Stereotactic Radiosurgery for Trigeminal Neuralgia Caused by Vertebrobasilar Compression: A Report of Four Cases.

BACKGROUND: Microvascular decompression (MVD) of the trigeminal nerve is an effective procedure for treating patients with trigeminal neuralgia (TGN). However, vertebrobasilar decompression involves technical difficulties and demonstrates a higher risk of minor trigeminal hypesthesia/hypalgesia, transient diplopia, and hearing loss. Stereotactic radiosurgery (SRS) has been an effective alternative treatment for TGN. Few studies reported the treatment results of SRS for TGN caused by vertebrobasilar compression. This report presents the treatment results of SRS using gamma knife (GK) in four TGN cases. MATERIALS AND METHODS: GK-SRS was performed for TGN due to vertebrobasilar compression in four patients, including two males and two females, aged 67-90 years. The maximum dose of 80 Gy was delivered at the retrogasserian portion (RGP) of the ipsilateral trigeminal nerve root. RESULTS: All four cases with TGN achieved relief in four to 10 months after GK-SRS. However, TGN recurred 41 months after GK-SRS in one of the four cases. A second GK-SRS at the root entry zone (REZ) at a maximum dose of 70 Gy relieved pain again 10 days later. TGN in another case among the four partially recurred in three years but did not deteriorate until the patient died from old age 62 months after GK-SRS. The other three cases, including the one with repeat GK-SRS, were alive with complete TGN remission at the end of follow-up of 20-52 months. GK-SRS-related adverse effects were not observed in any case. CONCLUSIONS: GK-SRS was a safe and effective treatment in all four TGN cases due to vertebral artery (VA)-basilar artery (BA) compression, although a second treatment session was added again for pain recurrence in one of the four cases.

Conservative management of placenta increta after first trimester abortion by transcatheter arterial chemoembolization: a case report and review of the literature.

INTRODUCTION: Placenta increta is a potentially life-threatening condition that may complicate a first trimester abortion in rare occasion. However, the therapeutic value of transcatheter arterial chemoembolization for the conservative management of this disorder is not described. CASE REPORT: A 27-year-old woman (gravida 3, para 1) with significant obstetric history for one previous lower segment cesarean section and one dilatation and curettage for missed abortion had uncomplicated dilatation and curettage for missed abortion. Eight weeks after curettage, the patient presented with increased amounts of vaginal bleeding. Image diagnostic modalities localized the heterogeneous mass within the myometrium in the fundal portion of the uterine corpus. Initially, arteriovenous fistula formation after abortion was suspected. However, an elevated serum hCG value indicated the presence of retained placental tissue and gave the diagnosis of persistent placenta increta after a first trimester abortion. Transcatheter arterial chemoembolization with dactinomycin was initiated to achieve immediate hemostasis and cytocidal effects on the placental tissue. The post-interventional course was uneventful. Twenty days after chemoembolization, the serum hCG value decreased to a normal level and the mass lesion disappeared on ultrasonography without secondary hemorrhagic complications. CONCLUSIONS: After precise diagnostic imaging, transcatheter arterial chemoembolization is a useful minimally invasive procedure to achieve uterine preservation in women with placenta increta masquerading as arteriovenous fistula after a first trimester abortion.

Computed tomographic angiography in diagnosis and management of placental polyp with neovascularization.

OBJECTIVE: To evaluate the neovascularization in placental polyp tissue by computed tomographic angiography and to determine the need for uterine artery embolization before hysteroscopic resection. STUDY DESIGN: Seventeen consecutive women with suspected placental polyp were enrolled in this retrospective study. Neovascularization in placental polyp tissue was assessed by computed tomographic angiography. Cases with neovascularization were treated by hysteroscopic resection with preoperative uterine artery embolization, while cases without neovascularization were treated by hysteroscopic resection alone. RESULTS: Of 17 patients with suspected placental polyp after abortion or parturition, nine patients were diagnosed to have placental polyp with prominent neovascularization by computed tomographic angiography, and were treated by uterine artery embolization followed by hysteroscopic resection. Two patients subsequently conceived after conservative management. CONCLUSIONS: After precise evaluation of neovascularization by computed tomographic angiography, hysteroscopic resection with preoperative uterine artery embolization is an effective minimally invasive procedure to conservatively treat placental polyp with prominent neovascularization.

