Usefulness of Stent Implantation for Treatment of Intracranial Atherosclerotic Stenoses / 신경중재치료의학

PURPOSE: We evaluated the usefulness of intracranial stent implantation for treating patients with atherosclerotic stenosis and with recurrent, ischemic, neurological symptoms despite having undergone medical therapy. MATERIALS AND METHODS: Between March 2004 and April 2010, we attempted intracranial, stent-assisted angioplasty in 77 patients with 85 lesions (anterior circulation 73 cases, posterior circulation 12 cases) and who had ischemic neurological symptoms with more than 50% major cerebral artery stenosis. We analyzed the results regarding the technical success rate, complication rate, and restenosis rate during the mean 29.4 month follow-up period. RESULTS: Intracranial stent implantation was successfully performed in 74 cases (87.1%). In nine cases among the 11, failed cases, stent implantation failure was due to the tortuosity of the target vessel. One patient experienced middle cerebral artery rupture during the procedure, and we embolized the vessel using a microcoil. Five patients developed cerebral infarction in three weeks after the procedure, three of whom improved using conservative management, although the other, two patients expired. The mean number of residual stenoses decreased from 72.3% to 14.7%. Three patients demonstrated significant in-stent restenosis, i.e. more than 50%, during the follow-up period. CONCLUSION: As stent-assisted angioplasty in intracranial, atherosclerotic stenosis is effective and relatively safe, it can be considered as an alternative treatment for patients with recurrent, ischemic, neurologic symptoms despite having undergone medical therapy.

The Efficacy of Unenhanced MR Imaging for the Diagnosis of Acute Appendicitis: A Performance Comparison Versus Abdominal Ultrasonography

PURPOSE: To evaluate the efficacy of unenhanced MR imaging compared to the diagnostic accuracy, advantage, and limitations of abdominal ultrasonography in the diagnosis of acute appendicitis. MATERIALS AND METHODS: The study included 40 patients suspected of having acute appendicitis and who were subjected to an unenhanced MR image, as well as an abdominal ultrasonography. A T1 FLASH in an axial image, a chemical shift-selective fat suppressed T2 HASTE in an axial image, as well as a T2 HASTE in an axial and coronal image were obtained as unenhanced MR images. The diagnosis was established based on a surgical or clinical follow-up of the unenhanced MR results, which were then statistically compared to the ultrasonographic results. RESULTS: The surgical or clinical follow-up results revealed that 25 patients were positively diagnosed with appendicitis. Of these, 7 patients had symptoms of acute appendicitis with no pathologic diagnoses, whereas the 8 remaining patients were diagnosed with another condition. The sensitivity and accuracy of the unenhanced MR imaging was 92% and 90%, compared to ultrasonography which was 68% and 72.5% accurate, respectively. The differences in sensitivity and accuracy between the two methods were found to be statistically significant (p < .05, chi-square test). Based on these results, unenhanced MR imaging was superior to sonography for the diagnosis of appendicitis. CONCLUSION: Unenhanced MR imaging may be a useful modality for the diagnosis of acute appendicitis, especially for suboptimal or nondiagnostic sonographies, as well as patients that are particularly sensitive to radiation exposure.

