Revision Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery for Recurrent Acute Ischemic Stroke Due to Delayed Occlusion of the Bypass Graft.

Intravenous thrombolysis (IVT) and endovascular treatment (EVT) are currently the main treatments for reperfusion in acute ischemic stroke. Although the EVT recanalization rate has increased, unsuccessful recanalization is still observed in 10-30% cases. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is considered a rescue therapy in such cases, but in most centers it is not usually performed for acute ischemic stroke. Graft occlusion is rare following STA-MCA bypass, but it might lead to recurrent ischemic stroke. We hereby report on a patient with right MCA infarction and in whom EVT failed due to complete proximal internal carotid artery occlusion. He underwent an emergency STA-MCA bypass, resulting in a full recovery of his motor weakness. However, six months later, the patient experienced recurrent acute ischemic stroke due to bypass graft occlusion. His EVT failed again but revision bypass surgery, using STA remnant branch, was successful with full motor weakness recovery. We recommend a revision bypass surgery as a feasible therapeutic option for recurrent cerebral infarction caused by delayed STA graft occlusion.

Patient Selection and Clinical Efficacy of Urgent Superficial Temporal Artery-Middle Cerebral Artery Bypass in Acute Ischemic Stroke Using Advanced Magnetic Resonance Imaging Techniques.

BACKGROUND: Selected patients with acute ischemic stroke might benefit from superficial temporal artery-middle cerebral artery (STA-MCA) bypass, but the indications for urgent STA-MCA bypass are unknown. OBJECTIVE: To report our experiences of urgent STA-MCA bypass in patients requiring urgent reperfusion who were ineligible for other reperfusion therapies, using advanced magnetic resonance imaging (MRI) techniques. METHODS: The inclusion criteria for urgent STA-MCA bypass were as follows: acute infarct volume <70 mL with a ratio of perfusion/diffusion lesion volume ≥1.2, and a regional cerebral blood volume ratio >0.85. From January 2013 to October 2015, 21 urgent STA-MCA bypass surgeries were performed. The control group included 19 patients who did not undergo bypass surgery mainly due to refusal of surgery or the decision of the neurologist. Clinical and radiological data were compared between the surgery and control group. RESULTS: The median age of the control group (70 years, interquartile range [IQR] 58-76) was higher than that of the surgery group (62 years, IQR 49-66), but the median preoperative diffusion and perfusion lesion volumes of the surgery group (13.8 mL, IQR 7.5-26.0 and 120.9 mL, IQR 84.9-176.0, respectively) were higher than those of the control group (5.6 mL, IQR 2.1-9.1 and 69.7 mL, IQR 23.9-125.3, respectively). Sixteen (76.2%) patients in the surgery group and 2 (10.5%) patients in the control group had favorable outcomes ( P < .001). Logistic regression analysis identified bypass surgery as the strongest predictive factor. CONCLUSION: STA-MCA bypass can be used as a therapeutic tool for acute ischemic stroke. Advanced MRI techniques are helpful for selecting patients and for decision making.

Impact of Prehospital Intervention on Delay Time to Thrombolytic Therapy in a Stroke Center with a Systemized Stroke Code Program.

BACKGROUND: The use of emergency medical services (EMS) and notification to hospitals by paramedics for patients with suspected stroke are crucial determinants in reducing delay time to acute stroke treatment. The aim of this study is to investigate whether EMS use and prehospital notification (PN) can shorten the time to thrombolytic therapy in a stroke center with a systemized stroke code program. METHODS: Beginning in January 2012, stroke experts in our stroke center received direct calls via mobile phone from paramedics prenotifying the transport of patients with suspected stroke. We compared baseline characteristics and prehospital/in-hospital delay time in stroke patients treated with intravenous recombinant tissue plasminogen activator for 44 months with and without EMS use and/or PN. RESULTS: Intravenous thrombolytic therapy was performed on 274 patients. Of those patients, 215 (78.5%) were transported to the hospital via EMS and 59 (21.5%) were admitted via private modes of transportation. The patients who used EMS had shorter median onset-to-arrival times (62 minutes versus 116 minutes, P < .001). There was no difference in in-hospital delay time between the 2 groups. In 28 cases (13%) of EMS transport, EMS personnel called the clinical staff to notify the incoming patient. Prenotification by EMS was associated with shorter median door-to-imaging time (9 minutes versus 12 minutes, P = .045) and door-to-needle time (20 minutes versus 29 minutes, P = .011). CONCLUSIONS: We found that EMS use reduces prehospital delay time. However, EMS use without prenotification does not shorten in-hospital processing time in a stroke center with a systemized stroke code program.

