Comparison of Stent-Assisted Coil Embolization Versus Coil Embolization Alone for Ruptured Cerebral Aneurysms with Mild Symptoms: A Single-Clinic Experience.

Purpose: To evaluate the safety and efficacy of stent-assisted coil embolization (SAC) in acutely ruptured cerebral aneurysms without severe symptoms, and thus, the usefulness of the stent itself in patients with subarachnoid hemorrhages. Materials and Methods: From January 2017 to June 2019, 118 patients were treated with coil embolization for acutely ruptured cerebral aneurysms without severe symptoms (Hunt & Hess grade ≤ 3). The periprocedural complications, six-month modified Rankin scores (mRS), and six-month radiologic outcomes were compared between 56 patients with SAC and 62 patients without SAC (non-SAC). Results: The rate of good clinical outcomes (mRS ≤ 2), as well as the rate of hemorrhagic and ischemic complications, showed no significant difference between the SAC and non-SAC groups. Moreover, compared to the non-SAC group, the SAC group showed a lower recanalization rate on the six-month follow-up angiogram (20% vs. 39.3%, p = 0.001). Conclusion: Although stent use was not significantly associated with clinical outcomes in coil embolization of ruptured cerebral aneurysms with non-severe symptoms (Hunt & Hess grade ≤ 3), it significantly decreased the rate of recanalization on follow-up cerebral angiograms.

Motion Correction of Dual Volume Reconstruction of Three­dimensional Digital Subtraction Angiography for Follow­up Evaluation of Intracranial Coiled Aneurysms.

PURPOSE: To evaluate the usefulness of the "Motion Correction" function of the dual volume-3D-volume-rendering technique (DV-3D-VRT) in follow-up digital subtraction angiography (DSA) of intracranial coiled aneurysms. MATERIALS AND METHODS: This study used data collected from consecutive, follow-up DSAs after the coiling of 64 intracranial aneurysms in 59 patients. We performed subtracted 3D-rotational angiographies (3D-RAs) on all DSAs and obtained DV-3D-VRT images. We then assessed recurrence using DV-3D-VRT images with and without the motion correction functions (MC(+) vs. MC(-)) and observed which method showed better agreement with the reference assessment (using a combination of 2D DSA and TOF MRA images). RESULTS: The recurrence of MC(-) DV-3D-VRT images showed 51.6% (33/64) agreement with the reference assessment, whereas the MC(+) DV-3D-VRT images showed 78.1% (50/64) (P = 0.035, McNemar test). CONCLUSION: Motion correction is a useful complementary imaging technique in evaluating aneurysm recurrence after endovascular embolization. MC(+) DV-3D-VRT image showed higher inter-observer agreement than MC(-) DV-3D-VRT.

Complications of endovascular treatment for intracranial aneurysms: Management and prevention.

Endovascular coiling for intracranial aneurysms has become an accepted treatment with good clinical results and provides adequate protection against rebleeding and rupture of aneurysms. However, despite the experience, preparation, or skill of the physician, complications during endovascular treatment still occur. The main complications of endovascular coiling are: procedural aneurysmal perforations by the microcatheter, micro-guidewire, or coil, and thromboembolic events. Such situations are unexpected, complex, and can have devastating consequences. In this article, we present a comprehensive review of the two most common complications, aneurysmal perforation and thromboembolism during endovascular coiling, and how we can prevent or overcome these complications to achieve a satisfactory outcome. In addition, as the flow diverter has been become an important tool for management of large, wide necked, and other anatomically challenging aneurysms, we also describe complications stemming from the use of the tool, which remains a novel treatment option for complex aneurysms.

CT Differentiation of Female Peritoneal Tuberculosis and Peritoneal Carcinomatosis From Normal-Sized Ovarian Cancer.

