Byeong-Chae Kim

Early Outcome of Combined Thrombolysis Based on the Mismatch on Perfusion CT

Background: Possible factors associated with early outcome after thrombolysis are the recanalization time and the status of tissue. We assessed whether combined intravenous (IV) and intra-arterial (IA) thrombolysis performed according to the status of tissue based on perfusion computed tomography (PCT) is beneficial for the early outcome in patients with acute ischemic stroke. Methods: To improve the recanalization time, we assumed that combined IA thrombolysis after IV thrombolysis would be beneficial. Eligible patients for combined thrombolysis were selected according to the status of tissue based on PCT. Recanalization was defined as Thrombolysis in Myocardial Infarction (TIMI) grade 2 or 3. ‘Good functional outcome’ was defined as a Modified Rankin Scale (mRS) score of 2 or less at discharge. Results: Eighteen patients (11 men) underwent combined IV/IA thrombolysis. The recanalization rate after combined IV/IA thrombolysis was 88.9% (TIMI 2, 4; TIMI 3, 12). A good functional outcome at discharge was noted in 12 patients (66.7%). The incidence of symptomatic intracranial hemorrhage was 5.6% (1/18). Conclusions: The results of this study suggest that combined IV/IA thrombolysis based on the presence of mismatches on PCT might have a relatively high rate of recanalization and a favorable early outcome. In addition, the incidence of symptomatic intracranial hemorrhage was acceptable.

White Matter Hyperintensity as a Factor Associated with Delayed Mood Disorders in Patients with Acute Ischemic Stroke

Background: Mood disorder is a frequent complication of stroke. Comorbid depressive and anxiety disorders are very common, indicating that it is advisable to assess both disorders at the same time. The aim of the present study was to examine the prevalence of post-stroke depression (PSD) and poststroke anxiety (PSA) at baseline and to evaluate factors related to delayed PSD and PSA at 3 months after stroke onset. Methods: This was a prospectively registered and retrospectively analyzed study of patients with acute ischemic stroke between January 2009 and March 2010. Patients included in this study were interviewed in order to evaluate their Hospital Anxiety and Depression Scale (HADS) scores. In this study, each depression and anxiety score was dichotomized into ‘nondepressive and nonanxious’ (HADS-D and HADS-A ≤7) and ‘depressive and anxious’ (HADS-D and HADS-A >7). Multiple logistic regression analysis was used to evaluate the independent factors of depressive and anxious symptoms 3 months after stroke onset. Results: Of the 133 patients, 47.4% were ‘depressive’ and 56.4% were ‘anxious’ at baseline. The depressive and anxious groups had a significantly higher frequency of severe white matter hyperintensity (WMH) than the nondepressive and nonanxious groups (p < 0.05). The independent factors of PSD and PSA at 3 months were deep white matter hyperintensities (DWMH) and modified Rankin scale 0 to 1 at 3 months. Conclusion: In conclusions, the results of our study demonstrated that delayed depression and anxiety after ischemic stroke were related to the severity of DWMH and unfavorable outcomes at 3 months, regardless of anti-anxiety treatment. Our results suggested that WMH might be associated with pathomechanism of delayed depression and anxiety.

Cerebral embolism of iodized oil (lipiodol) after transcatheter arterial chemoembolization for hepatocellular carcinoma.

Cerebral lipiodol embolism is a rare complication of transcatheter arterial chemoembolization (TACE). Its pathological mechanism remains ambiguous despite several investigations. In Case 1, a 67‐year‐old man with hepatocellular carcinoma (HCC) experienced neurological deficits soon after undergoing a fourth session of TACE. Computed tomography (CT) scan showed multiple hyperdense lesions along the gyrus of frontal lobes and in the subcortical white matter. Transcranial Doppler (TCD) and transesophageal echocardiogram performed during the intravenous injection of agitated saline documented the presence of a right‐to‐left shunt (RLS) by demonstrating microbubbles in the left middle cerebral artery and left atrium. In Case 2, a 63‐year‐old woman underwent a third TACE due to a large HCC. After the procedure, her mental status deteriorated. Brain CT showed multiple hyperdense lesions on the cerebral and cerebellar cortex. TCD with agitated saline showed multiple microembolic signals shortly after the injection of agitated saline. The risk of cerebral lipiodol embolism may increase with recurrence and progression of HCC in patients who have a pre‐existing RLS in the heart or lung. A test for the detection of an RLS may be necessary to identify patients with a heightened risk of cerebral embolism when multiple TACE procedures are required. TACE for HCC can cause pulmonary embolism or infarction. 1,2 However, cerebral lipiodol embolism is rare after TACE. There have been several reports of cerebral embolism after TACE, but their exact mechanism has not yet been fully elucidated. We report herein 2 patients who developed cerebral lipiodol embolism after undergoing multiple TACE procedures for remnant HCC through a pre‐existing RLS.

Internal border zone lesions as a predictor of early neurological deterioration in minor stroke patients with severe arterial steno-occlusion.

