Soonchan Park

Complications in Stent-Assisted Endovascular Therapy of Ruptured Intracranial Aneurysms and Relevance to Antiplatelet Administration: A Systematic Review

BACKGROUND AND PURPOSE: Despite the increasing use of stent-assisted coiling for ruptured intracranial aneurysms, there is little consensus regarding the appropriate antiplatelet administration for this. The objectives of this systematic review were to provide an overview of complications and their association with the method of antiplatelet administration in stent-assisted coiling for ruptured intracranial aneurysms. MATERIALS AND METHODS: A comprehensive search of the literature in the data bases was conducted to identify studies reporting complications of stent-assisted coiling for ruptured intracranial aneurysms. The pooled event rate of preprocedural thromboembolisms, hemorrhages, and mortality was estimated from the selected studies. Subgroup analyses were performed by the method of antiplatelet administration (pre-, postprocedural, and modified). Meta-analysis was conducted to compare periprocedural complications and mortality between ruptured intracranial aneurysms and unruptured intracranial aneurysms. RESULTS: Of the 8476 studies identified, 33 with 1090 patients were included. The event rates of thromboembolism and intra- and postprocedural hemorrhage were 11.2% (95% CI, 9.2%–13.6%), 5.4% (95% CI, 4.1%–7.2%), and 3.6% (95% CI, 2.6%–5.1%), respectively. Subgroup analyses of thromboembolism showed a statistically significant difference between groups (P < .05). In the preprocedural and modified antiplatelet groups, the risk for thromboembolism in stent-assisted coiling for ruptured intracranial aneurysm was not significantly different from that for unruptured intracranial aneurysm, though this risk of the postprocedural antiplatelet group was significantly higher in ruptured intracranial aneurysms than in unruptured intracranial aneurysms. CONCLUSIONS: On the basis of current evidence, complications of stent-assisted coiling for ruptured intracranial aneurysm may be affected by the method of antiplatelet administration.

Glutamine and Glutamate Complex, as Measured by Functional Magnetic Resonance Spectroscopy, Alters During Face-Name Association Task in Patients with Mild Cognitive Impairment and Alzheimer’s Disease

BACKGROUND The metabolite response during a memory task in Alzheimers disease (AD) patients is unknown. OBJECTIVE To investigate the metabolite changes in subjects with AD, amnestic mild cognitive impairment (aMCI), and cognitively normal (CN) elderly during a memory task using functional magnetic resonance spectroscopy (fMRS). METHODS This study involved 23 young normal controls (YC), 24 CN elderly, 24 aMCI, and 24 mild and probable AD individuals. fMRS data were acquired at the precuneus and posterior cingulate brain regions during a face-name association task. Statistical analyses of quantified metabolites were performed to evaluate differences of the metabolite values between the stimulation conditions and among the four subject groups. Receiver operating curve analysis was performed to evaluate whether the metabolic changes after functional activations can differentiate the subject groups. RESULT Glutamine and glutamate complex (Glx) was statistically significantly different between the fixation and repeat conditions in aMCI (p = 0.0492) as well as between the fixation and the novel conditions in the AD (p = 0.0412) group. The total N-acetylaspartate (tNAA) was statistically significantly different among the four subject groups in the fixation condition (DF = 3, F = 7.673, p <  0.001), the novel condition (DF = 3, F = 6.945, p <  0.001), and the repeat condition (DF = 3, F = 7.127, p <  0.001). tNAA, tCr, and mIns could be used to differentiate CN from aMCI. Furthermore, tNAA, tCr, Glx, and Glu could also differentiate CN from AD, and aMCI from AD. CONCLUSION Glx was altered during a stimulation that may be used to evaluate neuronal dysfunction in a demented patient. tNAA and tCr were reduced in patients with AD.

