Gradual expansion of stent retriever in mechanical thrombectomy for curved middle cerebral artery: structural findings of the stent for predictable recanalization results.

BACKGROUND: Trevo Provue stent retriever with visible struts under fluoroscopy may be useful in identifying the optimal position and expansion of the stent during the procedure. This study aimed to demonstrate and analyze changes in the segmental diameter of a radio-opaque stent retriever after deployment according to recanalization results, and its relationship with the angle of the occluded segment of the middle cerebral artery (MCA). METHODS: Forty-one patients who underwent mechanical thrombectomy using a Trevo stent retriever were divided into two groups according to Thrombolysis in Cerebral Infarction (TICI) score (TICI 0-2a and TICI 2b/3). The proximal (Pt), middle (Mt), and distal diameter (Dt) of the deployed stent, at three post-deployment waiting times (t = 0, 3, and 5 min), were measured, and ratios of Mt to Pt (Mt/Pt) and of Mt to Dt (Mt/Dt) were calculated. RESULTS: TICI 2b/3 was achieved in 31 patients (75.6%) and TICI 0-2a in 10 patients (24.4%). In the TICI 2b/3 group, both changes of Mt/Pt (P < 0.001) and Mt/Dt (P = 0.001) until 3 min were significant and all Mt/Pt (each P < 0.01), M3/D3 (P = 0.014), and M5/D5 (P = 0.012) were significantly larger than those in the TICI 0-2a group. The angle of the MCA was significantly correlated with Mt/Pt and Mt/Dt (P < 0.001). CONCLUSION: The diameter of the stent retriever after deployment was associated with the recanalization results in mechanical thrombectomy following MCA occlusion.

Relationships between Head Circumference Percentile, Lumbar Puncture Pressure, and Cerebrospinal Fluid Space in Young Children: Increased Cerebrospinal Space and Pressure May Result in Compensatory Enlargement of Head Circumference Only in the Infant Period.

BACKGROUND: The aim of this study was to retrospectively evaluate and analyze the relationships between head circumference percentile (HCP), lumbar puncture pressure (LPP), and cerebrospinal fluid (CSF) space. METHODS: The 88 patients were divided into 3 age groups (group 1, up to 12 months; group 2, 12-36 months; group 3, 36-72 months). RESULTS: In group 1 (n = 40), there was a significant positive correlation of the HCP with the LPP (r =0.414, p =0.008), Evans ratio (r =0.365, p =0.021), and thickness of subdural hygroma (SDHG; r =0.403, p =0.010). Group 2 (n = 29) revealed a significant positive correlation between the LPP and the thickness of SDHG (r =0.459, p =0.012). Group 3 (n = 19) showed no significant correlation among these factors. Overall, age was related with SDHG thickness both in infants and toddlers, while HCP was related with LPP, Evans ratio, and SDHG thickness only in infants, and LPP was related with SDHG thickness only in toddlers. CONCLUSION: We suggest that increased cerebrospinal space and pressure may result in compensatory enlargement of head circumference only in the infant period, and the SDHG thickness decreases with age during the infant and toddler phases.

Comparison of Outcomes at Trauma Centers versus Non-Trauma Centers for Severe Traumatic Brain Injury.

OBJECTIVE: Traumatic brain injury (TBI) is one of the most common injuries in patients with multiple trauma, and it associates with high post-traumatic mortality and morbidity. A trauma center was established to provide optimal treatment for patients with severe trauma. This study aimed to compare the treatment outcomes of patients with severe TBI between non-trauma and trauma centers based on data from the Korean Neuro-Trauma Data Bank System (KNTDBS). METHODS: From January 2018 to June 2021, 1122 patients were enrolled in the KNTDBS study. Among them, 253 patients from non-traumatic centers and 253 from trauma centers were matched using propensity score analysis. We evaluated baseline characteristics, the time required from injury to hospital arrival, surgery-related factors, neuromonitoring, and outcomes. RESULTS: The time from injury to hospital arrival was shorter in the non-trauma centers (110.2 vs. 176.1 minutes, p=0.012). The operation time was shorter in the trauma centers (156.7 vs. 128.1 minutes, p0.003). Neuromonitoring was performed in nine patients (3.6%) in the non-trauma centers and 67 patients (26.5%) in the trauma centers (p<0.001). Mortality rates were lower in trauma centers than in non-trauma centers (58.5% vs. 47.0%, p=0.014). The average Glasgow coma scale (GCS) at discharge was higher in the trauma centers (4.3 vs. 5.7, p=0.011). For the Glasgow outcome scale-extended (GOSE) at discharge, the favorable outcome (GOSE 5-8) was 17.4% in the non-trauma centers and 27.3% in the trauma centers (p=0.014). CONCLUSION: This study showed lower mortality rates, higher GCS scores at discharge, and higher rates of favorable outcomes in trauma centers than in non-trauma centers. The regional trauma medical system seems to have a positive impact in treating patients with severe TBI.

