Co-existing Mediastinal Venous Malformation and Fusiform Superior Vena Cava Aneurysm in a Patient with Ischemic Stroke: A Case Report and Review of Literature.

BACKGROUND: Mediastinal venous malformation (MVM) and fusiform superior vena cava aneurysm (F-SVCA) are both rare congenital vascular anomalies. CASE PRESENTATIONS: A 46-year-old male presented with acute ischemic stroke of unknown etiology. Computed tomography (CT) angiography revealed the coexistence of MVM and F-SVCA. Diagnostic venography demonstrated a significant reduction in blood flow velocity within the F-SVCA, but failed to identify a direct connection to the left heart system or pulmonary vein. The patient expired due to extensive brain damage caused by a stroke. CONCLUSION: This case may increase the necessity of meticulous radiological evaluation and preventive management for these anomalies, as mediastinal vascular anomalies can result in thromboembolic complications.

Deep Learning Prediction of Axillary Lymph Node Metastasis in Breast Cancer Patients Using Clinical Implication-Applied Preprocessed CT Images.

Background: Accurate detection of axillary lymph node (ALN) metastases in breast cancer is crucial for clinical staging and treatment planning. This study aims to develop a deep learning model using clinical implication-applied preprocessed computed tomography (CT) images to enhance the prediction of ALN metastasis in breast cancer patients. Methods: A total of 1128 axial CT images of ALN (538 malignant and 590 benign lymph nodes) were collected from 523 breast cancer patients who underwent preoperative CT scans between January 2012 and July 2022 at Hallym University Medical Center. To develop an optimal deep learning model for distinguishing metastatic ALN from benign ALN, a CT image preprocessing protocol with clinical implications and two different cropping methods (fixed size crop [FSC] method and adjustable square crop [ASC] method) were employed. The images were analyzed using three different convolutional neural network (CNN) architectures (ResNet, DenseNet, and EfficientNet). Ensemble methods involving and combining the selection of the two best-performing CNN architectures from each cropping method were applied to generate the final result. Results: For the two different cropping methods, DenseNet consistently outperformed ResNet and EfficientNet. The area under the receiver operating characteristic curve (AUROC) for DenseNet, using the FSC and ASC methods, was 0.934 and 0.939, respectively. The ensemble model, which combines the performance of the DenseNet121 architecture for both cropping methods, delivered outstanding results with an AUROC of 0.968, an accuracy of 0.938, a sensitivity of 0.980, and a specificity of 0.903. Furthermore, distinct trends observed in gradient-weighted class activation mapping images with the two cropping methods suggest that our deep learning model not only evaluates the lymph node itself, but also distinguishes subtler changes in lymph node margin and adjacent soft tissue, which often elude human interpretation. Conclusions: This research demonstrates the promising performance of a deep learning model in accurately detecting malignant ALNs in breast cancer patients using CT images. The integration of clinical considerations into image processing and the utilization of ensemble methods further improved diagnostic precision.

Gastrointestinal Bleeding in Extracorporeal Membrane Oxygenation Patients: A Comprehensive Analysis of Risk Factors and Clinical Outcomes.

Background: Extracorporeal membrane oxygenation (ECMO) is an intervention for severe heart and lung failure; however, it poses the risk of complications, including gastrointestinal bleeding (GIB). Comprehensive analyses of GIB in patients undergoing ECMO are limited, and its impact on clinical outcomes remains unclear. Methods: This retrospective study included 484 patients who received venovenous and venoarterial ECMO between January 2015 and December 2022. Data collected included patient characteristics, laboratory results, GIB details, and interventions. Statistical analyses were performed to identify risk factors and assess the outcomes. Results: GIB occurred in 44 of 484 patients (9.1%) who received ECMO. Multivariable analysis revealed that older age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.06; p=0.0130) and need to change the ECMO mode (OR, 3.74; 95% CI, 1.75-7.96; p=0.0006) were significant risk factors for GIB, whereas no association was found with antiplatelet or systemic anticoagulation therapies during ECMO management. Half of the patients with GIB (22/44, 50%) underwent intervention, with endoscopy as the primary modality (19/22, 86.4%). Patients who underwent ECMO and developed GIB had higher rates of mortality (40/44 [90.9%] vs. 262/440 [59.5%]) and ECMO weaning failure (38/44 [86.4%] vs. 208/440 [47.3%]). Conclusion: GIB in patients undergoing ECMO is associated with adverse outcomes, including increased risks of mortality and weaning failure. Even in seemingly uncomplicated cases, it is crucial to avoid underestimating the significance of GIB.