Alberta Stroke Program Early CT Score in the Prognostication after Endovascular Treatment for Ischemic Stroke: A Meta-analysis

Purpose The Alberta Stroke Program Early CT Score (ASPECTS) was devised to quantify the extent of early ischemic changes in the middle cerebral artery territory on brain CT. We performed a systematic review and meta-analysis of studies that presented clinical outcomes and baseline ASPECTS in ischemic stroke patients managed with endovascular methods to validate the use of ASPECTS for risk prognostication. Materials and Methods We searched the MEDLINE, EMBASE, and Cochran databases for observational or interventional studies that reported clinical outcomes and baseline ASPECTS in ischemic stroke patients treated with endovascular methods. Data were pooled to perform a meta-analysis for comparisons of clinical outcomes between high and low ASPECTS patients. Results A meta-analysis of 13 studies (six observational and seven interventional) revealed favorable outcomes (mRS sore 0-2 at 90 days) for high baseline ASPECTS (odds ratio=2.22; 95% CI: 1.74-2.86). Conclusion High ASPECTS is a predictor of favorable outcome after endovascular therapy for ischemic stroke.

Posterior root of lateral meniscus: the detailed anatomic description on 3T MRI.

Background Although there have been some attempts to reveal the anatomy of the posterior root of the lateral meniscus (PRLM) through cadaver studies, arthroscopy, or imaging, it has not yet been described fully. Purpose To describe clearly the unique features of the PRLM, including its course, configuration, and size, using 3.0-T magnetic resonance imaging (MRI). Material and Methods A total of 105 knee 3.0-T MR examinations of 103 patients with arthroscopically proven intact PRLM were reviewed retrospectively. Based on fat-saturated, proton-density-weighted (PDW) axial/coronal images and PDW sagittal images, the course, configuration, and attachment sites of the PRLM were evaluated. Results The majority of PRLM (76.2%) had two attachment sites: the medial tubercle along the intertubercular crest, just posteromedial to the tibial attachment of the anterior cruciate ligament (ACL), and the posterior slope of the lateral tubercle. The remaining cases (23.8%) had a solitary insertion on the intertubercular area (17 cases), or the posterior slope of the lateral tubercle (eight cases). The PRLM of the intertubercular area appeared as a dark signal line parallel to the tibial plateau on the mid-sagittal image and dark signal foci traversing the intertubercular crest on contiguous coronal images. Conclusion The PRLM inserts mainly in the intertubercular area with a thin, long anterior extension to the point just posteromedial to the tibial attachment of the ACL. It is well delineated on PDW 3.0-T MRI as a dark signal line parallel to the tibial plateau on mid-sagittal images and dark signal foci traversing the intertubercular crest on contiguous coronal images.

Quantitative susceptibility mapping to evaluate the early stage of Alzheimer's disease☆

The objective of this study was to evaluate susceptibility changes caused by iron accumulation in cognitive normal (CN) elderly, those with amnestic mild cognitive impairment (aMCI), and those with early state AD, and to compare the findings with gray matter volume (GMV) changes caused by neuronal loss. The participants included 19 elderly CN, 19 aMCI, and 19 AD subjects. The voxel-based quantitative susceptibility map (QSM) and GMV in the brain were calculated and the differences of those insides were compared among the three groups. The differences of the QSM data and GMVs among the three groups were investigated by voxel-based and region of interest (ROI)-based comparisons using a one-way analysis of covariance (ANCOVA) test with the gender and age as covariates. Finally, a receiver-operating-characteristic (ROC) curve analysis was performed. The voxel-based results showed that QSM demonstrated more areas with significant difference between the CN and AD groups compared to GMV. GMVs were decreased, but QSM values were increased in aMCI and AD groups compared with the CN group. QSM better differentiated aMCI from CN than GMV in the precuneus and allocortex regions. In the accumulation regions of iron and amyloid β, QSM can be used to differentiate between CN and aMCI groups, indicating a useful an auxiliary imaging for early diagnosis of AD.

