Sclerotherapy with intralesional bleomycin injection under guidance of multi-slice CT for retrobulbar orbital low-flow vascular lesions-single-center experience

OBJECTIVE

This study investigated the safety and efficacy of sclerotherapy with intralesional bleomycin injection (IBI) for retrobulbar orbital low-flow vascular lesions under multi-slice computed tomography (CT) guidance.

METHODS

Between January 2010 and September 2021, consecutive patients with retrobulbar orbital low-flow vascular lesions who underwent CT-guided IBI at a tertiary centre in Taiwan were enrolled. Their medical records and imaging data were retrospectively collected.

RESULTS

This study enrolled 13 patients (7 male and 6 female patients; age range: 1-57 years; mean age: 25.9 years) with lymphatic malformation (LM, n = 4), venolymphatic malformation (n = 1), and venous malformation (VM, n = 8). The overall radiological response rate was 76.9% (10 of 13); the radiological response rate was 75.0% in the VM group (6 of 8) and 75.0% in the LM group (3 of 4). Moreover, 3 patients (23.1%) had minor complications and 1 (7.7%) had a major complication. The mean clinical and radiological follow-up was 8.3 months and no recurrence or progression was reported.

CONCLUSION

CT-guided IBI is an effective and relatively safe minimally invasive treatment for retrobulbar orbital low-flow vascular lesions, with an overall radiological response rate of 76.9% in a mean of 1.5 sessions and a low complication rate.

ADVANCES IN KNOWLEDGE

CT-guided sclerotherapy with IBI is a relatively safe, effective, and feasible alternative treatment option for retrobulbar orbital low-flow vascular lesions.

Focused ultrasound combined with radiotherapy for malignant brain tumor: a preclinical and clinical study

INTRODUCTION

Blood-brain barrier (BBB) remains to be the major obstacle to conquer in treating patients with malignant brain tumors. Radiation therapy (RT), despite being the mainstay adjuvant modality regardless of BBB, the effect of radiation induced cell death is hindered by the hypoxic microenvironment. Focused ultrasound (FUS) combined with systemic microbubbles has been shown not only to open BBB but also potentially increased regional perfusion. However, no clinical study has investigated the combination of RT with FUS-BBB opening (RT-FUS).

METHODS

We aimed to provide preclinical evidence of RT-FUS combination in GBM animal model, and to report an interim analysis of an ongoing single arm, prospective, pilot study (NCT01628406) of combining RT-FUS for recurrent malignant high grade glioma patients, of whom re-RT was considered for disease control. In both preclinical and clinical studies, FUS-BBB opening was conducted within 2 h before RT. Treatment responses were evaluated by objective response rate (ORR) using magnetic resonance imaging, progression free survival, and overall survival, and adverse events (AE) in clinical study. Survival analysis was performed in preclinical study and descriptive analysis was performed in clinical study.

RESULTS

In mouse GBM model, the survival analysis showed RT-FUS (2 Gy) group was significantly longer than RT (2 Gy) group and control, but not RT (5 Gy) group. In the pilot clinical trial, an interim analysis of six recurrent malignant high grade glioma patients underwent a total of 24 RT-FUS treatments was presented. Three patients had rapid disease progression at a mean of 33 days after RT-FUS, while another three patients had at least stable disease (mean 323 days) after RT-FUS with or without salvage chemotherapy or target therapy. One patient had partial response after RT-FUS, making the ORR of 16.7%. There was no FUS-related AEs, but one (16.7%) re-RT-related grade three radiation necrosis.

CONCLUSION

Reirradiation is becoming an option after disease recurrence for both primary and secondary malignant brain tumors since systemic therapy significantly prolongs survival in cancer patients. The mechanism behind the synergistic effect of RT-FUS in preclinical model needs further study. The clinical evidence from the interim analysis of an ongoing clinical trial (NCT01628406) showed a combination of RT-FUS was safe (no FUS-related adverse effect). A comprehensive analysis of radiation dosimetry and FUS energy distribution is expected after completing the final recruitment.

MRI Radiomics for Predicting Survival in Patients with Locally Advanced Hypopharyngeal Cancer Treated with Concurrent Chemoradiotherapy

A reliable prognostic stratification of patients with locally advanced hypopharyngeal cancer who had been treated with concurrent chemoradiotherapy (CCRT) is crucial for informing tailored management strategies. The purpose of this retrospective study was to develop robust and objective magnetic resonance imaging (MRI) radiomics-based models for predicting overall survival (OS) and progression-free survival (PFS) in this patient population. The study participants included 198 patients (median age: 52.25 years (interquartile range = 46.88-59.53 years); 95.96% men) who were randomly divided into a training cohort (n = 132) and a testing cohort (n = 66). Radiomic parameters were extracted from post-contrast T1-weighted MR images. Radiomic features for model construction were selected from the training cohort using least absolute shrinkage and selection operator-Cox regression models. Prognostic performances were assessed by calculating the integrated area under the receiver operating characteristic curve (iAUC). The ability of radiomic models to predict OS (iAUC = 0.580, 95% confidence interval (CI): 0.558-0.591) and PFS (iAUC = 0.625, 95% CI = 0.600-0.633) was validated in the testing cohort. The combination of radiomic signatures with traditional clinical parameters outperformed clinical variables alone in the prediction of survival outcomes (observed iAUC increments = 0.279 [95% CI = 0.225-0.334] and 0.293 [95% CI = 0.232-0.351] for OS and PFS, respectively). In summary, MRI radiomics has value for predicting survival outcomes in patients with hypopharyngeal cancer treated with CCRT, especially when combined with clinical prognostic variables.

Multimodal Neural Evidence on the Corticostriatal Underpinning of Suicidality in Late-Life Depression

BACKGROUND

Suicidality involves thoughts (ideations and plans) and actions related to self-inflicted death. To improve management and prevention of suicidality, it is essential to understand the key neural mechanisms underlying suicidal thoughts and actions. Following empirically informed neural framework, we hypothesized that suicidal thoughts would be primarily characterized by alterations in the default mode network indicating disrupted self-related processing, whereas suicidal actions would be characterized by changes in the lateral prefrontal corticostriatal circuitries implicating compromised action control.

METHODS

We analyzed the gray matter volume and resting-state functional connectivity of 113 individuals with late-life depression, including 45 nonsuicidal patients, 33 with suicidal thoughts but no action, and 35 with past suicidal action. Between-group analyses revealed key neural features associated with suicidality. The functional directionality of the identified resting-state functional connectivity was examined using dynamic causal modeling to further elucidate its mechanistic nature. Post hoc classification analysis examined the contribution of the neural measures to suicide classification.

RESULTS

As expected, reduced gray matter volumes in the default mode network and lateral prefrontal regions characterized patients with suicidal thoughts and those with past suicidal actions compared with nonsuicidal patients. Furthermore, region-of-interest analyses revealed that the directionality and strength of the ventrolateral prefrontal cortex-caudate resting-state functional connectivity were related to suicidal thoughts and actions. The neural features significantly improved classification of suicidal thoughts and actions over that based on clinical and suicide questionnaire variables.

CONCLUSIONS

Gray matter reductions in the default mode network and lateral prefrontal regions and the ventrolateral prefrontal cortex-caudate connectivity alterations characterized suicidal thoughts and actions in patients with late-life depression.

