Feasibility of Single-Shot Whole Thoracic Time-Resolved MR Angiography to Evaluate Patients with Multiple Pulmonary Arteriovenous Malformations

Objective@#To evaluate the feasibility of single-shot whole thoracic time-resolved MR angiography (TR-MRA) to identify the feeding arteries of pulmonary arteriovenous malformations (PAVMs) and reperfusion of the lesion after embolization in patients with multiple PAVMs. @*Materials and Methods@#Nine patients (8 females and 1 male; age range, 23–65 years) with a total of 62 PAVMs who underwent percutaneous embolization for multiple PAVMs and were subsequently followed up using TR-MRA and CT obtained within 6 months from each other were retrospectively reviewed. All imaging analyses were performed by two independent readers blinded to clinical information. The visibility of the feeding arteries on maximum intensity projection (MIP) reconstruction and multiplanar reconstruction (MPR) TR-MRA images was evaluated by comparing them to CT as a reference. The accuracy of TR-MRA for diagnosing reperfusion of the PAVM after embolization was assessed in a subgroup with angiographic confirmation. The reliability between the readers in interpreting the TR-MRA results was analyzed using kappa (κ) statistics. @*Results@#Feeding arteries were visible on the original MIP images of TR-MRA in 82.3% (51/62) and 85.5% (53/62) of readers 1 and 2, respectively. Using the MPR, the rates increased to 93.5% (58/62) and 95.2% (59/62), respectively (κ = 0.760 and 0.792, respectively). Factors for invisibility were the course of feeding arteries in the anteroposterior plane, proximity to large enhancing vessels, adjacency to the chest wall, pulsation of the heart, and small feeding arteries. Thirty-seven PAVMs in five patients had angiographic confirmation of reperfusion status after embolization (32 occlusions and 5 reperfusions).TR-MRA showed 100% (5/5) sensitivity and 100% (32/32, including three cases in which the feeding arteries were not visible on TR-MRA) specificity for both readers. @*Conclusion@#Single-shot whole thoracic TR-MRA with MPR showed good visibility of the feeding arteries of PAVMs and high accuracy in diagnosing reperfusion after embolization. Single-shot whole thoracic TR-MRA may be a feasible method for the follow-up of patients with multiple PAVMs.

Effect and mechanism of chitosan-based nano-controlled release system on the promotion of cell cycle progression gene expression / 대한치과보철학회지

Purpose@#In our previous studies, application of trichloroacetic acid (TCA) to gingival fibroblasts or to canine palatal soft tissue was verified to alter the expression of several genes responsible for cell cycle progression. In order to confirm this effect in a system allowing sequential release of TCA and epidermal growth factor (EGF), expression of various cell cycle genes following the application of the agents, using hydrophobically modified glycol chitosan (HGC)-based nano-controlled release system, was explored in this study. @*Materials and methods@#HGCbased nano-controlled release system was developed followed by loading TCA and EGF. The groups were defined as the control (CON); TCA-loaded nano-controlled release system (EXP1); TCA- and EGF- individually loaded nano-controlled release system (EXP2). At 24- and 48 hr culture, expression of 37 cell cycle genes was analyzed in human gingival fibroblasts. Correlations and the influential genes were also analyzed. @*Results@#Numerous genes such as cyclins (CCNDs), cell division cycles (CDCs), cyclin-dependent kinases (CDKs), E2F transcription factors (E2Fs), extracellular signal-regulated kinases (ERKs) and other cell cycle genes were significantly up-regulated in EXP1 and EXP2. Also, cell cycle arrest genes of E2F4, E2F5, and GADD45G were up-regulated but another cell cycle arrest gene SMAD4 was down-regulated. From the multiple regression analysis, CCNA2, CDK4, and ANAPC4 were determined as the most influential factors on the expression of ERK genes. @*Conclusion@#Application of TCA and EGF, using the HGC-based nano-controlled sequential release system significantly up-regulated various cell cycle progression genes, leading to the possibility of regenerating oral soft tissue via application of the proposed system.