White matter integrity associated with clinical symptoms in tinnitus patients: A tract-based spatial statistics study

AbstractObjectiveTo assess the relationship between white matter (WM) integrity and clinical variables in tinnitus patients using diffusion tensor imaging (DTI).MethodsSixty-seven tinnitus patients and 39 healthy controls were enrolled in this study. The tinnitus duration, laterality, pitch and characteristics, and two psychological self-rating tests were used as independent variables. Differences between patients and controls in diffusion indices were evaluated using tract-based spatial statistics (TBSS), and multiple regression between DTI values in significant clusters and clinical variables was investigated. TBSS correlation analysis between the clinical variables and DTI indices was performed in tinnitus patients.ResultsThe tinnitus group had higher mean diffusivity (MD) and axial diffusivity in WM under the auditory cortex and limbic system compared with control group. Depression symptom score (BDI) was the only significant variable affecting MD and axial diffusivity value in these clusters. TBSS correlation analysis with BDI in tinnitus patients showed BDI was associated with diffusion indices in widespread regions of WM.ConclusionsWM integrity in tinnitus was associated with depression symptoms in both inter- and intragroup analyses. Our results support the hypothesized implication of altered WM integrity in the physiopathology of emotional symptoms of tinnitus.Key Points• WM integrity of left auditory-limbic circuit in tinnitus is different in controls. • Depression symptoms are a significant clinical variable affecting DTI values. • DTI value is correlated with depression symptoms in tinnitus patients.

Ruptured intramuscular ganglion cyst in the gastrocnemius medialis muscle: sonographic appearance.

We report the case of a 55‐year‐old woman who presented with a severe pain and a mass in the proximal portion of the medial calf. On sonography, the lesion appeared as a poorly defined hypoechoic lesion with interspersed muscle bundles. A total excision of the lesion was performed. On microscopic examination, the specimen demonstrated cystic lesions surrounded by fibrous walls within the muscle bundles. A ruptured intramuscular ganglion cyst diagnosis was made based on the histopathologic findings.

Relationship between adverse events and antiplatelet drug resistance in neurovascular intervention: a meta-analysis

Background This meta-analysis aimed to evaluate the association between antiplatelet resistance and the risk of procedure-related complications in neurovascular interventions. Methods We identified relevant articles by searching electronic databases and reviewed the reference lists of selected papers. The risk of adverse events between antiplatelet responders and hyporesponders during neurointervention was compared in eligible clinical studies. Risk ratios (RRs) and 95% CIs were pooled using a random-effects meta-analysis. Results Of 2134 potentially relevant studies, our search identified 15 studies enrolling a total of 2365 patients. Pooled RRs showed thromboembolic events (TEE) were more frequent in hyporesponders (RR 2.634, 95% CI 1.465 to 4.734). However, hemorrhagic complications did not differ between the two groups (RR 1.236, 95% CI 0.642 to 2.380). In subgroup analysis, hyporesponders showed a higher prevalence of TEE with standard antiplatelet medication, but there was no obvious difference in TEE between the two arms when using a modified antiplatelet medication (RR 3.645, 95% CI 1.537 to 8.646; and RR 1.877, 95% CI 0.749 to 4.751). Studies using stent placement for aneurysms showed a higher TEE rate in hyporesponders (RR 3.221, 95% CI 1.899 to 5.464). Conclusion Antiplatelet resistance was significantly associated with TEE in neurointervention, and this adverse event was associated with individually-intensified antiplatelet medication as well as the type of neurointerventional procedure. Our findings support the use of antiplatelet resistance assays and tailored antiplatelet medications in neurovascular stent placement as a management strategy to reduce thromboembolic risk.

Compliant neurovascular balloon catheters may not be compatible with liquid embolic materials: intraprocedural rupture of the protecting balloon during tumor embolization using n-butyl cyanoacrylate and lipiodol mixture