Background: Early neurological deterioration (END) of acute ischemic stroke may be important because it can predict clinical outcomes. We described several cases with similar clinical findings but different outcomes and analyzed the characteristics of their imaging studies. We retrospectively analyzed minor stroke patients with severe arterial stenosis within 6 hours of stroke onset. We defined END as 4 or more deterioration of the National Institutes of Health Stroke Scale score. Diffusion‐weighted imaging (DWI) lesions were classified as lesions of the pial artery (PI), perforating artery (PAI) and border‐zone (BZ). Results: We consecutively analyzed a total of 12 subjects in this study. The patterns of initial DWI lesions were internal BZ (50%), PI (50%), PAI (25%), and cortical BZ (16.7%). Among them, the number of subjects with END was 5, and the frequency of internal BZ on initial DWI was significantly higher in patients with END than in those without. Conclusions: In conclusion, the results of this study suggest that when internal BZ infarcts are detected in patients with acute minor strokes accompanied by severe arterial stenosis, close observation and careful management should be performed because END can be induced at an early stage.

Accessible and informative sectioned images and surface models of the maxillofacial area for orthognathic surgery.

BACKGROUNDnThe aim of this study was to describe sectioned images and stereoscopic anatomic models of the maxillofacial area by using Visible Korean which are beneficial for medical education and clinical training in the field of orthognathic surgery.nnnMATERIALS AND METHODSnSerially sectioned images of the maxillofacial area of a cadaver were created. Significant structures in the sectioned images were outlined and stacked to build surface models.nnnRESULTSnBrowsing software (95.1 MB) and portable document format (PDF) file (142 MB) that were constructed are freely downloadable from our website (http://anatomy.co.kr). In the browsing software, the names of structures associated with malocclusion and orthognathic surgery could be viewed on the sectioned images. In the PDF file, surface models and stereoscopic maxillofacial structures were displayed in real-time.nnnCONCLUSIONSnThe state-of-the-art sectioned images, outlined images, and surface models that were arranged and systematised in this study, may help students and trainees investigate the anatomy of the maxillofacial area for orthognathic surgery.

Unusual Carotid Stenosis Detected by F-18 FDG PET/CT

A 69-year-old woman presented with recurrent transient monocular blindness of the left eye. She also presented with a urine frequency and worsening pain in the lower extremities. She had hypertension and diabetes mellitus. Laboratory tests suggested diabetes insipidus. Brain magnetic resonance (MR) angiograms showed stenosis at both cervical carotid arteries ( fig. 1 a–c) F-18 fluorodeoxyglucose positron emission tomography (FDGPET) scans with contrast enhancement revealed a soft tissue infiltrate that encased the symptomatic left common carotid artery, and the maximum standardized value of the lesion was 5.3 ( fig. 1 d, e). Then further investigations and treatment were performed. What is your diagnosis? Received: January 29, 2013 Accepted after revision: February 13, 2013 Published online: April 26, 2013

Usefulness of 3-dimensional stereotactic surface projection FDG PET images for the diagnosis of dementia.

Abstract To compare diagnostic performance and confidence of a standard visual reading and combined 3-dimensional stereotactic surface projection (3D-SSP) results to discriminate between Alzheimer disease (AD)/mild cognitive impairment (MCI), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD). [18F]fluorodeoxyglucose (FDG) PET brain images were obtained from 120 patients (64 AD/MCI, 38 DLB, and 18 FTD) who were clinically confirmed over 2 years follow-up. Three nuclear medicine physicians performed the diagnosis and rated diagnostic confidence twice; once by standard visual methods, and once by adding of 3D-SSP. Diagnostic performance and confidence were compared between the 2 methods. 3D-SSP showed higher sensitivity, specificity, accuracy, positive, and negative predictive values to discriminate different types of dementia compared with the visual method alone, except for AD/MCI specificity and FTD sensitivity. Correction of misdiagnosis after adding 3D-SSP images was greatest for AD/MCI (56%), followed by DLB (13%) and FTD (11%). Diagnostic confidence also increased in DLB (visual: 3.2; 3D-SSP: 4.1; Pu200a<u200a0.001), followed by AD/MCI (visual: 3.1; 3D-SSP: 3.8; P = 0.002) and FTD (visual: 3.5; 3D-SSP: 4.2; P = 0.022). Overall, 154/360 (43%) cases had a corrected misdiagnosis or improved diagnostic confidence for the correct diagnosis. The addition of 3D-SSP images to visual analysis helped to discriminate different types of dementia in FDG PET scans, by correcting misdiagnoses and enhancing diagnostic confidence in the correct diagnosis. Improvement of diagnostic accuracy and confidence by 3D-SSP images might help to determine the cause of dementia and appropriate treatment.

Infectious Intracranial Aneurysm Presenting with a Series of Strokes as a Complication of Pneumococcal Meningitis

A 40-year-old healthy man presented with headache and fever. Streptococcus pneumoniae was detected in cerebrospinal fluid culture. The initial brain computed tomogram (CT) showed no significant abnormality ( fig. 1 a–c). On day 2, the patient progressed to a comatose mental state, and a follow-up brain CT showed subarachnoid and intraventricular hemorrhages with an infectious aneurysm (IA) that had rapidly developed and multiple stenoses in the cerebral arteries ( fig. 1 d–f). The patient died. IA can develop as early as 24–48 h after a bacterial embolus, and an aneurysm may enlarge rapidly [1, 2] . Follow-up angiography and operative treatment should be considered for patients with IA.