Safety and tolerability of asunercept plus standard radiotherapy/temozolomide in Asian patients with newly-diagnosed glioblastoma: a phase I study

Asunercept (company code APG101 [Apogenix AG]; company code CAN008 [CANbridge Pharmaceuticals]) is a novel glycosylated fusion protein that has shown promising effectiveness in glioblastoma. This Phase I study was initiated to evaluate the tolerability and safety of asunercept in combination with standard radiotherapy and temozolomide (RT/TMZ) in Asian patients with newly diagnosed glioblastoma. This was the Phase I portion of a Phase I/II open label, multicenter trial of asunercept plus standard RT/TMZ. Adults with newly-diagnosed glioblastoma received surgical resection followed by standard RT/TMZ plus asunercept 200 mg/week (Cohort 1) or 400 mg/week (Cohort 2) by 30-min IV infusion. The primary endpoint was the safety and tolerability of asunercept during concurrent asunercept and RT/TMZ; dose-limiting toxicities were observed for each dose. Secondary endpoints included pharmacokinetics (PK) and 6-month progression-free survival (PFS6). All patients (Cohort 1, n = 3; Cohort 2, n = 7) completed ≥ 7 weeks of asunercept treatment. No DLTs were experienced. Only one possibly treatment-related treatment emergent adverse event (TEAE), Grade 1 gingival swelling, was observed. No Grade > 3 TEAEs were reported and no TEAE led to treatment discontinuation. Systemic asunercept exposure increased proportionally with dose and showed low inter-patient variability. The PFS6 rate was 33.3% and 57.1% for patients in Cohort 1 and 2, respectively. Patients in Cohort 2 maintained a PFS rate of 57.1% at Month 12. Adding asunercept to standard RT/TMZ was safe and well tolerated in patients with newly-diagnosed glioblastoma and 400 mg/week resulted in encouraging efficacy.

Trial registration NCT02853565, August 3, 2016.

A Neural Network Approach to Identify Glioblastoma Progression Phenotype from Multimodal MRI

The phenotypes of glioblastoma (GBM) progression after treatment are heterogeneous in both imaging and clinical prognosis. This study aims to apply radiomics and neural network analysis to preoperative multimodal MRI data to characterize tumor progression phenotypes. We retrospectively reviewed 41 patients with newly diagnosed cerebral GBM from 2009-2016 who comprised the machine learning training group, and prospectively included 18 patients from 2017-2018 for data validation. Preoperative MRI examinations included structural MRI, diffusion tensor imaging, and perfusion MRI. Tumor progression patterns were categorized as diffuse or localized. A supervised machine learning model and neural network-based models (VGG16 and ResNet50) were used to establish the prediction model of the pattern of progression. The diffuse progression pattern showed a significantly worse prognosis regarding overall survival (p = 0.032). A total of 153 of the 841 radiomic features were used to classify progression patterns using different machine learning models with an overall accuracy of 81% (range: 77.5-82.5%, AUC = 0.83-0.89). Further application of the pretrained ResNet50 and VGG 16 neural network models demonstrated an overall accuracy of 93.1 and 96.1%. The progression patterns of GBM are an important prognostic factor and can potentially be predicted by combining multimodal MR radiomics with machine learning.

MRS as an Aid to Diagnose Malignant Transformation in Low-Grade Gliomas with Increasing Contrast Enhancement

BACKGROUND AND PURPOSE

Increased contrast enhancement has been used as a marker of malignant transformation in low-grade gliomas. This marker has been found to have limited accuracy because many low-grade gliomas with increased contrast enhancement remain grade II. We aimed to investigate whether MR spectroscopy can contribute to the diagnosis of malignant transformation in low-grade gliomas with increased contrast enhancement.

MATERIALS AND METHODS

Patients with low-grade gliomas who had contemporaneous MR spectroscopy and histopathology for tumor regions with increased contrast enhancement between 2004 and 2015 were retrospectively reviewed. Clinical data collected were sex and age, Karnofsky Performance Scale, histologic subtypes, isocitrate dehydrogenase 1 mutation status, disease duration, adjuvant therapy, and post-radiation therapy duration. Imaging data collected were contrast-enhancement size, whole-tumor size, MR spectroscopy metabolite ratios, and tumor grades of regions with increased contrast enhancement. Diagnostic values of these factors on malignant transformation of low-grade gliomas were statistically analyzed.

RESULTS

A total of 86 patients with 96 MR spectroscopy studies were included. Tumor grades associated with increased contrast enhancement were grade II (n = 42), grade III (n = 27), and grade IV (n = 27). On multivariate analysis, the NAA/Cho ratio was the only significant factor (P < .001; OR, 7.1; 95% CI, 3.2-16.1) diagnostic of malignant transformation. With 0.222 as the cutoff value, the sensitivity, specificity, and accuracy of NAA/Cho for diagnosing malignant transformation were 94.4%, 83.3%, and 89.6%, respectively.

CONCLUSIONS

MR spectroscopy complements conventional MR imaging in the diagnosis of malignant transformation in a subgroup of low-grade gliomas with increased contrast enhancement.

Subtracted Computed Tomography Angiography in the Evaluation of Coronary Arteries With Severe Calcification or Stents Using a 320-Row Computed Tomography Scanner

PURPOSE

Coronary computed tomography angiography (CCTA) has its limitations in evaluating arteries with stents or heavy calcification. This study compares the diagnostic performance of subtracted coronary computed tomography angiography (SCCTA) and nonsubtracted coronary computed tomography angiography (NSCCTA) in evaluating coronary artery disease (CAD) and in-stent restenosis (ISR).

MATERIALS AND METHODS

Twelve patients with stents and 20 patients with heavy coronary calcifications (total Agatston's score >400) underwent both SCCTA and invasive coronary angiography (ICA) with an interval of <3 months. Four subjects in the stented group also had heavy calcifications. Overall, 30 stented segments and 202 calcified segments were assessed to compare the diagnostic performance of SCCTA and NSCCTA in detecting ISR and CAD.

RESULTS

For the 30 stented segments, SCCTA/NSCCTA had a sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) (shown in %) of 66.7/100, 100/55.6, 96.7/60, 100/20, and 96.4/100 in diagnosing ISR, respectively. For the 202 calcified segments, SCCTA/NSCCTA had a sensitivity, specificity, accuracy, PPV, and NPV of 68.8/84.4, 97.6/76.5, 93.1/77.7, 84.6/40.3, and 94.3/96.3 in diagnosing CAD, respectively. For both stented and calcified segments, SCCTA was significantly superior to NSCCTA in specificity and accuracy. For the calcified segments, SCCTA was significantly superior to NSCCTA in PPV. There was no significant difference in the diagnostic performance of SCCTA between the stented and calcified segments.

CONCLUSIONS

The diagnostic accuracy and specificity of SCCTA are significantly superior to those of NSCCTA in evaluating CAD and ISR. SCCTA shows no statistical difference in its diagnostic performance between the stented and calcified segments.

