Angiographic tapering sign as a surrogate marker for large vessel occlusion due to intracranial atherosclerotic stenosis and its clinical implication: a retrospective matched case-control study.

BACKGROUND: The purpose of this study was to investigate whether the initial DSA appearance of the occlusion during mechanical thrombectomy (MT) can help distinguish the nature of the underlying lesion and predict radiological and clinical outcomes. METHODS: We retrospectively reviewed cases of patients with acute ischemic stroke who underwent MT for anterior circulation occlusion between March 2017 and February 2020. Underlying intracranial atherosclerotic stenosis (ICAS) was determined based on the presence of fixed stenosis after endovascular treatment. Patients were categorized based on the appearance of the occlusion observed in the initial DSA as tapering sign (+) or (-) groups. We performed 1:2 propensity score matching to establish a proper control group among the tapering sign (-) group. We analyzed and compared baseline characteristics and clinical outcomes between the two groups. RESULTS: A total of 293 patients (tapering sign (+), n=47; tapering sign (-), n=246) were included in the analysis. The procedure time of MT was significantly longer for the tapering sign (+) group, and the successful recanalization rate after MT was significantly lower in the tapering sign (+) group than in the tapering sign (-) group. Logistic regression showed that ICAS-related occlusion was strongly associated with a positive angiographic tapering sign, and the angiographic tapering sign was a negative factor for the first-pass effect during MT. However, a 3-month good functional outcome was not significantly associated with the angiographic tapering sign. CONCLUSIONS: The tapering sign on the initial DSA could be a surrogate marker for ICAS-related occlusion and procedural difficulty. However, its clinical significance remains unclear.

Intracranial non-occlusive intraluminal thrombus may indicate underlying etiology of large vessel occlusion in patients undergoing endovascular therapy.

BACKGROUND: The underlying etiology of intracranial non-occlusive intraluminal thrombus (iNOT) remains unknown. This study aimed to investigate whether the presence of iNOT can indicate the underlying etiology of large vessel occlusion (LVO) in patients undergoing endovascular therapy (EVT). METHODS: Among patients who underwent EVT at three comprehensive stroke centers, we included those with intracranial LVO in the anterior circulation. The presence of iNOT was determined by pretreatment DSA. We investigated the association between iNOT and intracranial atherosclerotic stenosis (ICAS) related LVO. RESULTS: Of 546 patients, 44 (8.1%) had iNOT. Patients with iNOT were younger, had less hypertension, atrial fibrillation, and a history of antiplatelet use. In addition, the involvement of the M1 segment of the middle cerebral artery (MCA) was more frequent. However, they had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission and longer onset to recanalization time compared with patients with no iNOT. In a logistic regression model adjusting for age, sex, atrial fibrillation, smoking, prior antiplatelet and anticoagulant use, intravenous tissue plasminogen activator, NIHSS on admission, number of technical trials, intraprocedural re-occlusion, and the location of LVO (p<0.10 in the univariate analysis), the presence of iNOT was significantly associated with ICAS related LVO (adjusted OR 3.04; 95% CI 1.33 to 6.90; p=0.007). CONCLUSIONS: The presence of iNOT may reflect an underlying ICAS related LVO in patients undergoing EVT.

Pazopanib-induced severe acute liver injury: A case report.

RATIONALE: Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the United States. Painkillers and fever antipyretics are the most common cause of DILI. Hepatic injury can be provoked by DILI as hepatocellular or cholestatic type. PATIENT CONCERNS: A 48-year-old woman presented jaundice accompanied by nausea and vomiting. The patient was an inactive hepatitis B carrier with low viral titer and was diagnosed renal cell carcinoma (RCC) with hepatic metastasis requiring pazopanib treatment. Prior to administration of pazopanib, tenofovir administration was started to prevent exacerbation of hepatitis B. The patient was referred to clinic of gastroenterology department due to sudden elevation of bilirubin after 5 weeks of pazopanib treatment. DIAGNOSES: Abdominal ultrasound and computed tomography showed non-specific finding other than metastatic nodule in the liver and liver cirrhosis. After then, the patient was performed liver biopsy, and the biopsy result was acute cholestatic hepatitis with centrilobular area necrosis and portal inflammation. Therefore, considering the clinical history and biopsy results, the patient was diagnosed as DILI due to pazopanib. INTERVENTIONS: After the biopsy, empirical steroid therapy was initiated and after 7 weeks of pazopanib discontinuation. OUTCOMES: The total bilirubin level returned to normal from peak level of 24.61 to 1.52 mg/dL. LESSONS: In patients with renal cell carcinoma, pazopanib treatment requires clinical caution as it causes rare complications such as severe jaundice and acute cholestatic hepatitis.