Comparison of Preventable Trauma Death Rates in Patients With Traumatic Brain Injury Before and After the Establishment of Regional Trauma Center: A Single Center Experience.

Objective: To compare preventable trauma death rates (PTDRs) in patients with traumatic brain injury before and after the establishment of a regional trauma center (RTC) at a single center. Methods: Our institution established an RTC in 2014. A total of 709 patients were enrolled from January 2011 to December 2013 (before RTC) and 672 from January 2019 to December 2021 (after RTC). The revised trauma score, injury severity score, and trauma and injury severity score (TRISS) were evaluated. Definitive preventable (DP), possibly preventable (PP), and non-preventable deaths were defined as TRISS >0.5, TRISS 0.25-0.5, and TRISS <0.25, respectively. PTDR was the proportion of deaths from DP+PP out of all deaths, and the preventable major trauma death rate (PMTDR) was the proportion of deaths from DP+PP out of all DP+PP. Results: The overall mortality rates before and after the establishment of RTC were 20.3 and 13.1%, respectively. PTDR was lower after the establishment of RTC than before (90.3% vs. 79.5%). The PMTDR was also lower after the establishment of RTC than before (18.8% vs. 9.7%). The ratio of direct hospital visits was higher in patients before the establishment of RTC than in those after (74.9% vs. 61.3%, p<0.001). Conclusion: Establishing the RTC reduced PTDRs. Additional studies on factors associated with PTDR reduction are required.

Four French sheath-based transradial cerebral angiographies in the elderly: A single neurointerventionalist's experience.

BACKGROUND: Catheter angiography via transradial access (TRA) is better at reducing access site complications and morbidity than via transfemoral access (TFA). The rate of periprocedural complications increases in elderly populations and using a smaller sheath can help reduce access site complications. The aim of this study was to assess the feasibility and safety of 4 F sheath-based TRA cerebral angiography in elderly patients (≥65 years) and compare it to TFA cerebral angiography. METHODS: The medical records of elderly patients undergoing diagnostic cerebral angiography with a single neurointerventionalist via TRA (57 cases, from July 2019 to December 2020) versus TFA (69 cases, from January 2018 to June 2019) were retrospectively reviewed. All TRA angiographies were performed via right radial artery access with a 4 F sheath and a 4 F Simmons 2 catheter. RESULTS: There were no significant differences (TRA vs. TFA) in age (71.1 ± 4.0 vs. 72.1 ± 4.6 years, p = 0.189), accessed vessels (3.9 ± 0.5 vs. 3.9 ± 0.6, p = 0.852), fluoroscopy time (7.1 ± 3.3 vs. 7.6 ± 3.5 min, p = 0.068), and radiation exposure (42.1 ± 15.8 vs. 47.0 ± 13.7 Gy-cm2, p = 0.067). However, the procedure duration was significantly shorter in the TRA group (17.2 ± 3.9 vs. 19.0 ± 6.0 min, p = 0.003). Painful groin hematoma occurred in 2 of the 69 cases (2.9%) in the TFA group. In the TRA group, access site complications were not occurred; however, catheter kinks occurred in 2 of 57 cases (3.5%). CONCLUSIONS: The 4 F sheath-based TRA is a feasible option for diagnostic cerebral angiography in elderly patients. However, care should be taken during catheter manipulation.