Activation of Protein C and Its Distribution between Its Inhibitors, Protein C Inhibitor, α1-Antitrypsin and α2-Macroglobulin, in Patients with Disseminated intravascular Coagulation

Activation and inactivation of protein C during the clinical course of disseminated intravascular coagulation (DIC) was studied in three patients by qualitative (Western blotting) and quantitative (ELISA) analysis and the intensity of procoagulant activity monitored by the measurement of thrombin and factor Xa antithrombin III complexes. In one patient, inhibitor complexes of APC with protein C inhibitor (PCI) and α1-antitrypsin (α1-AT) were observed and the latter predominated at presentation. Both disappeared during the development of remission but the loss of α1-AT complexes preceded PCI complexes which on Western blotting appeared to increase in intensity prior to disappearance. The two other patients bled to death from uncontrollable haemorrhage. In both cases, APC/inhibitor complexes with α2-macroglobulin (α2-M) in addition to PCI and αr-AT were detected and persisted until death. Although PCI appeared to be the primary inhibitor in all three cases, α1-antitrypsin and particularly α2-macroglobulin appeared to assume greater roles in the two fatal cases. These data are similar to previous findings in an experimental animal model of DIC that suggested that α2-macroglobulin and α1-antitrypsin become more important inhibitors of APC as the primary inhibitor PCI is consumed in the face of a sustained procoagulant challenge.

Female sex, good performance status, and bevacizumab-induced hypertension associated with survival benefit in Asian patients with recurrent glioblastoma treated with bevacizumab

AIM

The goals of this study were to assess the activity and safety profile of bevacizumab in Taiwan Chinese patients with recurrent glioblastoma, to determine whether their response differed from that reported in other clinical trials, and to examine potential prognostic factors for survival.

METHODS

We retrospectively assessed patients who received bevacizumab for recurrent glioblastoma between 2012 and 2015. Twelve predefined variables and the outcomes of our cohort were analyzed.

RESULTS

In total, 76 patients with recurrent glioblastoma were analyzed. The overall response rate was 59.2%, including 19 patients (25.0%) with complete response and 26 patients (34.2%) with partial response. The median progression-free survival and overall survival were 5.2 months (95% confidence interval [CI], 4.6-5.8 months) and 7.8 months (95% CI, 5.8-9.8 months), respectively. Multivariate analysis identified sex and grade 3 posttreatment hypertension (systolic ≥ 160 mmHg or diastolic ≥ 100 mmHg) as the only independent predictive factors for progression-free survival and overall survival. Eastern Cooperative Oncology Group performance status was also found to be independently predictive of improved overall survival.

CONCLUSION

We showed good responses using bevacizumab and the progression-free survival and overall survival were comparable with those previously reported. The adverse events of bevacizumab in our study were generally acceptable and manageable. Female sex, good performance status, and grade 3 posttreatment hypertension were suggested to be associated with survival benefits.

Accuracy of circulating histones in predicting persistent organ failure and mortality in patients with acute pancreatitis

BACKGROUND

Early prediction of acute pancreatitis severity remains a challenge. Circulating levels of histones are raised early in mouse models and correlate with disease severity. It was hypothesized that circulating histones predict persistent organ failure in patients with acute pancreatitis.

METHODS

Consecutive patients with acute pancreatitis fulfilling inclusion criteria admitted to Royal Liverpool University Hospital were enrolled prospectively between June 2010 and March 2014. Blood samples were obtained within 48 h of abdominal pain onset and relevant clinical data during the hospital stay were collected. Healthy volunteers were enrolled as controls. The primary endpoint was occurrence of persistent organ failure. The predictive values of circulating histones, clinical scores and other biomarkers were determined.

RESULTS

Among 236 patients with acute pancreatitis, there were 156 (66·1 per cent), 57 (24·2 per cent) and 23 (9·7 per cent) with mild, moderate and severe disease respectively, according to the revised Atlanta classification. Forty-seven healthy volunteers were included. The area under the receiver operating characteristic (ROC) curve (AUC) for circulating histones in predicting persistent organ failure and mortality was 0·92 (95 per cent c.i. 0·85 to 0·99) and 0·96 (0·92 to 1·00) respectively; histones were at least as accurate as clinical scores or biochemical markers. For infected pancreatic necrosis and/or sepsis, the AUC was 0·78 (0·62 to 0·94). Histones did not predict or correlate with local pancreatic complications, but correlated negatively with leucocyte cell viability (r = -0·511, P = 0·001).

CONCLUSION

Quantitative assessment of circulating histones in plasma within 48 h of abdominal pain onset can predict persistent organ failure and mortality in patients with acute pancreatitis. Early death of immune cells may contribute to raised circulating histone levels in acute pancreatitis.

Cystic nodal metastasis in patients with oropharyngeal squamous cell carcinoma receiving chemoradiotherapy: Relationship with human papillomavirus status and failure patterns

Objectives

We investigated the relationships of cystic nodal metastasis, human papillomavirus (HPV) status, and treatment failure patterns in patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with chemoradiotherapy.

Methods

We retrospectively reviewed pretreatment MRI and clinical courses of patients with OPSCC whose tumors were tested for HPV-induced p16 expression via immunohistochemistry and who completed chemoradiotherapy. Cervical cystic nodal metastasis and necrotic nodal metastasis were classified on MRI.

Results

Of 98 patients eligible for analysis, 33 were p16-positive. Cystic nodal metastasis was significantly more prevalent in p16-positive than in p16-negative patients (39.4% versus 18.5%, respectively; p = 0.025). Necrotic nodal metastasis was significantly more prevalent in p16-negative than in p16-positive patients (73.8% versus 51.5%, respectively; p = 0.027). On multivariate analysis, necrotic nodal metastasis (odds ratio [OR] = 7.310, p = 0.011) was an independent predictor of regional failure, while advanced nodal stage (OR = 4.119, p = 0.022) and cystic nodal metastases (OR = 0.087, p = 0.026) were independent positive and negative predictors of distant failure, respectively.

Conclusions

Cervical cystic and necrotic nodal metastases are associated with HPV-induced p16-positive and p16-negative OPSCC, respectively. Patients with necrotic nodal metastasis at presentation have an increased risk of regional failure. Distant failure is directly and inversely correlated with advanced nodal stage and cystic nodal metastasis, respectively.

Diffusion-Weighted Imaging of Periventricular Leukomalacia in Very Young Children: Assessment of Peritrigonal Stripe of Restricted Diffusion

Purpose In periventricular leukomalacia (PVL), apparent diffusion coefficient (ADC) reduction, normally shown as dark stripe in the peritrigonal (PT) white matter, may be incomplete. We assessed the PT dark stripe to differentiate between PVL patients and control subjects. Patients and Methods We reviewed the magnetic resonance studies of 27 neonates and young children with PVL and 67 control subjects to assess the PT dark stripe on ADC maps. In PVL patients, the assessment was referred to the location of PVL lesion on fluid-attenuated inversion recovery (FLAIR) imaging. In the controls, the PT region or the location corresponding to FLAIR hyperintensity was evaluated for the dark stripe. We compared the prevalence of the dark stripe on ADC map and the PT FLAIR hyperintensity between the PVL and the control subjects. Results On ADC map, complete PT dark stripe was present in 67 (100%) of 67 controls but only in 4 (14.8%) of 27 PVL patients (p-value < 0.01), with sensitivity of 0.85, specificity of 1.0, and accuracy of 0.96. PT FLAIR hyperintensity was present in 44 (65.7%) of 67 controls and in 18 (66.7%) of 27 PVL patients (p = 0.920). Conclusion PVL patients can be differentiated from the control subjects with PT dark stripe on ADC map.