Post-Stroke Cognitive Impairment: Pathophysiological Insights into Brain Disconnectome from Advanced Neuroimaging Analysis Techniques / 대한뇌졸중학회지

The neurological symptoms of stroke have traditionally provided the foundation for functional mapping of the brain. However, there are many unresolved aspects in our understanding of cerebral activity, especially regarding high-level cognitive functions. This review provides a comprehensive look at the pathophysiology of post-stroke cognitive impairment in light of recent findings from advanced imaging techniques. Combining network neuroscience and clinical neurology, our research focuses on how changes in brain networks correlate with post-stroke cognitive prognosis. More specifically, we first discuss the general consequences of stroke lesions due to damage of canonical resting-state large-scale networks or changes in the composition of the entire brain. We also review emerging methods, such as lesion-network mapping and gradient analysis, used to study the aforementioned events caused by stroke lesions. Lastly, we examine other patient vulnerabilities, such as superimposed amyloid pathology and blood-brain barrier leakage, which potentially lead to different outcomes for the brain network compositions even in the presence of similar stroke lesions. This knowledge will allow a better understanding of the pathophysiology of post-stroke cognitive impairment and provide a theoretical basis for the development of new treatments, such as neuromodulation.

Post-Stroke Cognitive Impairment: Pathophysiological Insights into Brain Disconnectome from Advanced Neuroimaging Analysis Techniques / 대한뇌졸중학회지

The neurological symptoms of stroke have traditionally provided the foundation for functional mapping of the brain. However, there are many unresolved aspects in our understanding of cerebral activity, especially regarding high-level cognitive functions. This review provides a comprehensive look at the pathophysiology of post-stroke cognitive impairment in light of recent findings from advanced imaging techniques. Combining network neuroscience and clinical neurology, our research focuses on how changes in brain networks correlate with post-stroke cognitive prognosis. More specifically, we first discuss the general consequences of stroke lesions due to damage of canonical resting-state large-scale networks or changes in the composition of the entire brain. We also review emerging methods, such as lesion-network mapping and gradient analysis, used to study the aforementioned events caused by stroke lesions. Lastly, we examine other patient vulnerabilities, such as superimposed amyloid pathology and blood-brain barrier leakage, which potentially lead to different outcomes for the brain network compositions even in the presence of similar stroke lesions. This knowledge will allow a better understanding of the pathophysiology of post-stroke cognitive impairment and provide a theoretical basis for the development of new treatments, such as neuromodulation.

From Bound Cells Comes a Sound Mind: The Role of Neuronal Growth Regulator 1 in Psychiatric Disorders

Cell-to-cell adhesion is important for maintenance of brain structure and function. Abnormal neuronal cell adhesion and loss of its connectivity are considered a main cause of psychiatric disorders such as major depressive disorder (MDD). Various cell adhesion molecules (CAMs) are involved in neuronal cell adhesions and thereby affect brain functions such as learning and memory, cognitive functions, and psychiatric functions. Compared with other CAMs, neuronal growth regulator 1 (Negr1) has a distinct functioning mechanism in terms of its cross-talk with cytokine receptor signaling. Negr1 is a member of the immunoglobulin LON (IgLON) family of proteins and is involved in neuronal outgrowth, dendritic arborization, and synapse formation. In humans, Negr1 is a risk gene for obesity based on a genome-wide association study. More recently, accumulating evidence supports that it also plays a critical role in psychiatric disorders. In this review, we discuss the recent findings on the role of Negr1 in MDD, focusing on its regulatory mechanism. We also provide evidence of putative involvement of Negr1 in other psychiatric disorders based on the novel behavioral phenotypes of Negr1 knockout mice.

Individual-Level Lesion-Network Mapping to Visualize the Effects of a Stroke Lesion on the Brain Network: Connectograms in Stroke Syndromes

Modified Transosseous Wiring Technique for Neglected Fracture–Dislocation of the Proximal Interphalangeal Joint

BACKGROUND: Fracture–dislocation of the proximal interphalangeal (PIP) joint of the finger is challenging due to the high risk of stiffness. The purpose of this study is to evaluate the clinical and radiological results of a modified transosseous wiring technique for the management of chronic fracture–dislocations of the PIP joint. METHODS: Ten patients (nine men and one woman; mean age, 38.3 years; range, 21 to 69 years) with neglected fracture–dislocation of the PIP joint were included. The mean duration from injury to operation was 14.7 weeks (range, 3 to 66 weeks). The dorsolateral approach and extension block pinning were used to reduce dislocation. After thorough debridement of the scar tissues in the dorsal dead space and the fracture site, the reduction was maintained with transosseous wiring. Radiologic evaluations of bone union and arthritic changes and clinical evaluations (range of motion of the PIP joint and Disabilities of the Arm, Shoulder and Hand [DASH] score) were performed. The mean follow-up period was 12.9 months (range, 12 to 19 months). RESULTS: All patients demonstrated evidence of radiographic healing within a mean healing time of 6 weeks (range, 4 to 10 weeks); however, one had a widened gap and one had an early arthritic change. The mean range of motion in the PIP joint was 81° (range, 50° to 105°). The mean DASH score was 21.6 (range, 7.5 to 35.8). CONCLUSIONS: For chronic fracture–dislocation of the PIP joint, transosseous wiring with direct curettage and optimal bone purchase can provide satisfying outcome.