Comparison of complications after closure of totally implantable venous access devices with non-absorbable suture and n-butyl-2-cyanoacrylate (NBCA) skin adhesive: Propensity score matching analysis.

PURPOSE: This study aimed to compare the complication rates of non-absorbable suture (NAS) and n-butyl-2-cyanoacrylate (NBCA) skin adhesive for skin closure during totally implantable venous access devices (TIVADs) implantation. METHODS: Between March 2020 and February 2021, 586 consecutive patients who underwent TIVAD implantation were retrospectively analyzed. Two groups of patients suture with NAS (n = 299) or NBCA (n = 287) were followed up for 18 months to compare the occurrence of infection, thrombosis, and non-thrombotic malfunction. A total of 364 cases were extracted using propensity score matching in a 1:1 ratio. Mean TIVADs maintenance days were analyzed using Kaplan-Meier survival analysis. RESULTS: Nineteen cases of complications occurred (0.294/1000 catheter-days) in the NAS group and 17 cases (0.210/1000 catheter-days) in the NBCA group. The difference in the complication rates between the two groups was not statistically significant (p = 0.725) after propensity score matching. Mean TIVADs maintenance days were 627.3 days in NAS group and 697.6 days in NBCA group. There was no statistically significant difference in the number of TIVADs maintenance days between the two groups (p = 0.081). CONCLUSION: In TIVADs implantation, skin closure using NBCA showed no difference in the occurrence of infectious complications compared with conventional non-absorbable skin suture.

The Risk of Venous Thromboembolism in Korean Patients with Breast Cancer: A Single-Center Experience.

The relationship between cancer and venous thromboembolism (VTE) has long been described. The risk of VTE in Asian patients with breast cancer remains largely unknown. This study described the incidence and risk factors of VTE in Korean patients with breast cancer. Data were collected from a retrospective database of patients who underwent breast cancer surgery between 2011 and 2020 at a single institution. The Cox proportional-hazards model was used to identify factors associated with VTE occurrences. Among the 2246 patients with breast cancer, 48 (2.1%) developed VTE during a median follow-up period of 53 months. The average incidence of VTE was 459 per 100,000 person-years. Age ≥ 60 years, male sex, chronic kidney disease, reconstructive procedures, and stage II or higher were independent predictive factors for VTE. VTE was associated with poor disease-free survival (hazard ratio (HR), 6.140; 95% confidence interval (CI), 3.480-10.835), and overall survival (HR, 8.842; 95% CI 4.386-17.824). Most VTE events were manageable with anticoagulation; three (6.3%) patients died of VTE, despite intensive care. The incidence of VTE was significantly elevated in Korean patients with breast cancer. Since VTE has a negative effect on oncologic outcomes of breast cancer, clinicians should manage its risk throughout their lifetime.

Acute Ileal Diverticulitis: Computed Tomography and Ultrasound Findings.