A Framework (SOCRATex) for Hierarchical Annotation of Unstructured Electronic Health Records and Integration Into a Standardized Medical Database: Development and Usability Study.

BACKGROUND: Although electronic health records (EHRs) have been widely used in secondary assessments, clinical documents are relatively less utilized owing to the lack of standardized clinical text frameworks across different institutions. OBJECTIVE: This study aimed to develop a framework for processing unstructured clinical documents of EHRs and integration with standardized structured data. METHODS: We developed a framework known as Staged Optimization of Curation, Regularization, and Annotation of clinical text (SOCRATex). SOCRATex has the following four aspects: (1) extracting clinical notes for the target population and preprocessing the data, (2) defining the annotation schema with a hierarchical structure, (3) performing document-level hierarchical annotation using the annotation schema, and (4) indexing annotations for a search engine system. To test the usability of the proposed framework, proof-of-concept studies were performed on EHRs. We defined three distinctive patient groups and extracted their clinical documents (ie, pathology reports, radiology reports, and admission notes). The documents were annotated and integrated into the Observational Medical Outcomes Partnership (OMOP)-common data model (CDM) database. The annotations were used for creating Cox proportional hazard models with different settings of clinical analyses to measure (1) all-cause mortality, (2) thyroid cancer recurrence, and (3) 30-day hospital readmission. RESULTS: Overall, 1055 clinical documents of 953 patients were extracted and annotated using the defined annotation schemas. The generated annotations were indexed into an unstructured textual data repository. Using the annotations of pathology reports, we identified that node metastasis and lymphovascular tumor invasion were associated with all-cause mortality among colon and rectum cancer patients (both P=.02). The other analyses involving measuring thyroid cancer recurrence using radiology reports and 30-day hospital readmission using admission notes in depressive disorder patients also showed results consistent with previous findings. CONCLUSIONS: We propose a framework for hierarchical annotation of textual data and integration into a standardized OMOP-CDM medical database. The proof-of-concept studies demonstrated that our framework can effectively process and integrate diverse clinical documents with standardized structured data for clinical research.

Development of canine PD-1/PD-L1 specific monoclonal antibodies and amplification of canine T cell function.

Interruption of the programmed death 1 (PD-1) / programmed death ligand 1 (PD-L1) pathway is an established and effective therapeutic strategy in human oncology and holds promise for veterinary oncology. We report the generation and characterization of monoclonal antibodies specific for canine PD-1 and PD-L1. Antibodies were initially assessed for their capacity to block the binding of recombinant canine PD-1 to recombinant canine PD-L1 and then ranked based on efficiency of binding as judged by flow cytometry. Selected antibodies were capable of detecting PD-1 and PD-L1 on canine tissues by flow cytometry and Western blot. Anti-PD-L1 worked for immunocytochemistry and anti-PD-1 worked for immunohistochemistry on formalin-fixed paraffin embedded canine tissues, suggesting the usage of this antibody with archived tissues. Additionally, anti-PD-L1 (JC071) revealed significantly increased PD-L1 expression on canine monocytes after stimulation with peptidoglycan or lipopolysaccharide. Together, these antibodies display specificity for the natural canine ligand using a variety of potential diagnostic applications. Importantly, multiple PD-L1-specific antibodies amplified IFN-γ production in a canine peripheral blood mononuclear cells (PBMC) concanavlin A (Con A) stimulation assay, demonstrating functional activity.

Differentiation of salivary gland tumors through tumor heterogeneity: a comparison between pleomorphic adenoma and Warthin tumor using CT texture analysis.

