Fetal Hepatic Hemangioma Diagnosed in Utero Using Doppler Microvascular Imaging

A 35-year-old pregnant woman was referred to our institution at 33 weeks' gestation for evaluation of a fetal abdominal tumor. B-mode ultrasonography demonstrated a massive lesion. Bidirectional power Doppler mode showed abundant blood flow surrounding the tumor. On superb micro-vascular imaging, various Doppler signal patterns were observed within the tumor, including diffuse fine dotted-like signals, linear flow, and internal shunt flow. Sequential observations of the tumor and cardiac cycles also revealed pulsatile flow beneath the edges of the tumor and continuous fine flow in the central area, resembling a 'centripetal fill-in' appearance on contrast computed tomography. Therefore, we assumed the fetal tumor to be a hepatic hemangioma. Fetal heart failure was detected at 37 weeks' gestation, and a 2,484-g female infant was delivered with 1- and 5-min Apgar scores of 7 and 8, respectively. A postnatal contrast computed tomography examination showed a progressive centripetal fill-in appearance, leading to a diagnosis of hepatic hemangioma. Kasabach-Merritt syndrome was also noted. Intensive treatment was performed, and the infant was discharged at 3 months after birth. In summary, we experienced a case of hepatic hemangioma diagnosed in utero using superb micro-vascular imaging. And basing seamless postnatal treatments on prenatal imaging findings may help to reduce the perinatal mortality.

Successful Superficial Blood Sampling to Localize a Fibroblast Growth Factor-23-Producing Tumor

BACKGROUND Tumor-induced osteomalacia (TIO) is a paraneoplastic syndrome caused by aberrant fibroblast growth factor-23 (FGF-23)-producing tumors. Early surgical resection is the optimal strategy for preventing TIO progression. Thus, tumor localization is a priority for successful treatment. A simple and safe examination method to identify functional endocrine tumors is essential to achieve better outcomes in patients with TIO. CASE REPORT A 64-year-old Japanese man with recurrent fractures, hypophosphatemia, and elevated alkaline phosphatase and FGF-23 levels (109 pg/mL) was admitted to our university hospital and was diagnosed with FGF23-related hypophosphatemic osteomalacia. Notably, the superficial dorsal vein in the patient's left foot exhibited a high FGF-23 level (7510 pg/mL). Octreotide and ¹⁸F-fluorodeoxyglucose (FDG) scintigraphy and systemic venous sampling revealed that the tumor in the third basal phalanx of the left foot was responsible for FGF-23 overproduction. Tumor resection resulted in a rapid decrease in serum FGF-23 levels and an increase in serum phosphorus levels. CONCLUSIONS Octreotide scintigraphy, FDG-positron emission tomography, and systemic venous sampling are the standard methods for localizing functional endocrine tumors. However, the limited availability and invasive nature of these examinations hinder effective treatment. Here, we highlight the importance of peripheral superficial blood sampling as an alternative to conventional systemic methods for confirming the presence of FGF-23-producing tumors. Clinicians should consider TIO as a potential cause of acquired hypophosphatemic osteomalacia. Furthermore, peripheral superficial vein blood sampling may be useful for confirming the localization of FGF-23-producing tumors.

Value of fat-suppressed T2-weighted imaging for predicting short-term pain relief after sclerotherapy for venous malformations in the extremities

PURPOSE

This study aimed to evaluate the value of fat-suppressed T2-weighted imaging (FS-T2WI) for predicting short-term pain relief after polidocanol sclerotherapy for painful venous malformations (VMs) in the extremities.

MATERIALS AND METHODS

This retrospective study included patients with painful VMs in the extremities between October 2014 and September 2021, had their first sclerotherapy without history of surgical therapy, and underwent magnetic resonance imaging before sclerotherapy. Pain relief was assessed 2 months after 3% polidocanol sclerotherapy and was categorized as follows: progression, no change, partial relief, or free of pain. The associations between pain relief and imaging features on FS-T2WI were analyzed.

RESULTS

The study included 51 patients. The no change, partial relief, and free of pain groups included 6 (11.8%), 25 (49.0%), and 20 (39.2%) patients, respectively. No patient experienced progressive pain. The lesion diameter was ≤ 50 mm in 13 (65.0%) patients in the free of pain group, whereas it was > 50 mm in all patients in the no change group (p = 0.019). The lesions showed well-defined margin in 15 (75.0%) patients in the free of pain group, whereas they showed ill-defined margin in 5 (83.3%) patients in the no change group (p = 0.034). The most common morphological type was cavitary in the free of pain group (14 [70.0%] patients), whereas there was no patient with cavitary type lesion in the no change group (p = 0.003). Drainage vein was demonstrated in 6 (100%), 22 (88.0%), and 11 (55.0%) patients in the no change, partial relief, and free of pain group, respectively (p = 0.011).

