Asymptomatic Cerebral Vasoconstriction after Carotid Artery Stenting

BACKGROUND AND PURPOSE

Carotid artery stent placement is widely performed for treatment of carotid stenosis. The purpose of this study is to present our observations on cerebral vasoconstriction in ipsilateral anterior circulation during immediate poststenting angiography in patients with near-total occlusion of the proximal ICA.

MATERIALS AND METHODS

We retrospectively reviewed patient data from December 2008 to December 2018. There were 28 patients with carotid near-total occlusion. Two neuroradiologists reviewed the final cerebral angiographic finding of carotid artery stent placement to evaluate the presence of vasoconstriction or vasodilation.

RESULTS

A total of 28 patients with near-total occlusion (mean ± standard deviation age, 69.0 ± 6.5 years; 92.9% male) were analyzed. Ten patients showed vasoconstriction in the treated territory, and 18 patients did not show vasoconstriction after carotid artery stenting. There were no statistically significant differences in comorbidity, frequency of symptomatic lesions, antiplatelet medication, mean procedure time, and initial NIHSS and baseline modified Rankin scale scores between the 2 groups. However, vasoconstriction is more likely to happen in patients with isolated territory from the contralateral anterior and posterior circulation (66.7% in the isolated territory group and 12.5% in the not-isolated territory group; P < .05). No headache or neurologic deficit was noted in all 10 patients with cerebral vasoconstriction.

CONCLUSIONS

Cerebral vasoconstriction may occur after carotid artery stenting more frequently than expected. It occurs more frequently in patients with near-total occlusion and with isolation of the cerebral circulation. A large-scale study is necessary to assess the clinical implications of cerebral vasoconstriction after carotid artery stenting.

Rifaximin treatment is associated with reduced risk of cirrhotic complications and prolonged overall survival in patients experiencing hepatic encephalopathy

BACKGROUND

Rifaximin might decrease the risk of portal hypertension-related complications by controlling small intestinal bacterial overgrowth.

AIM

To evaluate whether rifaximin was associated with the risk of death and cirrhotic complications.

METHODS

We conducted a retrospective study that included 1042 patients experiencing hepatic encephalopathy (HE): 421 patients without hepatocellular carcinoma (HCC; the non-HCC cohort) and 621 patients with HCC (the HCC cohort). The primary endpoint was overall survival and secondary endpoints were recurrence of HE and the development of spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and variceal bleeding.

RESULTS

In the non-HCC cohort, 145 patients received rifaximin plus lactulose (the rifaximin group) and 276 patients received lactulose alone (the control group). The multivariate analysis revealed that rifaximin was significantly associated with lower risk of death (adjusted hazard ratio [aHR], 0.697; P = .024) and reduced the risk of recurrent HE (aHR, 0.452; P < .001), SBP (aHR, 0.210; P < .001) and variceal bleeding (aHR, 0.425; P = .011) but not HRS (aHR, 0.598; P = .08). In the HCC cohort, 173 patients received rifaximin plus lactulose and 448 patients received lactulose. Rifaximin was not associated with the risk of death (aHR, 1.177; P = .121). Rifaximin was associated with lower risk of SBP (aHR, 0.323; P < .001) but not with variceal bleeding (aHR, 0.660; P = .104) or recurrent HE (aHR, 0.689; P = .057). The risk of Clostridium difficile-associated diarrhoea was not different between the groups (aHR, 0.028; P = .338).

CONCLUSIONS

In patients without HCC, rifaximin treatment was significantly associated with prolonged overall survival and reduced risks of spontaneous bacterial peritonitis, variceal bleeding and recurrent hepatic encephalopathy.

Intraosseous cranial dural arteriovenous fistula treated with transvenous embolization

BACKGROUND AND PURPOSE

We analyzed the angiographic architecture of intraosseous dural arteriovenous fistulas (DAVFs) and evaluated the use of transvenous embolization for curative treatment.

MATERIALS AND METHODS

The study population consisted of 6 patients with intraosseous DAVFs from 3 hospitals. In all of these patients, we retrospectively reviewed the medical records and images, and we were able to confirm the lesions in all patients from CT, MR imaging, and angiographic images. 3D rotational angiographic coronal source images clearly demonstrated the presence of an intraosseous DAVF in 2 patients.