Successful management of interstitial pregnancy with fetal cardiac activity by laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization.

INTRODUCTION: Interstitial pregnancy is a rare but dangerous form of ectopic pregnancy. Although various forms of minimally invasive management for this disorder have been previously reported, optimal treatment regimen has not been yet unknown due to its rarity. CASE REPORT: A 29-year-old married woman with no previous disease history was referred under suspicion of ectopic pregnancy. Serum hCG value was 95,365 mIU/mL. On ultrasonographic examination, gestational sac with a viable embryo was identified in the left cornual region. Three-dimensional computed tomographic angiography showed prominent vascular mass in the left cornual region. Preoperative transcatheter uterine artery embolization followed by laparoscopic-assisted cornual resection with local methotrexate injection was successfully performed. CONCLUSIONS: Laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization for interstitial pregnancy with prominent vascular flow is a safe and reliable minimally invasive procedure for woman wishing fertility preservation.

Progressive formation of uterine arteriovenous fistula after laparoscopic-assisted myomectomy.

INTRODUCTION: Laparoscopic-assisted myomectomy (LAM) is a minimally invasive procedure with many advantages. However, progressive formation of uterine arteriovenous fistula (AVF) after LAM is not described as a significant complication. CASE REPORT: A 39-year-old nulligravida underwent LAM for multiple myomas. On ultrasonography obtained 13 days after LAM, a prominent vascular mass was identified in the post-myomectomy scar. Computed tomographic angiography showed AVF originating from the left uterine artery. Uterine AVF was endovascularly embolized by metallic coils to avoid future hemorrhage. CONCLUSIONS: Development of uterine AVF after LAM is a potentially life-threatening complication. Early diagnosis and endovascular management can provide a significant benefit for a woman wishing uterine preservation.

Influence of monitor luminance and room illumination on soft-copy reading evaluation with electronically generated contrast-detail phantom: comparison of cathode-ray tube monitor with liquid crystal display.

The influence of monitor brightness and room illumination on soft-copy diagnosis by both cathode-ray tube (CRT) monitor and liquid crystal display (LCD) was evaluated and compared using a contrast-detail phantom. Nine observers (7 radiologists and 2 radiological technicians) interpreted six types of electronically generated contrast-detail phantom images using a 21-inch CRT (2,048x2,560) and a 21-inch LCD (2,048x2,560) under 6 kinds of viewing conditions, i.e. monitor brightness of 330 cd/m2 or 450 cd/m2, and room illumination of 20, 100 or 420 lux at the center of the display. Observers were requested to determine the visible borderline of the objects. Between 330 cd/m2 and 450 cd/m2, no significant difference in the visible area was found under any of the three lighting conditions. However, in two low-contrast phantom images, the visible area on the LCD was significantly larger than that on the CRT, independent of both monitor brightness and room illumination. (p<0.05). The effect of room illumination was not significant, suggesting that the use of LCD at high room illumination is acceptable.

Intra- and interobserver agreement and performance score of breast phantom image interpretation: influence of ambient room lighting levels.

The influence of ambient room lighting conditions on soft-copy breast phantom image interpretation was evaluated by comparing cathode ray tube (CRT) monitors with liquid crystal displays (LCDs). Nine observers were asked to use a three-point scale to rate the visibility of various phantom objects (masses, specks, and fibers) displayed on a 21-inch CRT (2,560 x 2,048) and a 21-inch LCD (2,560 x 2,048) under three different levels of ambient lighting (20, 100 and 420 lux at the display center). Each phantom image was interpreted twice, and the reproducibility of judgment and inter-observer agreement was evaluated using kappa statistics. Except for the "mass" score, the LCD score showed a significantly higher value (p<0.05) compared with that of CRT. Nevertheless, no significant differences were found among the three lighting levels. Furthermore, intra- and inter-observer agreement in judgments showed no effects of room illumination. Although the breast phantom objects were better visualized on LCDs than on CRT monitors, room illumination did not affect the performance score of soft-copy reading.