Magnetization Transfer Contrast Angiography for Organized Thrombosed Intracranial Aneurysm in TOF MR Angiography: a Case Report

A 66-year-old woman was referred for treatment of incidental detection of two intracranial aneurysms. Time-of-flight MR angiography (TOF MRA) revealed two aneurysms at the M1 segment of the right middle cerebral artery, and clinoid segment of left internal carotid artery, respectively. On digital subtraction angiography, there was a saccular aneurysm on the left internal carotid artery, but the other aneurysm was not detected on the right middle cerebral artery. Based on comprehensive review of imaging findings, organized thrombosed aneurysm was judged as the most likely diagnosis. In the presented report, magnetization transfer (MT) pulse to TOF MRA was used, to differentiate aneurysm-mimicking lesion on TOF MRA. We report that MT technique could be effective in differentiating true aneurysm, from possible T1 high signal artifact on TOF MRA.

The Spinal Instability Neoplastic Score (SINS) as a Surgical Decision-Making Tool for the Treatment of Spine Metastasis / 대한척추외과학회지

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To investigate the potential clinical use of the spinal instability neoplastic score (SINS) for determining the surgical strategy, especially regarding the need for anterior support. SUMMARY OF LITERATURE REVIEW: The SINS seems to enable an improved qualitative and quantitative assessment of spinal instability in patients with spinal metastasis. MATERIALS AND METHODS: We retrospectively reviewed 69 consecutive patients who underwent surgical treatment for spinal metastasis. We assessed the patients' preoperative status with respect to each component of the SINS. Multiple logistic regression was performed to calculate odds ratios (ORs) representing the associations among SINS, age, Eastern Cooperative Oncology Group performance status, modified Tokuhashi score, as well as the preoperative Nurick grade variables and reconstruction of the anterior spinal column. RESULTS: Among the 6 items in the SINS, those indicating the degree of collapse and alignment had significantly higher scores in those who underwent corpectomy and anterior support (p<0.001). Multiple logistic regression revealed that the total SINS was the only factor significantly associated with predicting whether anterior support should be performed (adjusted OR=1.595). Receiver operating characteristic (ROC) curve analysis suggested that a cut-off value of 10 points on the SINS scale could be used to decide whether anterior support following corpectomy should be performed (AUC=0.706). CONCLUSIONS: The SINS, insofar as it assesses the degree of collapse and alignment, is a potentially useful tool for determining the surgical strategy in patients with spinal metastasis, especially for deciding upon the necessity of additional anterior support procedures.

A Case of Ceruminous Adenoma Arising from the External Auditory Canal / 고신대학교의과대학학술지

Ceruminous adenoma is a benign neoplasm of the ceruminous gland, and its development in human external auditory canal is very rare. Due to the limited number of cases, controversy still exists about nomenclature, classification, diagnosis and its treatment. Recently we experienced a 55 years old woman who was diagnosed with ceruminous adenoma of the external auditory canal, and who was treated with wide excision. So we report this uncommon case in combination with a review of the literature.

The Nutritional Status and the Clinical Outcomes of Patients With a Spinal Cord Injury Using Nutritional Screening Tools

OBJECTIVE: To assess the nutritional status of Korean patients with spinal cord injury (SCI), identify the predictors of undernutrition, and investigate the relationship between undernutrition and clinical outcomes. METHODS: A retrospective study design was used to determine the nutritional status of 130 patients over 19 years old admitted to the rehabilitation hospital of Yonsei University Health System between June 2015 and February 2017. The nutritional status was assessed using the malnutrition universal screening tool (MUST) and the spinal nutrition screening tool (SNST). The relationship between undernutrition and clinical outcomes was examined by comparing a low-risk group with an at-risk group using a t-test. RESULTS: Among the SCI patients, 70 (50.8%) were confirmed with undernutrition based on the MUST scores, while 60 (46.2%) had undernutrition based on the SNST scores. It was found that undernutrition has an effect on functional outcomes. CONCLUSION: We assessed the undernutrition risk in Korean SCI patients, and found that approximately 50% of the patients were at risk of undernutrition. We also found that undernutrition can affect functional recovery.