PURPOSE: We compared the diagnostic performance of CT texture analysis in single-phase CT scan with that of conventional enhancement pattern analysis in a two-phase CT scan for discrimination of salivary gland tumors, Warthin tumor (WT) from pleomorphic adenoma (PA). METHODS: One hundred seventy-eight patients with PA and 84 patients with WT were selected and CT texture analysis was separately performed on early (40s) and delayed (180s) phases, after injection of the contrast agent, using commercially available software. The attenuation changes and enhancement patterns were visually and quantitatively assessed with Hounsfield units (HU). Differences between PAs and WTs were analyzed using χ2 test and independent t test. Diagnostic performance of texture parameters in single-phase CT was compared with that of dynamic enhancement pattern in two-phase CT using the McNemar test. RESULTS: Ratio of tumoral HU (delayed phase/early phase) was significantly higher in PAs compared with WTs (p < 0.001). Tumor heterogeneity parameters, standard deviation (SD) and entropy, were significantly lower in WTs regardless of the type of filter used (p ≤ 0.001). Mean with coarse filter (AUC = 0.944) on early phase scan and entropy with medium filter (AUC = 0.901) on delayed scan were best discriminators between PAs and WTs. Diagnostic accuracy of mean (90.5%) on early scan and entropy (84.7%) on delayed scan was not significantly different from the accuracy (89.3%) of conventional wash-out pattern for distinguishing WTs from PAs (p = 0.742, p = 0.088, respectively). CONCLUSION: Diagnostic performance of texture parameters was similar to that of quantitative enhancement pattern for differentiating WTs from PAs, with the advantage in lower radiation exposure.

Discrimination of HPV status using CT texture analysis: tumour heterogeneity in oropharyngeal squamous cell carcinomas.

PURPOSE: To evaluate the diagnostic performance of texture analysis for discriminating human papillomavirus (HPV) status in patients with oropharyngeal squamous cell carcinoma (OPSCC) in the primary tumours and metastatic lymph nodes. METHODS: Ninety-five patients with primary tumour and 91 with metastatic lymph nodes with confirmed HPV status, who underwent pretreatment contrast-enhanced CT (CECT), were included as the discovery population. CT texture analysis was performed using commercially available software. Differences between HPV-positive and HPV-negative groups were analysed using the χ2 test (or Mann-Whitney U test) and independent t test (or Fisher's exact test). ROC curve analysis was performed to discriminate HPV status according to heterogeneity parameters. Diagnostic accuracy was evaluated in the separate validation population (n = 36) from an outside hospital. RESULTS: HPV positivity was 52.6% for primary tumours and 56.0% for metastatic lymph nodes. The entropy and standard deviation (SD) values in the HPV-positive group were significantly lower. Entropy using the medium filter was the best discriminator between HPV-positive and HPV-negative primary OPSCCs (AUC, 0.85) and SD without the filter for metastatic lymph nodes (AUC, 0.82). Diagnostic accuracy of entropy for the primary tumour was 80.0% in the discovery group and 75.0% in the validation group. In cases of metastatic lymph node, the accuracy of SD was 79.1% and 78.8%, respectively. CONCLUSION: Significant differences were found in heterogeneity parameters from texture analysis of pretreatment CECT, according to HPV status. Texture analysis could be used as an adjunctive tool for diagnosis of HPV status in clinical practice.

Failed dural puncture during needle-through-needle combined spinal-epidural anesthesia: a case series.

OBJECTIVE: Combined spinal-epidural (CSE) anesthesia is a widely used neuraxial anesthetic technique. In clinical practice, failed dural puncture during needle-through-needle technique occasionally occurs, with incidence of 5%-29%. We radiologically evaluated four cases of failed dural puncture during needle-through-needle CSE anesthesia. CASE SERIES: Four patients received CSE anesthesia for elective orthopedic surgery. CSE procedures were performed in the same manner using a CSE device for needle-through-needle technique. An epidural needle was inserted in midline at L4/5 interspaces using loss of resistance to air whilst patients lay in the lateral decubitus position. The spinal needle was then inserted through the epidural needle for subarachnoid block, however, negative cerebrospinal flow was identified. Subsequently, radiographic imaging using C-arm fluoroscopy was performed to evaluate the status of needles. We found that epidural needles were considerably deviated from the midline, while spinal needles exited epidural needles, not through back holes, but through the Tuohy curve in three patients. In one patient, when the spinal needle was inserted to 12 mm, the anesthesiologist felt the needle touching the bony structure. The spinal needle was in contact with the superior articular process of the fifth lumbar vertebra, which was confirmed by C-arm radiography. CONCLUSION: Excessive paramedian deviation of the epidural needle may affect dural puncture during needle-through-needle CSE technique. Moreover, wrong passage of the spinal needle through Tuohy curve instead of the back hole, may contribute to failure of dural puncture.