Multi-institutional analysis of early glottic cancer from 2000 to 2005.

BACKGROUND: The purpose of this study is to analyze the outcome of patients with early glottic cancer (GC) treated with radiotherapy (RT) with or without chemotherapy at 10 institutions in the Tokai District, Japan. METHODS: Ten institutions combined data from 279 patients with T1-T2 GC treated with RT with or without chemotherapy between 2000 and 2005. The overall survival rate, disease-specific survival rate, and local control rate were evaluated in 270 patients, except for incomplete cases due to issues such as discontinuation, using the method of Kaplan-Meier and compared using the log-rank test. Results were considered statistically significant at the level of p < 0.05. RESULTS: For 122 patients, the tumors were classified as T1a, while 64 patients had T1b tumors, and 84 patients had T2 tumors. In three cases of T1 tumors, the subtype was unknown. Combined chemoradiotherapy (CRT) was administered during each stage, and various chemotherapy drugs and regimens were used. The median follow-up period was 55.4 months. The 5-year LC rates for T1a, Tb, and T2 tumors in all patients were 87.9%, 82.7%, and 74.1%, respectively. The difference between T1a and T2 was statistically significant (p = 0.016). The 5-year LC rates for T1a, Tb, and T2 with CRT were 92.7%, 78.6%, and 80.7%, respectively, while the rates with radiation alone were 86.5%, 83.8%, and 64.4%, respectively. The difference between CRT and RT alone was not statistically significant in each stage. CONCLUSIONS: In this survey, CRT was performed for early GC at most institutions in clinical practice. Our data showed no statistical difference in the LC rates between CRT and RT alone in each stage. However, there was a tendency for the LCRs of the CRT group to be more favorable than those of the RT group in the T2-stage.

Temporary endovascular balloon occlusion of the bilateral internal iliac arteries to control hemorrhage during laparoscopic-assisted vaginal hysterectomy for cervical myoma.

OBJECTIVE: To report our initial experience with temporary endovascular balloon occlusion of the bilateral internal iliac arteries to control hemorrhage during laparoscopic-assisted vaginal hysterectomy (LAVH) for cervical myoma. STUDY DESIGN: Thirteen patients with cervical myoma were treated by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries from September 2008 to October 2010. Preoperative evaluation of cervical myoma was made by ultrasonography, magnetic resonance imaging and three-dimensional computerized tomographic angiography, and curative management was made by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries. RESULTS: Nine patients with extracervical myoma and 4 patients with intracervical myoma were successfully managed by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries. For extracervical myomas, the median extirpated uterine weight was 591 g (range 360-1010 g). Median duration required for placement of balloon occlusion catheter was 60 min (range 47-69 min). Median surgical duration was 98.5 min (range 77-149 min). Median duration of endovascular balloon occlusion of the bilateral internal iliac arteries was 66 min (range 42-98 min). The median estimated blood loss was 355 mL (range 50-1950 mL). For intracervical myomas, the median extirpated uterine weight was 513 g (range 302-710 g). Median duration required for placement of balloon occlusion catheter was 63 min (range 42-76 min). Median surgical duration was 96.5 min (range 92-100 min). Median duration of endovascular balloon occlusion of the bilateral internal iliac arteries was 49 min (range 44-60 min). The median estimated blood loss was 210 mL (range 150-650 mL). Transfusion of preoperatively donated autologous blood negated the need for bank blood. There were no major interventional radiological and surgical complications in the present case series. CONCLUSIONS: Temporary endovascular balloon occlusion of the bilateral internal iliac arteries is a feasible minimally invasive alternative to control hemorrhage during LAVH for cervical myoma.

Diagnostic multimodal imaging and therapeutic transcatheter arterial chemoembolization for conservative management of hemorrhagic cesarean scar pregnancy.