CONCLUSION

A lesion size of 50 mm or less, a well-defined margin, a cavitary type, and no drainage vein on FS-T2WI were significant features for predicting short-term pain relief after polidocanol sclerotherapy for painful VMs in the extremities.

Head and Neck Arteriovenous Malformations: Clinical Manifestations and Endovascular Treatments

Arteriovenous malformations (AVMs) are vascular malformations that present high-flow direct communication between the arteries and veins, not involving the capillary beds. They can be progressive and lead to various manifestations, including abnormal skin or mucosal findings, ischemia, hemorrhage, and high-output heart failure in severe cases. AVMs often involve the head and neck region. Head and neck AVMs can present region-specific clinical manifestations, angioarchitecture, and complications, especially in cosmetic appearance and ingestion, respiratory, and neuronal functions. Therefore, when planning endovascular treatment of head and neck AVMs, physicians should consider not only the treatment strategy but also the preservation of the cosmetic appearance and critical functions. Knowledge of the functional vascular anatomy as well as treatment techniques should facilitate a successful management. This review summarizes AVMs' clinical manifestations, imaging findings, treatment strategy, and complications.

Utility of non-contrast-enhanced magnetic resonance imaging in predicting preoperative clinical stage and prognosis in patients with thymic epithelial tumor

PURPOSE

The purpose of this study was to find useful imaging features on non-contrast-enhanced magnetic resonance imaging (MRI) that can divide patients with thymic epithelial tumor (TET) into clinical stage I-II and III-IV groups under assumption that contrast media are contraindicated.

MATERIALS AND METHODS

This retrospective study included 106 patients (median age, 60 years; range, 27-82 years; 62 women) with surgically resected TET who underwent MRI between August 1986 and July 2015. All cases were classified according to the 2015 WHO classification and staged using the eighth edition of the TNM system. Two radiologists independently evaluated 14 categories of MRI findings; the findings in patients with stage I-II were compared with those of patients with stage III-IV using a logistic regression model. Disease-specific survival associated with significant findings was calculated using the Kaplan-Meier method.

RESULTS

Univariate analysis showed that stage III-IV patients were more likely to have tumors with an irregular contour, heterogeneity on T1WI, low-signal intensity on T2WI, irregular border with lung, findings of great vessel invasion (GVI) (hereafter, GVI sign), pericardial thickening/nodule, and lymphadenopathy (all, P < 0.01). On multivariable analysis, only two findings, irregular border between tumor and lung (odds ratio [OR], 272.8; 95% CI 26.6-2794.1; P < 0.001) and positive GVI sign (OR, 49.3; 95% CI 4.5-539.8; P = 0.001) remained statistically significant. Patients with one or both features had significantly worse survival (log-rank test, P < 0.001).

CONCLUSION

For patients with TET who are unable to receive contrast for preoperative staging, the two image findings of an irregular border between tumor and lung and the positive GVI sign on non-contrast-enhanced MRI could be helpful in determining stage III-IV disease which is associated with a worse survival.

Super-selective and staged glue embolization for labral AVMs using ultra-thin microcatheters: report of two cases

BACKGROUND

Treating arteriovenous malformation (AVM) is challenging because of the high recurrence rate and because incomplete resection or embolization can induce aggressive growth. However, a standard strategy is not fully established. Although transcatheter arterial embolization (TAE) is currently almost always part of the treatment, in many cases, single treatment is not curative and only palliative. Additionally, the success and complication rates associated with TAE alone are unclear, and there has been limited study of staged TAE for facial AVMs. Furthermore, few reports have described the details of the procedure.

CASE-PRESENTATION

We report two cases of AVM of the upper lip in patients who were successfully treated by staged super-selective TAE at several-month intervals using ultra-thin microcatheters and n-butyl-2-cyanoacrylate.

CONCLUSION

Staged and super-selective TAE may prevent complications and provide high curability and might be a useful treatment in cases of AVM.