Infection of human intestinal epithelial cells by invasive bacteria activates NF-κB and increases ICAM-1 expression through NOD1

BACKGROUND/AIMS@#Nucleotide-binding oligomerization domain 1 (NOD1) is required for primary intestinal epithelial cells (IECs) to respond to natural mucopeptides secreted by gram-negative bacteria. Infection of human IECs with invasive bacteria up-regulates intercellular adhesion molecule-1 (ICAM-1) expression. However, the role of NOD family members in host defense has been largely unknown. The aim of this study was to determine whether there is a functional role for NOD1 in the up-regulation of ICAM-1 expression in invasive bacteria-infected IECs.@*METHODS@#ICAM-1 mRNA expression was compared between controls, Caco-2 or HT29 cells transfected with an empty vector, and IECs stably transfected with a dominant-negative (DN) NOD1. Expression was compared using qualitative reverse transcription polymerase chain reaction (RT-PCR), real-time RT-PCR, and flow cytometry after infection with enteroinvasive Escherichia coli O29:NM or Shigella flexneri. Nuclear factor kB (NF-κB) activation was determined by electrophoretic mobility shift assays.@*RESULTS@#DN NOD1 significantly inhibited the up-regulation of ICAM-1 expression in response to an enteroinvasive bacterial infection. The Caco-2 cells transfected with DN NOD1 manifested marked inhibition of NF-kB activation in response to E. coli O29:NM infection.@*CONCLUSIONS@#Signaling through NOD1 may play an essential role in neutrophil trafficking following infection with enteroinvasive bacteria.

The Spinal Instability Neoplastic Score (SINS) as a Surgical Decision-Making Tool for the Treatment of Spine Metastasis

OBJECTIVES@#To investigate the potential clinical use of the spinal instability neoplastic score (SINS) for determining the surgical strategy, especially regarding the need for anterior support.SUMMARY OF LITERATURE REVIEW: The SINS seems to enable an improved qualitative and quantitative assessment of spinal instability in patients with spinal metastasis.@*MATERIALS AND METHODS@#We retrospectively reviewed 69 consecutive patients who underwent surgical treatment for spinal metastasis. We assessed the patients' preoperative status with respect to each component of the SINS. Multiple logistic regression was performed to calculate odds ratios (ORs) representing the associations among SINS, age, Eastern Cooperative Oncology Group performance status, modified Tokuhashi score, as well as the preoperative Nurick grade variables and reconstruction of the anterior spinal column.@*RESULTS@#Among the 6 items in the SINS, those indicating the degree of collapse and alignment had significantly higher scores in those who underwent corpectomy and anterior support (p<0.001). Multiple logistic regression revealed that the total SINS was the only factor significantly associated with predicting whether anterior support should be performed (adjusted OR=1.595). Receiver operating characteristic (ROC) curve analysis suggested that a cut-off value of 10 points on the SINS scale could be used to decide whether anterior support following corpectomy should be performed (AUC=0.706).@*CONCLUSIONS@#The SINS, insofar as it assesses the degree of collapse and alignment, is a potentially useful tool for determining the surgical strategy in patients with spinal metastasis, especially for deciding upon the necessity of additional anterior support procedures.

Long-Term Results of CyberKnife Radiosurgery for Vestibular Schwannoma / 대한평형의학회지

OBJECTIVE: Since the 2000s, CyberKnife radiosurgery (CKRS) is either a primary or an adjunct management approach used to treat patients with vestibular schwannoma (VS). The goals of CKRS are prevention of tumor growth, preservation of cranial nerve function and prevention of new neurologic deficiencies. The aim of this study was to assess the efficacy and safety of CKRS, in terms of tumor control, hearing preservation, and complications. METHODS: Forty patients with VS underwent CKRS as a treatment modality for from January 2010 to February 2016. The long term results of 32 patients were evaluated who received CKRS as primary treatment. 8 patients presented with previously performed surgical resection. Information related to clinical history, Brain MRI and outcomes of patients with VS collected retrospectively by reviewing patient's chart and telephone survey. RESULTS: The mean tumor volume was 3.3 cm³ and the mean follow-up was 41 months. The most recent follow-up showed that tumor size decreased in 17 patients (42.5%), displayed no change in 19 patients (47.5%), and increased in 4 patients (10%). Progression-free survival rates after CKRS at 1, 3, and 5 years were 95%, 90%, and 90%. After CKRS, 13 patients experienced hearing degradation. The overall rate of preservation of serviceable hearing at the long-term follow-up was 60%. Vertigo, ataxia, and headache were improved after CKRS compared with pretreated status. But, facial weakness, trigeminal nerve neuropathy, and tinnitus were worsen. CONCLUSION: CKRS provide an excellent tumor control rate and a comparable hearing preservation rate in VS patients. Also CKRS is associated with low rate of cranial neuropathy, other complications.