OBJECTIVE: To evaluate the value of emergency transcatheter arterial chemoembolization (TACE) for initial conservative management of hemorrhagic cesarean scar pregnancy after multimodal image diagnosis. STUDY DESIGN: Five consecutive cases of hemorrhagic cesarean scar pregnancy were diagnosed for precise localization of ectopic placentation site, depth of placental invasion and uteroplacental neovascularization by imaging studies including color Doppler ultrasonography, magnetic resonance imaging (MRI) and three-dimensional computerized tomographic angiography. Emergency TACE with dactinomycin was initially performed to achieve immediate hemostasis and cytotoxic effects on chorionic villous tissue. Then, the need for either expectant management or subsequent hysteroscopic resection was individually determined. Systemic methotrexate (MTX) administration was added when delayed decline of serum hCG value was noted. RESULTS: On MRI, total placental invasion to the serosa of the anterior uterine wall was diagnosed in three cases, while the two remaining cases showed subtotal invasion to the anterior uterine wall. All cases were managed by emergency TACE as an initial conservative measure. Subsequently, spontaneous expulsion of gestational products occurred in one case of subtotal placental invasion. Additional MTX administration was required to achieve complete resorption of cesarean scar pregnancy in two cases of total placental invasion. In one case of subtotal placental invasion, successful hysteroscopic resection was performed under laparoscopic guidance, whereas, in one case of total placental invasion, hysteroscopic removal of gestational products was incomplete due to the risk of uterine perforation and additional systemic MTX administration was required for complete resolution. Uterine preservation was achieved in all cases without unfavorable effects of TACE or secondary hemorrhagic complications. CONCLUSIONS: This small case series emphasizes that TACE is potentially useful as an initial emergency intervention for conservative management of hemorrhagic cesarean scar pregnancy to achieve immediate hemostasis and direct cytotoxic effects on chorionic villous tissue with minimal systemic side effects of chemotherapeutic agent.

Placental polyp with prominent neovascularization.

Placental polyp is a potentially life-threatening disorder that develops after abortion or parturition. Evaluation of neovascularization by multimodal imaging is potentially useful in management of placental polyp in a woman who wishes to preserve fertility.

Late occurrence of severe hyponatremia followed by extrapontine osmotic demyelination syndrome after successful conservative management of postpartum hemorrhage due to placenta accreta by uterine artery embolization.

Development of severe hyponatremia followed by extrapontine osmotic demyelination syndrome was reported as a significant late complication after successful conservative management of postpartum hemorrhage due to placenta accreta by uterine artery embolization.

Combined chemoradiotherapy for early glottic cancer in clinical practice in Japan: analysis of 10 institutions.

AIM: To conduct a retrospective analysis regarding treatment strategies for early glottic cancer (GC) at ten institutions. PATIENTS AND METHODS: A questionnaire-based survey was used to obtain personal and medical information on patients who started radiation therapy for T1 or T2 GC between January 2000 and December 2005. RESULTS: A total of 279 patients were registered for the survey, of whom 124 patients were classified as T1a, with 65 patients as T1b and 87 patients as T2. The rates of chemoradiotherapy for T1a, T1b and T2 were 24%, 23% and 60%, respectively. A comparison of results for academic and non-academic hospitals showed statistically different rates of combination therapy for T1a (6.9% vs. 39.3%, respectively; p<0.001) and T1b (11.4% vs. 36.6%, respectively; p<0.05) but not for T2 (70.0% vs. 54.4%, respectively; p = 0.158). CONCLUSION: In clinical practice, combined chemoradiotherapy was performed for early GC at most institutions in Tokai District, Japan.

Temporary endovascular balloon occlusion of the bilateral internal iliac arteries for control of hemorrhage during laparoscopic-assisted myomectomy in a nulligravida with a large cervical myoma.