High residual platelet reactivity (HRPR) for adenosine diphosphate (ADP) stimuli is a determinant factor for long-term outcomes in acute ischemic stroke with anti-platelet agents: The meaning of HRPR after ADP might be more prominent in large atherosclerotic infarction than other subtypes of AIS.

High residual platelet activation (HRPA) after ADP stimuli has associated with recurrent vascular events in acute atherothrombosis with the use of antiplatelet agents (APAs). However, there has been little evidence supporting this association in acute ischemic stroke (AIS). In this study, we evaluated the influences of HRPR after ADP stimuli on the 1-year incidence of recurrent cardiovascular events and mortality in AIS with APAs. We conducted an observational, referral center cohort study on 968 AIS patients with APAs from January 2010 to December 2013 who were evaluated using optical platelet aggregometry (OPA). All patients received the dual APA combination of aspirin and clopidogrel or aspirin alone. We evaluated their platelet function 5 days after hospital admission using OPA. HRPR after ADP stimuli was defined as platelet aggregation of 70 % or greater according to OPA after 10 µM ADP stimuli. The primary endpoint was a composite of all causes of death, myocardial infarction, and stroke at the 1-year follow-up. The secondary endpoints were each component of the primary endpoint. The event rate of primary endpoint was 11.3 % (109/968). Its rate was significantly higher in the patients with HRPR (16.7 %) than in those without (9.7 %). HPRP was independently associated with the primary endpoint (OR = 1.97, CI 1.22-3.18, p < 0.01). According to the AIS subtype, the presence of HRPR was independently significant for the occurrence of the primary endpoint in the large artery atherosclerosis (LAA) subtype only (OR = 2.26, CI 1.15-4.45, p = 0.02). In this study, the presence of HRPR after ADP stimuli is associated with a poor long-term outcome after acute ischemic stroke. In particular, the influence of this factor might be more prominent in LAA compared with other types of AIS.

CT-based assessment of renal function impairment in patients with acute unilateral ureteral obstruction by urinary stones.

PURPOSE: The purpose of our study was to evaluate computed tomography (CT) imaging factors related to renal function impairment in patients with acute unilateral ureteral obstruction by urinary stones. MATERIALS AND METHODS: The study included 94 patients who had acute unilateral ureteral obstruction due to a urinary stone and a normal contralateral kidney. We retrospectively investigated the serum creatinine (SCr) levels immediately prior to CT examination and at least 1 week after treatment. CT examinations were performed using a CT urography protocol, including pre- and post-contrast images. The 67 patients with a SCr change of less than 0.3 mg/dL constituted group A. The other 27 patients with a SCr decrease of more than 0.3 mg/dL constituted group B. To evaluate factors related to renal function impairment, differences in CT imaging factors between the two groups, including the cortical and medullary density, renal and pelvic anteroposterior diameter, and perinephric fluid, were statistically analyzed. RESULTS: The SCr immediately prior to CT examination significantly differed between the two groups. The follow-up SCr after resolution did not significantly differ between the two groups. The difference in the mean cortical and medullary HU on the nephrographic phase between the obstructed kidney and normal kidney was higher in group B than in group A (27.1 ± 23.1 and 69.4 ± 59.1 vs. 5.7 ± 8.8 and 31.8 ± 34.8; p < 0.001 and p = 0.004, respectively). The cut-off point for the difference in the mean cortical HU on the nephrographic phase between the obstructed kidney and normal kidney for renal function impairment was 15 HU, as determined by a receiver operating characteristic curve analysis. CONCLUSIONS: Patients with significantly impaired renal function due to an acute unilateral ureteral obstruction may show a decreased nephrogram of the affected kidney and a significant difference in the HU on the nephrographic phase between the obstructed and normal kidney.