Morphological and molecular expression patterns of neural precursor cells derived from human fetal spinal cord in two-, three-dimensional, and organoid culture environments.

Recently, interest in three-dimensional (3D) cell or tissue organoids that may, in vitro, overcome not only the practical problems associated with fetal tissue transplantation, but also provide a potential source for the regeneration of injured spinal cords, has been increasing steadily. In this study, we showed that human neural precursor cells (hNPCs) derived from the fetal spinal cord could be incubated in serum free medium at two dimensional (2D), three dimensional (3D) and tissue organoid-systems. Additionally, we investigated morphological changes over time along with the expression of proteoglycans, collagen, or myelin in 2D, 3D and tissue-like organoids. 2D cells exhibited a spindle-shaped morphology with classic hill and valley growth patterns, while 3D cells grew as clusters of undifferentiated cells and cell sheets (tissue organoids) that gradually rolled up like a carpet without forming a circular cell mass. Immunostaining was performed to demonstrate the expression of TUJ-1, MAP-2, GAD 65/67 and ChAT in 2D cells or tissue-like organoids, which stained positively for them. In addition, we observed the immunoreactivity of HNu, NG2, TUJ-1, and GFAP in tissue-like organoids. The organoid culture system studied in our work may be used as therapeutic agents for spinal cord injury (SCI), and as raw materials needed for development of new medicines to improve human responses and cure diseases.

The Relationship Between Trauma Scoring Systems and Outcomes in Patients With Severe Traumatic Brain Injury.

Objective: This study investigated the relationship between trauma scoring systems and outcomes in patients with severe traumatic brain injury (TBI). Methods: From January 2018 to June 2021, 1,122 patients with severe TBI were registered in the Korean Neuro-Trauma Data Bank System. Among them, 697 patients with data on trauma scoring systems were included in the study. According to the Glasgow Outcome Scale-Extended score, the patients were divided into unfavorable and favorable outcome groups. The abbreviated injury scale (AIS), injury severity score (ISS), revised trauma score (RTS), and trauma and injury severity score (TRISS) were evaluated. Results: The AIS head score was higher in the unfavorable outcome group than in the favorable outcome group (4.39 vs. 4.06, p<0.001). ISS was also higher in the unfavorable outcome group (27.27 vs. 24.22, p=0.001). The RTS and TRISS were higher in the favorable outcome group (RTS, 4.74 vs. 5.45, p<0.001; TRISS, 48.05 vs. 71.02, p<0.001). In comparing the survival and death groups, the ISS was lower in the survival group (25.76 vs. 27.29, p=0.036). Furthermore, RTS was higher in the survival group (5.26 vs. 4.54, p<0.001), as was TRISS (62.11 vs. 44.91, p<0.001). Conclusion: Trauma scoring systems, including ISS, RTS, and TRISS, provide tools for quantifying posttraumatic risk and can be used to predict prognosis. Among these, TRISS is an indicator of the predicted survival rate and is considered a clinically useful tool for predicting unfavorable and favorable outcomes in patients with severe TBI.

Clinical Outcome of Patients Diagnosed Traumatic Intracranial Epidural Hematoma With Severe Brain Injury (Glasgow Coma Scale ≤8) Who Undergo Surgery: A Report From the Korean Neuro-Trauma Data Bank System.

Objective: To evaluate the clinical outcomes and prognostic factors in surgically treated patients with severe brain injury (Glasgow Coma Scale [GCS] score ≤8) diagnosed with traumatic epidural hematoma (EDH). Methods: From January 2018 to June 2021, 1,122 patients with an initial GCS score ≤8 were retrospectively enrolled in the Korean Neuro-Trauma Data Bank System. Clinical data of 79 surgically treated patients with EDH were compared between the unfavorable (scores of 1-4 on the Glasgow Outcome Scale-Extended [GOSE]) and favorable (score of 5-8 on the GOSE) outcome groups. Results: The overall mortality rate was 13.9%, and 60.8% of the patients had good outcomes at six months post-trauma. In the univariate analysis, increasing age (p=0.010), lower initial GCS score (p=0.001), higher Rotterdam computed tomography (CT) score (p=0.012), craniotomy rather than craniectomy (p=0.032), larger EDH volume (p=0.007), and loss of pupillary reactivity (unilateral unreactive pupil, p=0.026; bilateral unreactive pupils, p<0.001), were significantly correlated with unfavorable outcomes. Of these factors, increasing age (p=0.011) and bilateral unreactive pupils (p=0.002) were the most significant risk factors in the multivariate logistic regression analysis. The interval from admission to the brain CT scan was not correlated with the outcome; however, it was significantly longer in the unfavorable outcome group. Conclusion: Despite severe brain injury, more than half of the patients with EDH had favorable outcomes after surgical treatment. Our findings suggest that prompt diagnosis and surgical treatment should be considered for such cases.

