First-Pass Recanalization with EmboTrap II in Acute Ischemic Stroke (FREE-AIS): A Multicenter Prospective Study

Objective@#We aimed to evaluate the efficacy of EmboTrap II in terms of first-pass recanalization and to determine whether it could yield favorable outcomes. @*Materials and Methods@#In this multicenter, prospective study, we consecutively enrolled patients who underwent mechanical thrombectomy using EmboTrap II as a front-line device. The primary outcome was the first pass effect (FPE) rate defined by modified Thrombolysis In Cerebral Infarction (mTICI) grade 2c or 3 by the first pass of EmboTrap II. In addition, modified FPE (mFPE; mTICI grade 2b–3 by the first pass of EmboTrap II), successful recanalization (final mTICI grade 2b–3), and clinical outcomes were assessed. We also analyzed the effect of FPE on a modified Rankin Scale (mRS) score of 0–2 at 3 months. @*Results@#Two hundred-ten patients (mean age ± standard deviation, 73.3 ± 11.4 years; male, 55.7%) were included. Ninetynine patients (47.1%) had FPE, and mFPE was achieved in 150 (71.4%) patients. Successful recanalization was achieved in 191 (91.0%) patients. Among them, 164 (85.9%) patients underwent successful recanalization by exclusively using EmboTrap II. The time from groin puncture to FPE was 25.0 minutes (interquartile range, 17.0–35.0 minutes). Procedure-related complications were observed in seven (3.3%) patients. Symptomatic intracranial hemorrhage developed in 14 (6.7%) patients. One hundred twenty-three (58.9% of 209 completely followed) patients had an mRS score of 0–2. Sixteen (7.7% of 209) patients died during the follow-up period. Patients who had successful recanalization with FPE were four times more likely to have an mRS score of 0–2 than those who had successful recanalization without FPE (adjusted odds ratio, 4.13;95% confidence interval, 1.59–10.8; p = 0.004). @*Conclusion@#Mechanical thrombectomy using the front-line EmboTrap II is effective and safe. In particular, FPE rates were high. Achieving FPE was important for an mRS score of 0–2, even in patients with successful recanalization.

Assessment of Hand Motor Function in a Non-human Primate Model of Ischemic Stroke

Ischemic stroke results from arterial occlusion and can cause irreversible brain injury. A non-human primate (NHP) model of ischemic stroke was previously developed to investigate its pathophysiology and for efficacy testing of therapeutic candidates; however, fine motor impairment remains to be well-characterized. We evaluated hand motor function in a cynomolgus monkey model of ischemic stroke. Endovascular transient middle cerebral artery occlusion (MCAO) with an angiographic microcatheter induced cerebral infarction. In vivo magnetic resonance imaging mapped and measured the ischemia-induced infarct lesion. In vivo diffusion tensor imaging (DTI) of the stroke lesion to assess the neuroplastic changes and fiber tractography demonstrated three-dimensional patterns in the corticospinal tract 12 weeks after MCAO. The hand dexterity task (HDT) was used to evaluate fine motor movement of upper extremity digits. The HDT was modified for a home cage-based training system, instead of conventional chair restraint training. The lesion was localized in the middle cerebral artery territory, including the sensorimotor cortex. Maximum infarct volume was exhibited over the first week after MCAO, which progressively inhibited ischemic core expansion, manifested by enhanced functional recovery of the affected hand over 12 weeks after MCAO. The total performance time decreased with increasing success rate for both hands on the HDT. Compensatory strategies and retrieval failure improved in the chronic phase after stroke. Our findings demonstrate the recovery of fine motor skill after stroke, and outline the behavioral characteristics and features of functional disorder of NHP stroke model, providing a basis for assessing hand motor function after stroke.