A systemized stroke code significantly reduced time intervals for using intravenous tissue plasminogen activator under magnetic resonance imaging screening.

BACKGROUND: A stroke code can shorten time intervals until intravenous tissue plasminogen activator (IV t-PA) treatment in acute ischemic stroke (AIS). Recently, several reports demonstrated that magnetic resonance imaging (MRI)-based thrombolysis had reduced complications and improved outcomes in AIS despite longer processing compared with computed tomography (CT)-based thrombolysis. METHODS: In January 2009, we implemented CODE RED, a computerized stroke code, at our hospital with the aim of achieving rapid stroke assessment and treatment. We included patients with thrombolysis from January 2007 to December 2008 (prestroke code period) and from January 2009 to May 2013 (poststroke code period). The IV t-PA time intervals and 90-day modified Rankin Scale (mRS) scores were collected. RESULTS: During the observation period, 252 patients used IV t-PA under the CODE RED (MRI based: 208; CT based: 44). The remaining 71 patients (MRI based: 53; CT based: 18) received it before the implementation of our stroke code. After implementation of CODE RED, door-to-image time, door-to-needle time, and the onset-to-needle time were significantly reduced by 11, 18, and 22 minutes in MRI-based thrombolysis. Particularly, the proportion of favorable outcome (mRS score 0-2) was significantly increased (from 41.5% to 60.1%, P = .02) in poststroke than in prestroke code period in MRI-based thrombolysis. However, in ordinal regression, the presence of stroke code showed just a trend for favorable outcome (odds ratio, .99-2.87; P = .059) at 90 days of using IV t-PA after correction of age, sex, and National Institutes of Health Stroke Scale. CONCLUSIONS: In this study, we demonstrated that a systemized stroke code shortened time intervals for using IV t-PA under MRI screening. Also, our results showed a possibility that a systemized stroke code might enhance the efficacy of MRI-based thrombolysis. In the future, we need to carry out a more detailed prospective study about this notion.

The rCBV ratio on perfusion-weighted imaging reveals the extent of blood flow on conventional angiography after acute ischemic stroke.

OBJECTIVE: In this study, we evaluated the relationship between the rCBV (regional cerebral blood flow volume) ratio on perfusion-weighted imaging (PWI) and the extent of collateral flow on conventional angiography. METHODS: We recruited 98 patients with AIS (within 24h after ischemic events). All the patients were evaluated by MRI, including PWI and diffusion-weighted imaging (DWI), and underwent digital subtraction angiography (DSA) of the brain. We hypothesized that the rCBV ratio on PWI could reveal the extent of the blood flow and predict early neurological deterioration (END) within 7 days after AIS. RESULTS: The rCBV ratio on PWI was significantly correlated with its extent on DSA (p<0.01). During the observation period, 24 patients (24.5%) experienced END. The univariate analysis revealed that severe neurological deficit at admission (p<0.01), the volume of the ischemic lesion on DWI (p<0.01), poor blood flow on DSA (p<0.01), the presence of DPM (p=0.05) and a low rCBV ratio on PWI (p<0.01) were related to END occurrence. The multivariate analysis showed that the presence of a low rCBV ratio on PWI was independently significant as a correlate of END (OR, 5.64; 95% CI, 1.68-18.90; p<0.01). CONCLUSION: This study shows that the rCBV ratio on PWI may be a useful tool to reveal the status of blood flow after AIS. Moreover, the extent of collateral flow may be an important parameter that subtly influences the fate of DPM in AIS.

Breast US in patients with breast cancer presenting as only microcalcifications on mammography: can US differentiate ductal carcinoma in situ from invasive cancer?