The C-terminal region of Bfl-1 sensitizes non-small cell lung cancer to gemcitabine-induced apoptosis by suppressing NF-κB activity and down-regulating Bfl-1.

Gemcitabine is used to treat several cancers including lung cancer. However, tumor cells often escape gemcitabine-induced cell death via various mechanisms, which include modulating bcl-2 family members and NF-κB activation. We previously reported that the C-terminal region of Bfl-1 fused with GFP (BC) is sufficient to induce apoptosis in 293T cells. In the present study, we investigated the anti-tumor effect of combined BC gene therapy and gemcitabine chemotherapy in vitro and in vivo using non-small cell lung cancer cell lines and a xenograft model. Cell lines were resistant to low dose gemcitabine (4-40 ng/ml), which induced NF-κB activation and concomitant up-regulation of Bfl-1 (an NF-κB-regulated anti-apoptotic protein). BC induced the apoptosis of A549 and H157 cells with caspase-3 activation. Furthermore, co-treatment with BC and low dose gemcitabine synergistically and efficiently induced mitochondria-mediated apoptosis in these cells. When administered alone or with low dose gemcitabine, BC suppressed NF-κB activity, inhibited the nuclear translocation of p65/relA, and down-regulated Bfl-1 expression. Furthermore, direct suppression of Bfl-1 by RNA interference sensitized cells to gemcitabine-induced cell death, suggesting that Bfl-1 importantly regulates lung cancer cell sensitivity to gemcitabine. BC and gemcitabine co-treatment also showed a strong anti-tumor effect in a nude mouse/A549 xenograft model. These results suggest that lung cancer cells become resistant to gemcitabine via NF-κB activation and the subsequent overexpression of Bfl-1, and that BC, which has both pro-apoptotic and NF-κB inhibitory effects, could be harnessed as a gene therapy to complement gemcitabine chemotherapy in non-small cell lung cancer.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling.

OBJECTIVE: Endovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups. METHODS: Between January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with single-microcatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively. RESULTS: Clinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01). CONCLUSION: Long-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

In vivo scintigraphic imaging of antitumor effects by combined radioiodine therapy and human sodium iodide symporter gene immunotherapy.

In a previous study, we demonstrated that pcDNA3.1/hNIS (human sodium iodide symporter) vaccination generated hNIS-associated CD8+IFN-gamma+ (interferon-gamma) T cells, which are known to be involved in antitumor immunity. However, the immune response induced was insufficient to control tumor growth in vivo, which required a novel approach to potentiate hNIS vaccination effects. In the present study, we administered 131I radioiodine therapy prior to hNIS vaccination in CT26/hNIS tumor-bearing mice to facilitate the vaccine-induced immune response. We characterized hNIS-associated cytotoxic T-cell immune response and the antitumor effects induced by this 131I + hNIS combination therapy. The survival rates of CT26/hNIS tumor cells were significantly reduced by 131I treatment compared with the parental CT26 cells in vitro. 131I + hNIS combination therapy stably suppressed tumor growth below or near the original tumor size level of initial treatment, achieving 100% survival rates. Specifically, 131I + hNIS therapy enhanced IFN-gamma production, hNIS-associated antitumor cytotoxic T-lymphocyte (CTL) response, and induced more dendritic cells but reduced T-regulatory cells in tumor masses. Collectively, these results suggest that combined therapy effectively enhances hNIS-associated antitumor immune response, leading to CT26/hNIS tumor growth inhibition and complete survival in Balb/C mice. These findings provide a novel and effective means of treating cancer.