RESULTS

An intraosseous DAVF was located at the upper clivus in 1, the petrous apex in 1, and the lower clivus adjacent to the hypoglossal canal in 4 cases. All of the cases showed the presence of a dilated venous pouch, manifest as an osteolytic lesion on CT and as an intraosseous signal-intensity void on MR images. All patients were treated with transvenous embolization by targeting the dilated venous pouch and its connecting tributaries. Four intraosseous DAVFs were immediately completely embolized. One patient had a residual shunt, but the shunt disappeared 1 month later. One patient presented with a simultaneous DAVF in the ipsilateral cavernous sinus without a significant amount of shunt. None of the patients had procedural complications, and 5 patients recovered from the presenting symptoms.

CONCLUSIONS

An intraosseous DAVF could be completely cured with transvenous embolization. For curative treatment, the intraosseous dilated venous pouch can be the target lesion for endovascular treatment.

Proton magnetic resonance spectroscopic findings of cerebral fat embolism induced by triolein emulsion in cats

BACKGROUND

In experimental studies, embolization of the cerebral hemisphere with triolein emulsion has revealed reversible magnetic resonance imaging (MRI) findings in the subacute stage.

PURPOSE

To investigate the changes in the major metabolites, by proton magnetic resonance spectroscopy (MRS), in a cerebral fat embolism induced by a triolein emulsion.

MATERIAL AND METHODS

The internal carotid arteries of 19 cats were injected with a triolein emulsion, and multivoxel MRS was performed 30 min, 1 day, and 7 days later. In the control group, six cats were injected with normal saline. The MR spectra were evaluated for N-acetyl aspartate (NAA), creatine (Cr), and choline (Cho), along with the presence of lipid and lactate. Semiquantitative analyses of NAA/Cr, Cho/Cr, NAA/Cho, and lipid/Cr ratios compared the median values of the ipsilateral metabolite ratios with those of the contralateral side and in the control group for each point in time.

RESULTS

The NAA/Cr, Cho/Cr, and NAA/Cho ratios in the ipsilateral cerebral hemisphere of the embolized group after 30 min, 1 day, and 7days were not significantly different from the contralateral hemisphere of the embolized and control groups (P>0.05). The lipid/Cr ratio in the ipsilateral cerebral hemisphere of the embolized group was significantly higher when compared with the control group (P=0.012 at 30 min, P=0.001 on day 1, and P=0.018 on day 7).

CONCLUSION

Cerebral fat embolism induced by a triolein emulsion resulted in no significant change in the major metabolites of the brain in the acute stage, except for an elevated lipid/Cr ratio, which suggests the absence of any significant hypoxic-ischemic changes in the lesions embolized using a fat emulsion.

Angiographic examination of spontaneous putaminal hemorrhage

BACKGROUND

This study was carried out to examine indications for angiographic evaluation in the case of spontaneous putaminal hemorrhage.

METHODS

Angiographic examinations were performed on 62 consecutive adults with spontaneous putaminal hemorrhage without remarkable subarachnoid hemorrhage. Most patients were evaluated using conventional catheter angiography except for hypertensive patients over the age of 60 who underwent a magnetic resonance angiogram or a computed tomography angiogram. Computed tomography and clinical factors such as age and hypertension were correlated with the angiographic findings.

RESULTS

Nine of the 62 patients (15%) exhibited angiographic abnormalities, including middle cerebral artery aneurysm (n = 1), arteriovenous malformations (n = 3), moyamoya disease (n = 2), and the moyamoya phenomenon associated with a proximal middle cerebral artery occlusion (n = 3). The angiographic yield was significantly higher (1) among patients at or below the median age of 55 compared with those above (9/33, 27%, versus 0/29, 0%; p < 0.01), and (2) among patients without hypertension compared with those with hypertension (5/9, 56%, versus 4/53, 8%; p < 0.01).

CONCLUSIONS

Although our data could be biased due to the patient selection procedure, they suggest that angiographic evaluation is highly useful for spontaneous putaminal hemorrhage regardless of volume and shape of the hematomas, excepting hypertensive patients over 55 years of age.