PURPOSE: To retrospectively review sonographic findings of breast cancers presenting as only microcalcifications on mammography and to evaluate factors essential for differentiating ductal carcinoma in situ (DCIS) from invasive cancers. METHODS: We retrospectively reviewed the medical records of 620 consecutive patients with confirmed breast cancer according to surgery performed between March 2008 and October 2011 at our institution. Of these, 53 lesions from 52 patients who had only microcalcifications without a mass or other associated findings on mammography were selected. Sonographic findings of microcalcification areas were analyzed and correlated with the histopathological findings. RESULTS: Of the 53 lesions, 26 (49.18 %) were classified as invasive cancer and 27 (50.9 %) as DCIS. Ultrasonography (US) showed only echogenic calcifications in five (9.4 %), calcifications within hypoechoic parenchymal thickening in 14 (26.4 %), calcifications within ductal changes in three (5.7 %), and calcifications within a mass in 14 (26.4 %). Seventeen (32.1 %) lesions were not visible on US. Negative findings in US were more frequently observed for DCIS (n = 15, 55.6 %) than for invasive cancers (n = 2, 7.7 %) (p < 0.001). Masses (n = 11, 42.3 % of invasive cancer; n = 3, 11.1 % of DCIS; p = 0.01) were more frequently observed in invasive cancers than in DCIS. CONCLUSIONS: US findings of breast cancers presenting as only mammographic microcalcifications were significantly different between DCIS and invasive cancers. Targeted US of microcalcifications might be helpful for predicting invasive cancers and for determining the clinical preoperative work-up, including axillary staging.

Application of 31P MR spectroscopy to the brain tumors.

OBJECTIVE: To evaluate the clinical feasibility and obtain useful parameters of (31)P magnetic resonance spectroscopy (MRS) study for making the differential diagnosis of brain tumors. MATERIALS AND METHODS: Twenty-eight patients with brain tumorous lesions (22 cases of brain tumor and 6 cases of abscess) and 11 normal volunteers were included. The patients were classified into the astrocytoma group, lymphoma group, metastasis group and the abscess group. We obtained the intracellular pH and the metabolite ratios of phosphomonoesters/phosophodiesters (PME/PDE), PME/inorganic phosphate (Pi), PDE/Pi, PME/adenosine triphosphate (ATP), PDE/ATP, PME/phosphocreatine (PCr), PDE/PCr, PCr/ATP, PCr/Pi, and ATP/Pi, and evaluated the statistical significances. RESULTS: The brain tumors had a tendency of alkalization (pH = 7.28 ± 0.27, p = 0.090), especially the pH of the lymphoma was significantly increased (pH = 7.45 ± 0.32, p = 0.013). The brain tumor group showed increased PME/PDE ratio compared with that in the normal control group (p = 0.012). The ratios of PME/PDE, PDE/Pi, PME/PCr and PDE/PCr showed statistically significant differences between each brain lesion groups (p < 0.05). The astrocytoma showed an increased PME/PDE and PME/PCr ratio. The ratios of PDE/Pi, PME/PCr, and PDE/PCr in lymphoma group were lower than those in the control group and astrocytoma group. The metastasis group showed an increased PME/PDE ratio, compared with that in the normal control group. CONCLUSION: We have obtained the clinically applicable (31)P MRS, and the pH, PME/PDE, PDE/Pi, PME/PCr, and PDE/PCr ratios are helpful for differentiating among the different types of brain tumors.

Acoustic radiation force impulse elastography for hepatocellular carcinoma-associated radiofrequency ablation.