T1 invasive lung adenocarcinoma: Thin-section CT solid score and histological periostin expression predict tumor recurrence

Adenocarcinoma is the most common histological type of non-small cell lung cancer (NSCLC), and various biomarkers for predicting its prognosis after surgical resection have been suggested, particularly in early-stage lung adenocarcinoma. Periostin (also referred to as POSTN, PN or osteoblast-specific factor) is an extracellular matrix protein, the expression of which is associated with tumor invasiveness in patients with NSCLC. In the present study, the novel approach, in which the thin-section CT findings prior to surgical resection and periostin expression of resected specimens were analyzed in combination, was undertaken to assess whether the findings could be a biomarker for predicting the outcomes following resection of T1 invasive lung adenocarcinoma. A total of 73 patients who underwent surgical resection between January 2000 and December 2009 were enrolled. A total of seven parameters were assessed in the thin-section CT scans: i) Contour; ii) part-solid ground-glass nodule or solid nodule; iii) percentage of solid component (the CT solid score); iv) presence of air-bronchogram and/or bubble-like lucencies; v) number of involved vessels; vi) shape linear strands between the nodule and the visceral pleura; and vii) number of linear strands between the nodule and the visceral pleura. Two chest radiologists independently assessed the parameters. Periostin expression was evaluated on the basis of the strength and extent of staining. Univariate and multivariate analyses were subsequently performed using the Cox proportional hazards model. There was a substantial to almost perfect agreement between the two observers with regard to classification of the seven thin-section CT parameters (κ=0.64-0.85). In the univariate analysis, a CT solid score >80%, pathological lymphatic invasion, tumor and lymph node status and high periostin expression were significantly associated with recurrence (all P<0.05). Multivariate analysis demonstrated that a CT solid score >80% and high periostin expression were risk factors for recurrence (P=0.002 and P=0.011, respectively). The cumulative recurrence rates among the three groups (both negative, CT solid score >80% or high periostin expression, or both positive) were significantly different (log-rank test, P<0.001). Although the solid component is already known to be a major predictor of outcome in lung adenocarcinomas according to previous studies, the combined analysis of CT solid score and periostin expression might predict the likelihood of tumor recurrence more precisely.

Vessel Occlusion using Hydrogel-Coated versus Nonhydrogel Embolization Coils in Peripheral Arterial Applications: A Prospective, Multicenter, Randomized Trial

PURPOSE

To evaluate the safety and effectiveness of hydrogel-coated coils for vessel occlusion in the body trunk.

MATERIALS AND METHODS

A total of 77 patients with various peripheral vascular lesions, treatable by embolization with coils, were randomized (hydrogel group, n = 38; nonhydrogel group, n = 39). In the hydrogel group, embolization of the target vessel was conducted using 0.018-inch hydrogel-coated coils (AZUR 18; Terumo Medical Corporation, Tokyo, Japan) with or without bare platinum coils. The nonhydrogel group received both bare platinum coils and fibered coils without the use of hydrogel-coated coils.

RESULTS

Complete target vessel occlusion was accomplished in 36 patients in the hydrogel group and 37 patients in the nonhydrogel group. No major adverse events were observed in either group. The median number of coils/vessel diameter and the median total coil length/vessel diameter were significantly larger in the nonhydrogel group than in the hydrogel group (P = .005 and P = .004, respectively). The median embolization length was significantly longer in the nonhydrogel group (31.95 mm) than in the hydrogel group (23.43 mm) (P = .002). If no expansion was assumed, the median packing density in the hydrogel group was 44.9%, which was similar to that in the nonhydrogel group (46.5%) (P = .79). With full expansion assumed, the median packing density in the hydrogel group was 125.7%.

CONCLUSIONS

Hydrogel-coated coils can be safely used for peripheral vascular coil embolization, and hydrogel-coated and conventional coils in combination allow for a shorter embolization segment and shorter coil length.

Location of embolization affects patency after coil embolization for pulmonary arteriovenous malformations: importance of time-resolved magnetic resonance angiography for diagnosis of patency

OBJECTIVES

This study aimed to assess the diagnostic accuracy of computed tomography (CT) and time-resolved magnetic resonance angiography (TR-MRA) for patency after coil embolization of pulmonary arteriovenous malformations (PAVMs) and identify factors affecting patency.

METHODS

Data from the records of 205 patients with 378 untreated PAVMs were retrospectively analyzed. Differences in proportional reduction of the sac or draining vein on CT between occluded and patent PAVMs were examined, and receiver operating characteristic analysis was performed to assess the accuracy of CT using digital subtraction angiography (DSA) as the definitive diagnostic modality. The accuracy of TR-MRA was also assessed in comparison to DSA. Potential factors affecting patency, including sex, age, number of PAVMs, location of PAVMs, type of PAVM, and location of embolization, were evaluated.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CT were 82%, 81%, 77%, 85%, and 82%, respectively, when the reduction rate threshold was set to 55%, which led to the highest diagnostic accuracy. The sensitivity, specificity, PPV, NPV, and accuracy of TR-MRA were 89%, 95%, 89%, 95%, and 93%, respectively. On both univariable and multivariable analyses, embolization of the distal position to the last normal branch of the pulmonary artery was a factor that significantly affected the prevention of patency.