A Prospective Study on the Value of Ultrasound Microflow Assessment to Distinguish Malignant from Benign Solid Breast Masses: Association between Ultrasound Parameters and Histologic Microvessel Densities

OBJECTIVE: To investigate the value of ultrasound (US) microflow assessment in distinguishing malignant from benign solid breast masses as well as the association between US parameters and histologic microvessel density (MVD). MATERIALS AND METHODS: Ninety-eight breast masses (57 benign and 41 malignant) were examined using Superb Microvascular Imaging (SMI) and contrast-enhanced US (CEUS) before biopsy. Two radiologists evaluated the quantitative and qualitative vascular parameters on SMI (vascular index, morphology, distribution, and penetration) and CEUS (time-intensity curve analysis and enhancement characteristics). US parameters were compared between benign and malignant masses and the diagnostic performance was compared between SMI and CEUS. Subgroup analysis was performed according to lesion size. The effect of vascular parameters on downgrading Breast Imaging Reporting and Data System (BI-RADS) category 4A masses was evaluated. The association between histologic MVD and US parameters was analyzed. RESULTS: Malignant masses were associated with a higher vascular index (15.1 ± 7.3 vs. 5.9 ± 5.6), complex vessel morphology (82.9% vs. 42.1%), central vascularity (95.1% vs. 59.6%), penetrating vessels (80.5% vs. 31.6%) on SMI (all, p < 0.001), as well as higher peak intensity (37.1 ± 25.7 vs. 17.0 ± 15.8, p < 0.001), slope (10.6 ± 11.2 vs. 3.9 ± 4.2, p = 0.001), area (1035.7 ± 726.9 vs. 458.2 ± 410.2, p < 0.001), hyperenhancement (95.1% vs. 70.2%, p = 0.005), centripetal enhancement (70.7% vs. 45.6%, p = 0.023), penetrating vessels (65.9% vs. 22.8%, p < 0.001), and perfusion defects (31.7% vs. 3.5%, p < 0.001) on CEUS (p ≤ 0.023). The areas under the receiver operating characteristic curve (AUCs) of SMI and CEUS were 0.853 and 0.841, respectively (p = 0.803). In 19 masses measuring < 10 mm, central vascularity on SMI was associated with malignancy (100% vs. 38.5%, p = 0.018). Considering all benign SMI parameters on the BI-RADS assessment, unnecessary biopsies could be avoided in 12 category 4A masses with improved AUCs (0.500 vs. 0.605, p < 0.001). US vascular parameters associated with malignancy showed higher MVD (p ≤ 0.016). MVD was higher in malignant masses than in benign masses, and malignant masses negative for estrogen receptor or positive for Ki67 had higher MVD (p < 0.05). CONCLUSION: US microflow assessment using SMI and CEUS is valuable in distinguishing malignant from benign solid breast masses, and US vascular parameters are associated with histologic MVD.

Increased CD68/TGFβ Co-expressing Microglia/Macrophages after Transient Middle Cerebral Artery Occlusion in Rhesus Monkeys

The function of microglia/macrophages after ischemic stroke is poorly understood. This study examines the role of microglia/macrophages in the focal infarct area after transient middle cerebral artery occlusion (MCAO) in rhesus monkeys. We measured infarct volume and neurological function by magnetic resonance imaging (MRI) and non-human primate stroke scale (NHPSS), respectively, to assess temporal changes following MCAO. Activated phagocytic microglia/macrophages were examined by immunohistochemistry in post-mortem brains (n=6 MCAO, n=2 controls) at 3 and 24 hours (acute stage), 2 and 4 weeks (subacute stage), and 4, and 20 months (chronic stage) following MCAO. We found that the infarct volume progressively decreased between 1 and 4 weeks following MCAO, in parallel with the neurological recovery. Greater presence of cluster of differentiation 68 (CD68)-expressing microglia/macrophages was detected in the infarct lesion in the subacute and chronic stage, compared to the acute stage. Surprisingly, 98~99% of transforming growth factor beta (TGFβ) was found colocalized with CD68-expressing cells. CD68-expressing microglia/macrophages, rather than CD206⁺ cells, may exert anti-inflammatory effects by secreting TGFβ after the subacute stage of ischemic stroke. CD68⁺ microglia/macrophages can therefore be used as a potential therapeutic target.