AIM: To evaluate the potential usefulness of acoustic radiation force impulse (ARFI) images for evaluation of hepatocellular carcinomas (HCC)-associated radiofrequency ablation. METHODS: From January 2010 to June 2010, a total of 38 patients with HCC including recurred HCCs after RFA underwent ARFI elastography. The brightness of tumor was checked and the shear wave velocity was measured for the quantification of stiffness. According to the brightness, the tumors were classified as brighter, same color and darker compared with adjacent parenchyma. Using the same methods, 8 patients with recurred HCCs after RFA state were evaluated about the brightness compared with adjacent RFA ablation area. RESULTS: In the 38 patients with HCCs, 20 (52.6%) were brighter than surrounding cirrhotic parenchyma. Another 13 (34.2%) were darker. The others (5 cases, 13.2%) were seen as the same color as the adjacent liver parenchyma. Post-RFA lesions were darker than previous tumor and surrounding parenchyma in all 38 cases. However, recurred HCCs were brighter than the treated site in all 8 cases. CONCLUSION: Using ARFI technique is helpful for differential diagnosis in order to detect recurred HCCs more easily in patients with confusing status.

Risk factors for recurrent symptomatic pigmented biliary stones after percutaneous transhepatic biliary extraction.

PURPOSE: To evaluate risk factors for the recurrence of biliary stones after a percutaneous transhepatic biliary stone extraction. MATERIALS AND METHODS: The procedures were performed on 339 patients between July 2004 and December 2008 (54 months). Medical records and images were retrospectively reviewed for 135 patients (mean age, 66.4 years; 83 men and 52 women) who had undergone follow-up for a mean of 13.2 months (range, 3-37 months). To evaluate risk factors for the recurrence of biliary stones, variables were evaluated with univariate and multivariate analyses. Variables included sex, age, stone location, number of stones, stone size, presence of a peripapillary diverticulum, application of antegrade sphincteroplasty, presence of a biliary stricture, largest biliary diameter before the procedure, and gallbladder status. RESULTS: Thirty-three of the 135 patients (24%) had recurrent symptomatic biliary stones and underwent an additional extraction. The mean time to recurrence was 17.2 months +/- 8.7. Univariate analysis of risk factors for recurrence of biliary stones demonstrated that location, number of stones, stone size, application of antegrade sphincteroplasty, presence of a biliary stricture, and biliary diameter were significant factors (P < .05). With use of multivariate analysis, the number of stones (> or =6; relative risk, 64.8; 95% confidence interval: 5.8, 717.6) and stone size (> or =14 mm; relative risk, 3.8; 95% confidence interval: 1.138, 13.231) were determined to be significant risk factors. CONCLUSIONS: The independent risk factors for recurrence of symptomatic biliary stones after percutaneous transhepatic biliary stone extraction were a stone size of at least 14 mm and the presence of at least six stones.

Actinomycosis of the appendix mimicking appendiceal tumor: a case report.

Actinomycosis is an uncommon chronic infectious disease. Common sites of involvement include the cervicofacial, thoracic and abdominopelvic regions. In abdominopelvic actinomycosis, the ileocecal region, including the appendix, is the most commonly involved site. In some reports, limited appendiceal actinomycosis has revealed a thickened appendiceal wall with peri-appendiceal inflammation as acute appendicitis or perforated appendicitis. We experienced pathologically confirmed intraluminal limited appendiceal actinomycosis without peri-appendiceal infiltration. Here, we report the computed tomography and ultrasound findings.

Regional cerebral blood volume ratio on perfusion MRI on the growth of infarct size in acute ischemic stroke.

We hypothesized that the relative regional cerebral blood volume (rCBV) ratio could help predict the risk of infarct growth on follow-up magnetic resonance imaging (MRI) in patients with diffusion perfusion mismatch (DPM) on the time-to-peak (TTP) map. We recruited 60 patients with acute middle cerebral arterial (MCA) infarction who had been evaluated by perfusion MRI within 24 h of initial ischemic events, and assessed the predictive role of the rCBV ratio on infarct growth in patients with DPM. Among 60 patients with acute MCA ischemic stroke, 41 (68.3%) patients had DPM on the initial MRI. Follow-up MRI revealed ischemic lesion enlargement in 19 (31.7%) of these 41 patients. The presence of DPM had no effect on the rate of lesion enlargement. Patients with ischemic lesion growth in follow-up images had a significantly lower rCBV ratio than patients without (0.81 +/- 0.22 vs. 1.08 +/- 0.20, p < 0.01). In this study, the decreased rCBV ratio on perfusion MRI has a predictive value for the growth of ischemic lesions after acute ischemic stroke with DPM on the TTP map.

