RIAs). In this study, we analyzed procedural results, clinical outcomes, and follow-up angiographic findings for patients undergoing EVT for RIA under local anesthesia (LA) with conscious sedation (CS). METHODS: We retrospectively evaluated 308 consecutive patients who underwent EVT for RIAs at a single institution between June 2009 and February 2017. EVT under LA with CS was considered for all patients with aneurysmal subarachnoid hemorrhage, regardless of Hunt and Hess (HH) scale score. RESULTS: EVT was performed for 320 aneurysms in 308 patients with subarachnoid hemorrhages. The mean patient age was 55.5±12.6 years. Moderate (III) and poor (IV, V) HH grades were observed in 75 (24.4%) and 77 patients (25%), respectively. Complete occlusion immediately after EVT was achieved for 270 (84.4%) of 320 aneurysms. Thromboembolic complications and intraprocedural ruptures occurred in 25 (7.8%) and 14 cases (4.3%), respectively. The morbidity rate at discharge (as defined by a modified Rankin scale score of 3 or greater) was 27.3% (84/308), while the mortality rate was 11.7% (36/308). Follow-up angiographic results were available for 210 (68.1%) of 308 patients. Recanalization was observed in 64 (29.3%) of 218 aneurysms in 210 patients. CONCLUSION: Based on our experience, EVT for RIAs under LA with CS was feasible, regardless of the clinical grade of the subarachnoid hemorrhage. Complication rates and follow-up angiographic results were also comparable to those observed when GA was used to perform the procedure.

Biliary Anastomotic Stricture after Surgical Management of Mirizzi Syndrome: Treated with Long-term Percutaneous Transhepatic Biliary Drainage / 대한췌담도학회지

Mirizzi syndrome (MS) is a rare complication of cholecystolithiasis that is characterized by obstruction of the common hepatic duct due to mechanical compression by impacted stones in the neck of the gallbladder or the cystic duct. Treatment of MS is surgical, and operative procedure would vary depending on its classification type. Biliary stricture after surgical treatment of MS is an unusual complication and endoscopic approach is not possible for patients who have undergone bilioenteric anastomosis. We report a case of a 60-year-old patient with biliary anastomotic stricture after surgical management of MS who was successfully treated with long-term percutaneous transhepatic biliary drainage.

Cystic Neck Mass in an Adult: Unusual Manifestation of a Mediastinal Mature Teratoma

Anterior mediastinal teratomas are congenital tumors containing derivatives of all three germ layers. They usually grow slowly and are often detected incidentally by imaging studies. We describe the case of a 38-year-old man with an anterior mediastinal teratoma extending to the anterior neck, which resulted in a cystic neck mass.

Magnetic Resonance Imaging Findings of Early Spondylodiscitis: Interpretive Challenges and Atypical Findings

MR findings of early infectious spondylodiscitis are non-specific and may be confused with those of other conditions. Therefore, it is important to recognize early MR signs of conditions, such as inappreciable cortical changes in endplates, confusing marrow signal intensities of vertebral bodies, and inflammatory changes in paraspinal soft tissues, and subligamentous and epidural spaces. In addition, appreciation of direct inoculation, such as in iatrogenic spondylodiscitis may be important, because the proportion of patients who have undergone recent spine surgery or a spinal procedure is increasing. In this review, the authors focus on the MR findings of early spondylodiscitis, atypical findings of iatrogenic infection, and the differentiation between spondylodiscitis and other disease entities mimicking infection.