Dichotomizing Level of Pial Collaterals on Multiphase CT Angiography for Endovascular Treatment in Acute Ischemic Stroke: Should It Be Refined for 6-Hour Time Window? / 신경중재치료의학

PURPOSE: Although endovascular treatment is currently thought to only be suitable for patients who have pial arterial filling scores >3 as determined by multiphase computed tomography angiography (mpCTA), a cut-off score of 3 was determined by a study, including patients within 12 hours after symptom onset. We aimed to investigate whether a cut-off score of 3 for endovascular treatment within 6 hours of symptom onset is an appropriate predictor of good functional outcome at 3 months. MATERIALS AND METHODS: From April 2015 to January 2016, acute ischemic stroke patients treated with mechanical thrombectomy within 6 hours of symptom onset were enrolled into this study. Pial arterial filling scores were semi-quantitatively assessed using mpCTA, and clinical and radiological parameters were compared between patients with favorable and unfavorable outcomes. Multivariate logistic regression analysis was then performed to investigate the independent association between clinical outcome and pial collateral score, with the predictive power of the latter assessed using C-statistics. RESULTS: Of the 38 patients enrolled, 20 (52.6%) had a favorable outcome and 18 had an unfavorable outcome, with the latter group showing a lower mean pial arterial filling score (3.6±0.8 vs. 2.4±1.2, P=0.002). After adjusting for variables with a P-value of 2 vs. ≤2. CONCLUSION: A pial arterial filling cut-off score of 2 as determined by mpCTA appears to be more suitable for predicting clinical outcomes following endovascular treatment within 6 hours of symptom onset than the cut-off of 3 that had been previously suggested.

Does Multiphasic Contrast Enhanced Fluid Attenuated Inversion Recovery Magnetic Resonance Imaging Enhance the Detectability of Small Intracerebral Metastases?

PURPOSE@#To determine adequate timing of acquisition of contrast-enhanced fluid attenuated inversion recovery (FLAIR) by using multiphasic contrast-enhanced FLAIR magnetic resonance imaging (MRI) and to evaluate added value in detecting small intracerebral metastases 5 mm or less.@*MATERIALS AND METHODS@#Twenty-nine patients, that underwent multiphasic contrast-enhanced FLAIR MRI and contrast-enhanced T1 weighted image (T1WI) were included and total number of small intracerebral metastases was 131. Sensitivity, specificity and accuracy of lesion detection were evaluated. Contrast ratio (CR) and enhancement ratio of each lesion were compared and analyzed among each imaging sequence.@*RESULTS@#Sensitivity, specificity and accuracy of lesion detection were increased when contrast-enhanced FLAIR was added to contrast-enhanced T1WI. Area of under receiver operating characteristic curve significantly increased by addition of contrast-enhanced FLAIR than using contrast-enhanced T1WI alone (p < 0.05). CR was significantly higher in contrast-enhanced T1WI than FLAIR (p < 0.001). All of the above results were not different according to time of acquisition of contrastenhanced FLAIR.@*CONCLUSION@#There was advantage of conducting contrast-enhanced FLAIR MRI, but multiphasic contrast-enhanced FLAIR did not provide additional information for detection of small intracerebral metastases compared with single-phase FLAIR MRI.

An Innovative Ultrasound Technique for Evaluation of Tumor Vascularity in Breast Cancers: Superb Micro-Vascular Imaging / 한국유방암학회지

Tumor vascularity is an important indicator for differential diagnosis, tumor growth, and prognosis. Superb micro-vascular imaging (SMI) is an innovative ultrasound technique for vascular examination that uses a multidimensional filter to eliminate clutter and preserve extremely low-velocity flows. Theoretically, SMI could depict more vessels and more detailed vascular morphology, due to the increased sensitivity of slow blood flow. Here, we report the early experience of using SMI in 21 breast cancer patients. We evaluated tumor vascular features in breast cancer and compared SMI and conventional color or power Doppler imaging. SMI was superior to color or power Doppler imaging in detecting tumor vessels, the details of vessel morphology, and both peripheral and central vascular distribution. In conclusion, SMI is a promising ultrasound technique for evaluating microvascular information of breast cancers.

