Hong Il Ha

Intracranial Stenting of Severe Symptomatic Intracranial Stenosis: Results of 100 Consecutive Patients

BACKGROUND AND PURPOSE: There are a few reports regarding the outcome evaluation of balloon-expandable intracranial stent placement (BEICS). The purpose of our study was to evaluate the outcome and factors related to the adverse events (AEs) of BEICS. MATERIALS AND METHODS: We evaluated 100 consecutive patients who underwent BEICS. We assessed the procedural success (residual stenosis <50%), AEs (minor strokes, major strokes, and death), clinical outcome, and restenosis (>50%) at 6 months. We also analyzed 18 factors including symptom patterns related to AE rate. Symptom patterns revealed 1) stable patients (n = 73) with improving, stationary, or resolved symptoms; and 2) unstable patients (n = 27) with gradual worsening or fluctuating symptoms (National Institutes of Health Stroke Scale [NIHSS] ≥4) within 2 days before stent placement. RESULTS: The procedural success rate was 99%. Overall, there were 10 (10%) AEs within the 6 months: 4 (4%) minor strokes, 3 (3%) major strokes, and 3 (3%) deaths including a death from myocardial infarction. AE rate was 4.1% in stable and 25.9% in unstable patients. Restenosis at 6 months revealed 0% (0/59). Good outcome (modified Rankin Scale ≤2) at 6 months was 97% (71/73) in stable and 67% (18/27) in unstable patients. Stepwise logistic regression model revealed that symptom pattern (unstable versus stable) was the only significant risk factor (OR, 8.167; 95% CI, 1.933–34.500; P = .004). CONCLUSION: BEICS revealed a low AE and good outcome rate at 6 months, especially in the stable patients. Midterm outcome was also favorable in the unstable patient group.

Measurement of Kidney Volume with Multi-Detector Computed Tomography Scanning in Young Korean

Purpose Kidney volume is regarded as the most precise indicator of kidney size. However, it is not widely used clinically, because its measurement is difficult due to the complex kidney shape. We attempted to evaluate the normal kidney volume in young Korean men by using multi-detector computed tomography (MDCT). Materials and Methods We retrospectively reviewed MDCT data of young Korean men (113 patients). After data processing, we measured the volume and length of the kidneys. Body parameters (height, body weight, body-surface area, and total body water) and laboratory data were collected. Glomerular filtration rate (GFR) was calculated using Cockcroft-Gault (CG) equation. Results The mean kidney volume was 205.29 ± 36.81 cm3; and mean kidney length was 10.80 ± 0.69 cm. The former correlated significantly with height, body weight, body-surface area, and total body water (p < 0.05, correlation coefficient : γ = 0.328, 0.649, 0.640, and 0.638, respectively). The latter also correlated significantly with all body indexes, however the correlation was weaker, except with height (p < 0.05, correlation coefficient : γ = 0.457, 0.473, 0.505, and 0.503, respectively). Only kidney volume significantly predicted estimated GFR (adjusted R2 = 0.431, F = 85.90 and p < 0.05). Conclusion The kidney volume measured with MDCT is correlated well with body parameters, and is useful to predict renal function.

Head and Neck Vascular Lesions: Characterization of the Flow Pattern by the Use of Three-Phase CT

Objective This study was designed to evaluate the usefulness of three-phase CT to characterize the hemodynamics of vascular lesions in the head and neck area. Materials and Methods We analyzed vascular malformations of head and neck regions in 21 patients with the use of three-phase CT, including pre-contrast phase, vascular phase (scan delay: 20-35 seconds after intravenous contrast material injection) and equilibrium phase (scan delay: 3-5 minutes) imaging. The flow characteristic of each lesion was determined and categorized as either a high- or a low-flow lesion according to findings on selective arteriography and/or direct puncture venography. The CT number was acquired from two areas in a vascular lesion, sorted by the enhancement pattern: area 1, a highly enhanced area seen on the vascular phase; area 2, a delayedly enhanced area seen on the equilibrium phase. The CT numbers of each phase were compared between high- and low-flow lesions with use of the unpaired t-test. The flow patterns of high- and low-flow lesions were analyzed by assessment of time-density curves of three phase CT. Results High-flow lesions were detected in nine patients and low-flow lesions were detected in 12 patients. On the vascular phase, the CT number of areas 1 and 2 of high-flow lesions was significantly higher than for low-flow lesions (p < 0.05). Contrary to early peaks seen in time-density curves of high-flow lesions, low-flow lesions showed a delayed peak. Conclusion Three-phase CT seems to be a valuable non-invasive method to differentiate a high-flow lesion from a low flow lesion of head and neck vascular lesions.