MR Imaging Findings of Acute Gouty Arthritis

PURPOSE: The purpose of this study was to describe the clinical and MR imaging features of acute gouty arthritis and to define the characteristic findings that would be helpful for differentiating acute gouty arthritis from septic arthritis. MATERIALS AND METHODS: The authors retrospectively studied seven patients who suffered from acute gouty arthritis. The MR imaging findings were analyzed by two musculoskeletal radiologists who focused on joint effusion, subchondral bone erosion, bone marrow edema, synovial thickening (regular and even, or irregular and nodular), and the soft tissue changes (edema or abscess). The clinical records of the patients were reviewed with regard to age and gender, the clinical presentation and the laboratory findings (serum uric acid, WBC, erythrocyte sedimentation rate, C-reactive protein and synovial fluid culture). RESULTS: The patients consisted of six men and one woman whose mean age was 41 years (age range: 24-65 years). The joints involved were the knee (n=6), and ankle (n=1). Two patients had medical histories of gouty attacks that involved the first metatarsophalangeal joint. In six cases, the serum uric acid level during acute attacks was elevated. In all the patients, the affected joint became swollen, hot, erythematous and extremely tender, and this was accompanied by a high ESR and a high C-reactive protein level at the time of presentation. The results of Gram stain and culture of the synovial fluid were negative. In all patients, the MR images showed large amounts of joint effusion, thick irregular and nodular synovial thickening and soft tissue edema without subchondral bone erosions and soft tissue abscess. In one case, subchondral bone marrow edema of the medial femoral condyle was present. In five cases, there were multiple low signal foci in the joint on the spin-echo T2-weighted MR image. CONCLUSION: Even though the MR imaging findings of acute gouty arthritis are nonspecific, it should be considered as a possible diagnosis when a large amount of joint effusion, irregular and nodular synovial thickening and soft tissue edema without subchondral bone erosion, bone marrow edema or soft tissue abscess are seen in the knee or ankle joint, and especially if this is accompanied by the clinical and laboratory features of infection.

A Case of Cavitary Lung Lesion as a Consequence of Smoke Inhalation Injury / 결핵및호흡기질환

Toxic gases and soot deposition as a consequence of smoke inhalation can cause direct injury to the upper and lower airways and even to the lung parenchyma. A delay in proper and prompt therapy can be detrimental to critically ill burn patients with an inhalation injury. Therefore, serial chest radiography is an important diagnostic tool for pulmonary complications during treatment. The radiographic findings of the chest include normal, consolidation, interstitial and alveolar infiltrates, peribronchial thickening, atelectasis, cardiogenic and non-cardiogenic pulmonary edema, and a pneumothorax as acute complications of smoke inhalation. In addition, bronchiectasis, bronchiolitis obliterans and pulmonary fibrosis can occur as late complications. We encountered a case of 44-year-old male who presented with acute lung injury after an inhalation injury. He required endotracheal intubation and mechanical ventilation due to respiratory failure. He was managed successfully with conservative treatment. Later, a cavitary lesion of the left upper lobe was observed on the chest radiography and computed tomography, which was complicated by massive hemoptysis during the follow-up. However, the cavitary lesion disappeared spontaneously without any clinical consequences.

A Case of Disseminated Coccidioidomycosis Involving Lung and Skin in Patient with Diabetes Mellitus and Iatrogenic Cushings Syndrome / 결핵및호흡기질환

Coccidioidomycosis is caused by a dimorphous fungus, Coccidioides, which consists of two species, C. immitis and C. posadasii. Although these organisms are genetically distinct and do not exchange DNA, they appear identical phenotypically and the disease or immune response to the organisms is also identical. Coccidioides grows as a mycelium in the soil and is mainly found in Southwestern United States, northwestern Mexico, and Argentina. An infection usually results from inhaling the spores of the fungus in an endemic area. Patients with a localized infection and no risk factors for complications often require only a periodic reassessment to demonstrate the resolution of the self-limited process. However, patients with extensive spread of infection or high risk of complications as a result of immunosuppression or other preexisting factors require a variety of treatment strategies such as antifungal therapy, surgical debridement, or both. Korea is not endemic area of a coccidioidomycosis. We report a case of disseminated coccidioidomycosis involving the lung and skin, which was detected incidentally after sunburn in a 69 year-old Korean male with diabetes mellitus and iatrogenic Cushings syndrome, with a review of the relevant literature.

Evaluation of the Appendix Base Location in Acute Appendicitis Using Sonography and its Clinical Significance