Early-Stage Glioblastomas: MR Imaging-Based Classification and Imaging Evidence of Progressive Growth

BACKGROUND AND PURPOSE

The serial imaging changes describing the growth of glioblastomas from small to large tumors are seldom reported. Our aim was to classify the imaging patterns of early-stage glioblastomas and to define the order of appearance of different imaging patterns that occur during the growth of small glioblastomas.

MATERIALS AND METHODS

Medical records and preoperative MR imaging studies of patients diagnosed with glioblastoma between 2006 and 2013 were reviewed. Patients were included if their MR imaging studies showed early-stage glioblastomas, defined as small MR imaging lesions detected early in the course of the disease, demonstrating abnormal signal intensity but the absence of classic imaging findings of glioblastoma. Each lesion was reviewed by 2 neuroradiologists independently for location, signal intensity, involvement of GM and/or WM, and contrast-enhancement pattern on MR imaging.

RESULTS

Twenty-six patients with 31 preoperative MR imaging studies met the inclusion criteria. Early-stage glioblastomas were classified into 3 types and were all hyperintense on FLAIR/T2-weighted images. Type I lesions predominantly involved cortical GM (n = 3). Type II (n = 12) and III (n = 16) lesions involved both cortical GM and subcortical WM. Focal contrast enhancement was present only in type III lesions at the gray-white junction. Interobserver agreement was excellent (κ = 0.95; P < .001) for lesion-type classification. Transformations of lesions from type I to type II and type II to type III were observed on follow-up MR imaging studies. The early-stage glioblastomas of 16 patients were pathologically confirmed after imaging progression to classic glioblastoma.

CONCLUSIONS

Cortical lesions may be the earliest MR imaging-detectable abnormality in some human glioblastomas. These cortical tumors may progress to involve WM.

Arterial spin-labeling perfusion imaging of childhood meningitis: a case series

INTRODUCTION

Conventional magnetic resonance imaging (MRI), which is mainly used to detect complications, is ineffective in determining the neurological status of patients with meningitis. Hemodynamic change in the brain may be more indicative of the neurological status but few imaging studies have verified this. Arterial spin-labeling (ASL) perfusion, a noninvasive MR method requiring no contrast agent injection, can be used to measure cerebral blood flow (CBF).

CASE REPORTS

We describe three pediatric patients with meningitis, who all showed regions of increased CBF on perfusion imaging. One patient, presenting with headache and conscious disturbance, had CBF changes in the frontal, temporal, and occipital regions. The other two patients, presenting with hallucinations, memory deficits, and seizures, had CBF changes in the frontal and temporal regions.

CONCLUSION

ASL perfusion imaging may be helpful in assessing patients with meningitis, demonstrating CBF changes more strongly correlating with the neurological status, and detecting active brain abnormalities.

Prediction of Long-term Post-operative Testosterone Replacement Requirement Based on the Pre-operative Tumor Volume and Testosterone Level in Pituitary Macroadenoma

Non-functioning pituitary macroadenomas (NFPAs) are the most prevalent pituitary macroadenomas. One common symptom of NFPA is hypogonadism, which may require long-term hormone replacement. This study was designed to clarify the association between the pre-operative tumor volume, pre-operative testosterone level, intraoperative resection status and the need of long-term post-operative testosterone replacement. Between 2004 and 2012, 45 male patients with NFPAs were enrolled in this prospective study. All patients underwent transsphenoidal surgery. Hypogonadism was defined as total serum testosterone levels of <2.4 ng/mL. The tumor volume was calculated based on the pre- and post-operative magnetic resonance images. We prescribed testosterone to patients with defined hypogonadism or clinical symptoms of hypogonadism. Hormone replacement for longer than 1 year was considered as long-term therapy. The need for long-term post-operative testosterone replacement was significantly associated with larger pre-operative tumor volume (p = 0.0067), and lower pre-operative testosterone level (p = 0.0101). There was no significant difference between the gross total tumor resection and subtotal resection groups (p = 0.1059). The pre-operative tumor volume and testosterone level impact post-operative hypogonadism. By measuring the tumor volume and the testosterone level and by performing adequate tumor resection, surgeons will be able to predict post-operative hypogonadism and the need for long-term hormone replacement.

Solitary intracranial osteoma with attachment to the falx: a case report

Background

Intracranial osteomas are uncommon lesions that usually arise from the inner table of the cranium. There are few reports in the literature of intracranial osteomas with meninges attachment and without direct relation with the skull bone; these osteomas were mostly attached with dura. We report a rare osteoma with falx attachment.

Case

A 64-year-old woman presented with a 3-month history of intermittent tinnitus and dizziness. The scout film of petrous bone computed tomography scan revealed a high-density lesion in the frontal area. Magnetic resonance imaging showed a 2.5-cm mass attached to the surface of the falx in the right frontal parasagittal area. The patient underwent right frontal craniotomy, and a bony hard mass was found located in the right frontal parasagittal region extra-axially, with its medial surface attached to the falx. It could not be broken down by the cavitron ultrasonic surgical aspirator or even the cutting loop and was detached from the falx and removed in one piece. Histopathological examination showed a nodule with bony trabeculae and bone marrow tissue, compatible with osteoma. The postoperative course was uneventful, and the patient was discharged from the hospital with no neurological deficits one week after operation.

Conclusions

This is the first case report in the English literature of an intracranial osteoma arising from the falx. Because of their slow growth and their locations in silent brain areas, intracranial osteomas are usually diagnosed incidentally. Surgical resection is the primary treatment choice.

CT-guided core needle biopsy of deep suprahyoid head and neck lesions in untreated patients

This study aimed to evaluate the efficacy of CT-guided core needle biopsy (CNB) in the diagnosis of deep head and neck tumors in untreated patients. We retrospectively reviewed the records of ten consecutive CT-guided CNB procedures from ten patients without a related history from March 2004 to February 2012. The surgical results, treatment response and clinical follow-up were used as the diagnostic standards. All specimens were considered adequate. Nine out of ten cases matched the final diagnosis. Biopsy failed to diagnose the infratemporal meningioma en plaque in a particular case. Three cases were carcinomas. No complication was encountered. CT-guided core needle biopsy is an efficient and safe technique for histological diagnosis of skull base lesions in patients without a related history. This technique can offer a definite tissue diagnosis and avoid unnecessary surgical interventions for such patients.

Assessment of angiographic vascularity of meningiomas with dynamic susceptibility contrast-enhanced perfusion-weighted imaging and diffusion tensor imaging

BACKGROUND AND PURPOSE

The roles of DTI and dynamic susceptibility contrast-enhanced-PWI in predicting the angiographic vascularity of meningiomas have not been studied. We aimed to investigate if these 2 techniques could reflect the angiographic vascularity of meningiomas.