OBJECTIVE: The purpose of this study was to analyze the computed tomography (CT) features of female peritoneal tuberculosis and peritoneal carcinomatosis from normal-sized ovarian cancer for their differentiation. MATERIALS AND METHODS: We analyzed the CT features of 18 female peritoneal tuberculosis and 17 peritoneal carcinomatosis with proven normal-sized ovarian carcinomas. Omental change, mesenteric change, parietal peritoneal thickening, lymph node enlargement, ascites, ovarian CT attenuation, and ovarian capsular change were analyzed. RESULTS: Heterogeneous parenchymal hyperattenuation and capsular change of the ovary were more frequently seen in cases of peritoneal carcinomatosis than in cases of female peritoneal tuberculosis (P = 0.002, P < 0.001, respectively). There were no statistically significant differences in the other CT features. CONCLUSIONS: The differentiation of female peritoneal tuberculosis and peritoneal carcinomatosis with normal-sized ovarian cancer by CT may be a diagnostic challenge. Ovarian hyperattenuation and any prominent ovarian capsular change may facilitate the differentiation between these groups.

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.

Cost-Effectiveness Analysis of Endovascular Coiling versus Neurosurgical Clipping for Intracranial Aneurysms in Republic of Korea.

PURPOSE: The International Subarachnoid Aneurysm Trial (ISAT) revealed that in ruptured intracranial aneurysms (RA), endovascular coiling (EC) yields better clinical outcomes than neurosurgical clipping (NC) at 1 year. In unruptured aneurysms (UIA), EC is being increasingly used as an alternative to NC due to patients' preference. There is a lot of difference in treatment cost (EC vs. NC) between countries. There is one recently published study dealing with the comparative cost analysis only in UIAs in South Korea. But it is a hospital-based study. So, the authors performed a nation-wide cost effective comparison in our country. MATERIALS AND METHODS: This study was a retrospective analysis of healthcare big data open systems in Health Insurance Review & Assessment Service (HIRA). Hospital cost data of the recent 5 years (from January 2010 to December 2014) were analyzed according to patients' age and sex and the presence of subarachnoid hemorrhage. RESULTS: When comparing the total hospital costs for NC of a UIA (n=13,756) and EC of a UIA (n=17,666), NC [mean±standard deviation (SD): ￦7,987,179±3,855,029] resulted in significantly lower total hospital costs than EC [￦10,201,645±5,001,626, p<0.0001], although a shorter hospital stay with EC of a UIA [8.6 ±7.4 days] vs. NC [15.0 ±8.3 days, p<0.0001]. When comparing the total hospital costs for NC of a RA (n=7,293) and EC of a RA (n=6,954), NC [￦13,914,993±6,247,914] resulted in significantly lower total hospital costs than EC [￦16,702,446±7,841,141, p<0.0001], although shorter hospital stays for EC of a RA [19.8 ±11.4] vs. NC [23.0 ±10.3, p<0.0001]. CONCLUSION: The total hospital costs for the NC of both UIAs and RAs were found to be lower than those for EC in South Korea.

Recommendations for carotid stenting in Korea.

Carotid artery angioplasty with stenting (CAS) is being performed in many hospitals in Korea. Most of the guidelines which are being used are similar, but the practical aspects such as techniques are different between hospitals. For example, usage of various protective devices, the oral antiplatelet regimen prior to procedure and placing of temporary pacemaker to prevent bradycardia are different between hospitals. In this article, we summarize and propose the guidelines for CAS which is currently being accepted in Korea. These guidelines may be helpful in providing protocol to neurointerventionalist who perform CAS and to standardize the process including reporting of CAS in the future comparative trials in Korea.

Low-dose γ-irradiation induces dual radio-adaptive responses depending on the post-irradiation time by altering microRNA expression profiles in normal human dermal fibroblasts.

Exposure to high-dose ionizing radiation, including γ-radiation, induces severe skin disorders. However, the biological consequences and molecular mechanisms responsible for the response of human skin to low-dose γ-radiation (LDR) are largely unknown. In the present study, we demonstrate that LDR (0.1 Gy) induces distinct cellular responses in normal human dermal fibroblasts (NHDFs) depending on the post-irradiation time point. A MTT-based cell viability assay and propidium iodide staining-based cell cycle assay revealed that the viability and proportion of the cells in the G2/M phase were differed at 6 and 24 h post-irradiation. Reverse transcription quantitative PCR (RT-qPCR) revealed that LDR significantly upregulated the mRNA expression of collagen type I alpha 1 (COL1A1), but downregulated the mRNA expression of matrix metalloproteinase 1 (MMP1) at 24 h post-irradiation. MicroRNA (miRNA) microarray analysis further demonstrated that LDR induced changes in the expression profiles of specific miRNAs and that some of the deregulated miRNAs were specific to either the early or late radio-adaptive response. Our results suggest that LDR generates dual radio-adaptive responses depending on the post-irradiation time by altering specific miRNA expression profiles in NHDFs.