Multidetector CT Findings of Bowel Transection in Blunt Abdominal Trauma

Objective Though a number of CT findings of bowel and mesenteric injuries in blunt abdominal trauma are described in literature, no studies on the specific CT signs of a transected bowel have been published. In the present study we describe the incidence and new CT signs of bowel transection in blunt abdominal trauma. Materials and Methods We investigated the incidence of bowel transection in 513 patients admitted for blunt abdominal trauma who underwent multidetector CT (MDCT). The MDCT findings of 8 patients with a surgically proven complete bowel transection were assessed retrospectively. We report novel CT signs that are unique for transection, such as complete cutoff sign (transection of bowel loop), Janus sign (abnormal dual bowel wall enhancement, both increased and decreased), and fecal spillage. Results The incidence of bowel transection in blunt abdominal trauma was 1.56%. In eight cases of bowel transection, percentage of CT signs unique for bowel transection were as follows: complete cutoff in 8 (100%), Janus sign in 6 (100%, excluding duodenal injury), and fecal spillage in 2 (25%). The combination of complete cutoff and Janus sign were highly specific findings in patients with bowel transection. Conclusion Complete cut off and Janus sign are the unique CT findings to help detect bowel transection in blunt abdominal trauma and recognition of these findings enables an accurate and prompt diagnosis for emergency laparotomy leading to reduced mortality and morbidity.

Second-Line Irinotecan, Leucovorin, and 5-Fluorouracil for Gastric Cancer Patients after Failed Docetaxel and S-1.

Background. This retrospective study aimed to assess the efficacy and toxicities of second-line chemotherapy with irinotecan, leucovorin, and 5-fluorouracil (5-FU) in metastatic gastric cancer (MGC) patients previously treated with docetaxel and S-1 with or without oxaliplatin (DS/DOS). Patients and Methods. We reviewed the data of patients who had previously been treated with first-line DS/DOS and received biweekly irinotecan-based chemotherapy (FOLFIRI/IFL) between October 2004 and November 2011. Results. A total of 209 cycles were administered to 35 patients, with a median of 4 (range, 1–22) cycles each. The overall response rate in 29 response-assessable patients was 17.2%, including 2 complete and 3 partial responses. The median progression-free and overall survivals were 3.81 (95% confidence interval [CI], 1.82–5.80) months and 6.24 (95% CI, 1.44–11.04) months, respectively. The major grade 3/4 toxicity was neutropenia (8.6%). Conclusion. FOLFIRI/IFL chemotherapy showed modest antitumour activity and tolerable toxicities in DS/DOS-treated MGC patients.

Compression of the Main Pancreatic Duct by the Intrapancreatic-Replaced Common Hepatic Artery

We describe a unique case of a patient who presented with a linear, transverse, and incidentally-detected main pancreatic duct dilatation that was caused by the intrapancreatic-replaced common hepatic artery, detected on the MDCT, MRCP and endoscopic retrograde cholangiopancreatography. We believe this case to be the first of its kind reported in the literature.

A Case of Spontaneous Isolated Dissection of Left Gastric Artery

A 77-year-old woman was admitted to the emergency room due to sudden severe epigastric pain. Because she complained of very severe pain with 9-points on the numeric pain rating scale, the emergency physician suspected pain of vascular origin and computed tomography (CT) angiography was performed. The three-dimensional volume rendering (3-D VR) image revealed the anatomical variant of replaced left hepatic artery (LHA) arising from left gastric artery (LGA) (Fig. 1A). The diffuse irregular wall thickening of LGA with high attenuation, measuring 40 Hounsfield unit was noted on the non-enhanced phase (Fig. 1B). The irregular luminal narrowing through long segment of LGA and replaced LHA was noted on the arterial phase (Fig. 1C) and 3-D VR image (Fig. 1A). There was associated surrounding fat stranding. The curved multi-planar reformatted (MPR) image demonstrated the eccentric wall thickening (Fig. 1D), suggesting thrombosis in the false lumen. These CT findings were compatible with dissection of LGA. Therefore, the patient was diagnosed with spontaneous isolated dissection of LGA and replaced LHA. She received conservative management and the symptoms subsided after 1 week of treatment. Fig. 1 Multidetector computed tomography (MDCT) angiography of a 77-year-old woman with sudden severe epigastic pain. (A) The three-dimensional volume rendering image shows anatomical variant of the replaced left hepatic artery arising from the left gastric ... A spontaneous dissection of a splanchnic artery is a rare disease entity. The superior mesenteric artery is the most frequently reported artery. However, the incidence is very low, approximately 0.06% (1). According to our web-based search results, only two cases presenting LGA dissection have been reported (2,3). In one case, the dissection involved multiple splanchnic arteries; LGA, common hepatic artery and multiple intra-hepatic arteries (2). In both cases, gastric artery aneurysms were developed, which were found in a ruptured state. The rupture of gastric artery aneurysm showed high mortality, up to 70% (4). On the other hand, to the best of our knowledge, the isolated LGA dissection without aneurysm formation has not been reported yet. CT angiography has become the modality of choice for the patients with suspicious vascular-origin pain. As well as it is fast and noninvasive, it shows clear visualization of mesenteric vasculature with possible anatomical variants. Recent techniques of three-dimensional reconstruction allow us to accept the vascular anatomy intuitively. The intimal flap is pathognomonic finding of the dissection (5). However, the intimal flap is not always clearly visualized. The presence of thrombosis in the false lumen or eccentric mural thrombi is essential to diagnose the dissection in those cases (5). There are several image findings associated with dissection such as surrounding fat infiltration and development of aneurysm of involved arteries (5). With the advanced technology of CT angiography and knowledge of the image findings of splanchnic arterial dissection, the improved detection rate and diagnostic accuracy may be obtained in clinical medicine.

