Resection of focally progressive gastrointestinal stromal tumours resistant to imatinib therapy.

AIMS: To analyse the outcome of patients with gastrointestinal stromal tumour (GIST) who receive imatinib therapy and undergo subsequent resection of focally progressive disease. METHODS: We reviewed the records of all cases of GIST discussed at the West of Scotland Sarcoma regional multi-disciplinary team meeting between January 2002 and December 2009 inclusive. We analysed all patients who had undergone surgery for progressive disease on imatinib therapy. Focally progressive disease was diagnosed on computated tomography (CT) and positron-emission tomography-CT and was defined by a GIST lesion initially responsive to imatinib therapy but then underwent growth with evidence of metabolic activity. All procedures were undertaken in a university teaching hospital by a single surgeon. RESULTS: Nine patients were identified who underwent ten resections of focally progressive GIST. Six had previously undergone resection of their primary tumour while three had presented with un-resectable disease. Nine operations were for resection of a solitary progression while one operation was for three foci of progression. Five patients underwent liver resection which was confined to the segments were there was focal progression of GIST; of these one patient had multiple liver metastases and portal hypertension with a mass at the porta hepatis. The absolute survival for patients after resection was 18.4±13.7 months (mean±standard deviation), with progression free survival of 14.1±13.5 months equating to 56% at 1-year. Four patients had been switched from imatinib to sunitinib, for further multi-focal progression. CONCLUSIONS: Surgical resection of focally progressive GIST may prolong survival and a second or third resection is a feasible option in selected patients.

An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis.

OBJECTIVES: To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in delivery of the treatment. DESIGN: Prospective study. SETTING: A university teaching hospital in Hong Kong. PATIENTS: Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009. MAIN OUTCOME MEASURES: Time performance records including door-to-stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality. RESULTS: During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to-stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient. CONCLUSION: A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to-stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.

Intraobserver and interobserver variability for measuring the wall area of the basilar artery at the level of the trigeminal ganglion on high-resolution MR images.

We evaluated the intraobserver and interobserver variability for WA measurement of an atherosclerotic BA by using HRMRI. Ten consecutive patients underwent HRMRI, and the WA of the BA at the level of the trigeminal ganglion was measured by 2 independent readers and repeated by 1 reader 1 month later. There was strong agreement for intraobserver and interobserver measurements in the ICC and by the Bland-Altman method. Measurement of the WA in an atherosclerotic BA by HRMRI was reproducible.

Wingspan experience at Beijing Tiantan Hospital: new insights into the mechanisms of procedural complication from viewing intraoperative transient ischemic attacks during awake stenting for vertebrobasilar stenosis.

BACKGROUND AND AIM: Intracranial vertebrobasilar artery (VBA) stenosis portends a stroke and death rate of 8.5-22.8% annually despite medical therapy. Stenting has emerged as a treatment option but also carries substantial risk. Awake stenting under local anesthesia to minimize major procedural complication was investigated. METHODS: Between January 2007 and December 2008, 43 of 46 consecutive patients with severe symptomatic intracranial VBA stenosis underwent elective angioplasty assisted with self-expanding Wingspan stent under local anesthesia at our institute. All data were collected prospectively. RESULTS: All 43 patients tolerated the stenting procedure under local anesthesia well. Forty-two patients (97.7%) were stented successfully. Within 30 days, there were three periprocedural strokes, including thromboembolic infarct, pontine perforator infarct and intracranial hemorrhage, without fatality. In addition, five patients had intraoperative brainstem transient ischemic attacks (TIAs) seconds after the deployment of the stent delivery system across the tortuous VBA. The symptoms and signs included impaired consciousness (n=5), dysarthria (n=3), convulsion (n=2), conjugate horizontal gaze palsy (n=2), nystagmus (n=2) and pinpoint pupils (n=1). There was angiographic evidence of VBA straightening without thromboembolism. The TIAs resolved within minutes of prompt removal of the delivery catheter. CONCLUSIONS: VBA stenting under local anesthesia is feasible with a 7% periprocedural stroke risk. Awake stenting allows timely detection of intraoperative TIAs. The mechanism of intraoperative TIA appears to be stent delivery system induced VBA straightening and distortion of its vascular tree. A devastating stroke may ensue if the TIA is not detected and distortion of VBA perforators is not reversed promptly.

Long-term outcome of tandem stenting for stenoses of the intracranial vertebrobasilar artery and vertebral ostium.

BACKGROUND AND PURPOSE: Patients with symptomatic atherosclerotic stenosis of the intracranial vertebrobasilar artery (VBA) have a poor prognosis, and those with coexistent intracranial and extracranial stenoses have worse outcomes despite medical therapy. Our aim was to study the long-term outcome of patients with symptomatic atherosclerotic tandem stenoses at the intracranial VBA and the vertebral artery ostium (VAO) after elective stent placement. MATERIALS AND METHODS: Ten consecutive patients (mean age, 65.3 years) with this condition underwent elective stent placement at our institution between September 2001 and December 2007. Technical success was defined as stent placement of both VAO and intracranial VBA stenoses with complete stent coverage of the lesions, residual stenosis of < or = 30%, and good antegrade blood flow. The study end point was a composite of any stroke or death within 30 days and ischemic stroke in the VBA territory after 30 days. RESULTS: Technical success was obtained in 9 of 10 patients without any stroke or death within 30 days. During a median follow-up duration of 32 months, 1 patient had a fatal ischemic stroke in the VBA territory at 4 months, and the other 9 patients were free from stroke recurrence. Thus, the annual stroke rate in VBA territory (including any stroke or death within 30 days) was 3.8%. CONCLUSIONS: This pilot study shows that elective stent placement for patients with symptomatic atherosclerotic tandem stenoses at the intracranial VBA and VAO has an acceptable long-term outcome and may be considered as an alternative to medical therapy.

Susceptibility-weighted imaging in the diagnosis of early basal ganglia germinoma.

BACKGROUND AND PURPOSE: Germinomas originating from the basal ganglia (BG) are rare. Early diagnosis is important for favorable prognosis, but it is difficult due to the slow clinical course and subtle changes on neuroimaging. The purpose of this study was to evaluate the usefulness of susceptibility-weighted imaging (SWI) in the diagnosis of early BG germinoma. MATERIALS AND METHODS: From 2006 to 2008, 6 BG germinomas were diagnosed in children at our institution by pathology. Conventional MR imaging and SWI were available in all cases. Clinical, neuroradiologic, and follow-up features were retrospectively studied. RESULTS: Three cases were classified as early BG germinomas. Conventional MR imaging demonstrated that the tumor size was <10 mm in the largest diameter. The tumors were invisible or showed slight hyperintensity on T1-weighted images (T1WI) and patchy slight hyperintensity on T2-weighted images (T2WI) without mass effect or enhancement. On SWI, the tumors appeared as obvious hypointensity in the globus pallidus and putamen, and the size was larger than that on conventional T1WI and T2WI. The other 3 cases with tumor size >10 mm in largest diameter were classified as late BG germinomas, with tumor necrosis, fluid-fluid levels, and perifocal edema, including 1 case with subependymal spread. On SWI, only the solid portion of the tumors showed hypointensity. No recurrence was noted on follow-up. CONCLUSIONS: SWI appears to be more sensitive in detecting early BG germinomas than conventional MR imaging. This capability may prove to be useful in future attempts to characterize early BG germinomas.