BACKGROUND: Acute ileal diverticulitis is a rare disease mimicking acute appendicitis. Inaccurate diagnosis with a low prevalence and nonspecific symptoms leads to delayed or improper management. METHODS: This retrospective study aimed to investigate the characteristic sonographic (US) and computed tomography (CT) findings with clinical features in seventeen patients with acute ileal diverticulitis diagnosed between March 2002 and August 2017. RESULTS: The most common symptom was abdominal pain (82.3%, 14/17) localized to the right lower quadrant (RLQ) in 14 patients. The characteristic CT findings of acute ileal diverticulitis were ileal wall thickening (100%, 17/17), identification of inflamed diverticulum at the mesenteric side (94.1%, 16/17), and surrounding mesenteric fat infiltration (100%, 17/17). The typical US findings were outpouching diverticular sac connecting to the ileum (100%, 17/17), peridiverticular inflamed fat (100%, 17/17), ileal wall thickening with preserved layering pattern (94.1%, 16/17), and increased color flow to the diverticulum and surrounding inflamed fat on color Doppler imaging (100%, 17/17). The perforation group had a significantly longer hospital stay than non-perforation group (p = 0.002). In conclusion, acute ileal diverticulitis has characteristic CT and US findings that allow radiologists to accurately diagnose the disease.

Arterio-Biliary Fistula as a Rare Life-Threatening Complication of Transjugular Intrahepatic Portosystemic Shunt: A Case Report.

A 46-year-old male with alcoholic liver cirrhosis underwent a transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites. On the 9th day after the procedure, he presented with melena and decreasing hemoglobin levels. Hemobilia due to fistula formation between the right intrahepatic bile duct and right hepatic artery was suspected on computed tomography. Angiography revealed a fistula of the small branches of the hepatic segmental arteries, and right intrahepatic bile duct was confirmed; embolization was successfully performed with a coil for the eighth segmental hepatic artery, a glue-lipiodol mixture for the fifth segmental hepatic artery, and gelfoam slurry for the right anterior hepatic artery. However, 2 days after embolization, the patient died owing to aggravated disseminated intravascular coagulopathy. When gastrointestinal bleeding occurs after TIPS, careful evaluation is immediately required, and hemobilia should be considered.

A Motion Artifact Correction Algorithm for Cone-Beam CT in Patients with Hepatic Malignancies Treated with Transarterial Chemoembolization.

PURPOSE: To evaluate the effect of a motion artifact correction algorithm (MACA) on cone-beam computed tomography (CT) during transarterial chemoembolization for hepatic malignancies. MATERIALS AND METHODS: From June 2020 to March 2021, 42 patients with mild-to-severe motion artifacts detected using single cone-beam CT scans were evaluated retrospectively. The image quality of native and motion-corrected data was compared. The maximum intensity, sharpness, and full width at half maximum (FWHM) of 5 segmental hepatic arteries were quantitatively measured. The overall quality of maximum intensity projection (MIP) images, conspicuity of tumor-supplying arteries, and need for selective angiography to ascertain the vascular anatomy were qualitatively evaluated by multiple readers. Paired t and Wilcoxon signed rank tests were used to compare the parameters. RESULTS: The mean maximum intensity and sharpness increased from 2,792.01 HU ± 451.36 to 3,148.40 HU ± 594.46 and from 0.31 ± 0.02/mm to 0.34 ± 0.02/mm, respectively, using the MACA (both P < .001). The MACA decreased the mean FWHM from 2.02 mm ± 0.27 to 1.78 mm ± 0.26 (P < .001). The overall quality of the MIP images and the conspicuity of the tumor-supplying artery were enhanced from 2.5 to 3.0 points and from 3.0 to 4.0 points, respectively (both P < .001). Selective angiography was expected to be omitted in 7 cases (16.7%, 7/42) after using the MACA. CONCLUSIONS: The MACA significantly improved both quantitative and qualitative image quality of cone-beam CT in selected patients with motion artifacts during transarterial chemoembolization for hepatic malignancies.

Angiographic Findings of an Isolated Meandering Pulmonary Vein: A Case Report.