A multicenter, open-label, 24-week follow-up study for efficacy on cognitive function of donepezil in Binswanger-type subcortical vascular dementia.

OBJECTIVES: To evaluate the efficacy and tolerability of donepezil in patients with Binswanger type subcortical vascular dementia. METHODS: Patients (n = 34, mean age = 71.8 + 7.12) with Binswanger type subcortical vascular dementia from 8 multicenter, according to clinical and neuroradiological working criteria, were selected to receive donepezil 5 mg/day (n = 2) or donepezil 10 mg/day (n = 32, after 5 mg/day) for 24 weeks. Our primary endpoints were change from baseline to weeks 12 and 24 in the Seoul Neuropsychological Screening Battery-Dementia version (SNSB-D) and the Korean version of neuropsychiatric inventory (K-NPI). RESULTS: A total of 24 patients received donepezil completed the study (mean age = 72.0 + 7.5 K-Mini-Mental State Examination [MMSE] = 21.0 + 5.1). After 12 weeks and 24 weeks, patients showed improvements in cognitive function on the SNSB-D compared baseline of 16.29 points at 12 weeks (P < .05) and 12.44 points at 24 weeks (P < .05). Significant improvements were shown in only memory domain, immediate verbal recall and delayed recall tests. Subgroup with better cognitive function (SNSB-D > 100) were more effective in frontal and memory domains than the other subgroup (SNSB-D < 100). Withdrawal rates due to adverse events were very low (4.16%). CONCLUSIONS: Donepezil-treated patients with Binswanger type subcortical vascular dementia demonstrated significant improvement in cognition compared with baseline, and donepezil was well tolerated.

Gastrointestinal amyloidosis presenting with multiple episodes of gastrointestinal bleeding.

Amyloidosis is characterized by the extracellular deposition of amyloid protein in various organs. Gastrointestinal involvement in amyloidosis is common, but a diagnosis of amyloidosis is often delayed. Severe gastrointestinal hemorrhage in amyloidosis is rare but can be fatal in some cases. We experienced a case of a 49-year-old man who presented with recurrent massive hematochezia. Although embolization was performed eight times for bleeding from different sites of the small intestine, hematochezia did not cease. We report the case, with a review of the literature.

Recent epidemiological trends of stroke.

OBJECTIVE: Rapid increase in aged population and westernization of lifestyle have modified epidemiological status of stroke. The purpose of this study is to analyze changing trends of stroke epidemiology in South Korea. METHODS: We reviewed retrospectively medical records of 1,124 cases diagnosed as stroke among 54,534 patients who visited the Emergency Medical Center at our hospital from January 1994 to December 1996 (Group A). Also, we evaluated 1,705 cases diagnosed as stroke among 55,381 patients who visited to the same hospital from January 2003 to December 2005 (Group B). The variable features of stroke, such as age, sex, seasonal variation and distribution of stroke subtypes were studied by comparing group A with B. RESULTS: In group A, hemorrhagic stroke (67.9%) was more prevalent than ischemic stroke (32.1%). However, group B showed that the ratio of hemorrhagic stroke (40.3%) to ischemic stroke (59.6%) has been reversed. The highest incidence of stroke was noted in their sixties and seventies of age in group B, which was older than that of group A. In group A, male ischemic stroke (IS) patients outnumbered female patients (1.26:1). Moreover, this gender disproportion became higher in group B (1.53:1). In group A, the number of male intracerebral hermorrhage (ICH) patients were similar to that of female patients (0.97:1). However, male ICH patients outnumbered female patients in group B (1.23:1). As for subarachnoid hemorrhage (SAH), female patients outnumbered male patients more than two-fold in both groups. Both groups showed that the occurrence of ischemic stroke was highest in summer, but that of hemorrhagic stroke was the highest in winter. CONCLUSION: This study showed the changing trends of stroke in its distribution of subtypes. Multicenter prospective study using stroke registry would be required for the determination of national epidemiologic trends.