Posterior projecting carotid-A1 junctional aneurysms

The authors report on two types of carotid-A(1) junctional aneurysms projecting backwards. In the two A(1)-type examples, the aneurysm originated at the posterior wall of the proximal A(1) joining the carotid termination and could be clipped using an ipsilateral pterional approach. However, in the carotid-type example, the aneurysm originated at the posterior wall of the carotid termination just below the A(1) origin, and required a contralateral pterional approach to expose the aneurysm. Although the carotid-A(1) junctional aneurysms are rare, their exact location and size can affect the side of the operative approach.

Tongue abscess mimicking neoplasia

Tongue abscess is a very rare condition about which only sparse imaging findings have been reported. In 2 patients, a submucosal malignant tumor was suspected because of the presence of a painful hard tongue mass with intact mucosal surface. Differential diagnosis of the tongue abscess or malignancy was difficult on MR imaging or positron emission tomography-CT. In careful retrospective history taking, the symptoms had dated from an episode of eating fish several months before presentation. Plain radiographs and noncontrast CT images of the pharynx revealed a foreign body within the lesion. Thus, we present the imaging findings of 2 cases of malignancy mimicking tongue abscess as a result of impaction of a fish bone.

Anandamide mediates hyperdynamic circulation in cirrhotic rats via CB(1) and VR(1) receptors

BACKGROUND AND PURPOSE

Hyperdynamic circulation and mesenteric hyperaemia are found in cirrhosis. To delineate the role of endocannabinoids in these changes, we examined the cardiovascular effects of anandamide, AM251 (CB(1) antagonist), AM630 (CB(2) antagonist) and capsazepine (VR1 antagonist), in a rat model of cirrhosis.

EXPERIMENTAL APPROACH

Cirrhosis was induced by bile duct ligation. Controls underwent sham operation. Four weeks later, diameters of mesenteric arteriole and venule (intravital microscopy), arterial pressure, cardiac output, systemic vascular resistance and superior mesenteric artery (SMA) flow were measured after anandamide, AM251 (with or without anandamide), AM630 and capsazepine administration. CB(1), CB(2) and VR1 receptor expression in SMA was assessed by western blot and RT-PCR.

KEY RESULTS

Anandamide increased mesenteric vessel diameter and flow, and cardiac output in cirrhotic rats, but did not affect controls. Anandamide induced a triphasic arterial pressure response in controls, but this pattern differed markedly in cirrhotic rats. Pre-administration of AM251 blocked the effects of anandamide. AM251 (without anandamide) increased arterial pressure and systemic vascular resistance, constricted mesenteric arterioles, decreased SMA flow and changed cardiac output in a time-dependent fashion in cirrhotic rats. Capsazepine decreased cardiac output and mesenteric arteriolar diameter and flow, and increased systemic vascular resistance in cirrhotic rats, but lacked effect in controls. Expression of CB(1) and VR1 receptor proteins were increased in cirrhotic rats. AM630 did not affect any cardiovascular parameter in either group.

CONCLUSIONS AND IMPLICATIONS

These data suggest that endocannabinoids contribute to hyperdynamic circulation and mesenteric hyperaemia in cirrhosis, via CB(1)- and VR1-mediated mechanisms.

PC-Based 3D Reconstruction of MR Angiography in Evaluation of Intracranial Aneurysms. The Value of Pre-Treatment Planning for Embolization and Post-Treatment Follow-up

SUMMARY

In this study, we present our experiences of personal computer-based 3D reconstructions of MRA for pre-treatment planning and post-treatment follow-up for cerebral aneurysms. Twentynine ruptured or unruptured intracranial aneurysm patients with 36 intracranial aneurysms, who underwent embolization and pretreatment and/or follow up 3D MRA were included in this study. All 29 patients were examined by DSA and MRA before (18 patients, 24 aneurysms) and/or after embolization (16 patients, 17 aneurysms). The MRA source images were transported to a personal computer in DICOM format for viewing, post-processing, and 3D reconstruction. DSA and PC based SSD 3D MRA equally well demonstrated most aneurysms before embolization (17 patients, 22 aneurysms). The depiction of aneurysm morphology, neck evaluation and branch vessel interpretation were much easier on 3D MRA, which has the ability to manipulate images in real time. When the vascular anatomy was complicated by another vascular system, the anterior or posterior circulations were separately reconstructed easily by using PC based reconstruction software. The 3D MRA also well demonstrated post-embolization recurrence or remnant aneurysmal cavities. In one giant aneurysm, the 3D MRA was unable to show the entire aneurysmal sac due to a blood flow saturation effect, but this was resolved by additional contrast material injection. PC-based 3D MRA proved to be a useful tool for the pretreatment planning of embolization procedures and for follow up after treatment in the case of cerebral aneurysms.