CONCLUSIONS

TR-MRA appears to be an appropriate method for follow-up examinations due to its high accuracy for the diagnosis of patency after coil embolization of PAVMs. The location of embolization is a factor affecting patency.

KEY POINTS

• Diagnosis of patency after coil embolization for pulmonary arteriovenous malformations (PAVMs) is important because a patent PAVM can lead to neurologic complications. • The diagnostic accuracies of CT with a cutoff value of 55% and TR-MRA were 82% and 93%, respectively. • The positioning of the coils relative to the sac and the last normal branch of the artery was significant for preventing PAVM patency.

Follow-up non-contrast MRA after treatment of intracranial aneurysms using microcoils with prominent metallic artifact: a comparative study of TOF-MRA and Silent MRA

PURPOSE

Some of the detachable microcoils are associated with the prominent metallic artifact. We have applied Silent MRA to reduce the artifact. In this study, we present a retrospective study in which Silent MRA is used for cases showing prominent metallic artifact on conventional TOF-MRA due to a detachable bare platinum microcoil (Barricade coil).

MATERIALS AND METHODS

Fifteen patients, who had undergone endosaccular embolization using Barricade coil and other detachable microcoils up to 3 days previously, were scanned with TOF-MRA and silent MRA at the same time. The treatment DSA and follow-up MRA images were graded by two experienced neuroradiologists, focusing on the visibility of residual aneurysm and parent arterial lumen.

RESULTS

DSA images showed residual aneurysm (RA) in four, residual neck (RN) in six, and complete occlusion (CO) in five patients. TOF-MRA images showed RN in five, CO in four, mild defect (MD) in one, severe defect (SD) in three, and complete defect in two. In contrast, on Silent MRA, the grades were RA in two, RN in five, CO in five, and MD in three.

CONCLUSION

Barricade coils are associated with prominent metallic artifact on TOF-MRA. Silent MRA is useful for follow-up MRA after embolization using Barricade coils. The metallic artifacts were compared between TOF-MRA and Silent MRA in patients treated by using Barricade coils. Barricade coils are associated with more metallic artifact on TOF-MRA than Silent MRA. Silent MRA is useful for follow-up MRA after embolization using Barricade coils.

Internal coil packing method for the Amplatzer vascular plug 4

The Amplatzer vascular plugs (AVPs), including AVP 4, have excellent occlusion; however, insufficient embolization or recanalization may occasionally occur. This study aimed to evaluate the feasibility and effectiveness of internal coil packing method to insert microcoils into the AVP 4 using an experimental vascular model. The insertion of a 1.7 F microcatheter through the nitinol mesh of the AVP 4 was not possible. Only 0.010-inch electrolytic detachable microcoils could be inserted through catheter tips in contact with nitinol mesh. The internal coil packing of the AVP 4 may be accomplished by inserting 0.010-inch microcoils into the AVP 4 in cases of continued perfusion or recanalization with required short-segment embolization.

A Rare Case of Cerebral Air Embolism Caused by Pulmonary Arteriovenous Malformation After Removal of a Central Venous Catheter

Cerebral air embolism following central venous catheter (CVC) removal is extremely rare. We report a case of cerebral air embolism with loss of consciousness after removal of CVC caused by pulmonary arteriovenous malformation (PAVM). Computed tomography revealed air bubbles in the internal carotid arteries along the sulci in the cerebral hemispheres, as well as a PAVM. The cerebral air embolism was treated with hyperbaric oxygen and intravenous thrombolytic therapy, and transcatheter embolization of the PAVM was performed. When inserting/removing CVC in a patient with a small PAVM, treatment of the PAVM, irrespective of its size, could prevent the type of complication that occurred in our present case.

Treatment of a Large Pharyngeal Venous Malformation using Transoral Sclerotherapy

Management of venous malformation (VM) in the pharynx is challenging because of difficulties in needle access and the presence of nerves as well as other critical anatomical structures around the lesion. We describe the successful treatment of a large pharyngeal VM using transoral sclerotherapy. The patient, a 21-yearold male, visited our hospital for sclerotherapy treatment consultation after complaining of difficulty in swallowing because of a pharyngeal VM. Transoral sclerotherapy was successful, and the symptoms showed complete alleviation. Using a flat detector-equipped angiographic C-arm CT (CACT) enabled the precise assessment of sclerosant placement, facilitating safer sclerotherapy in the pharynx.