Usefulness of Dual Volume Reconstruction of Threedimensional Rotational Angiography in the Surgical Treatment of Spinal Vascular Malformations: Assessment of Image Similarity Between Angiography and Microscopy.

AIM: To describe and demonstrate the close analogy between dual volume reconstruction images derived using three-dimensional digital subtraction angiography (3D-DSA) and surgical microscopic images. MATERIAL AND METHODS: From 2013 to 2018, 12 patients with spinal vascular malformation (SVM) underwent preoperative 3D-DSA with dual volume reconstruction followed by surgery for the SVM without prior endovascular treatment. Two spinal neurosurgeons involved in each operation were surveyed regarding the similarity between the dual volume images of 3D-DSA and the surgical microscopic images with respect to the following four aspects: (1) relationship between bony structures and the entry artery going to the feeder; (2) feeding artery; (3) shunting point or nidus location; and (4) draining vein. RESULTS: The patients were diagnosed with spinal dural arteriovenous fistulas (n=8) and spinal arteriovenous malformations (n=4). Two, six, and four lesions showed cervical, thoracic, and lumbar area distribution, respectively. All operations were successful and without complications. The correspondence between dual volume images and intraoperative microscopic images, with respect to bony structure and entry artery, showed perfect reliability (k=1.000; p=0.000) and a high level of similarity in all cases. With respect to the feeding artery, shunt point/nidus location, and draining vein, there was substantial reliability between the operator and the observer (k=0.750; p=0.045). CONCLUSION: Images obtained using the dual volume reconstruction technique of the 3D-DSA exhibit a reliable similarity to real microscopic images and are useful in the surgical treatment of SVMs with respect to surgical planning, targeting, and orientation.

Risk factors of postoperative remote intracerebral hemorrhage after craniotomy for ruptured cerebral aneurysms.

OBJECTIVE: We aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms. METHODS: We retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors' institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant. RESULTS: We enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis. CONCLUSIONS: POP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.

Does work time limit for resident physician affect short-term treatment outcome and hospital length of stay in patients with spontaneous intracerebral hemorrhage?: a two-year experience at a single training hospital in South Korea.

OBJECTIVE: To compare short-term treatment outcomes at hospital discharge and hospital length of stay (LOS) in patients with spontaneous intracerebral hemorrhage (sICH) before and after introduction of resident physician work time limit (WTL). METHODS: We retrospectively reviewed consecutive patients treated for sICH at our institution between 2016 and 2019. Then we dichotomized these patients into two groups, pre-WTL and post-WTL. We analyzed demographic elements and clinical features, and hospital length of stay (LOS). We evaluated short-term outcome using modified Rankin scale score at hospital discharge and then divided it into "good" and "poor" outcome groups. We subsequently, compared short-term treatment outcome and hospital LOS between the pre-WTL and post-WTL groups. RESULTS: Out of 779 patients, 420 patients (53.9%) were included in the pre-WTL group, and 359 (46.1%) in post-WTL. The mortality rate in sICH patients was higher in the post-WTL group (pre-WTL; 13.6% vs. post-WTL; 17.3%), but there was no statistically significant difference in short-term outcome including mortality (p=0.332) between the groups. The LOS also, was not significantly different between the two groups (pre-WTL; 19.0 days vs. post-WTL; 20.2 days) (p=0.341). The initial Glasgow Coma Scale score, personal stroke history, and mean age were the only independent outcome predicting factors for patients with sICH. CONCLUSIONS: Some neurosurgeons may expect poorer outcome for sICH after implementation of the WTL of the K-MHW for resident physician however, enforcement of the WTL did not significantly influence the short-term outcome and hospital LOS for sICH in our hospital. Further well-designed multi-institutional prospective studies on the effects of WTL in sICH patient outcome, are anticipated.

Sagittal alignment correlates with the C1-C2 fixation angle and functional outcome after posterior atlantoaxial fixation for traumatic atlantoaxial instability.