"Mirror" aneurysms involving the bilateral distal posterior cerebral artery. A case report of endovascular treatment and literature review

SUMMARY

We report the case of patient with bilateral and symmetrical aneurysms, mirror image, of the distal posterior cerebral artery (PCA) who presented with subarachnoid haemorrhage. The aneurysms were treated by endovascular approach using Guglielmi detachable coils (GDCs). A review of the pathophysiology, clinical manifestations and management of mirror aneurysms is presented and discussed.

The role of endoscopic retrograde pancreatography in the treatment of traumatic pancreatic duct injury

BACKGROUND

The status of the main pancreatic duct (MPD) is the most important determinant of the morbidity and mortality associated with pancreatic trauma. Early diagnosis and optimal treatment are critical, especially when there is MPD injury.

METHODS

Twenty-three patients with pancreatic trauma were studied prospectively with respect to clinical and laboratory findings, CT, and endoscopic retrograde pancreatography (ERP). Treatment modalities and clinical outcome were assessed in relation to ERP findings.

RESULTS

The pancreatic duct was injured in 14 of 23 patients (11 MPD, 3 branch duct). Contrast leakage from the MPD into peritoneal cavity at ERP confirmed MPD injury in 8 patients, who underwent surgical exploration. Three patients with leakage from a branch duct into the pancreatic parenchyma recovered with conservative treatment. Three patients in whom ERP demonstrated contrast leakage from the MPD confined to the parenchyma underwent successful transpapillary stent insertion with complete resolution of the leak at 3-month follow-up. Patients who underwent ERP more than 72 hours after trauma had a significantly higher rate of pancreas-associated complications and a tendency to remain hospitalized longer than patients who underwent ERP earlier.

CONCLUSION

Early ERP is one of the most useful methods for demonstrating MPD injury. ERP assists with treatment planning based on the degree of pancreatic duct injury.

Comparison of the efficacy and safety of different formulations of omeprazole-based triple therapies in the treatment of Helicobacter pylori-positive peptic ulcer

Little is known about the efficacy and safety of different formulations of omeprazole-based triple therapy regimens for the treatment of Helicobacter pylori-positive peptic ulcer. We compared the efficacy and safety of two formulations of omeprazole used in triple therapies in patients with H. pylori-positive active peptic ulcer. Seventy-four patients with endoscopically proven H. pylori-positive active peptic ulcer were randomized to two groups, each with 37 patients, to receive either OAC-I (6 weeks of "A" formulation of omeprazole [20 mg twice daily] plus 2 weeks of amoxicillin [1.0 g twice daily] and clarithromycin [500 mg twice daily] or OAC-II (6 weeks of "B" formulation of omeprazole [20 mg twice daily] plus 2 weeks of the same antibiotics. The H. pylori and ulcer healing status were assessed at the baseline and at the 6-week endpoint of therapy. Gastrointestinal symptoms, documentation of adverse events, and standard laboratory examinations were assessed at each visit. Eradication of H. pylori (intention to treat [n = 74]/per protocol [n = 66]) and healing of the ulcer were successful in 83.8%/96.9% and 93.8%, respectively, of the OAC-I group patients, and in 91.9%/100% and 97.1%, respectively, of the OAC-II group patients (P = 0.477; P = 0.608). The OAC-I group experienced rapid resolution of symptoms, but no significant differences were found between the two groups for number of days taken for resolution of gastrointestinal symptoms, adverse events, and laboratory findings. The two different formulations of omeprazole used in triple therapy regimens produced similar efficacy and safety results after 6 weeks of treatment in patients with H. pylori-positive active peptic ulcer.