The Change of the Auricular Shape after Middle Ear Surgery Via Retroauricular Approach; Is the Reconstruction of Posterior Auricular Muscle Effective? / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Many patients experience middle ear surgery via retroauricular approach. While not a main interest of the surgery, the change of the auricular shape after surgery has been a subject of complaint by some patients. In this study, we wanted to determine if a change in the auricular shape occurs after middle ear surgery and evaluate the possibility of using reconstruction of posterior auricular muscle as a treatment option for this kind of change. SUBJECTS AND METHOD: Forth patients who received middle ear surgery were enrolled in this study. Retroauricular incision and canal up mastoidectomy were carried out to all patients. The patients were separated into two groups randomly before surgery: one group that had the reconstruction of posterior auricular muscle during surgery, and the other that did not. The average of heights of the helix was compared. Also, patients were asked to fill out a questionnaire about auricular shape before and after surgery. RESULTS: The heights of helix increased about 1.6 mm after surgery; however, the difference of increment as a result of reconstruction of posterior auricular muscle was not statistically significant. Questionnaire about the change of auricular shape after surgery showed that only 8% patients had noticed about the change of auricular shape after surgery. CONCLUSION: Most patients have no complaint about auricular shape after middle ear surgery via retroauricular approach. The average of heights of the helix increases after middle ear surgery. However, the reconstruction of the posterior auricular muscle is not effective for reducing the observed increment of heights of the helix following middle ear surgery via retroauricular approach.

Hemorrhagic Rupture of Arachnoid Cyst into the Intradural Space

A 7-year-old boy, diagnosed with an arachnoid cyst and subdural effusion on initial MRI, was admitted with left limb weakness and no history of head trauma. A subsequent follow-up MRI showed different stages of hematoma within multilayered enhancing membranes and in the arachnoid cyst, which was separated by the cerebrospinal fluid cleft. Craniotomy and fenestration of the cyst wall and hematoma removal were performed. The patient was diagnosed as a having a hemorrhagic rupture of an arachnoid cyst into the intradural space, probably via some one-way valve-like defect, based on the MRI and surgical findings. The MRI features and possible mechanism of this rare disease are discussed within the literature review.

The Pallidal Index in Patients with Acute-on-Chronic Liver Disease: Is It a Predictor of Severe Hepatic Encephalopathy?

PURPOSE: To evaluate the clinical significance of T1 high signal intensity on the globus pallidus as a predictor of severe hepatic encephalopathy in patients with acute-on-chronic liver failure (ACLF), which is a distinct syndrome characterized by multi-organ dysfunction including cerebral failure. MATERIALS AND METHODS: From January 2002 to April 2014, we retrospectively reviewed the magnetic resonance imaging (MRI) findings and clinical and magnetic resonance (MR) features of 74 consecutive patients (44 men and 30 women; mean age, 59.5 years) with liver cirrhosis. The chronic liver failure-sequential organ failure assessment score was used to diagnose ACLF. The pallidal index (PI), calculated by dividing the mean signal intensity of the globus pallidus by that of the subcortical frontal white matter were compared according to ACLF. The PI was compared with the Model for End-Stage Liver Disease (MELD) score in predicting the development of ACLF. RESULTS: Fifteen patients who were diagnosed with ACLF had higher hepatic encephalopathy grades (initial, P = 0.024; follow-up, P = 0.002), MELD scores (P < 0.001), and PI (P = 0.048). In the ACLF group, the mean PI in patients with cerebral failure was significantly higher than that in the patients without cerebral failure (1.33 vs. 1.20, P = 0.039). In patients with ACLF, the area under the curve (AUC) for PI was 0.680 (95% confidence intervals [CI], 0.52–0.85), which was significantly lower than that for the MELD score (AUC, 0.88; 95% CI, 0.77–0.99) (P = 0.04). CONCLUSION: The PI can be an ancillary biomarker for predicting the development of ACLF and severe hepatic encephalopathy.