A meandering pulmonary vein (MPV) is a rare pulmonary vascular anomaly characterized by an abnormal course of the pulmonary vein draining into the left atrium. We report the case of a 55-year-old female who was diagnosed with a right MPV on pulmonary angiography. Enhanced chest CT revealed a vascular structure with an abnormal course that drained into the right superior pulmonary vein in the right upper lobe, which resembled a pulmonary arteriovenous malformation (AVM). Pulmonary angiography performed to discriminate between an MPV and pulmonary AVM showed no feeding artery, normal parenchymal staining, and drainage to the left atrium via the culprit vessel. Thus, the patient was diagnosed with MPV. When an MPV is difficult to differentiate from other vascular anomalies on enhanced chest CT, pulmonary angiography can be helpful. By recognizing the angiographic findings of an MPV, unnecessary treatment can be prevented.

Glue Embolization of Lymphopseudoaneurysm for Chylous Ascites after Retroperitoneal Surgery.

OBJECTIVE: To assess the safety and efficacy of lymphopseudoaneurysm (LPA) glue (n-butyl cyanoacrylate [NBCA]) embolization in the management of chylous ascites after retroperitoneal surgery. MATERIALS AND METHODS: A retrospective analysis from January 2014 to October 2018 was performed in six patients (4 females and 2 males; mean age, 45.3 ± 14.2 years; range, 26-61 years) who underwent LPA embolization for chylous ascites developing after retroperitoneal surgery involving the perirenal space (four donor nephrectomies, one partial nephrectomy, and one retroperitoneal lymphadenectomy). After placing a percutaneous drainage catheter into the LPA or adjacent lymphocele, embolization was performed by filling the LPA itself with a mixture of glue and Lipiodol (Guerbet). RESULTS: Daily drainage from percutaneously placed drains exceeded 300 mL/day despite medical and surgical treatment (volume: mean, 1173 ± 1098 mL; range, 305-2800 mL). Intranodal lymphangiography was performed in four of the six patients and revealed leakage in 2 patients. Percutaneous embolization of the LPA was successful in all patients using an NBCA and Lipiodol mixture in a ratio of 1:1-1:2 (volume: mean, 4.3 ± 1.1 mL; range, 3-6 mL). Chylous ascites was resolved and the drainage catheter was removed in all patients within 4 days after the procedure (mean, 2.0 ± 1.8 days; range, 0-4 days). No procedure-related complications or recurrence of chylous ascites occurred during a mean follow-up period of 37.3 months (range, 21.1-48.4 months). CONCLUSION: Glue embolization of LPA has the potential to be a feasible and effective treatment method for the management of chylous ascites after retroperitoneal surgery.

Ultrasound features of secondary appendicitis in pediatric patients.

PURPOSE: The purpose of this study was to evaluate the ultrasonographic findings of secondary appendicitis (SA) and to discuss the differential findings compared with primary appendicitis. METHODS: In this study, we analyzed the ultrasonographic findings of 94 patients under 15 years old of age treated at our institution from May 2005 to May 2014 who had bowel inflammation and an inflamed appendix with a maximal outer diameter >6 mm that improved with nonsurgical treatment (the SA group). Ninety-nine patients with pathologically proven acute appendicitis (the primary appendicitis [PA] group) from June 2013 to May 2014 and 44 patients with pathologically negative appendectomy results from May 2005 to May 2014 were also included to compare the ultrasonographic features of these conditions. A retrospective review of the ultrasonographic findings was performed by two radiologists. The clinical and laboratory findings were also reviewed. The results were statically analyzed using analysis of variance, the Pearson chi-square test, and the two-tailed Fisher exact test. RESULTS: Compared with PA, cases of SA had a smaller diameter (9.8 mm vs. 6.6 mm, P<0.001), and were less likely to show periappendiceal fat inflammation (98% vs. 6%, P<0.001) or an appendicolith (34% vs. 11%, P<0.001). SA showed mural hyperemia on color Doppler ultrasonography as frequently as PA (P=0.887). CONCLUSION: The ultrasonographic features of SA included an increased diameter compared to a healthy appendix and the same level of hyperemia as in PA. However, the diameter was commonly in the equivocal range (mean diameter, 6.6 mm), and periappendiceal fat inflammation was rarely present in SA.