A Comparison between Mechanical Thrombectomy and Intra-arterial Fibrinolysis in Acute Basilar Artery Occlusion: Single Center Experiences / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Recent advances in intra-arterial techniques and thrombectomy devices lead to high rate of recanalization. However, little is known regarding the effect of the evolvement of endovascular revascularization therapy (ERT) in acute basilar artery occlusion (BAO). We compared the outcome of endovascular mechanical thrombectomy (EMT) versus intra-arterial fibrinolysis (IAF)-based ERT in patients with acute BAO. METHODS: After retrospectively reviewed a registry of consecutive patients with acute ischemic stroke who underwent ERT from September 2003 to February 2015, 57 patients with acute BAO within 12 hours from stroke onset were enrolled. They were categorized as an IAF group (n=24) and EMT group (n=33) according to the primary technical option. We compared the procedural and clinical outcomes between the groups. RESULTS: The time from groin puncture to recanalization was significantly shorter in the EMT group than in the IAF group (48.5 [25.3 to 87.8] vs. 92 [44 to 179] minutes; P=0.02) The rate of complete recanalization was significantly higher in the EMT group than in the IAF group (87.9% vs 41.7%; P<0.01). The good outcome of the modified Rankin Scale score≤2 at 3 months was more frequent in the EMT group than in the IAF group, but it was not statistically significant (39.4% vs 16.7%; P=0.06). CONCLUSIONS: EMT-based ERT in patients with acute BAO is superior to IAF-based ERT in terms of the reduction of time from groin puncture to recanalization and the improvement of the rate of complete recanalization.

Primary Neuroendocrine Carcinoma of the Breast with Clinical Features of Inflammatory Breast Carcinoma: A Case Report and Literature Review / 한국유방암학회지

Primary neuroendocrine carcinoma of the breast (NECB) is a very rare type of invasive breast carcinoma. Most NECBs appear on breast imaging as solid masses of varied shapes and margins, and have worse clinical outcomes than does invasive ductal carcinoma, not otherwise specified. However, there have been no reports to date regarding NECB with features of inflammatory breast carcinoma. Here, we describe the clinical, radiol-ogic, and pathologic findings of the first reported case of primary NECB presenting as inflammatory breast carcinoma. The patient complained of diffuse right breast enlargement and erythema. Mammography identified severe breast edema and axillary lymphadenopathy. Ultrasound detected an irregular, angular, hypoechoic mass with dermal lymphatic dilatation. On magnetic resonance imaging, the mass had rim enhancement and the entire right breast showed heterogeneous enhancement with malignant kinetic features. Pathology identified the mass as a primary NECB with positive for synaptophysin, CD56, estrogen and progesterone receptors.

Pancreatic Adenosquamous Cell Carcinoma with Solitary Liver Metastasis Showing Different Imaging Features

Among exocrine pancreatic tumors, adenosquamous carcinoma is a rare, aggressive subtype with a poor prognosis and a high potential for metastases compared with its more conventional glandular counterpart, adenocarcinoma of the pancreas. We herein describe the imaging findings of pancreatic adenosquamous cell carcinoma with solitary liver metastasis showing different imaging features and also review the previous literature to recognize characteristic imaging features of pancreatic adenosquamous cell carcinoma.

Infratentorial and Intraparenchymal Subependymoma in the Cerebellum: Case Report

Subependymomas are rare benign tumors located in the ventricular system. Intraparenchymal subependymoma is extremely rare; only 6 cases have been reported, and all were located in the supratentorial region. We describe a case of infratentorial, intraparenchymal subependymoma in a 28-year-old man with intermittent headache. Imaging revealed a well-demarcated cystic and solid cerebellar mass near the fourth ventricle. The mass had a microcystic component and calcification without contrast enhancement. Complete surgical excision was performed, and histopathology confirmed a subependymoma.

Fluoroscopic Guided Fogarty Embolectomy for an Angio-Seal Embolism in the Popliteal Artery

The Angio-Seal is a widely used arterial closure device that helps achieve faster hemostasis and provide early ambulation to patients. However, it can cause various complications in clinical practice. We present the uncommon complication of popliteal artery occlusion following Angio-Seal deployment, and describe an effective interventional approach to its treatment. Because fluoroscopy-guided Fogarty embolectomy has the advantages of complete removal of the embolus without fragmentation, and clear visualization of the exact location of the embolus during the procedure, it is a suitable method for treating this complication.