The C1-C2 angle has been shown to correlate with subaxial alignment under various conditions. The aim of this study was to evaluate the correlation between the C1-C2 fixation angle and subaxial sagittal alignment as well as the impact of the sagittal vertical axis (SVA) on functional outcomes in traumatic atlantoaxial (A-A) instabilities. The data of 36 patients who underwent posterior C1-C2 fixation for traumatic A-A instability between December 2005 and September 2015 were retrospectively reviewed. Radiographic parameters, including the C1-C2 angle, occipitocervical angle, C2-C7 angle, and C2-C7 SVA, were measured before surgery and at 1-year follow-up. Clinical outcomes were measured using the visual analogue scale (VAS) and Neck Disability Index (NDI). The preoperative and postoperative relationships between parameters were analyzed. In preoperative and postoperative radiographs, the C1-C2 angle correlated with the C2-C7 angle (r = -0.347, p = 0.038, and r = -0.339, p = 0.043, respectively) and the C2-C7 SVA (r = 0.648, p < 0.001, and r = 0.436, p = 0.008, respectively). The postoperative C2-C7 SVA was directly proportional to the preoperative C2-C7 SVA and postoperative C1-C2 angle (postoperative C2-C7 SVA = 0.72 + 0.669 × [preoperative C2-C7 SVA] + 0.555 × [postoperative C1-C2], r2 = 0.677, p < 0.001). The postoperative C2-C7 SVA correlated with postoperative VAS (rs = 0.382, p = 0.021) and NDI (rs = 0.476, p = 0.003). The postoperative C2-C7 SVA was affected by the preoperative C2-C7 SVA and the postoperative C1-C2 angle and showed significant positive correlation with postoperative NDI. The C1-C2 fixation angle and the preoperative C2-C7 SVA should be carefully considered to avoid postoperative sagittal imbalance.

Practical Dose Parameter Values for the Prediction of the Adverse Effect of Neurointerventional Radiation: Relationship Between the Dose Parameters and Temporary Alopecia After Intracranial Coil Embolization.

OBJECTIVE: To present values for the dose parameters predictive of alopecia as an adverse effect induced by neuroembolization using a biplane fluoroscopy. METHODS: This study included a total of 151 patients (52 men, mean age of 55.1 ± 12.2 years) treated for intracranial neuroembolization between 2014 to 2018 with the following criteria: 1) obtainable dose report with digital subtraction angiographic image records, 2) no history of radiation exposure 6 months prior to the first procedure, and 3) and clinical follow-up performed through 12 months following the procedure. Patients were divided into 2 groups according to their presentation of alopecia during the follow-up period. RESULTS: Eighteen (11.9%) patients developed alopecia 10 to 30 days after the procedure (average: 18.5 ± 5.3 days). Sixteen (88.9%) patients in the alopecia group were affected by projection of the A-plane fluoroscopy. Area under the receiver operating characteristic analysis curves of 0.865 (P = 0.000) and 0.831 (P = 0.000) were used to compute the optimal A-plane dose area product (255.4 Gy-cm2; sensitivity: 0.875; specificity: 0.805; Youden J = 0.682) and cumulative dose (4437.5 mGy; sensitivity, 0.750; specificity, 0.805; Youden J = 0.556) cutoff values, respectively, capable of distinguishing patients with alopecia (n = 16) from subtotal patients (n = 149). CONCLUSIONS: The dose area product and the cumulative dose may be useful, intuitive factors for predicting the adverse effects of the neurointerventional radiation. Further multicenter research should be performed to confirm the efficacy and utility of the reference values of dose area product and cumulative dose for preventing excessive irradiation during neurointerventional procedures.

Idiopathic Pseudoaneurysm of External Carotid Artery with Delayed Facial Palsy After Covered Stenting.