Altered microRNA expression profiles are involved in resistance to low-dose ionizing radiation in the absence of BMI1 in human dermal fibroblasts.

The polycomb group RING finger protein, B-cell­specific moloney murine leukemia virus integration site 1 (BMI1), has emerged as a key regulator of cell proliferation, cell cycle, cell immortalization, chemoresistance and radioresistance. Although the radioresistant effect of BMI1 has been thoroughly investigated, the effectiveness of this factor on low-dose radiation (LDR) resistance has not been explored. Here, we demonstrate that BMI1 is not critical for altering cell viability or cell growth in response to LDR, but BMI1 changes cellular gene expression profiles in response to LDR. Normal human dermal fibroblasts (NHDFs) stably expressing BMI1 short hairpin RNA (shRNA) did not exhibit changes in cell viability or cell cycle distribution assays following exposure to 0.1 Gy of γ-radiation. However, microRNA (miRNA) microarrays revealed that a lack of BMI1 leads to changes in miRNA expression in response to LDR. Bioinformatics analyses demonstrated that predicted target genes of the altered miRNAs are functionally involved in both negative and positive regulation of cell growth, cell proliferation, cell cycle and apoptosis. Therefore, these results indicate that low radiosensitivity even in the absence of the radioresistant factor BMI1 is related with the altered miRNA expression profiles in NHDF.

Recent update of guidelines for neurointerventional procedures.

Treatment guidelines of the neurointerventional procedures are continuously updated. However, these guidelines differ between countries and even medical societies within the same country because of the differing interests and patient groups. The differences between guidelines are confusing to many neurointerventionalists. Recently "Clinical Research Center for Stroke" in Korea updated "Clinical Practice Guidelines for Stroke" for the patients in Korea. So we introduce those guidelines and compare several recent guidelines of international medical societies for neurointerventionalists.

Ultrasonographic analysis of subcutaneous angiolipoma.

OBJECTIVE: To describe and analyze the ultrasonographic appearance of subcutaneous angiolipoma in pathology-proven cases. MATERIALS AND METHODS: We retrospectively searched the January 2004 to May 2011 surgical pathology database for cases of pathology-proven angiolipoma. The ultrasonographic findings were analyzed for angiolipoma size, shape, margin, echo texture, echogenicity, acoustic enhancement, calcifications, and color Doppler flow. RESULTS: Of 31 angiolipomas, 19 lesions occurred in an upper extremity, one in a lower extremity, nine in the chest and abdominal wall, and two in the back. The mean tumor size was 17.7 mm. Twenty-five cases (80%) appeared as oval mass and all tumors had well-defined margins. All cases showed hyperechoic; 14 (45%), homogeneous; 17 (55%), heterogeneous. Seven cases (23%) showed blood flow in the mass. Acoustic enhancement and calcification was not shown in any cases. A correct preoperative diagnosis was made in three cases (10%) by ultrasonography. CONCLUSIONS: Most subcutaneous angiolipomas are oval-shaped, have well-defined margins, and hyperechoic appearance on ultrasonography. Although color Doppler flow of subcutaneous angiolipoma is not seen in many cases, it may helpful in differentiating angiolipoma from ordinary subcutaneous lipoma.

Classification of persistent primitive trigeminal artery (PPTA): a reconsideration based on MRA.