MATERIALS AND METHODS

Thirty-two consecutive patients with meningiomas who had preoperative dynamic susceptibility contrast-enhanced-PWI, DTI, and conventional angiography were retrospectively included. The correlations between angiographic vascularity of meningiomas, classified with a 4-point grading scale, and the clinical or imaging variables-age and sex of patient, as well as size, CBV, fractional anisotropy, and ADC of meningiomas-were analyzed. The meningiomas were dichotomized into high-vascularity and low-vascularity groups. The differences in clinical and imaging variables between the 2 groups were compared. Receiver operating characteristic curve analysis was used to determine the diagnostic performance of these variables.

RESULTS

In meningiomas, angiographic vascularity correlated positively with CBV but negatively with fractional anisotropy. High-vascularity meningiomas demonstrated significantly higher CBV but lower fractional anisotropy as compared with low-vascularity meningiomas. In differentiating between the 2 groups, the area under the curve values were 0.991 for CBV and 0.934 for fractional anisotropy on receiver operating characteristic curve analysis.

CONCLUSIONS

CBV and fractional anisotropy correlate well with angiographic vascularity of meningiomas. They may differentiate between low-vascularity and high-vascularity meningiomas.

Differentiation of primary central nervous system lymphomas and glioblastomas: comparisons of diagnostic performance of dynamic susceptibility contrast-enhanced perfusion MR imaging without and with contrast-leakage correction

BACKGROUND AND PURPOSE

Contrast leakage results in underestimation of the CBV of brain tumors. Our aim was to compare the diagnostic performance of DSC perfusion MR imaging without and with mathematic contrast-leakage correction in differentiating PCNSLs and glioblastomas.

MATERIALS AND METHODS

Perfusion parameters-CBV, corrected CBV, and leakage coefficient-were measured in enhancing tumor portions and contralateral NAWM of 15 PCNSLs and 20 glioblastomas, respectively. The ratios of CBV and corrected CBV were calculated by dividing the tumor values by those obtained from contralateral NAWM. A paired t test was used to compare tumor K2 and NAWM K2, as well as tumor CBV ratios without and with leakage correction. Comparisons of CBV, corrected CBV, and K2 between PCNSLs and glioblastomas were done by using a 2-sample t test. The diagnostic performance of DSC perfusion MR imaging without and with contrast-leakage correction was assessed with receiver operating characteristic curve analysis.

RESULTS

PCNSLs and glioblastomas demonstrated higher K2 than those in their contralateral NAWM. Corrected CBV ratios were significantly higher than the uncorrected ones for both tumors. PCNSLs had lower CBV ratios (P < .001), lower corrected CBV ratios (P < .001), and higher K2 (P = .001) compared with glioblastomas. In differentiating between PCNSLs and glioblastomas, the area under the curve of the CBV ratio, corrected CBV ratio, and K2 were 0.984, 0.940, and 0.788, respectively.

CONCLUSIONS

PCNSL can be differentiated from glioblastoma with CBV ratios, corrected CBV ratios, and K2. CBV without contrast-leakage correction seems to have the best diagnostic performance in differentiating the 2 tumors.

Differentiation of pyogenic brain abscesses from necrotic glioblastomas with use of susceptibility-weighted imaging

BACKGROUND AND PURPOSE

A common imaging finding in brain abscess and necrotic glioblastoma is a T2 hypointense margin. The features of this hypointense rim on SWI have not been previously described, to our knowledge. We aimed to differentiate abscesses from glioblastomas by assessing the morphology of their lesion margin by using SWI.

MATERIALS AND METHODS

T2WI and SWI were performed in 12 abscesses and 20 rim-enhancing glioblastomas. On T2WI and SWI, the prevalence and the border types (complete versus incomplete) of hypointense rims were qualitatively assessed. On SWI, the contour (smooth versus irregular) and the location of hypointense rims relative to the contrast-enhancing rims as well as the prevalence of the "dual rim sign," defined as 2 concentric rims at lesion margins with the outer one being hypointense and the inner one hyperintense relative to cavity contents, were also analyzed.

RESULTS

Prevalence and the border types of the hypointense rims on T2WI were not different between abscesses and glioblastomas. On SWI, there were significantly more hypointense rims that were complete (P < .001) and smooth (P < .001), having the same location as the contrast-enhancing rims (P < .001) for abscesses. A dual rim sign was present in 9 of 12 abscesses but absent in all glioblastomas (P < .001).

CONCLUSIONS

SWI may be helpful in differentiating pyogenic abscesses from necrotic glioblastomas. The dual rim sign is the most specific imaging feature distinguishing the 2.

Differentiation of tumefactive demyelinating lesions from high-grade gliomas with the use of diffusion tensor imaging

BACKGROUND AND PURPOSE

TDLs may be indistinguishable from high-grade gliomas on conventional MR imaging. The role of DTI in differentiating TDLs from high-grade gliomas is not clear, and quantitative comparison between the 2 has not been reported. Here we aimed to differentiate TDLs from high-grade gliomas by using DTI.

MATERIALS AND METHODS

DTI was performed in 8 TDLs and 13 high-grade gliomas. The presence of 3 findings (ie, intralesional hyperintensities on the FA map, restricted diffusion in the lesion periphery, and a perilesional hyperintense FA rim) was assessed by visual inspection. The FA and MD values were measured in the central nonenhancing portion, peripheral enhancing portion, and perilesional edema for each lesion and compared between the 2 groups respectively.

RESULTS

TDLs had a significantly higher incidence of intralesional hyperintensities on FA maps (P = .049) but a lower incidence of a perilesional hyperintense FA rim (P < .001), compared with those of high-grade gliomas on visual inspection. TDLs had significantly higher FA (P = .004) and lower MD (P = .001) values in the peripheral enhancing portions of the lesions compared with those of high-grade gliomas. In perilesional edema, FA values were significantly higher in high-grade gliomas (P = .001).

CONCLUSIONS

DTI is helpful in differentiating TDLs from high-grade gliomas by using visual inspection and quantitative analysis.

Differentiation of brain abscesses from necrotic glioblastomas and cystic metastatic brain tumors with diffusion tensor imaging

BACKGROUND AND PURPOSE

The differentiation of abscesses from glioblastomas and metastases may not always be possible on the basis of DWI. Our hypothesis was that differences in diffusion properties as detected by DTI allow differentiation of abscess from glioblastomas and metastasis. Furthermore, diagnostic performance of tensor metrics quantifying anisotropy or tensor shapes is better than that of ADC in measuring mean diffusivity for this purpose.

MATERIALS AND METHODS

DTI was performed in 15 abscesses, 15 necrotic glioblastomas, and 26 cystic metastases. In each lesion, manually segmented into 4 regions of interest (ie, cystic cavity, enhancing rim, and immediate [edema most adjacent to the enhancing rim] and distant zones of edema), FA, ADC, C(l), C(p), and C(s) values were measured and statistically compared among groups and evaluated with ROC curve analysis. The presence of a hyperintense FA rim (a rim of edematous tissue that was hyperintense on the FA map) was assessed visually.

RESULTS

Abscess was significantly different from glioblastoma for all tensor metrics measured in the cystic cavity and immediate zone of edema and for all except C(l) in the enhancing rim. Abscess was significantly different from metastasis for all tensor metrics measured in the cystic cavity and enhancing rim and for FA, ADC, and C(l) in immediate zone of edema. The incidence of a hyperintense FA rim was significantly higher in glioblastoma and metastasis compared with abscess. The 3 tensor metrics with the highest performance in differentiating abscess from glioblastoma and metastasis were FA, C(l), and C(s) of the cystic cavity.