A Retrograde Transvenous Embolization Technique with Balloon-Assisted Arterial Aspiration for a Peripheral Arteriovenous Malformation with a Venous Pouch

Management of arteriovenous malformations (AVMs) is challenging, and there is no consensus regarding either the ideal approach or the treatment timing. Percutaneous embolization is the most frequent approach currently used and is considered the first-line technique for AVMs. There is an ongoing discussion about the best technical approach to embolize AVMs. AVMs associated with a dominant outflow vein (DOV) are rare. Embolization of both the DOV and the nidus is considered more effective. Herein, we report a novel technique of transvenous embolization of a DOV under negative pressure from an arterial balloon catheter in a case of a peripheral AVM. This technique allows the embolization of the DOV and the nidus retrogradely.

Ultraselective embolization using a 1.7-Fr catheter and soft bare coil for small intestinal bleeding

OBJECTIVE

We aimed to evaluate the safety and efficacy of embolization using a 1.7-Fr catheter and soft bare coil to treat acute small intestinal bleeding.

MATERIAL AND METHODS

Subjects were five consecutive patients who experienced onset of melena with small intestinal bleeding and underwent transcatheter arterial embolization with 1.7-Fr catheters and 0.010-inch detachable bare coils (five procedures in total). Technical success, clinical success, relative post-procedural complications, arterial bleeding source and cause, and relationship between coagulopathy and embolization efficacy were examined by capsule endoscopy.

RESULTS

We achieved 100% technical and clinical success for the five transcatheter arterial embolizations. All catheterizations of the vasa recta of the bleeding artery (jejunal artery, n = 2; ileal artery, n = 3) were possible with a 1.7-Fr catheter. We achieved high embolization efficacy in two patients with coagulopathy. No rebleeding, intestinal ischemia, or necrosis was observed on follow-up capsule endoscopy. We confirmed that peptic ulcers/ulcer scars were the cause of bleeding for all patients.

CONCLUSION

Embolization with 0.010-inch coils using a 1.7-Fr catheter and catheterization of the vasa recta of bleeding vessels was effective and safe for treating small intestinal bleeding.

Endovascular Management of Intractable Postpartum Hemorrhage Caused by Vaginal Laceration

PURPOSE

We evaluated the management of transcatheter arterial embolization for postpartum hemorrhage caused by vaginal laceration.

MATERIALS AND METHODS

We reviewed seven cases of patients (mean age 30.9 years; range 27-35) with intractable hemorrhages and pelvic hematomas caused by vaginal lacerations, who underwent superselective transcatheter arterial embolization from January 2008 to July 2014. Postpartum hemorrhage was evaluated by angiographic vascular mapping to determine the vaginal artery's architecture, technical and clinical success rates, and complications.

RESULTS

The vaginal artery was confirmed as the source of bleeding in all cases. The artery was found to originate from the uterine artery in three cases, the uterine and obturator arteries in two, or the internal pudendal artery in two. After vaginal artery embolization, persistent contrast extravasation from the inferior mesenteric artery as an anastomotic branch was noted in one patient. Nontarget vessels (the inferior vesical artery and nonbleeding vaginal arterial branches) were embolized in one patient. Effective control of hemostasis and no post-procedural complications were confirmed for all cases.

CONCLUSION

Postpartum hemorrhages caused by vaginal lacerations involve the vaginal artery arising from the anterior trunk of the internal iliac artery with various branching patterns. Superselective vaginal artery embolization is clinically acceptable for the successful treatment of vaginal laceration hemorrhages, with no complications. After vaginal artery embolization, it is suggested to check for the presence of other possible bleeding vessels by pelvic aortography with a catheter tip at the L3 vertebral level, and to perform a follow-up assessment.

Management of visceral artery embolization using 0.010-inch detachable microcoils

Transcatheter coil embolization is used primarily to treat arterial hemorrhages, tumors, aneurysms, and vascular malformations. However, conventional microcatheter systems cannot always be employed in difficult cases. In this technical note, we describe how small-diameter primary coils and microcatheter tips that are thinner than normal can be used to increase the safety and reliability of coil embolization.

Follow-up of true visceral artery aneurysm after coil embolization by three-dimensional contrast-enhanced MR angiography

PURPOSE

We aimed to evaluate the outcomes of coil embolization of true visceral artery aneurysms by three-dimensional contrast-enhanced magnetic resonance (MR) angiography.