BACKGROUND: Idiopathic pseudoaneurysms of the external carotid artery (ECA) between the internal maxillary artery and the facial artery are rare. Endovascular covered stenting is an alternative method for surgically challenging cases; however, movable and flexible vessels may prevent the maintenance of the stent. CASE DESCRIPTION: A 26-year-old woman presented with sudden swelling and pain of the left chin due to a pseudoaneurysm of the proximal ECA trunk. She had undergone endovascular covered stenting and suddenly developed facial palsy at postprocedural 1 week. Regrowth of the aneurysm and slippage of the stent were detected, and additional stenting was performed. Swelling and pain of the chin and neck and subsequently the facial palsy completely resolved, and the patient made a full recovery. CONCLUSIONS: The ECA aneurysm between the internal maxillary artery and facial artery may be more floating and changeable than any other portions of the ECA, and regrowth of the ECA aneurysm may cause delayed complication. In addition, knowledge of the mechanism is necessary to help in the endovascular treatment.

[A case of anti-LKM 1 positive autoimmune hepatitis accompanied by systemic lupus erythematosus].

Overlap of autoimmune hepatitis and systemic lupus erythematosus (SLE) is a comparatively rare condition. Although both autoimmune hepatitis and SLE can share common autoimmune features such as polyarthralgia, hypergammaglobulinemia and positive ANA, it has been considered as two different entities. We report a case of anti-LKM1 positive autoimmune hepatitis who developed SLE two years later. The presence of interface hepatitis with lymphoplasma cell infiltrates and rosette formation points to the autoimmune hepatitis rather than SLE hepatitis. Autoimmune hepatitis is infrequently accompanied by SLE, therefore, it could be recommended to investigate for SLE in patients with autoimmune hepatitis.

Cloning and expression of partial Japanese flounder (Paralichthys olivaceus) IgD.

The cDNA sequence of the Japanese flounder (Paralychthys olivaceus) IgD has been previously reported (GenBank accession no. AB052658) and this was followed by the detection of IgD mRNA expression in some flounder organ tissues. However, it has not been determined whether the flounder IgD gene is virtually expressed into IgD protein. To characterize the flounder immunoglobulins utilized in elucidating the mechanism, evolution and diversity of the flounder immune system, antibodies specific to IgD and IgM were necessary. In the present study, partial flounder recombinant IgD (rIgD), IgM (rIgM) and the conserved regions of IgD and IgM (rCIg) were produced by cloning the cDNA sequence using isotype specific primers which were designed to produce unique fragments of IgD and IgM specific amino acid sequences. The production of recombinant Igs was ascertained by SDS-gel electrophoresis and immunoblot analysis using anti-T7 d Taq antibody. The produced recombinant Igs were purified using affinity columns, and used as immunogens. Antibodies specific to the isotype of flounder Igs were generated by immunizing rabbits with rfIgs and the antibodies produced were identified by enzyme-linked immunosorbent assay (ELISA) and immunoblotting. Specificities of the generated antibodies were evaluated by testing cross-reactivity between recombinant IgM and IgD. By ELISA, rabbit antibodies against the rfIgD fragment (anti-rfIgD) failed to recognize any kind of flounder serum Igs, whereas respective antibodies against rfCIg (anti-rfCIg) and rfIgM fragments (anti-rfIgM) reacted with serum Igs. Likewise, in immunoblot assays, though anti-rfIgD did not, both anti-rfCIg and anti-rfIgM bound with the ~85 kd flounder IgM heavy chain. By flow cytometry analysis, anti-rfCIg, anti-rfIgD and anti-rfIgM reacted with 6%, 3% and 6.5% of cells, respectively, suggesting that flounder IgD is not secreted in serum but expressed on flounder B-like cell surfaces as in mammals. Antibodies produced against recombinant flounder Igs could be used to develop sandwich assay systems for detecting flounder Igs and for further investigating the flounder immune system.

[A case of Diphyllobothrium latum infection in a patient with abdominal pain].

The growing popularity of eating raw fish has resulted in increase of certain human parasitic infection, such as diphyllobothriasis. Even though, upper and lower gastrointestinal endoscopy reveal no specific abnormality, if a patient complains of persistent abdominal pain, we should consider the possibility of parasitic infection. Careful history taking and stool examination can avoid further invasive study. We report a case of Diphyllobothrium latum infection in a patient with vague abdominal pain who showed normal finding on endoscopy.