CONCLUSIONS

DTI is able to differentiate abscess from glioblastoma and metastasis. FA, C(l), and C(s) outperformed ADC in diagnostic performance comparisons.

Carotid stenting of asymptomatic and symptomatic carotid artery stenoses with and without the use of a distal embolic protection device

OBJECTIVE

The objective of this study was to evaluate the incidence of symptomatic and clinically silent embolic following carotid angioplasty and stent placement (CAS) with and without the use of an embolic protection device (EPD).

MATERIALS AND METHODS

Between January 2006 and April 2009, 76 patients with carotid stenosis underwent 79 CAS procedures (three patients had bilateral CAS). In this group, 44 of the 79 procedures were performed with an EPD, and 35 were performed without an EPD. In the EPD group, 26 treated hemispheres received pre- and post-operative diffusion-weighted MRI (DWI), and in the non-EPD group, 16 treated hemispheres received pre- and post-operative DWI.

RESULTS

All 79 procedures were technically successful without significant residual stenosis. In the EPD group, there were three symptomatic ischaemic events (6.8%), and 4 of the 26 (15.4%) treated hemispheres which received MRI showed new DWI lesions. In the non-EPD group, there was one symptomatic ischaemic event (2.9%), one mortality (2.9%) due to reperfusion injury with intracranial haemorrhage, and three of the 16 (18.8%) treated hemispheres which received MRI showed new DWL lesions.

CONCLUSIONS

The results of this retrospective analysis do not show demonstrable benefits of reducing new DWI lesions or major/minor ischaemic events after CAS with a filter protection device. Further investigations with more accurate risk-analysis strategies remain necessary in hopes of selecting patients most likely to benefit from the use of an embolic protection device.

Diffusion tensor images and magnetic resonance spectroscopy in primary central nervous system T-cell lymphoma: a case report

PURPOSE

Primary central nervous system lymphoma (PCNSL) is rare and usually B cell in origin. T-cell lymphoma constitutes only 1.8% to 4.6% of the PCNSL, and may present as solitary or multiple homogeneous enhanced lesions. There have been few reports showing unusual leukoencephalopathy in PCNSL, which may be confused with other white matter diseases including multiple sclerosis and acute disseminated encephalomyelitis.

CASE REPORT

We reported a patient with T-cell PCNSL who presented a progressive dull response and extrapyramidal symptoms. Brain magnetic resonance imaging showed multiple focal leukoencephalopathy. Diffusion weighted imaging demonstrated hyper-intensity lesions and apparent diffusion coefficient images showed hypo-intensity lesions. Diffuse tensor images showed decreased fractional anisotropy. Pathology examination finally confirmed T-cell lymphoma.

CONCLUSION

Although recent development of neuro-imaging studies, the diagnosis of PCNSL still await further pathological confirmation in some occasions.

Asymmetric involvement in sporadic creutzfeldt-jakob disease: clinical, brain imaging, and electroencephalographic studies

OBJECTIVE

To ascertain the characteristics of patients with sporadic Creutzfeldt-Jakob disease (CJD) and to determine the findings of electroencephalography (EEG) and brain magnetic resonance imaging (MRI).

METHODS

We pooled patients at a hospital from 2000 to 2008, and classified them according to WHO diagnostic criteria as having probable or possible CJD. We retrospectively analyzed their clinical manifestations, brain MRI, and EEG findings to evaluate correlations among them.

RESULTS

In this study, 12 probable and 4 possible CJD patients were identified. Ten patients with probable CJD had asymmetric manifestations with hemiparesis, focal myoclonus, dystonia or apraxia; 9 had clinical manifestations mimicking the corticobasal syndrome. In contrast, neurological examinations did not show asymmetric signs in 4 patients with possible CJD. EEG showed a typical periodic sharp wave complex (PSWC) in 12 patients with probable CJD; most of them had bright signal intensity on diffusion-weighted imaging of the cortex and/or basal ganglia. There was a high tendency for asymmetric clinical manifestations that correlated with the presentation of PSWC and cortical lesions observed on the brain MRI scan.

CONCLUSIONS

Our study indicates that asymmetric extrapyramidal symptoms/signs, in clinical features with characteristic abnormalities on MRI and EEG findings, might contribute to early diagnosis of sporadic CJD.

Peritumoral edema of meningiomas and metastatic brain tumors: differences in diffusion characteristics evaluated with diffusion-tensor MR imaging

INTRODUCTION

We prospectively compared the fractional anisotropy (FA) and mean diffusivity (MD) of the peritumoral edema of meningiomas and metastatic brain tumors with diffusion-tensor magnetic resonance (MR) imaging.

METHODS

The study protocol was approved by the local ethics committee, and written informed consent was obtained. Preoperative diffusion-tensor MR imaging was performed in 15 patients with meningiomas and 11 patients with metastatic brain tumors. Regions of interest (ROI) were placed in the peritumoral edema and normal-appearing white matter (NAWM) of the contralateral hemisphere to measure the FA and MD. The FA and MD ratios were calculated for each ROI in relation to the NAWM of the contralateral hemisphere. Changes in peritumoral MD and FA, in terms of primary values and ratios, were compared using a two-sample t-test; P < 0.05 was taken as indicating statistical significance.

RESULTS

The mean MD values (x10(-3) mm(2)/s) of the peritumoral edema for metastases and meningiomas, respectively, were 0.902 +/- 0.057 and 0.820 +/- 0.094, the mean MD ratios were 220.3 +/- 22.6 and 193.1 +/- 23.4, the mean FA values were 0.146 +/- 0.026 and 0.199 +/- 0.052, and the mean FA ratios were 32.3 +/- 5.9 and 46.0 +/- 12.1. All the values were significantly different between metastases and meningiomas (MD values P = 0.016, MD ratios P = 0.006, FA values P = 0.005, FA ratios P = 0.002).

CONCLUSION

The peritumoral edema of metastatic brain tumors and meningiomas show different MD and FA on diffusion-tensor MR imaging.

Prenatal MR imaging of a meconium pseudocyst extending to the right subphrenic space with right lung compression

Meconium pseudocyst results from a loculated inflammation occurring in response to spillage of meconium into the peritoneal cavity after a bowel perforation. Certain cystic lesions, such as abscesses and dermoid and epidermoid cysts, are known to show reduced water diffusion on DWI. MRI has recently become a valuable adjunct to ultrasonography for fetal gastrointestinal anomalies. Complementary to ultrasonography, prenatal MRI can help further characterize the lesion and can clearly demonstrate the anatomical relationship between the lesion and adjacent organs. We report a case of meconium pseudocyst that was prenatally imaged with ultrasonography and MRI, postnatally complicated by pneumoperitoneum, and proved by postnatal surgery and histopathology. We emphasize the MRI of the pseudocyst, particularly T1-weighted and diffusion-weighted imaging.

