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.

Hospital Volume Threshold Associated with Higher Survival after Endovascular Recanalization Therapy for Acute Ischemic Stroke / 대한뇌졸중학회지

Background@#and Purpose Endovascular recanalization therapy (ERT) is becoming increasingly important in the management of acute ischemic stroke (AIS). However, the hospital volume threshold for optimal ERT remains unknown. We investigated the relationship between hospital volume of ERT and risk-adjusted patient outcomes. @*Methods@#From the National Health Insurance claims data in Korea, 11,745 patients with AIS who underwent ERT from July 2011 to June 2016 in 111 hospitals were selected. We measured the hospital’s ERT volume and patient outcomes, including the 30-day mortality, readmission, and postprocedural intracranial hemorrhage (ICH) rates. For each outcome measure, we constructed risk-adjusted prediction models incorporating demographic variables, the modified Charlson comorbidity index, and the stroke severity index (SSI), and validated them. Risk-adjusted outcomes of AIS cases were compared across hospital quartiles to confirm the volume-outcome relationship (VOR) in ERT. Spline regression was performed to determine the volume threshold. @*Results@#The mean AIS volume was 14.8 cases per hospital/year and the unadjusted means of mortality, readmission, and ICH rates were 11.6%, 4.6%, and 8.6%, respectively. The VOR was observed in the risk-adjusted 30-day mortality rate across all quartile groups, and in the ICH rate between the first and fourth quartiles (P<0.05). The volume threshold was 24 cases per year. @*Conclusions@#There was an association between hospital volume and outcomes, and the volume threshold in ERT was identified. Policies should be developed to ensure the implementation of the AIS volume threshold for hospitals performing ERT.

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 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.

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.

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.

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.