Endoscopic mucosal resection with a ligation device for early gastric cancer and precancerous lesions: comparison of its therapeutic efficacy with surgical resection

Endoscopic mucosal resection with a ligation device (EMR-L) has become important in the curative treatment of precancerous lesions and early gastric cancers (EGCs), but little is known of the long-term efficacy and survival rates of EMR-L compared with surgical resection. We analyzed the therapeutic efficacy and safety of EMR-L in cases of EGC and precancerous lesions and compared the results of EMR-L with those of gastrectomy in patients with EGC over the same periods. EMR-L was performed on 20 EGCs and 54 precancerous lesions including tubular adenomas with or without severe dysplasias in 74 patients. Macroscopic type, size and location of the lesion were determined by endoscope, and the depth of invasion in EGCs was determined by endoscopic ultrasonography and confirmed by pathologic examination of the resected specimens. All the EGC cases were endoscopically followed up for at least 18 months (range, 18-66 months). Patients were selected that underwent subtotal gastrectomy and the survival rates were compared with those that underwent EMR-L. Complete resection was made in a single EMR-L treatment session in 61 cases (82.4%; 91.5%, were precancerous lesions and 65% were EGCs). After a repeat trial of EMR-L, the total rate of complete resection of precancerous lesions and EGCs was 92.6% and 85.0%, respectively. The survival rate of EGCs showed that complete resection by EMR-L resulted in 2 and 5 year survival rates of 100% and 95%, which are comparable to those of surgery (100% and 100%). This study suggests that EMR-L is a technically simple, minimally invasive and highly safe and effective treatment modality for selective EGCs, and offers an alternative to surgical treatment.

Successful management with glue injection of arterial rupture seen during embolization of an arteriovenous malformation using a flow-directed catheter: a case report

We present a case in which an arterial rupture occurring during embolization of an arteriovenous malformation of the left occipital lobe with a flow-directed microcatheter, was successfully sealed with a small amount of glue. We navigated a 1.8-Fr Magic catheter through the posterior cerebral artery, and during superselective test injection, extravasation was observed at the parieto-occipital branch. The catheter was not removed and the perforation site was successfully sealed with a small amount of glue injected through the same catheter. Prompt recognition and closure of the perforation site is essential for good prognosis.

DNA analysis by flow cytometry in early gastric cancer

OBJECTIVES

Flow cytometric analysis of a paraffin-embedded block of tissue provides rapid and accurate means of analyzing the DNA content of a tumor. The aim of this study was to clarify the clinical significance of flow cytometric findings in early gastric cancer(EGC). Thus we conducted this study to investigate whether DNA contents of tumor cells can correlate with known prognostic indices in patients with EGC.

METHODS

The flow cytometric DNA analysis was performed with paraffin-embedded specimens from tumors of 107 patients with EGC. Flow cytometric analysis was performed using a FACScan (Becton Dickinson). In constructing the histogram, 30,000 cells were scanned from each section and results were scored. The S-phase fraction was obtained according to the CellFit cell cycle analysis (Becton Dikinson). Frequencies of aneuploidy in tumors with various clinical and pathologic parameters were compared using the chi-square test. Mean SPF/PI valuse were compared by the student t-test.

RESULTS

Diploidy pattern was observed in 80 (75%) cases while aneuploidy was seen in 27(25%) cases. Aneuploidy was more frequently detected in tumors with submucosal involvement (32.7%) and lymph node (+) group (30.8%) than in the mucosal tumor (17.3%) and lymph node (-) group (24.5%), but the differences were not significant. Frequency of aneuploidy was not affected by either the histologic type or morphologic classification. On the other hand, high proliferative activities (SPF/PI) significantly correlated with the submucosal tumor invasion (66.7% vs. 45%; p < 0.05) and lymph node metastasis (28.6% vs. 7.5%; p < 0.05).

CONCLUSION

Tumor aggressiveness is not directly related to DNA aneuploidy but proliferative activities are responsible for the aggressive nature of early gastric cancer. The results of this study show that DNA analysis by flow cytometry in considered to be one method of determining the biological activity of gastric cancer cells.