PURPOSE: The purpose of this study is to investigate the location of appendiceal base using sonography in acute appendicitis and the usefulness of the appendiceal base marking in deciding the incision site of appendectomy. MATERIALS AND METHODS: We performed appendix sonography in 813 patients and 381 patients were diagnosed as acute appendicitis. During sonography, we marked the base of the appendix on the skin of the patients' abdomen. After appendiceal base marking, we measured the distance from McBurney's point to the appendiceal base. The marking was used as the guide for incision site for appendectomy by the surgeon. Among 381 patients, we excluded 78 patients due to nonvisualization of the cecoappendiceal junction (n = 6), pregnancy appendicitis (n = 2), false positive appendicitis (n = 3) and no reply from the surgeon (n = 67). So we investigated 303 patients prospectively. After operation, we asked the surgeon whether the appendiceal base marking was helpful for appendectomy or not. RESULTS: The base of the appendix at McBurney's point were 31%, lying within 2 cm from McBurney's point were 20%, within 5 cm were 28%, more than 5 cm were 21%. For the usefulness of appendiceal base marking, 95% showed good correlation with marking and surgical incision, and 5% revealed poor correlation. CONCLUSION: The base of the appendix was located in diverse areas of the abdomen, although most frequent in the McBurney's point and within 2 cm from the McBurney's point. Appendiceal base marking on the skin of the abdomen after diagnosis of acute appendicitis could be an useful method to guide the surgeon for decision of surgical incision site.

Metastatic Bone Tumors with Sunburst Periosteal Reaction

PURPOSE: The purpose of this study was to describe the clinical and imaging features of metastatic bone tumors with sunburst periosteal reaction and to define the characteristic findings which would be helpful for differentiating metastatic bone tumors from primary malignant bone tumors. MATERIALS AND METHODS: The authors retrospectively reviewed the cases of nine patients with pathologically confirmed metastatic bone tumors with sunburst periosteal reaction, for which imaging studies (plain radiographs [n=9], radioisotope [RI] scans [n=4], magnetic resonance [MR] images [n=6], and computed tomographic [CT] scans [n=4]) were performed. The imaging studies of each lesion were analyzed by two musculoskeletal radiologists focusing on the metastatic site, patterns of bone response, signal intensity characteristics and pattern of contrast enhancement on MR. The clinical records of the patients were reviewed with regard to the age and sex of the subjects, the clinical presentation, and the origin of the primary tumors. RESULTS: The cases consisted of six men and three women, whose mean age was 62 years (age range, 50-88 years). The primary tumors were adenocarcinoma of the stomach [n=4], adenocarcinoma of the lung [n=2], adenocarcinoma of the prostate [n=1], hepatocellular carcinoma of the liver [n=1], and adenocarcinoma of unknown origin [n=1]. The sites of metastatic involvement exhibiting sunburst periosteal reaction were the scapula [n=2], proximal humerus [n=2], rib [n=1], iliac bone [n=1], tibia [n=1], spine [n=1], and proximal phalanx [n=1]. In all patients, the imaging findings showed osteolytic [n=3] or osteoblastic [n=6] lesions with sunburst periosteal reaction. In six cases, the lesions were iso-intense on the T1-weighted images and heterogeneously hyperintense on the T2-weighted images. The gadolinium-enhanced T1-weighted images showed a nearly homogenous enhancement of the lesions without any central necrotic portion. CONCLUSION: Although metastatic bone tumor exhibiting sunburst periosteal reaction is rare, it should be included along with primary malignant bone tumors in the differential diagnosis of bone lesions with sunburst periosteal reaction, especially in older patients with or without a known primary malignancy.

Sclerosing Peritonitis with Gross Calcification: Case Report

Sclerosing peritonitis is an uncommon complication of continuous ambulatory peritoneal dialysis (CAPD) and can lead to small bowel dysfunction involving abdominal pain, progressive loss of ultrafiltration, and small intestinal obstruction. Peritoneal thickening, in which calcification can develop, often starts as a small plaque which gradually becomes larger. We report a case of CAPD-related calcifying peritonitis.

MRI Findings of the Brain in High-Voltage Electrical Burn Patient: Case Report

We report the delayed sequelae arising in a case of electrical injury, reviewing the literature on the subject and focusing on the MRI findings of the brain. A 23-year-old male suffered burns to the left parietal scalp, both feet, and the anterior chest wall. Neurological symptoms and MRI abnormalities appeared 14 days after the insult and continued for about three months. T1-weighted MR images demonstrated homogeneous hypointensity, while T2-weighted images depicted hyperintense finger-like projections. Contrast-enhanced T1-weighted images demonstrated strong band-like enhancement, indicating meningeal hyperemia. Follow-up MR imaging showed that the lesion had disappeared, indicating that the cerebral edema and meningeal hyperemia were reversible.