BACKGROUND: Persistent primitive trigeminal artery (PPTA) is the most common permanent carotid-basilar anastomosis. Magnetic resonance angiography (MRA) has become the primary non-invasive imaging technique for evaluation of cerebral vascular anatomy and can provide detailed 3D imaging of intracranial vessels. PURPOSE: To evaluate the usefulness of MRA for the detection of PPTA and to re-classify its variations based on the embryologic types of PcomA and its relationship with the basilar artery and its branches. MATERIAL AND METHODS: Of the total 7329 patients who underwent MRA at our institution from March 2008 through November 2010, we retrospectively analyzed the MRAs of 24 patients with a PPTA. Special attention was given to defining the relationship of the PPTA and the basilar artery with PcomA and to determine the site of origin, size, and course of the PPTA. The PPTA classification included five types based on their anatomic relationship to the neighboring arteries. Clinical features and associated vascular anomalies are also described. RESULTS: Twenty-four (17 women and seven men, 34 ~ 81 years of age, mean age 59.67 years) of the 7329 patients had a PPTA (0.33 %). Eleven cases (45.8%) were classified as type 1, three (12.5%) as type 2, five (20.8%) as type 3, one (4.2%) as type 4, and four (16.7%) as type 5b. Fifteen PPTAs (62.5%) were located on the left side and nine were located (37.5%) on the right side. The basilar artery proximal to the insertion of the PPTA showed severe to moderate hypoplasia in 13 cases (54%). Nine intracranial artery aneurysms were detected in seven (29%) of the 24 study patients. CONCLUSION: This study revealed five types of PPTA and necessitates an adjustment of the previous classification of PPTA on the basis of our MRA examinations. A PPTA should be considered by both the clinician and the radiologist who interpret MR angiography.

Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients.

INTRODUCTION: Intra-arterial (IA) thrombolysis with plasminogen activator is well-known, but the use of IA tirofiban as an adjuvant for IA thrombolysis is not well-known. We investigated the feasibility of IA tirofiban as an adjuvant after unsuccessful IA recanalization with urokinase (UK) for acute ischemic stroke. METHODS: We retrospectively analyzed all 16 consecutive patients (11 men and five women; mean age, 61.3 years; range, 36-85 years) who were treated with IA tirofiban after isolated IA thrombolysis with UK or bridging therapy with systemic recombinant tissue plasminogen activator (rt-PA; 0.6 mg/Kg) and IA UK for acute ischemic stroke. Outcome measures included angiographic recanalization (thrombolysis in cerebral infarction, TICI), symptomatic and asymptomatic intracerebral hemorrhage (ICH), mortality, and functional independence at 3 months (modified Rankin Scale, 0-2). RESULTS: Among the 16 patients treated with IA tirofiban as an adjuvant, 10 patients had conventional dose (<25 ug/kg, bolus) and six patients had high dose (≥25 ug/kg, bolus) of IA tirofiban after unsuccessful IA thrombolysis whether systemic rt-PA used or not. Successful angiographic recanalization (TICI grade 2b or 3) was achieved in 13 patients (13/16) and a functional independence at 3 months in eight patients (8/16). Three months after therapy, three patients had died. There were two patients of symptomatic ICH and four asymptomatic ICH. CONCLUSION: Conventional dose of IA tirofiban as an adjuvant during IA thrombolysis for acute ischemic stroke seems feasible. However, further dose escalation studies should be performed regarding the IA use of tirofiban for acute ischemic stroke.

The Efficacy of Simultaneous Bilateral Internal Carotid Angiography during Coil Embolization for Anterior Communicating Artery Aneurysms.

OBJECTIVE: Successful coil embolization of anterior communicating (A-com) artery aneurysms requires good visualization and understanding of the entire H complex. Bilateral carotid angiography may optimize anatomical understanding and visualization of the H complex. We therefore assessed the efficacy of simultaneous bilateral internal carotid angiography during coil embolization for A-com artery aneurysms. METHODS: Of the 153 patients with intracranial saccular aneurysms who underwent embolization between July 2008 and December 2009, 12 had A-com artery aneurysms and were embolized under bilateral carotid angiography. Patients were evaluated angiographically, immediately and 6 months (n=11) after embolization, using a 3-point scale (complete, residual neck, residual aneurysm). The safety, performance and efficacy of this approach were retrospectively evaluated. RESULTS: In all patients, bilateral internal carotid artery angiography provided more detailed anatomical information and understanding around the A-com artery, and, in complex situations, it allowed for more effective coil embolization through bilateral routes to the A-com artery. Angiography immediately after embolization showed occlusion of 11 of the 12 (92%) aneurysms, with none of these 11 showing evidence of recanalization at 6 months. CONCLUSION: These findings indicate that simultaneous bilateral carotid angiography during coil embolization of selected complex A-com artery aneurysms provided improved anatomical understanding, and resulted in more effective and safer procedures than typical unilateral angiography.