Radiofrequency ablation treatment for renal cell carcinoma: early clinical experience.

OBJECTIVE: To evaluate the early clinical experience associated with radiofrequency (RF) ablation in patients with renal cell carcinoma (RCC). MATERIALS AND METHODS: The RF ablation treatment was performed on 17 tumors from 16 patients (mean age, 60.5 years; range, 43-73 years) with RCC. The treatment indications were localized, solid renal mass, comorbidities, high operation risk, and refusal to perform surgery. All tumors were treated by a percutaneous CT (n = 10), followed by an US-guided (n = 2), laparoscopy-assisted US (n = 2), and an open (n = 2) RF ablation. Furthermore, patients underwent a follow-up CT at one day, one week, one month, three and six months, and then every six months from the onset of treatment. We evaluated the technical success, technical effectiveness, ablation zone, benign periablation enhancement, irregular peripheral enhancement, and complications. RESULTS: All 17 exophytic tumors (mean size, 2.2 cm; range, 1.1-5.0 cm) were completely ablated. Technical success and effectiveness was achieved in all cases and the mean follow-up period was 23.8 months (range, 17-33 months). A local recurrence was not detected in any of the cases; however, five patients developed complications as a result of treatment, including hematuria (n = 2), mild thermal injury of the psoas muscle (n = 1), mild hydronephrosis (n = 1), and fistula formation (n = 1). CONCLUSION: The RF ablation is an alternative treatment for exophytic RCCs and represents a promising treatment for some patients with small RCCs.

Cilostazol reduces PAC-1 expression on platelets in ischemic stroke.

BACKGROUND AND PURPOSE: Cilostazol, a phosphodiesterase III inhibitor, is known to be a useful antiplatelet agent that inhibits the progression of atherosclerosis in ischemic stroke. This study investigated the effects of combining cilostazol with aspirin on the expressions of P-selectin and PAC-1 on activated platelets in acute ischemic stroke. METHODS: We analyzed 70 patients with acute ischemic stroke (<72 hrs of an ischemic event). The daily intake was 100 mg of aspirin in 37 patients and 100 mg of aspirin plus 200 mg of cilostazol in 33 patients. The expressions of P-selectin and PAC-1 on activated platelets were measured on the day of admission and 5 days later. We also evaluated the clinical progression using the National Institutes of Health Stroke Scale (NIHSS) at the same times. RESULTS: After 5 days the extent of PAC-1 expression on activated platelets was significantly lower for combined aspirin and cilostazol treatment (61.0+/-19.3%, p=0.008; mean+/-standard deviation) than the baseline level (70.9+/-12.9%), but did not differ between aspirin alone (66.0 +/-19.0%) and baseline (70.1+/-15.7%). The expression of P-selectin did not differ between combined aspirin and cilostazol treatment and baseline. The clinical progression did not differ between the two groups, as indicated by the absence of significant changes on the NIHSS in the acute period. CONCLUSIONS: This study found that the combined regimen of aspirin and cilostazol exerts the beneficial effect of reducing PAC-1 activity on activated platelets in acute ischemic stroke. However, the clinical outcome of this regimen was no better than that of the aspirin-only regimen. Therefore, further detailed studies of the possible clinical benefits of cilostazol in acute ischemic stroke are needed.

Hyaline vascular-type Castleman disease presenting as an esophageal submucosal tumor: case report.

Castleman disease is a relatively rare disorder of lymphoid tissue that involves the gastrointestinal tract in a variety of clinical and pathologic manifestations. A submucosal location has never been described in the medical literature. We report a case of esophageal Castleman disease involving the submucosal layer in a 62-year-old man, which was confirmed on pathology. Esophagography and CT demonstrated an intramural tumor, and a leiomyoma or leiomyosarcoma was suspected based on the known incidence of such tumors.