New approaches for measuring coagulation

Although specific assays of coagulation factors are essential for diagnostic purposes they only give partial information about an individual's haemostatic state. This can be better assessed by various global tests, and recent developments and evaluations of five such tests are described in this symposium: the PFA-100; waveform analysis; thrombin generation; overall haemostasis potential; thrombelastography. Each test has advantages in various applications, but the thrombin generation test and waveform analysis have been found most useful in haemophilia, whilst the PFA-100 is helpful in von Willebrand's disease.

Glioblastoma multiforme with diffusion-weighted magnetic resonance imaging characteristics mimicking primary brain lymphoma

✓ The authors report on the first case of corpus callosum glioblastoma multiforme (GBM) with diffusion-weighted (DW) magnetic resonance (MR) imaging findings that mimicked those for lymphoma but with MR spectroscopy results absent of lymphoma characteristics. This 68-year-old man presented with rapid, progressive impairment in short-term memory as well as slow responses and a change in his personality within 3 weeks of admission. Results of cranial computed tomography revealed a slightly hyperdense corpus callosum tumor with bihemispheric involvement. Magnetic resonance images showed a homogeneous mass with strong enhancement. The mass showed water restriction on DW MR images and apparent diffusion coefficient (ADC) maps but no markedly elevated lipid resonance on MR spectroscopy. The patient underwent tumor resection. Results of pathological studies with immunohistochemical analysis confirmed that the lesion was GBM.

Diffusion-weighted MR imaging together with ADC mapping and MR spectroscopy was reported to be useful in differentiating GBM and primary brain lymphoma. The lymphomas were hyperintense to gray matter on DW MR images and isointense to hypointense on ADC maps because of water restriction. In contrast, the GBMs were hyperintense to gray matter on both DW MR images and ADC maps because of the T2 shine-through effect. On MR spectroscopy, lipid resonance was markedly elevated in lymphoma but only slightly elevated in GBM.

Imaging of neck metastases

Awareness of the presence of cervical node metastasis is important in treatment planning and in prognostic prediction for patients with head and neck cancer. Currently, MRI and CT are commonly used to evaluate the primary tumor and the neck status. They characterize the cervical lymph nodes dependent on morphological criteria. However, metastases may be missed in some morphologically normal nodes. Conversely, it is difficult to discriminate reactive hyperplasia from metastasis in some enlarged nodes. Doppler ultrasound with fine-needle aspiration can overcome some of these limitations, but it is dependent on the sonographer's skill level and may be impractical in some cases due to too many questionable nodes. Positron emission tomography (PET) is a functional imaging that can detect metastasis lesions by pinpointing regions of high metabolism. It is better suited for assessing metastases to lymph nodes that appear morphologically normal. The main drawback of PET is its poor anatomical resolution. Side-by-side visual correlation of PET and CT/MRI can help determine the anatomical location of abnormal PET uptake and eliminate some false-positive PET findings caused by spatial errors. Fused PET/CT is considered to be the most accurate imaging modality for detecting nodal metastases, because it simultaneously provides prompt and accurate coregistration of functional and anatomical images. However, it is expensive, less-often available, and still constrained by technical resolution limits for tiny nodal metastases. Diffusion-weighted MRI, dynamic contrast-enhanced MRI, and nanoparticle-enhanced MRI are novel imaging technologies that have been exploited to enhance the detection of metastatic nodes. The initial results have been promising; however, micrometastases can still not be detected, and the extra costs and logistical burdens associated with these techniques prevent them from gaining wider acceptance. To date, neck dissection with detailed pathological examination is the gold standard. There is always a need for further refinement of the imaging techniques that can provide accurate information that approaches this gold standard.

Autocrine VEGF mediates the antiapoptotic effect of CD154 on CLL cells

CD154 is an important regulator of chronic lymphocytic leukaemia (CLL)-cell survival. In CLL, high serum levels of VEGF are a feature of advanced disease, and we and others have previously shown that CLL cells produce and secrete this growth factor. Since CD154 stimulates VEGF production in other cell types, and VEGF is known to promote cell survival, we examined whether the cytoprotection of CLL cells by CD154 involves VEGF. We report for the first time that treatment of CLL cells with CD154 results in increased VEGF production and demonstrate involvement of NF-kappaB in this process. Moreover, we show that CD154-induced CLL-cell survival is reduced by anti-VEGF-neutralising antibody and by inhibiting VEGF receptor (VEGFR) signalling with SU5416. However, addition of exogenous VEGF alone or blocking secreted autocrine VEGF had little or no effect on CLL-cell survival. We therefore conclude that CLL-cell cytoprotection in the presence of CD154 requires combined signalling by both CD40 and VEGFR. This combined signalling and resulting cytoprotection were shown to involve NF-kappaB activation and increased survivin production. In conclusion, our findings identify autocrine VEGF as an important mediator of the antiapoptotic effect of CD40 ligation, and thus provide new insights into CLL-cell rescue by CD154 in lymphoreticular tissues.

Rosai—Dorfman disease with dural sinus invasion

✓ Rosai—Dorfman disease (RDD) is an idiopathic proliferation of histiocytes that affects the lymph nodes. Central nervous system involvement in the absence of nodal disease is extremely rare. On neuroimaging studies, intracranial RDD appears as solitary or multiple well-circumscribed, dura-based lesions. The authors report on two cases of RDD with locally aggressive features including dural sinus invasion, which to their knowledge has never before been described.

A 60-year-old woman presented with progressive dizziness and vertigo that had lasted for 1 week. Cranial computerized tomography and magnetic resonance imaging revealed an extraaxial homogeneous lobulated enhancing mass involving the right occipital lobe and the right cerebellar hemisphere. Invasion of the right transverse sinus was identified on a cerebral digital subtraction angiogram. A 59-year-old man with no prior medical illness experienced progressive weakness of both upper extremities and a partial complex seizure. Magnetic resonance imaging of his brain revealed a well-circumscribed enhancing mass in the left frontal lobe with extension to the right frontal lobe and invasion of the superior sagittal sinus. Both patients underwent resection of their brain masses. Pathological studies identified the disease as RDD in both patients.

Combined hepatocellular-cholangiocarcinoma: a case report

Combined hepatocellular-cholangiocarcinoma (HCC-CC) is a rare primary liver tumour. We report a carrier of both HBV and HCV presenting with intermittent abdominal pain, fever, chillness and elevated á-fetoprotein (AFP) of 1197 ng/ml. Computed tomography showed an irregular hypodense mass in the left lateral segment of the liver with vague contrast enhancement and multiple regional lymphadenopathy. Hepatic angiogram showed that the mass was hypovascular and the left portal vein was occluded with a tapered end. Percutaneous ultrasound-guided core needle biopsy of the liver yielded HCC-CC. We suggest that HCC-CC should be considered in hypovascular liver tumours with striking elevation of serum AFP and multiple regional lymphadenopathy.