Subcutaneous panniculitis-like T-cell lymphoma: US and CT findings in three patients.

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare disorder. We examined two females and one male with multiple soft-tissue masses in the abdominal wall. One of these three patients also had soft-tissue masses in the right thigh and right buttock. The histologic diagnosis was revealed as SPTCL in all three cases. The ultrasound (US) findings in two of these cases were diffuse, ill-defined hyperechoic areas with a linear vascular signal. The findings of the abdominal and pelvic computed tomography (CT) scanning with contrast enhancement were multiple enhancing nodules with an infiltrative pattern of peripheral subcutaneous fat layer in all three cases. We report US and CT findings of SPTCL in these three patients.

Intermittent sonographic guidance in air enemas for reduction of childhood intussusception.

OBJECTIVE: The purpose of this study was to prospectively assess the value of intermittent sonographic guidance in nonsurgical air reduction of childhood intussusception. METHODS: The study group included 86 consecutive childhood intussusceptions confirmed on sonography for which we designed an air enema. With intermittent sonographic guidance of our own method, air was gradually injected to the initial intracolonic pressure of 60 mm Hg, which we attempted for 30 seconds on the initial attempt. If the air enema reduction attempts were not successful at a given pressure setting, we repeated the technique at each pressure setting upgraded by increments of 20 mm Hg up to 120 mm Hg. Surgery was performed when even repeated reduction attempts at the maximum intracolonic pressure of 120 mm Hg were unsuccessful. We calculated the successful reduction rate for the intussusceptions at each pressure setting. RESULTS: The overall success rate of sonographically guided air enema reductions was 95% (82/86). The success rates of air enema reductions at 60, 80, 100, and 120 mm Hg showed progressive increases of 53% (42/86), 67% (58/86), 78% (67/86), and 95% (82/86), respectively, with no immediate recurrence and no gross perforation. CONCLUSIONS: The use of intermittent sonographic guidance in air enemas is thought to help safely increase successful reductions of childhood intussusception even with sufficient air enema attempts.

Improved sonographic imaging of hepatic hemangioma with contrast-enhanced coded harmonic angiography: comparison with MR imaging.

The aim of this study was to compare peripheral nodular enhancement with centripetal progression on contrast-enhanced coded harmonic angio (CHA) with those as seen on magnetic resonance imaging (MRI) scan. A total of 20 patients with 24 hemangiomas confirmed by dynamic contrast-enhanced MRI were included in this study. All 20 patients were examined with CHA in conjunction with a galactose-based microbubble contrast agent (SH U 508A) and with interval delay scanning. The pattern and the time of contrast enhancement were recorded on CHA images. We compared CHA images with MRI in terms of the similarity of contrast-enhanced peripheral nodules. The significance of size of tumor and baseline echogenicity on the ability to see peripheral nodular enhancement was independently assessed. Peripheral nodular enhancement was shown on CHA in 22 (92%) of 24 hemangiomas. Of 22 hemangiomas, 21 (95%) with peripheral nodular enhancement had progressive centripetal fill-in on CHA images. In 4 (80%) of 5 hemangiomas less than 1.5 cm in diameter, contrast-enhanced peripheral nodules were depicted on CHA images. In terms of the similarity of peripheral nodules, CHA images showed the similarity more than "similar" grade with MRI in 21 (95%) of 22 hemangiomas. This study shows that CHA is approximately equal to MRI in its ability to show peripheral nodular enhancement with centripetal progression, even in small hemangiomas.