The Pallidal Index in Patients with Acute-on-Chronic Liver Disease: Is It a Predictor of Severe Hepatic Encephalopathy?

PURPOSE: To evaluate the clinical significance of T1 high signal intensity on the globus pallidus as a predictor of severe hepatic encephalopathy in patients with acute-on-chronic liver failure (ACLF), which is a distinct syndrome characterized by multi-organ dysfunction including cerebral failure. MATERIALS AND METHODS: From January 2002 to April 2014, we retrospectively reviewed the magnetic resonance imaging (MRI) findings and clinical and magnetic resonance (MR) features of 74 consecutive patients (44 men and 30 women; mean age, 59.5 years) with liver cirrhosis. The chronic liver failure-sequential organ failure assessment score was used to diagnose ACLF. The pallidal index (PI), calculated by dividing the mean signal intensity of the globus pallidus by that of the subcortical frontal white matter were compared according to ACLF. The PI was compared with the Model for End-Stage Liver Disease (MELD) score in predicting the development of ACLF. RESULTS: Fifteen patients who were diagnosed with ACLF had higher hepatic encephalopathy grades (initial, P = 0.024; follow-up, P = 0.002), MELD scores (P < 0.001), and PI (P = 0.048). In the ACLF group, the mean PI in patients with cerebral failure was significantly higher than that in the patients without cerebral failure (1.33 vs. 1.20, P = 0.039). In patients with ACLF, the area under the curve (AUC) for PI was 0.680 (95% confidence intervals [CI], 0.52–0.85), which was significantly lower than that for the MELD score (AUC, 0.88; 95% CI, 0.77–0.99) (P = 0.04). CONCLUSION: The PI can be an ancillary biomarker for predicting the development of ACLF and severe hepatic encephalopathy.

Effect of Patient Education on Reducing Medication in Spinal Cord Injury Patients With Neuropathic Pain

OBJECTIVE: To determine whether providing education about the disease pathophysiology and drug mechanisms and side effects, would be effective for reducing the use of pain medication while appropriately managing neurogenic pain in spinal cord injury (SCI) patients. METHODS: In this prospective study, 109 patients with an SCI and neuropathic pain, participated in an educational pain management program. This comprehensive program was specifically created, for patients with an SCI and neuropathic pain. It consisted of 6 sessions, including educational training, over a 6-week period. RESULTS: Of 109 patients, 79 (72.5%) initially took more than two types of pain medication, and this decreased to 36 (33.0%) after the educational pain management program was completed. The mean pain scale score and the number of pain medications decreased, compared to the baseline values. Compared to the non-response group, the response group had a shorter duration of pain onset (p=0.004), and a higher initial number of different medications (p<0.001) and certain types of medications. CONCLUSION: This study results imply that an educational pain management program, can be a valuable complement to the treatment of spinal cord injured patients with neuropathic pain. Early intervention is important, to prevent patients from developing chronic SCI-related pain.

Impact of Diltiazem Alone versus Diltiazem with Nitrate on Five-Year Clinical Outcomes in Patients with Significant Coronary Artery Spasm

PURPOSE: Calcium channel blockers diltiazem and nitrate have been used as selective coronary vasodilators for patients with significant coronary artery spasm (CAS). However, no study has compared the efficacy of diltiazem alone versus diltiazem with nitrate for long-term clinical outcomes in patients with CAS. MATERIALS AND METHODS: A total of 2741 consecutive patients without significant coronary artery disease with positive CAS by acetylcholine (Ach) provocation test between November 2004 and May 2014 were enrolled. Significant CAS was defined as a narrowing of >70% by incremental intracoronary injection of 20, 50, and 100 µg of Ach into the left coronary artery. Patients were assigned to either the diltiazem group (n=842) or the dual group (diltiazem with nitrate, n=1899) at physician discretion. To adjust for potential confounders, a propensity score matching (PSM) analysis was performed using the logistic regression model. After PSM analysis, two well-balanced groups (811 pairs, n=1622, C-statistic=0.708) were generated. RESULTS: At 5 years, there were similar incidences in primary endpoints, including mortality, myocardial infarction, revascularization, and recurrent angina requiring repeat coronary angiography between the two groups. Diltiazem alone was not an independent predictor for major adverse cardiovascular events or recurrent angina requiring repeat coronary angiography. CONCLUSION: Despite the expected improvement of endothelial function and the relief of CAS, the combination of diltiazem and nitrate treatment was not superior to diltiazem alone in reducing mortality and cardiovascular events up to 5 years in patients with significant CAS.