Temporal changes in factors associated with neutrophil elastase and coagulation in intensive care patients with a biphasic waveform and disseminated intravascular coagulation

Summary. The biphasic waveform is an early marker of disseminated intravascular coagulation (DIC). Neutrophil elastase (NE) cleaves coagulation factors; thus, elevated elastase levels or its dysregulation by alpha-1-protease inhibitor (Alpha1PI) may be linked to DIC. Time courses over a period were determined for factors associated with NE and coagulation in 14 Intensive Care Unit patients with a biphasic waveform who developed DIC. The data were analyzed using a random coefficient linear regression model to predict the variables' mean values on day 0 and their mean rates of change over the period in which the biphasic waveform appeared. The biphasic waveform was normal on day 0, maximized on day 1, and approached normal again by day 4. Alpha1PI/NE complex levels were 2.5-fold greater than normal for the entire period. The A1PI activity, antigen, and specific activity levels were normal on day 0 and increased thereafter by 21.0, 10.5, and 8.9% of normal per day, respectively. Factor II, V, VII, IX, and X activity levels were, respectively, 57, 46, 46, 77, and 46% of normal on day 0, whereas factor VIII and fibrinogen levels were normal. All coagulation factor levels trended upward with time but not significantly. The prothrombin time, but not the activated partial thromboplastin time, was prolonged, and the platelet counts and hematocrits were below normal on day 0 and remained so thereafter. We conclude that events associated with neutrophil activation, elastase release, and perturbations of coagulation precede both the appearance of the biphasic waveform and the diagnosis of DIC in these patients.

Uterine artery embolization for symptomatic uterine leiomyoma and adenomyosis

BACKGROUND AND PURPOSE

Uterine artery embolization (UAE) is increasingly accepted as an alternative treatment for symptomatic uterine leiomyoma and adenomyosis. The purpose of this study was to compare the outcomes of UAE in 3 diagnostic categories--submucosal leiomyoma, intramural leiomyoma, and adenomyosis--to assist in patient selection for this relative new form of therapy.

METHODS

The medical records of 43 patients (aged 22 to 54 years) who underwent UAE for symptomatic uterine leiomyoma or adenomyosis were retrospectively reviewed. Magnetic resonance imaging (MRI) was used for categorization of the patients into the 3 diagnostic categories, and also for objective measurement of the uterine and leiomyoma size, and subsequent imaging follow-up. UAE was performed using polyvinyl alcohol particles. Symptom improvement and complications after treatment were evaluated at gynecologist clinics using monthly questionnaires. The group differences in complete symptom resolution, uterine and leiomyoma size reduction, incidence of complications, and subsequent surgeries were analyzed.

RESULTS

The mean duration of follow-up was 10.9 months. Complete resolution of symptoms was achieved in 13 out of 16 patients with submucosal leiomyoma (81%), 3 out of 15 patients (20%) with intramural leiomyoma (p = 0.002) and 3 out of 12 patients (25%) with adenomyosis (p = 0.01). The average reduction of leiomyoma size in the submucosal and intramural groups was 56% and 29%, respectively (p = 0.02). None of the patients died. Severe complications occurred in 3 of 43 patients (7%), including permanent amenorrhea in 2 and pelvic actinomycosis in 1 patient. The incidence of complications (p = 0.17) and subsequent surgery (p = 0.67) did not differ significantly among the 3 groups.

CONCLUSIONS

UAE is an effective treatment for patients with symptomatic leiomyoma or adenomyosis. In this study, patients with submucosal leiomyoma had the best treatment outcome.

A longitudinal study of maternal dose response to low molecular weight heparin in pregnancy

OBJECTIVE

To assess the maternal response to low molecular weight heparin during pregnancy, by estimation of plasma anti-Xa activity, at three specified gestation points and in the nonpregnant state.

METHODS

A longitudinal, prospective, observational study was set in a tertiary referral recurrent miscarriage clinic. Twenty-four women, attending consecutively, were invited to participate and gave informed consent. Each woman had a history of recurring pregnancy loss and positive preconception screening for antiphospholipid syndrome. After confirmation of a viable pregnancy all subjects began taking 5000 IU of dalteparin once daily subcutaneously. Serial measurement of plasma anti-Xa activity after administration of dalteparin was performed at three standard gestation points (12, 24, and 36 weeks) and in the nonpregnant state (6 weeks postpartum).

RESULTS

Peak anti-Xa levels occurred at 4 hours postbolus in pregnancy, as compared with 2 hours in the nonpregnant state. The mean anti-Xa levels at 12, 24, and 36 weeks' gestation were significantly reduced, at 2 hours postinjection, as compared with the nonpregnant state (P <.001, P <.01, P <.001, respectively). The lowest dose-response curve was at 36 weeks' gestation. A repeated-measures analysis of variance found a significant difference (P <.05) between the 36-week group and the postterm group but not between any of the other groups.

CONCLUSION

During pregnancy, differences in the pharmacokinetics of low molecular weight heparin were observed, with an overall reduction in anti-Xa activity. On the basis of this study it is questionable to extrapolate dosing and lack of dose monitoring, in pregnant women, using data derived from a nonpregnant population.

Waveform analysis of clotting test optical profiles in the diagnosis and management of disseminated intravascular coagulation (DIC)

Transmittance waveform charts the changes in light transmittance on standard coagulation assays, such as the prothrombin time (PT) and activated partial thromboplastin time (APTT). Analysis and characterization of these data on photo-optical coagulation analysers provides additional qualitative and quantitative information to that obtained using the clotting time alone. The most thoroughly evaluated clinical application is that of the biphasic APTT waveform with disseminated intravascular coagulation (DIC). The degree of waveform abnormality correlates directly with the severity of haemostatic dysfunction and allows for both the prediction and monitoring from non-overt to overt DIC. As its performance is simple and rapid, this provides the means for targeting therapeutic intervention to an earlier stage of DIC. The recent identification that the mechanism underlying the biphasic waveform is a complex that exists in vivo between C reactive protein with very low density lipoprotein, provides potentially important insights into the molecular pathogenesis of DIC. Thus, in addition to the immediate clinical utility in diagnostic practice, it has important applications as a research tool. Preliminary experience in the application of this technology to the diagnosis and management of the haemophilias and the lupus anticoagulant syndrome has also provided evidence of the power and utility of waveform analysis in essentially simple clotting assays.

Sonographically guided antegrade common femoral artery access

OBJECTIVE

To evaluate the feasibility of sonographically guided antegrade common femoral artery puncture and superficial femoral artery access.

METHODS

Fifty antegrade common femoral artery punctures and superficial femoral artery access procedures were performed under sonographic guidance alone in 30 consecutive patients (24 male and 6 female; mean age, 55.1 +/- 25.7 years; range, 13-85 years). The indications were (1) insertion of a vascular sheath for balloon angioplasty in 42 attempts (24 patients with lower leg ischemia) and (2) insertion of an angiographic catheter for 1-shot intra-arterial chemoinfusion therapy in 8 attempts (6 patients with distal femoral osteosarcomas).

RESULTS

Technical success was achieved in 28 of 30 patients or 48 (96%) of 50 procedures (95% confidence interval, 80.39-98.32). The average procedure time +/- SD (excluding the failures) was 3 +/- 1 minutes (range, 2-6 minutes). In the 2 failures (2 [4%] of 50) in which common femoral artery punctures were accomplished, further superficial femoral artery cannulations were completed under fluoroscopic road map angiographic guidance. A small groin hematoma was noted in 1 patient. No arteriovenous fistula or pseudoaneurysm was encountered.

CONCLUSIONS

Sonographically guided antegrade common femoral artery puncture and selective cannulation of the superficial femoral artery are feasible and safe. They may be used as adjunctive modalities in difficult cases of common femoral artery access.