Pulmonary Complications in Major Burn Patients: Differences in Radiologic and Clinical Findings between Inhaled and Non-inhaled Burn

PURPOSE: To analyze differences in the radiologic and clinical findings of pulmonary complications between an inhalation and non-inhalation group of major burn patients, and to apply the findings to the specific diagnosis of pulmonary complications. MATERIALS AND METHODS: This study involved 45 major burn patients (18 with inhalation injury, and 27 without) in whom pulmonary complications ensued. Follow-up studies were based on chest radiographs obtained between initial burn day and postburn (PB) 57 (mean, day 27). Types, times of onset, underlying causes, and changes at follow-up study of pulmonary complications between the inhalation and the non-inhalation group were assessed. RESULTS: In the inhalation group, the most frequent complication was air-borne pneumonia (n=7, 39%); others were hydrostatic pulmonary edema (n=5, 28%), ARDS (n=5, 28%), atelectasis (n=5, 28%), inhalation pneumonitis (n=3, 17%), pleural effusion (n=3, 17%), and hematogenous pneumonia (n=1, 6%). In the non-inhalation group, airborne pneumonia (n=8, 30%) was also the most common complication; other were hydrostatic edema (n=6, 22%), ARDS (n=5, 19%), atelectasis (n=5, 19%), pleural effusion (n=5, 19%) and hematogenous pneumonia (n=2, 7%). The average times of onset were as follow: for airborne pneumonia, PB day 13.1 (range, 5-27) in the inhalation group, and PB day 21.7 (10-49) in the non-inhalation group; for hematogenous pneumonia, more than one month, regardless of inhalation; for ARDS, PB day 4.9 (2-15) and PB day 13 (7-20) in the inhalation and non-inhalation group, respectively; and for inhalation pneumonitis, PB day 1.7 (1-3). The most common probable cause of ARDS in the inhalation group was inhalation injury (3/5), and in the noninhalation group, sepsis (4/5). CONCLUSION: In major burn patients, pulnonary complications differed in terms of their onset time and causes between the inhalation group and the non-inhalation group. In such cases, awareness of the presence or absence of inhalation injury and the onset time of pulmonary complications is necessary if complications are to be specifically diagnosed.

Adenocarcinoma Arising in an Ileal Duplication Cyst with Peritoneal Seeding: A Case Report

We report a case in which mucinous adenocarcinoma arose in a duplication cyst at the distal ileum with in-traperitoneal seeding. A thirty-three-year-old male patient presented with abdominal distension. Ultrasonography, CT and MR imaging revealed a dumbbell-shaped cystic mass adherent to the small intestine. The wall of the mass was thickened in two areas and contained inhomogeneous materials. A large amount of ascites with irregular masses along the greater omentum were seen present. Surgery revealed a duplication cyst adherent to the ileum. Pathologic examination proved that the thickened portions of the wall of the mass were mucinous adenocarcinoma, and that the nodules on the greater omentum were metastatic adenocarcinoma.

Hepatic Infarction Complicating Acute Pancreatitis: A Case Report

Hepatic infarction is relatively uncommon and is usually related to surgery or interventional procedures. Pancreatitis-associated hepatic infarction has not been reported in the literature, and we now describe a case of hepatic infarction in a 31-year-old man with acute pancreatitis. Initial CT scanning demonstrated an enlarged pancreas with multifocal fluid collection, and a large wedge-shaped low attenuation lesion was seen in the right lobe of the liver along with thrombi in the posteroinferior branch of the right portal vein. Hepatic arteri-ography and SMA portography revealed a pseudoaneurysm in the right hepatic artery, thrombi in the main portal vein and its posteroinferior branch, and perfusion defects confined to S6 of the liver.

The Radiographic Spectrum of Pulmonary Complications in Major Burn Patient

In recent years, improved antibiotic care and physiologic fluid replacement in cases involving burn wounds have led to a decrease in the rate of fatalaties caused by wound sepsis and shock. There has, however, been an upsurge and relative increase in the frequency (15 -25%) and mortality rate (50 -89 %) of pulmonary complications. Since pulmonary lesions may result from direct injury to the respiratory tract caused by smoke inhalation, from circulatory, metabolic or infectious complications in cases involving cutaneous burns, or may develop during the therapeutic management of these lesions, a wide spectrum of pulmonary abnormalities can occur during the post-burn period. There is considerable overlap between their radiographic appearances, which are often nonspecific. Since the successful management of these patients is based on the early recognition and vig-orous treatment of lesions, familiarity with all facets of these complications, based on a pathophysiology of the injury and on the knowledge of the clinical setting, enables radiologists to make more specific diagnoses.