MATERIALS AND METHODS

We used three-dimensional contrast-enhanced MR angiography, which included source images, to evaluate 23 patients (mean age, 60 years; range, 28-83 years) with true visceral artery aneurysms (splenic, n=15; hepatic, n=2; gastroduodenal, n=2; celiac, n=2; pancreaticoduodenal, n=1; gastroepiploic, n=1) who underwent coil embolization. Angiographic aneurysmal occlusion was revealed in all cases. Follow-up MR angiography was conducted with either a 1.5 or 3 Tesla system 3-25 months (mean, 18 months) after embolization. MR angiography was evaluated for aneurysmal occlusion, hemodynamic status, and complications.

RESULTS

Complete aneurysmal occlusion was determined in 22 patients (96%) on follow-up MR angiography (mean follow-up period, 18 months). Neck recanalization, which was observed at nine and 20 months after embolization, was confirmed in one of eight patients (13%) using a neck preservation technique. In this patient, a small neck recanalization covered by a coil mass was demonstrated. The complete hemodynamic status after embolization was determined in 21 patients (91%); the visualization of several collateral vessels, such as short gastric arteries, after parent artery occlusion was poor compared with that seen on digital subtraction angiography in the remaining two patients (9%). An asymptomatic localized splenic infarction was confirmed in one patient (4%).

CONCLUSION

Our study presents the follow-up results from three-dimensional contrast-enhanced MR angiography, which confirmed neck recanalization, the approximate hemodynamic status, and complications. This effective and less invasive method may be suitable for serial follow-up after coil embolization of true visceral aneurysms.

Emergent interventional approach for aortogastric tube fistula with massive gastrointestinal bleeding

This report describes the successful endovascular treatment of a rare case of aortogastric tube fistula with massive gastrointestinal haemorrhage. The patient's history included oesophageal reconstruction for oesophageal carcinoma using a gastric tube. Emergent angiography revealed extravasation from the thoracic aorta into the thinner aortogastric tube fistula. A microcatheter was inserted into the aortogastric tube with the aortic approach for embolisation with a mixture of n-butyl cyanoacrylate and iodised oil to enable fluoroscopic visualisation. Aortography confirmed the complete absence of extravasation after embolisation, after which a stent graft was placed. This procedure demonstrated that transcatheter embolisation of the aortogastric tube fistula was possible, and that the technique can be used as an emergency option. CT imaging was performed 21 days after the procedure, and revealed no trace of extravasation or inflammation. There were no complications during the 14 months following the endovascular treatment; the patient remains in stable condition.

Pelvic arteriovenous malformation treated by superselective transcatheter venous and arterial embolization

We describe a rare case of hematuria and hemospermia associated with pelvic arteriovenous malformation (AVM) in a male patient treated by transcatheter embolization. Understanding AVM hemodynamics contributes to the elucidation of its pathology and improves the outcome of embolization. In the present case, multiple arteriolar components shunted to the initial part of a single dominant outflow vein. Superselective embolization of a draining vein and feeding artery with an n-butyl cyanoacrylate/lipiodol mixture and polyvinyl alcohol particles was effective in terms of shunt disappearance and minimizing the need for subsequent arterial embolization.

Coil Embolization of Splenic Artery Aneurysm with Preservation of the Parent Artery Using a Neck Remodeling Technique

We describe a case of a large and wide neck splenic artery aneurysm, treated by coil embolization using a balloon neck remodeling technique. The patency of the splenic artery was preserved without technical complications. This method should be considered as an alternative method for transcatheter management of splenic artery aneurysms.

[Intra-arterial cellular immunochemotherapy for unresectable pancreatic cancer with liver metastasis]

PURPOSE

To date, no treatment has had a significant impact on pancreatic cancer with liver metastasis. We performed locoregional cellular immunochemotherapy for unresectable pancreatic cancer with liver metastasis.

SUBJECTS AND METHODS

A 71-year-old man was diagnosed for unresectable stage IVb pancreatic cancer. This patient was given intra-arterial infusion of gemcitabine (GEM) 400 mg/body and intravenous infusion GEM 600 mg/body, simultaneously. The day after GEM infusion, he was given intra-arterial autologous tumor cell activated T lymphocytes (AuTL).

RESULTS

Tumor markers, such as CEA and CA19-9, had decreased a little. Primary tumor and metastatic liver tumor were reduced, but he died due to intra-abdominal dissemination within 5 months after diagnosis of unresectable pancreatic cancer.

CONCLUSIONS

Reduced primary pancreatic tumor and metastatic liver tumor was obtained by locoregional cellular immunochemotherapy. But we could not control intra-abdominal dissemination. In conclusion, we suggest that intra-abdominal AuLT infusion in combination with intra-arterial AuLT infusion may be advisable to patients for unresectable pancreatic carcinoma with intra-abdominal dissemination.