Quantification of myelin in children using multiparametric quantitative MRI: a pilot study.

PURPOSE: The purpose of this study was to evaluate the usefulness of multiparametric quantitative MRI for myelination quantification in children. METHODS: We examined 22 children (age 0-14 years) with multiparametric quantitative MRI. The total volume of myelin partial volume (Msum), the percentage of Msum within the whole brain parenchyma (Mbpv), and the percentage of Msum within the intracranial volume (Micv) were obtained. Four developmental models of myelin maturation (the logarithmic, logistic, Gompertz, and modified Gompertz models) were examined to find the most representative model of the three parameters. We acquired myelin partial volume values in different brain regions and assessed the goodness of fit for the models. RESULTS: The ranges of Msum, Mbpv, and Micv were 0.8-160.9 ml, 0.2-13%, and 0.0-11.6%, respectively. The Gompertz model was the best fit for the three parameters. For developmental model analysis of myelin partial volume in each brain region, the Gompertz model was the best-fit model for pons (R 2 = 74.6%), middle cerebeller peduncle (R 2 = 76.4%), putamen (R2 = 95.8%), and centrum semiovale (R 2 = 77.7%). The logistic model was the best-fit model for the genu and splenium of the corpus callosum (R 2 = 79.7-93.6%), thalamus (R 2 = 81.7%), and frontal, parietal, temporal, and occipital white matter (R 2 = 92.5-96.5%). CONCLUSIONS: Multiparametric quantitative MRI depicts the normal developmental pattern of myelination in children. It is a potential tool for research studies on pediatric brain development evaluation.

US Elastography Using Carotid Artery Pulsation May Increase the Diagnostic Accuracy for Thyroid Nodules with US-Pathology Discordance.

This study evaluated the diagnostic performance of ultrasound elastography (USE) using carotid arterial pulsation and determined the reproducibility of USE for thyroid nodules. A total of 148 patients with 173 thyroid nodules participated. The mean elasticity contrast index (ECI) was significantly higher in malignant nodules (3.1 ± 1.5) than in benign nodules (1.7 ± 0.8) (p < 0.001). When a cut-off ECI value of 3.5 was used, the diagnostic accuracy (78.6%) of gray-scale ultrasound (US) + ECI was the highest compared with that of the gray-scale US (76.9%) and ECI (67.1%). In 16 of 43 nodules (37.2%) with US-pathology, discordance could be correctly reclassified as benign (8 of 11) or malignant (8 of 32). The intra-class correlation coefficient for inter-observer agreement was 0.96, and those for intra-observer agreement were 0.97 and 0.98. Thyroid nodules with ECI values of >3.5 may have an additional value to increase the diagnostic accuracy for nodules with US-pathology discordance with reproducible results.

Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms: A Multicenter Study.

PURPOSE: To assess patient radiation doses during cerebral angiography and embolization of intracranial aneurysms across multi-centers and propose a diagnostic reference level (DRL). MATERIALS AND METHODS: We studied a sample of 490 diagnostic and 371 therapeutic procedures for intracranial aneurysms, which were performed at 23 hospitals in Korea in 2015. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time and total angiographic image frames were obtained and analyzed. RESULTS: Total mean DAP, CAK, fluoroscopy time, and total angiographic image frames were 106.2 ± 66.4 Gy-cm(2), 697.1 ± 473.7 mGy, 9.7 ± 6.5 minutes, 241.5 ± 116.6 frames for diagnostic procedures, 218.8 ± 164.3 Gy-cm(2), 3365.7 ± 2205.8 mGy, 51.5 ± 31.1 minutes, 443.5 ± 270.7 frames for therapeutic procedures, respectively. For diagnostic procedure, the third quartiles for DRLs were 144.2 Gy-cm(2) for DAP, 921.1 mGy for CAK, 12.2 minutes for fluoroscopy times and 286.5 for number of image frames, respectively. For therapeutic procedures, the third quartiles for DRLs were 271.0 Gy-cm(2) for DAP, 4471.3 mGy for CAK, 64.7 minutes for fluoroscopy times and 567.3 for number of image frames, respectively. On average, rotational angiography was used 1.5 ± 0.7 times/session (range, 0-4; n=490) for diagnostic procedures and 1.6 ± 1.2 times/session (range, 0-4; n=368) for therapeutic procedures, respectively. CONCLUSION: Radiation dose as measured by DAP, fluoroscopy time and image frames were lower in our patients compared to another study regarding cerebral angiography, and DAP was lower with fewer angiographic image frames for therapeutic procedures. Proposed DRLs can be used for quality assurance and patient safety in diagnostic and therapeutic procedures.