Plain Chest Radiographic Findings of Smoke Inhalation

PURPOSE: To evaluate the plain chest radiographic findings of smoke inhalation. MATERIALS AND METHODS:Our study included 72 burn patients who had suffered smoke inhalation. On admis-sion,all underwent serial portable chest AP radiography. We retrospectively reviewed the plain chest radi-ographs taken between admission and pootburn day five, evaluating the pattern, distribution, and time onset of direct injury to the respiratory system by smoke inhalation. The lesions were also assessed for change. RESULTS: In 16 of 72 patients (22%), abnormal findings of direct injury to the respiratory system by smoke in-halation were revealed by the radiographs. Abnormal findings were 15 pulmonary lesions and one subglottic tracheal narrowing. Findings of pulmonary lesions were multiple small patchy consolidations (10/15), peri-bronchial cuffing (8/15), and perivascular fuzziness (6/15). Patterns of pulmonary lesions were mixed alveolar and interstitial lesion (n=9), interstitial lesion (n=5), and alveolar lesion (n=1). No interlobular septal thicken-ing was observed. Pulmonary edema was distributed predominantly in the upper lung zone and perihilar re-gion, with asymmetricity. Its time of onset was within 24 hours in 13 cases, 24 -48 hours in two cases, and 48 -72 hours in one. Five of 16 patients progressed to ARDS. CONCLUSION: Chest radiographs showed that pulmonary lesions caused by inhalation injury were due to pul-monary edema, which the pattern of which was commonly mixed alveolar and interstitial.

MRI and CT Findings of Intracranial Neurosyphilis

PURPOSE: To evaluate the CT and MRI findings of neurosyphilis. MATERIALS AND METHODS: We retrospectivelyreviewed the CT and MR imaging findings in five patients with intracranial neurosyphilis confirmed by CSF, VDRL,TPHA, and clinical follow-up. MR imaging was performed in all five cases, and CT in two. RESULTS: The MRI and CTfindings of intracranial neurosyphilis included infarction (n=3), focal inflammation (n=1) and encephalopathy(n=1). There was a total of ten infaretions : three of the basal ganglia, two each of the frontal lobe, watershedzone, and cerebellum, and one of the occipital lobe. Intaretion was most common in MCA territory (n=9; 50%),followed by the watershed zone (16.6%), posterior cerebral artery territory (16.6%), and posterior inferiorcerebellar artery territory (11.1%), The size of the lesion varied from 1cm to larger than one lobe. One patientshowed diffuse high signal intensity in the left temporal lobe, but on follow-up MRI, this had resolved. CONCLUSION: The most common finding of neurosyphilis, as seen on MRI and CT, was infarction in middle cerebralarterial territory.

Bone and Joint changes following Electrical Burn: Plain Radiographic findings

PURPOSE: To evaluate the plain radiographic findings of bone and joint changes following electrical burn. MATERIALS AND METHODS: This study involved 19 patients with 27 bone and joints regions which had sufferedelectrical injury. The most common input and output sites were, respectively, the hand(7/14) and foot (6/10).Three other sites were involved. Four cases involved osteomyelitis, and in four, amputation was performed. Weobserved bone and joint changes, changes following osteomyelitis and changes in the amputation stump. We analyzedthe difference between input and output changes, and when this was interesting, the average time of onset wasassessed. RESULTS: In bone and joint changes following electrical burn, the most frequent radiographic findingwas joint contracture (n=16). Other findings included osteolysis (n=8), articular abnormalites (n=6), periostitis(n=5), fracture (n=5), acro-osteolysis (n=2), and heterotopic bone formation (n=2). In cases involvingosteomyelitis(n=4), aggravation of underlying bone changes was noted. CONCLUSION: In electrical burn, variouschanges were noted in bone and joints, and input injury was more severe than that of output.