Intramural esophageal dissection diagnosed on transabdominal ultrasonography

Intramural esophageal dissection (IED) is an uncommon yet important clinical entity characterized by a rupture or fissure in the esophageal submucosal layer. IED could occur spontaneously or secondary to direct extrinsic injury to the esophageal mucosa. Traditionally, IED has been diagnosed on the swallowing study using water-soluble contrast agents or barium. For alternative diagnostic modalities, upper gastrointestinal endoscopy and chest computed tomography have been frequently performed. However, to the best of our knowledge, the transabdominal ultrasonography (USG) appearance of IED has not been reported in the literature yet. We report an interesting case of IED, which was initially diagnosed on the transabdominal USG.

Comparison of the diagnostic performance of CT Hounsfield unit histogram analysis and dual-energy X-ray absorptiometry in predicting osteoporosis of the femur

PurposeTo evaluate the diagnostic performance of Hounsfield unit histogram analysis (HUHA) of precontrast abdominal-pelvic CT scans for predicting osteoporosis.Materials and methodsThe study included 271 patients who had undergone dual X-ray absorptiometry (DXA) and abdominal-pelvic CT within 1 month. HUHA was measured using commercial 3D analysis software (Aquarius iNtuition v4.4.12Ⓡ, TeraRecon) and expressed as a percentage of seven HU range categories related to the ROI: A < 0, 0 ≤ B < 25, 25 ≤ C < 50, 50 ≤ D < 75, 75 ≤ E < 100, 100 ≤ F < 130, and 130 ≤ G. A coronal reformatted precontrast CT image containing the largest Ward’s triangle was selected and then the ROI was drawn over the femoral neck. Correlation (r) and ROC curve analyses were used to assess diagnostic performance in predicting osteoporosis using the femur T-score as the reference standard.ResultsWhen the femur T-score was used as the reference, the rs of HUHA-A and HUHA-G were 0.74 and -0.57, respectively. Other HUHA values had moderate to weak correlations (r = -0.33 to 0.27). The correlation of HUHA-A was significantly higher than that of HUHA-G (p = 0.03). The area under the curve (0.95) of HUHA-A differed significantly from that of HUHA-G (0.90; p < 0.01). A HUHA-A threshold ≥ 27.7% was shown to predict osteoporosis based on a sensitivity and specificity of 95.6% and 81.7%, respectively.ConclusionThe HUHA-A value of the femoral neck is closely related to osteoporosis and may help predict osteoporosis.Key Points• HUHA correlated strongly with the DXA femur T-score (HUHA-A, r = 0.74).• The diagnostic performance of HUHA for predicting osteoporosis (AUC = 0.95) was better than that of the average CT HU value (AUC = 0.91; p < 0.05).• HUHA may help predict osteoporosis and enable semi-quantitative measurement of changes in bone mineral density.

Multicenter Phase II Study of Oxaliplatin, Irinotecan, and S-1 as First-line Treatment for Patients with Recurrent or Metastatic Biliary Tract Cancer

Purpose Although gemcitabine plus cisplatin has been established as the standard first-line chemotherapy for patients with advanced biliary tract cancer (BTC), overall prognosis remains poor. We investigated the efficacy of a novel triplet combination of oxaliplatin, irinotecan, and S-1 (OIS) for advanced BTC. Materials and Methods Chemotherapy-naive patientswith histologically documented unresectable or metastatic BTC were eligible for this multicenter, single-arm phase II study. Patients received 65 mg/m2 oxaliplatin (day 1), 135 mg/m2 irinotecan (day 1), and 40 mg/m2 S-1 (twice a day, days 1-7) every 2 weeks. Primary endpoint was objective response rate. Targeted exome sequencing for biomarker analysis was performed using archival tissue. Results In total, 32 patients were enrolled between October 2015 and June 2016. Median age was 64 years (range, 40 to 76 years), with 24 (75%) male patients; 97% patients had metastatic or recurrent disease. Response rate was 50%, and median progression-free survival and overall survival (OS) were 6.8 months (95% confidence interval [CI], 4.8 to 8.8) and 12.5 months (95% CI, 7.0 to 18.0), respectively. The most common grade 3-4 adverse events were neutropenia (32%), diarrhea (6%), and peripheral neuropathy (6%). TP53 and KRAS mutations were the most frequent genomic alterations (42% and 32%, respectively), and KRAS mutations showed a marginal relationship with worse OS (p=0.07). Conclusion OIS combination chemotherapy was feasible and associated with favorable efficacy outcomes as a first-line treatment in patients with advanced BTC. Randomized studies are needed to compare OIS with gemcitabine plus cisplatin.