Effect of Osteoporosis on Bone Density of Orthognathic Osteotomy Sites in Maxillofacial Region.

OBJECTIVES: The aims of this study were to investigate the availability of Hounsfield unit (HU) measurement of computed tomography (CT) in evaluating the bone density of certain sites by comparing bone density between CT and dual-energy x-ray absorptiometry (DEXA), and to evaluate the effects of osteoporosis on osteotomy sites in orthognathic surgery. METHODS: This retrospective study included 80 patients who had undergone both facial CT and DEXA at our hospital. We selected 7 regions of interest from among the osteotomy sites in bimaxillary orthognathic surgery. The patients were assigned to either the normal (control) group (n = 40) or the abnormal group (n = 40), and HU values were measured in each region of interest. RESULTS: There were statistically significant differences in the mean HU values between 2 groups at all the osteotomy sites in the maxilla and mandible, with the normal group showing higher values than the abnormal group (P < 0.05). In addition, there was a significant positive correlation between T-scores obtained with DEXA and the HU values on CT at the osteotomy sites (P < 0.01). Multiple regression analysis indicated that the abnormal group was more negatively associated with 6 osteotomy sites except for 1 maxillary area, as compared with the normal group. CONCLUSIONS: Measurement of HU values on CT can be valuable in assessing bone density of the maxilla and mandible. It is suggested that osteoporosis may affect bone density at the osteotomy sites in orthognathic surgery, and the preoperative measurement of HU values might be useful in predicting unfavorable fracture or the risks involved in such surgery.

The Correlations Between MRI Perfusion, Diffusion Parameters, and 18F-FDG PET Metabolic Parameters in Primary Head-and-Neck Cancer: A Cross-Sectional Analysis in Single Institute.

This study aimed to investigate the relationships among parameters from dynamic contrast-enhanced (DCE) MRI, diffusion-weighted MRI (DWI), and F-fluorodeoxyglucose (F-FDG) PET in patients with primary head-and-neck squamous cell carcinoma (HNSCC).A total of 34 patients with primary HNSCC underwent DCE-MRI, DWI, and F-FDG PET before treatment. The perfusion parameters (Ktrans, Ktransmax, Kep, Ve, Vp, and AUC60) from DCE-MRI and ADC (ADCmean, ADCmin) values from DWI were calculated within the manually placed ROI around the main tumor. Standardized uptake value (SUVmax, SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG = SUVmean × MTV) were calculated with thresholds of 3.0 SUV. The associations between parameters were evaluated by Pearson correlation analysis.Significant correlations were identified between Ktrans and Kep (r = 0.631), Ktrans and Ve (r = 0.603), Ktrans and ADCmean (r = 0.438), Ktransmax and Kep (r = 0.667), Ktransmax and Vp (r = 0.351), Ve and AUC60 (r = 0.364), Ve and ADCmean (r = 0.590), and Ve and ADCmin (r = 0.361). ADCmin was reversely correlated with TLG (r = -0.347). Tumor volume was significantly associated with Ktransmax (r = 0.348).The demonstrated relationships among parameters from DCE, DWI, and F-FDG PET suggest complex interactions among tumor biologic characteristics. Each diagnostic technique may provide complementary information for HNSCC.

Development of biomarker positivity analysis system for cancer diagnosis based on clinical data.

In Korea, there were 224,000 new cases of cancer and 75,334 deaths caused by cancer in 2013, which was three times more than the number of death caused by heart disease, the second leading cause of death. This study proposes a biomarker positivity analysis system based on clinical data, for personalized diagnosis and therapy of cancer. Data of 78,912 cases were obtained from immunopathology and surgical pathology reports. Data on sex, age, organ, diagnosis, and biomarkers were entered into a database. To verify the reliability of the clinical data, an additional 50,450 cases from positivity-related research papers were added. The proposed biomarker positivity analysis system makes it possible to extract and combine information for searching. The positivity values are in graphical and tabular format for ease of use. With a link to the internal network of the hospital, real-time pathology reports are available. Twenty-five pathology specialists are chosen as subjects to further confirm the reliability of this system; primary assessment results demonstrate a satisfaction level of 4.7 out of 5 and a concordance rate of 79% with positive data under the same conditions as reported in the literature. In the present study, analysis methods and platforms using large volumes of clinical and literature data are developed for cancer prognoses. It is expected that these tools will benefit both healthcare professionals and non-professionals involved in cancer diagnosis and treatment.