Background Simultaneous use of balloon catheters with embolic materials can cause unwanted rupture of the balloon occlusion catheters, which might cause a serious problem. Therefore, knowledge of the compatibility of occlusion balloon catheters with liquid embolic materials is important in various interventional procedures. Objective To determine the compatibility of occlusion balloon catheters with commonly used embolic materials in vitro. Methods We used three types of occlusion balloon catheters (Scepter C, Microvention, Tustin, California, USA; Hyperform, Covidien, Irvine, California, USA; and Ascent, Codman Neurovascular, Raynham, Massachusetts, USA) to test their tolerances to Lipiodol, n-butyl cyanoacrylate (NBCA; Histoacryl; B Braun, Melsungen, Germany), and dimethyl sulfoxide (DMSO) with Onyx. The balloon was inflated just as it is in an endovascular procedure, then put on a Petri dish to observe its morphological change after one drop of liquid embolic material was added using a 1 mL syringe. The presence of rupture and the time to rupture were evaluated by constant video monitoring. Additionally, we observed morphological changes of the balloon catheter surface after contact with embolic materials with a scanning electron microscope. Results Lipiodol or a 33% NBCA–Lipiodol mixture dropping onto the three types of balloon catheter resulted in ruptures of all three. All three types of balloon catheter were tolerant to NBCA and to DMSO followed by Onyx. Conclusions Glue embolization should not be performed with all three kinds of balloon catheter on the market, but DMSO and Onyx are compatible with those balloon catheters.

Angiofibroma of soft tissue: A recently described entity

To the Editor: Angiofibroma of soft tissue was first described by MarinoEnrıquez in 2012, as having the characteristics of a well circumscribed fibro-/fibroblastic tumor with unique vascular features. It is clinically and pathologically distinct from cellular angiofibroma and nasopharyngeal angiofibroma. Before this description was made, these entities had been mistaken as a vascular neoplasms, low-grade sarcomas, myxofibrosarcoma, or myxoid liposarcoma, depending on the clinical context. We recently experienced a case and reviewed the English literature for this newly described disease. A 51-year-old, previously healthy woman presented with a slow growing, painless mass in her thigh. She didn’t report a history of trauma. Ultrasonography revealed a 2.5 cm lobulated hypervascular mass in the rectus femoris muscle, suggesting a soft tissue tumor with cystic changes or combined with an infection. Magnetic resonance imaging showed a homogenously and strongly enhanced 2.5 cm mass with an infiltrative margin (Fig. 1a), suggesting a malignant soft tissue tumor. A needle biopsy showed a low grade fibrovascular lesion, which could not be subclassified; a complete excision was performed. To date, there has not been any clinical evidence of local recurrence or distant metastasis. Grossly, the tumor was an ovoid, solid mass, measuring 2.2 × 2.0 × 1.3 cm. The cut surface of the tumor was pinkish gray, smooth, rubbery with focal hemorrhage and an infiltrative margin. Microscopically, the tumor was vaguely lobulated, but uncapsulated, with alteranting myxoid and collagenous areas, and having regional variations in cellularity (Fig. 1b). Variable sized branching blood vessels with notably thick walls, were evenly distributed throughout the lesion (Fig. 1c). Among the capillary network, short spindle cells with a pale cytoplasm were present; they also had short, ovoid or tapering nuclei, with fine chromatin. Mitotic activity was absent. Multinucleated hyperchromatic cells were occasionally scattered throughout both the cellular and myxoid areas and some cells in the myxoid areas looked like pseudolipoblasts (Fig. 1d, inset), similar to those seen in myxoid liposarcoma. Mast cells and small lymphocytes were admixed with the spindle cells. Immunohistochemically, the spindle cells were partly positive for epithelial membrane antigen (EMA,1:100, Dako, Glostrup, Denmark, Figure S1a) and negative for smooth muscle actin (SMA, 1:50, Santa Cruz Biotechnology, Santa Cruz, CA, USA), desmin (1:25, DAKO), S-100 protein (1:500, ZYMED, San Francisco, CA, USA), CD34(1:500, Immunotech, Marseille, France), MDM2 (1:100, ZETA corporation, Arcadia, CA, USA), MUC-4 (1:100, Invitrogen, Carlsbad, CA, USA, Figure S1b) and CDK4 (1:50, INVITROGEN). The vascular pattern was highlighted by CD 34 staining of the endothelial cells and SMA. The Ki-67 (1:200, ZYMED) labeling index was less than 1%.