Outcomes of Esophageal Arterial Embolization for Treatment of Hemoptysis.

PURPOSE: To investigate safety and efficacy of esophageal arterial embolization (EAE) in addition to bronchial arterial embolization (BAE) for treatment of hemoptysis as well as the importance and characteristics of esophageal arteries in patients with hemoptysis. MATERIALS AND METHODS: Between January 2013 and December 2014, 20 patients (13 men and 7 women, mean age 58.4 y) underwent EAE in addition to BAE for hemoptysis. Retrospective review of patient records was performed to evaluate major causes of hemoptysis, treatment indications based on CT findings, esophageal angiography findings, and outcomes after embolization including clinical success rate and complications. RESULTS: Hemoptysis was caused by bronchiectasis (12 patients), tuberculosis (7 patients), and lobectomy (1 patient). CT showed lower lobe lung lesions in all (100%) patients. The esophageal arteries originated from the aorta between the carina and diaphragm (18 patients) or from the inferior phrenic arteries (2 patients) and were tortuous with longitudinal off-midline courses. Communications between the esophageal and the bronchial or inferior phrenic arteries were present in 12 patients. One patient who was treated using N-butyl cyanoacrylate developed dysphagia that resolved with medical treatment. Repeat BAE was performed in 2 patients 5 days and 20 days later, and the clinical success rate was 90% (18/20). CONCLUSIONS: EAE in addition to BAE is safe in the treatment of hemoptysis and should be considered for lower lobe lesions.

Intramural esophageal dissection diagnosed on transabdominal ultrasonography.

Intramural esophageal dissection (IED) is an uncommon yet important clinical entity characterized by a rupture or fissure in the esophageal submucosal layer. IED could occur spontaneously or secondary to direct extrinsic injury to the esophageal mucosa. Traditionally, IED has been diagnosed on the swallowing study using water-soluble contrast agents or barium. For alternative diagnostic modalities, upper gastrointestinal endoscopy and chest computed tomography have been frequently performed. However, to the best of our knowledge, the transabdominal ultrasonography (USG) appearance of IED has not been reported in the literature yet. We report an interesting case of IED, which was initially diagnosed on the transabdominal USG.

Zinc chelation reduces hippocampal neurogenesis after pilocarpine-induced seizure.

Several studies have shown that epileptic seizures increase hippocampal neurogenesis in the adult. However, the mechanism underlying increased neurogenesis after seizures remains largely unknown. Neurogenesis occurs in the subgranular zone (SGZ) of the hippocampus in the adult brain, although an understanding of why it actively occurs in this region has remained elusive. A high level of vesicular zinc is localized in the presynaptic terminals of the SGZ. Previously, we demonstrated that a possible correlation may exist between synaptic zinc localization and high rates of neurogenesis in this area after hypoglycemia. Using a lithium-pilocarpine model, we tested our hypothesis that zinc plays a key role in modulating hippocampal neurogenesis after seizure. Then, we injected the zinc chelator, clioquinol (CQ, 30 mg/kg), into the intraperitoneal space to reduce brain zinc availability. Neuronal death was detected with Fluoro Jade-B and NeuN staining to determine whether CQ has neuroprotective effects after seizure. The total number of degenerating and live neurons was similar in vehicle and in CQ treated rats at 1 week after seizure. Neurogenesis was evaluated using BrdU, Ki67 and doublecortin (DCX) immunostaining 1 week after seizure. The number of BrdU, Ki67 and DCX positive cell was increased after seizure. However, the number of BrdU, Ki67 and DCX positive cells was significantly decreased by CQ treatment. Intracellular zinc chelator, N,N,N0,N-Tetrakis (2-pyridylmethyl) ethylenediamine (TPEN), also reduced seizure-induced neurogenesis in the hippocampus. The present study shows that zinc chelation does not prevent neurodegeneration but does reduce seizure-induced progenitor cell proliferation and neurogenesis. Therefore, this study suggests that zinc has an essential role for modulating hippocampal neurogenesis after seizure.