Congenital macroglossia treated by 2-stage partial glossectomy.

Persistent macroglossia affects speech, swallowing, and the dentofacial skeleton. A range of tongue reduction methods have been proposed to preserve the mobility and sensation of the tongue. However, recent reports have shown that speech or esthetic problems still exists, even after a comprehensive glossectomy in early childhood. Because a large volume reduction of the anterior tongue in young growing children might result in a short tongue tip with functional difficulties, it is important to select the appropriate tongue reduction method considering the growth of the tongue.In the current report, a staged tongue reduction was planned to minimize the functional and esthetic problems after surgery. A 3-year-old girl visited our clinic because of congenital macroglossia, phonation problems, and prognathic appearance of the mandible. The tongue was first reduced by a central glossectomy. The speech intelligibility, tongue movement, and skeletal growth pattern were improved after the first surgery. The secondary peripheral tongue reduction was performed 6 years later to achieve an esthetically pleasing tongue appearance.This 2-stage partial glossectomy, central tongue reduction first followed later by a peripheral tongue reduction, ensures functional integrity of the tongue and can provide an esthetically pleasing result in growing children. The results demonstrated that this strategic combination of a staged tongue reduction can be a successful treatment option for macroglossia.

Spindle cell lipoma of the head and neck: CT and MR imaging findings.

INTRODUCTION: Spindle cell lipoma (SCL) is an uncommon benign lipomatous tumor, most commonly occurring in the posterior neck and shoulder. The purpose of this study was to investigate the CT and MR imaging features of SCL in the head and neck. METHODS: CT (n = 5) and MR (n = 3) images of seven patients (five men and two women; mean age, 54 years) with surgically proven SCL in the head and neck were retrospectively reviewed. The location and morphologic characteristics of SCL were documented as well. RESULTS: Six lesions were well-defined and located in the subcutaneous fat of the posterior neck (n = 4), anterior neck (n = 1), and buccal space (n = 1). One lesion was ill-defined and located deeply in the supraclavicular fossa, infiltrating the adjacent shoulder muscles. Intratumoral fat was identified in five lesions in various amounts. Compared with the adjacent subcutaneous fat, intratumoral fat was slightly hyperattenuated on CT scans and slightly hypointense on T1-weighted MR images. In five of six lesions in which postcontrast CT and/or MR images were obtained, significant enhancement was seen in the nonadipose component of the lesion. CONCLUSION: Various components of the adipose and nonadipose tissues may cause difficulty differentiating between SCL and other adipocytic tumors including liposarcoma radiologically. Although nonspecific, the radiologist should know the various imaging features of SCL, because the tumor can be cured by simple excision.

Pituitary apoplexy mimicking meningitis.

Pituitary apoplexy is a rare but life-threatening disorder. Clinical presentation of this condition includes severe headaches, impaired consciousness, fever, visual disturbance, and variable ocular paresis. The clinical presentation of meningeal irritation is very rare. Nonetheless, if present and associated with fever, pituitary apoplexy may be misdiagnosed as a meningitis. We experienced a case of pituitary apoplexy masquerading as a meningitis. A 42-year-old man presented with meningitis associated symptoms and initial imaging studies did not show evidence of intra-lesional hemorrhage in the pituitary mass. However, a follow-up imaging after neurological deterioration revealed pituitary apoplexy. Hereby, we report our case with a review of literatures.

Small submucosal tumors of the stomach: differentiation of gastric schwannoma from gastrointestinal stromal tumor with CT.