OBJECTIVE: To describe the preoperative evaluation and minimally invasive management of a large cervical myoma in a nulligravida who wished to preserve fertility. DESIGN: Case report. SETTING: Departments of obstetrics and gynecology and radiology at a general hospital. PATIENT(S): A 33-year-old nulligravida with a large cervical myoma. INTERVENTION(S): A large cervical myoma was preoperatively diagnosed by ultrasonography, magnetic resonance imaging, and computed tomographic angiography and was successfully treated with minimal blood loss by laparoscopic-assisted myomectomy combined with prophylactic temporary endovascular balloon occlusion of the bilateral internal iliac arteries. MAIN OUTCOME MEASURE(S): Uterine conservation. RESULT(S): Fertility preservation was achieved with minimal blood loss in a nulligravida with a large cervical myoma. CONCLUSION(S): Laparoscopic-assisted myomectomy combined with prophylactic endovascular balloon occlusion of the bilateral internal iliac artery was an effective minimally invasive procedure to preserve fertility in a nulligravida with a large cervical myoma.

Early diagnosis and endovascular management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy.

OBJECTIVE: To describe the diagnosis and management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy. DESIGN: Case reports. SETTING: Departments of Obstetrics and Gynecology and Radiology at General Hospital. PATIENT(S): A 32-year-old woman and a 41-year-old woman each developed uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy. INTERVENTION(S): Uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy was diagnosed on ultrasonography, computerized tomographic angiography, and digital subtraction angiography, and treated by transcatheter arterial embolization. MAIN OUTCOME MEASURE(S): Uterine conservation. RESULT(S): Fertility preservation was achieved in both of these women who developed uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy. CONCLUSION(S): Early diagnosis and endovascular management of uterine artery pseudoaneurysm after myomectomy are important to prevent life-threatening hemorrhage caused by pseudoaneurysmal rupture.

Diagnostic computed tomographic angiography and therapeutic emergency transcatheter arterial embolization for management of postoperative hemorrhage after gynecologic laparoscopic surgery.

STUDY OBJECTIVE: To evaluate the diagnostic value of 3-dimensional computed tomographic (CT) angiography and treatment efficacy of emergency transcatheter arterial embolization (TAE) for early postoperative hemorrhage after gynecologic laparoscopic surgery. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Department of gynecology at a general hospital. PATIENTS: Nine patients with early postoperative hemorrhage after gynecologic laparoscopic surgery were treated by TAE between January 2004 and October 2007. Diagnostic 3-dimensional CT angiography was performed for identification of the bleeding artery before TAE in 5 of those patients. INTERVENTIONS: Diagnostic 3-dimensional CT angiography and therapeutic emergency TAE. MEASUREMENTS AND MAIN RESULTS: In all, 2952 patients (1165 laparoscopic-assisted vaginal hysterectomy [LAVH], 1086 adnexal surgery, 417 laparoscopic-assisted myomectomy [LAM], 222 ectopic pregnancy surgery, and 62 other) were treated by laparoscopic surgery between January 1994 and October 2007. Fourteen patients developed postoperative hemorrhagic shock (5 LAVH [0.43%], 1 adnexal surgery [0.09%], 7 LAM [1.68%], 1 ectopic pregnancy surgery [0.45%]). Since 2004, instead of second laparotomy or laparoscopy, TAE was primarily chosen to manage the postoperative hemorrhage for 3 cases after LAVH and 6 cases after LAM. In 5 cases experienced in the last 2 years, diagnostic 3-dimensional CT angiography was performed to identify the bleeding artery before TAE. Transfusion of preoperatively donated autologous blood and intraoperatively salvaged autologous blood was sufficient to maintain vital functions of the patients except in 1 case of LAM that required homologous blood transfusion before TAE as a result of significant delay in establishing the diagnosis. Postembolization course was uneventful except in 1 case of LAVH that developed vaginal stump abscess and required transvaginal drainage twice after readmission. CONCLUSION: Emergency TAE is a safe and effective minimally invasive procedure for patients developing postoperative hemorrhage after gynecologic laparoscopic surgery. Diagnostic CT angiography could play a significant role in shortening the process of TAE by identifying the site of extravasation before TAE.