A Case Report of Displaced Anterior Junction Line Mimicking

On PA chest radiography, the anterior junction line(AJL) is seen to project from the upper right to the lowerleft of the upper third of the body of the sternum and represents the visceral and parietal pleura of each lungand a small quantity of mediastinal fat. In a patient with volume loss or expansion of a hemithorax, the AJL showsconsiderable shift and on PA chest radiography may mimic pneumothorax or pneumomediastimum. In such cases,widening and hyperlucency of the retrosternal space, seen on lateral view, which represents herniated lung with ashift of AJL, may be helpful for differentiation from pneumothorax or pneumomediastinum.

Radiologic Findings of Pulmonary Endometriosis

PURPOSE: To evaluate the effectiveness of percutaneous transluminal angioplasty (PTA) and pulsed-spraypharmacomechanical thrombolysis (PSPMT) using urokinase for the management of insufficient hemodialysis access. MATERIALS AND METHODS: Between September 1996 and May 1998, 21 insufficient hemodialysis accesses were treated in 16 patients (3 artificial arteriovenous fistulae, AVF ; and 13 arteriovenous graft, AVG). PTA and PSPMT were performed in 6 and 15 and 15 cases, respectively, and success and long-term patency rates were evaluated. RESULTS: The overall success rate of PTA and PSPMT for insufficient hemodialysis access was 76.2%(16/21). The success rates of PTA and PSPMT were 83.3%(5/6) and 73.3%(11/15), respectively. the primary patency rates of PSPMT were 69+/-12.8% at 6 months and 38+/-18.6% at 12 months. One of the two initially successful PTAs had been patent for 7months, and the second PTA was performed at that time due to venous stenosis. The other was patent for 15 months throughout the follow-up period. CONCLUSION: PTA and PSPMT are effective primary methods for the treatment of insufficient hemodialysis access ; success and patency rates were high, and the procedures can be performed repeatedly.

Polyarteritis Nodosa in Superior Mesenteric Artery: A Case Report

Polyarteritis nodosa(PAN) is a multisystem disease characterized by necrotizing vasculitis of small andmedium-sized arteries, and in 50% of all cases there is gastrointestinal involvement. We describe a patient withPAN involving the gastrointestinal tract. A small bowel series showed nodular fold thickening, submucosal fillingdefects, shallow ulcerations, segmental luminal narrowing, and decreased peristalsis at the duodenum, jejunum, andileum; superior mesenteric arteriography showed hypervascularity and microaneurysm. Segmental resection of thesmall bowel indicated the presence of PAN.

Effect of Cryosurgery on Hypertrophic Scars / Keloids / 대한피부과학회지

BACKGROUND: A variety of therapeutic regimens has been used in the treatment of hypertrophic scars/keloids with onsatisfactory final results. Application of cryosurgery could be beneficial sinee it was reported to produce less scarring and recurrence after treatment compared with other methods. Objective This study was undertaken to evaluate the effect of the cryosurgery through objective, quantitative measurement of hypertrophic scar/keloid thickness and to assess the influence of the cryosurgery on fibroblasts. The latter was achieved through fibroblast cultures established from hypertrophic scars/keloids. METHODS: Eight patients, ageA 17 to 47 years old, with hypertrophic scars/keloids were treated with liquid nitrogen using the cantact method. One freeze-thaw cycle of 10-30 seconds per lesion was employed, and if needed, treatment was repeated every 20 to 40 days. The thicknesses of the lesions were measured objective,ly with ultrasound in five patients, before and after cryosurgery and were compared with controlled scars in other areas. In three patients, we cultured fibroblasts from the treated and the untreated lesions and exmuned the rate of fibroblast proliferation and collagen production. RESULTS: In all five patients, thicknesses of the hypertrophic scars/keloids decreased compared to those of controlled areas after treatment. Five of 6 hypertrophic scar cell lines demonsbated decreased fibroblast proliferation rates in comparison to control fibroblast lines. Collagen produced by the fibroblasts was variable. CONCLUSION: Cyosurgery was effective and safe in the treatment of hypertrophic scars/keloids.