[Intra-arterial chemotherapy with gemcitabine (GEM) for unresectable pancreatic cancer]

PURPOSE

Most patients with pancreatic cancer are unresectable because of local invasion and liver metastasis at the time of diagnosis. To date, no treatment has had a significant impact on this disease. To deliver a high concentration of drug to the cancer, intra-arterial chemotherapy with GEM was performed in two patients with unresectable advanced cancer.

PATIENTS AND METHODS

One patient, a 70-year-old man with liver metastasis, was treated with arterial infusion of GEM 1,000 mg/body. Another patient, a 55-year-old woman with local invasion and distant metastatic lymphadenopathy, was given intra-arterial infusion of GEM 400 mg and intra-venous infusion of GEM 1,000 mg/body. The patients were given GEM weekly for 3 weeks followed by a week of rest.

RESULTS

In the first patient, the pain went away and CEA was decreased for 6 months. After that, the patient died due to intra-abdominal dissemination within 4 months. In the other patient, the pain went away. Tumor markers, such as CEA and CA19-9, were normalized and primary pancreatic cancer was reduced locally. The patient currently has a metastatic liver tumor, but she has had a significant improvement in performance status.

CONCLUSION

Intra-arterial chemotherapy with GEM may be tolerated in patients with unresectable pancreatic cancer.

Effects of previous noxious stimulus applied to remote areas on noxious stimulus-evoked c-Fos expression in the rat trigeminal nucleus caudalis

Noxious stimulus-evoked c-Fos expression in the spinal dorsal horn is modulated by noxious stimuli applied previously to remote areas of the body. To confirm the existence of such modulation in c-Fos expression in the trigeminal system, changes in c-Fos expression in the trigeminal nucleus caudalis induced by formalin injection into the rat whisker pad were examined by previously injecting formalin into different areas (contralateral whisker pad, ipsilateral or contralateral forepaw) of the body. Formalin injection-evoked c-Fos expression in this nucleus was significantly reduced by previous formalin injection into the contralateral whisker pad or ipsilateral forepaw but not into the contralateral forepaw. The interval between the two injections of formalin that produced a maximal reduction of formalin injection-evoked c-Fos expression was 1 h, and the reduction of c-Fos expression was less when the interval of the two noxious stimuli was longer or shorter than 1 h. These results suggested that noxious stimulus-evoked c-Fos expression in the trigeminal nucleus caudalis is reduced by noxious stimulus applied previously to remote areas, and the reduction is dependent on the area of previous noxious stimulation and interval between the two noxious stimuli.

Simultaneous activation of N-methyl-D-aspartate and neurokinin-1 receptors modulates c-Fos and Zif/268 expression in the rat trigeminal nucleus caudalis

We examined the acute expression of c-Fos or Zif/268 by simultaneous activation of N-methyl-D-aspartate receptor and neurokinin-1 receptor of the trigeminal nucleus caudalis in anesthetized rats. A selective N-methyl-D-aspartate receptor agonist, N-methyl-D-aspartate, and/or a selective neurokinin-1 receptor agonist, substance P, was applied topically to the dorsal surface of the spinal trigeminal tract. Immunohistochemically stained nuclei for c-Fos and Zif/268 at laminae I and II of the trigeminal nucleus caudalis were counted. Ipsilateral c-Fos and Zif/268 were increased significantly dose-dependently by N-methyl-D-aspartate (at 136 and 340 microM, and at 68, 136 and 340 microM, respectively). On the contralateral side, only Zif/268 increased significantly (at 68, 136 or 340 microM). These increases were abolished by D-2-amino-5-phosphonovaleric acid (at 25 mM), a selective N-methyl-D-aspartate receptor antagonist. Substance P (at 3.7 or 7. 4 microM) significantly increased dose-dependently ipsilateral c-Fos and Zif/268. On the contralateral side, only c-Fos was significantly increased (at 3.7 and 7.4 microM). These increases were abolished by D-2-amino-5-phosphonovaleric acid (at 25 mM) and L-703,606 (at 10 microM), a selective neurokinin-1 receptor antagonist. The combined application of N-methyl-D-aspartate 340 microM + substance P (at 0.74 or 3.7 microM) significantly increased ipsilateral c-Fos compared to either agent alone. Combined application of N-methyl-D-aspartate 340 microM + substance P at 0.74, 3.7 or 7.4 microM significantly increased ipsilateral Zif/268 expression compared to either drug alone. Other combinations did not increase c-Fos and Zif/268. Our results indicate that activation of N-methyl-D-aspartate or neurokinin-1 receptor of the trigeminal nucleus caudalis contributes to the acute induction of both c-Fos and Zif/268 on the ipsilateral superficial layer of this nucleus and simultaneous activation of both receptors by their agonists with specific concentrations produces a marked expression of these proteins. Simultaneous activation of N-methyl-D-aspartate and neurokinin-1 receptors under some specific conditions may augment synaptic transmission, contributing to long-term neuronal change.

Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia

Combined spinal and epidural anesthesia may increase the risk of epidurally administered drugs spreading into the subarachnoid space through the dural hole. We studied the effect of dural puncture with a 26-gauge needle on the spread of analgesia induced by epidural injection of local anesthetics. Forty patients were randomly assigned to control and dural puncture groups. In the dural puncture group, the dura was punctured with a 26-gauge Whitacre spinal needle at L2-3 but no drug was injected. In both groups, an 18-gauge epidural catheter was inserted 4 cm cephalad into the epidural space at L2-3 and 15 mL of 2% mepivacaine without epinephrine was injected. Analgesia was assessed by pinprick at 5, 10, 15, and 20 min after injection and at the end of surgery. The caudal spread of analgesia was significantly greater in the dural puncture group than in the control group 15 and 20 min after injection (P < 0.01), but the cranial spread of analgesia was not different between the two groups. We conclude that dural puncture (without drugs) using a 26-gauge Whitacre spinal needle before epidural injection increases caudal spread of analgesia induced by epidural local anesthetics.

[Rounded atelectasis with emphasis on its wide spectrum]

While rounded atelectasis (RA) is considered to be rather common in the United States and Europe, the total number of RA cases reported from Japan still remains approximately 30. We have long been aware that there are many variations in the radiographic appearance of so-called RA and that RA has never been clearly defined. We retrospectively reviewed 22 cases collected as RA and its variants from several institutions. We defined RA as "peripheral atelectasis mimicking tumor secondary to shrinkage or bending of the pleura of various degrees, and accompanied by lung distortion." The diagnostic criteria of typical RA include (1) peripheral tumoral shadow in contact with pleural effusion or thickened pleura, (2) acute angle between the pleura and the shadow, (3) convergence of the pulmonary vessels and bronchi and (4) volume loss of the affected lobe. However, there are cases which lack some of these criteria but are considered to be included in the broad category of RA. We propose that RA should be considered to be an entity having a wide spectrum. Typical lesions showing "cranial tilting" of Hanke are on one side of the spectrum and small linear or strand shadows extending from the thickened pleura are on the other.

[Hilar and mediastinal lymph node metastases from lung cancer; detection with CT and MR imaging]

Sixty-one patients with primary lung cancer, who had CT and MR imaging before surgery, were studied. MR imaging used spin-echo sequences with T1 weighted image and T2 weighted image (C-MRI), and included STIR technique (Stir-MRI). The accuracy of diagnosis of mediastinal lymphadenopathy (regarding 10 mm or larger in short transverse diameter as positive) was 89% by CT, 84% by C-MRI and 89% by Stir-MRI. The accuracy of diagnosis of hilar lymphadenopathy was 42% by CT, 67% by C-MRI, and 75% by Stir-MRI. The accuracy of diagnosis of mediastinal lymph node metastases was 89% by CT, 94% by C-MRI and 96% by Stir-MRI. The accuracy of diagnosis of hilar lymph node metastases was 78% by CT, 87% by C-MRI and 89% by Stir-MRI. The possibility of enhancement of diagnostic accuracy of lymph node metastases from lung cancer was suggested by combining MR imaging included STIR technique with CT.

[Bronchial atresia of additive anomalous bronchus]

A case of bronchial atresia of additive anomalous bronchus in right middle lobe was reported. A mass and emphysematous lung were found on the chest roentgenogram. CT, and MRI, and it is not difficult to diagnose.

[Computed tomography of obturator foramen hernia]

A 89 year-old female was admitted with the complaint of right hypochondralgia. And also she complained of right thigh pain after admission. On hospital day 4, she underwent CT examination in order to evaluate right thigh with severe pain. The preoperative diagnosis of obturator foramen hernia was performed.

[MR imaging of bone and soft tissue tumors]

One hundred sixty-one patients with tumors of bone or soft tissues underwent MRI. We believe to be able to differentiate benign from malignant lesions on the basis of imagings at internal, marginal, and peripheral properties. MR imagings demonstrated specific morphologic features that suggest the correct tissue diagnosis. MR imagings with STIR method or Gd-DTPA were more valuable. Because of the high contrast between the tumors and normal tissue, especially by STIR method, MRI provides improved detection and delineation of bone soft tissue tumors when compared to other diagnostic modalities.