Evaluation of the Effect of Hemoglobin or Hematocrit Level on Dural Sinus Density Using Unenhanced Computed Tomography

PURPOSE: To identify the relationship between hemoglobin (Hgb) or hematocrit (Hct) level and dural sinus density using unenhanced computed tomography (UECT). MATERIALS AND METHODS: Patients who were performed UECT and had records of a complete blood count within 24 hours from UECT were included (n=122). We measured the Hounsfield unit (HU) of the dural sinus at the right sigmoid sinus, left sigmoid sinus and 2 points of the superior sagittal sinus. Quantitative measurement of dural sinus density using the circle regions of interest (ROI) method was calculated as average ROI values at 3 or 4 points. Simple regression analysis was used to evaluate the correlation between mean HU and Hgb or mean HU and Hct. RESULTS: The mean densities of the dural sinuses ranged from 24.67 to 53.67 HU (mean, 43.28 HU). There was a strong correlation between mean density and Hgb level (r=0.832) and between mean density and Hct level (r=0.840). CONCLUSION: Dural sinus density on UECT is closely related to Hgb and Hct levels. Therefore, the Hgb or Hct levels can be used to determine whether the dural sinus density is within the normal range or pathological conditions such as venous thrombosis.

A Case of Langerhans Cell Histiocytosis Involving the Thyroid Gland: Ultrasonographic Finding

Langerhans cell histiocytosis is a rare, proliferative monoclonal histiocytic disease of unknown cause. Primary involvement of the thyroid gland by LCH is very rare, and most cases show evidence of LCH involving other organs. Herein, we report on a case of thyroid LCH in a patient diagnosed as pituitary gland LCH. When a patient with a history of LCH presents with enlargement of the thyroid gland or a neck mass, and ultrasonography shows a well-defined low echoic mass, LCH should be included in differential diagnosis. Fine needle aspiration can be useful for initial diagnosis; however, for differentiation with thyroiditis or thyroid cancer, core biopsy, positive S-100 protein, and CD1a immunohistochemical staining are needed.

Multimodal Imaging Follow-up of a Thrombosed Developmental Venous Anomaly: CT, CT Angiography and Digital Subtraction Angiography / 신경중재치료의학

We report a rare case of thrombosed developmental venous anomaly (DVA) in a 31-year old male with hemorrhagic cerebral venous infarction at the initial clinical presentation. In this case, sequential CT, CT angiography and digital subtraction angiography demonstrated thrombotic obstruction of the venous drainage from DVA, its progressive recanalization and temporal evolution of the affected brain parenchyma. The relevant previous literatures were reviewed and summarized.

Classification of Metastatic versus Non-Metastatic Axillary Nodes in Breast Cancer Patients: Value of Cortex-Hilum Area Ratio with Ultrasound / 한국유방암학회지

PURPOSE: To investigate the significance of the cortex-hilum (CH) area ratio and longitudinal-transverse (LT) axis ratio and the blood flow pattern for diagnosis of metastatic axillary lymph nodes by ultrasound in breast cancer patients. METHODS: From October 2005 to July 2006, we prospectively evaluated axillary nodes with ultrasound in 205 consecutive patients who had category 4B, 4C or 5 breast lesions according to the Breast Imaging Reporting and Data System-Ultrasound (BI-RADS-Ultrasound(R)). Among the 205, there were 24 patients who had pathologic verification of breast cancer and axillary lymph node status. For a total of 80 axillary nodes we measured the areas of the cortex and hilum of lymph nodes and calculated the area ratio. We also measured the length of the longitudinal and transverse axis of the lymph nodes and calculated the length ratio. We evaluated the blood flow pattern on power Doppler imaging and classified each lymph node into a central or peripheral pattern. Diagnostic performance was analyzed according to positive criteria for lymph node metastasis (CH area ratio >2, LT axis ratio <2, peripheral type on power Doppler imaging). RESULTS: The sensitivity of the CH area ratio was superior to that of the LT axis ratio (94.1% vs. 82.3%, p=0.031) and to that of the blood flow pattern (94.1% vs. 29.4%, p=0.009). For specificity, all three evaluating parameters had high values (89.1-95.6%) and no significant differences were found (p=0.121). The CH area ratio had a better positive predictive value than the LT axis ratio (94.1% vs. 80.0%, p=0.030) and power Doppler imaging (94.1% vs. 66.6%, p=0.028). For the negative predictive value, the CH area ratio was superior to the LT axis ratio (95.6% vs. 86.6%, p=0.035) and the blood flow pattern (95.6% vs. 63.0%, p=0.027). CONCLUSION: We recommend the CH area ratio of an axillary lymph node on ultrasound as a quantitative indicator for the classification of lymph nodes. The CH area ratio can improve diagnostic performance when compared with the LT axis ratio or blood flow pattern.