OBJECTIVE: To identify the CT features that help differentiate gastric schwannomas (GS) from small (5 cm or smaller) gastrointestinal stromal tumors (GIST) and to assess the growth rates of both tumors. MATERIALS AND METHODS: We included 16 small GSs and 56 GISTs located in the stomach. We evaluated the CT features including size, contour, surface pattern, margins, growth pattern, pattern and degree of contrast enhancement, and the presence of intralesional low attenuation area, hemorrhage, calcification, surface dimpling, fistula, perilesional lymph nodes (LNs), invasion to other organs, metastasis, ascites, and peritoneal seeding. We also estimated the tumor volume doubling time. RESULTS: Compared with GISTs, GSs more frequently demonstrated a homogeneous enhancement pattern, exophytic or mixed growth pattern, and the presence of perilesional LNs (each p < 0.05). The intralesional low attenuation area was more common in GISTs than GSs (p < 0.05). Multivariate analyses indicated that a homogeneous enhancement pattern, exophytic or mixed growth pattern, and the presence of perilesional LNs were statistically significant (p < 0.05). Tumor volume doubling times for GSs (mean, 1685.4 days) were significantly longer than that of GISTs (mean, 377.6 days) (p = 0.004). CONCLUSION: Although small GSs and GISTs show similar imaging findings, GSs more frequently show an exophytic or mixed growth pattern, homogeneous enhancement pattern, perilesional LNs and grow slower than GISTs.

Usefulness of the dynamic gadolinium-enhanced magnetic resonance imaging with simultaneous acquisition of coronal and sagittal planes for detection of pituitary microadenomas.

OBJECTIVE: Does dynamic gadolinium-enhanced imaging with simultaneous acquisition of coronal and sagittal planes improve diagnostic accuracy of pituitary microadenomas compared with coronal images alone? METHODS: Fifty-six patients underwent 3-T sella MRI including dynamic simultaneous acquisition of coronal and sagittal planes after gadolinium injection. According to conspicuity, lesions were divided into four scores (0, no; 1, possible; 2, probable; 3, definite delayed enhancing lesion). Additional information on supplementary sagittal images compared with coronal ones was evaluated with a 4-point score (0, no; 1, possible; 2, probable; 3, definite additional information). Accuracy of tumour detection was calculated. RESULTS: Average scores for lesion detection of a combination of two planes, coronal, and sagittal images were 2.59, 2.32, and 2.18. 6/10 lesions negative on coronal images were detected on sagittal ones. Accuracy of a combination of two planes, of coronal and of sagittal images was 92.86%, 82.14% and 75%. Six patients had probable or definite additional information on supplementary sagittal images compared with coronal ones alone (10.71%). CONCLUSION: Dynamic MRI with combined coronal and sagittal planes was more accurate for detection of pituitary microadenomas than routinely used coronal images. Simultaneous dynamic enhanced acquisition can make study time fast and costs low. KEY POINTS: We present a new dynamic MRI technique for evaluating pituitary microadenomas • This technique provides simultaneous acquisition of contrast enhanced coronal and sagittal images. • This technique makes the diagnosis more accurate and reduces the examination time. • Such MR imaging only requires one single bolus of contrast agent.

A comparison of the consumption of inhaled anesthetics according to fresh gas flow and anesthetic circuits.

BACKGROUND: In the Korean National Health Insurance Corporation (KNHIC), payment for inhaled anesthetics are made according to the simulated dose and not the consumed dose. We compare the consumption of inhaled anesthetics according to fresh gas flow (FGF) and anesthetic circuits to compare the consumption of anesthetics and the guidelines for KNHIC payments. METHODS: 161 patients were randomized into six groups who received isoflurane using a closed circuit (group I-C), a semi-closed circuit with FGF 3 L/min (group I-3), or 4 L/min (group I-4), as for the sevoflurane group (group S-C, S-3, and S-4). Mean arterial pressure (MAP) and heart rate (HR) were maintained within +/- 20% of baseline. Minimum alveolar concentration (MAC) and consumption of inhaled anesthetics were recorded by a new anesthetic machine. RESULTS: There were no significant differences among the groups for MAP, HR, and MAC. During anesthesia maintenance, the mean consumption per 15 minutes of inhaled anesthetics was significantly lower in group I-C (1.0 +/- 0.3 ml) than in group I-3 (3.5 +/- 0.7 ml) and than group I-4 (4.9 +/- 0.9 ml) and similar to the sevoflurane groups (group S-C [1.3 +/- 0.4 ml] vs group S-3 [5.3 +/- 1.0 ml] vs group S-4 [6.9 +/- 1.3 ml], respectively; P < 0.05). CONCLUSIONS: In sevoflurane groups, inhaled anesthetics were consumed more than in isoflurane groups. The KNHIC payment guidelines were close to the actual consumption of inhaled anesthetics under using a semi-closed circuit with FGF 3 L/min in sevoflurane and FGF 4 L/min in isoflurane.