Unilateral Hydronephrosis and Hydroureter by Foreign Body in Urinary Bladder: A Case Report

Foreign bodies inserted through the urethra are often found in the urinary bladder. We presently report the first case of hydronephrosis and hydroureter due to direct compression in the urinary bladder by silicon, which had been introduced by the patient himself 2 yr prior to presentation with severe right flank pain. Computed tomography indicated a convoluted, high-attenuation mass in the urinary bladder; unilateral hydronephrosis and hydroureter were also present due to direct compression by the mass. The foreign body was removed using a cystoscope. This foreign body was proven to be silicon.

Atypical Developmental Venous Anomaly Associated with Single Arteriovenous Fistula and Intracerebral Hemorrhage: a Case Demonstrated by Superselective Angiography

We present a case of developmental venous anomaly associated with arteriovenous fistula supplied by a single arterial feeder adjacent to a large acute intracerebral hemorrhage. The arteriovenous fistula was successfully obliterated by superselective embolization while completely preserving the developmental venous anomaly. Two similar cases, including superselective angiographic findings, have been reported in the literature; however, we describe herein superselective angiographic findings in more detail and demonstrate the arteriovenous shunt more clearly than the previous reports. In addition, a literature review was performed to discuss the association of a developmental venous anomaly with vascular lesions.

Thrombin-induced Migration and Matrix Metalloproteinase-9 Expression Are Regulated by MAPK and PI3K Pathways in C6 Glioma Cells

Glioblastoma multiforme is one of the most common and aggressive tumors in central nervous system. It often possesses characteristic necrotic lesions with hemorrhages, which increase the chances of exposure to thrombin. Thrombin has been known as a regulator of MMP-9 expression and cancer cell migration. However, the effects of thrombin on glioma cells have not been clearly understood. In the present study, influences of thrombin on glioma cell migration were examined using Boyden chamber migration assay and thrombin-induced changes in MMP-9 expression were measured using zymography, semi-quantitative RT-PCR, and Western blotting. Furthermore, underlying signaling pathways by which thrombin induces MMP-9 expression were examined. Thrombin-induced migration and MMP-9 expression were significantly potentiated in the presence of wortmannin, a PI3K inhibitor, whereas MAPK inhibitors suppressed thrombin-induced migration and MMP-9 expression in C6 glioma cells. The present data strongly demonstrate that MAPK and PI3K pathways evidently regulate thrombin-induced migration and MMP-9 expression of C6 glioma cells. Therefore, the control of these pathways might be a beneficial therapeutic strategy for treatment of invasive glioblastoma multiforme.

Bilateral Carotid and Vertebral Rete Mirabile Presenting with a Prominent Anterior Spinal Artery Mimicking a Spinal Dural AV Fistula at MRI

Bilateral carotid and vertebral rete mirabile (CVRM) is a very rare condition. We report a new case of CVRM initially detected by magnetic resonance imaging (MRI) of the cervical spine. MRI demonstrated tortuous vascular signal voids limited to the anterior cerebrospinal fluid space mimicking spinal dural arteriovenous fistula. A diagnosis of CVRM was confirmed on the basis of angiographic findings of rete formation associated with bilateral aplasia of the cavernous internal carotid and vertebral arteries without abnormal arteriovenous connection.