Stent-Graft Treatment of Dissecting Aneurysm in Association with Aortic Intramural Hematoma: When Should the Procedure Be Performed?

Purpose:

To report 2 cases of stent-graft implantation for localized dissecting aneurysm during the conservative treatment of aortic intramural hematoma.

Case Reports:

One patient underwent stent-graft implantation for 2 localized dissecting aneurysms about 23 months after symptom onset. Computed tomography (CT) 1 year after the procedure demonstrated aneurysm shrinkage. In the other patient, a localized dissecting aneurysm was treated about 3 months after symptom onset, even though the intramural hematoma had not resolved. CT scanning 3 months after the procedure demonstrated aneurysm shrinkage, but also revealed poor attachment of the distal stent-graft to the aortic wall due to subsequent resolution of the hematoma.

Conclusions:

Endograft implantation for treatment of localized dissecting aneurysm associated with aortic intramural hematoma should probably not be performed before the hematoma has completely resolved.

Current role of hybrid CT/angiography system compared with C-arm cone beam CT for interventional oncology

Hybrid CT/angiography (angiography) system and C-arm cone beam CT provide cross-sectional imaging as an adjunct to angiography. Current interventional oncological procedures can be conducted precisely using these two technologies. In this article, several cases using a hybrid CT/angiography system are shown first, and then the advantages and disadvantages of the hybrid CT/angiography and C-arm cone beam CT are discussed with literature reviews.

Time course of axial and radial diffusion kurtosis of white matter infarctions: period of pseudonormalization

BACKGROUND AND PURPOSE

Diffusion kurtosis is a statistical measure for quantifying the deviation of the water diffusion profile from a Gaussian distribution. The current study evaluated the time course of diffusion kurtosis in patients with cerebral infarctions, including perforator, white matter, cortical, and watershed infarctions.

MATERIALS AND METHODS

Subjects were 31 patients, representing 52 observations of lesions. The duration between the onset and imaging ranged from 3 hours to 122 days. Lesions were categorized into 4 groups listed above. Diffusion kurtosis images were acquired with b-values of 0, 1000, and 2000 s/mm(2) applied in 30 directions; variables including DWI signal, ADC, fractional anisotropy, radial diffusivity, axial diffusivity, radial kurtosis, and axial kurtosis, were obtained. The time courses of the relative values (lesion versus contralateral) for these variables were evaluated, and the pseudonormalization period was calculated.

RESULTS

Diffusion kurtosis was highest immediately after the onset of infarction. Trend curves showed that kurtosis decreased with time after onset. Pseudonormalization for radial/axial kurtosis occurred at 13.2/59.9 days for perforator infarctions, 33.1/40.6 days for white matter infarctions, 34.8/35.9 days for cortical infarctions, and 34.1/28.2 days after watershed infarctions. For perforator infarctions, pseudonormalization occurred in the following order: radial kurtosis, ADC, axial kurtosis, and DWI.

CONCLUSIONS

Diffusion kurtosis variables in lesions increased early after infarction and decreased with time. Information provided by diffusion kurtosis imaging, including axial and radial kurtosis, seems helpful in conducting a detailed evaluation of the age of infarction, in combination with T2WI, DWI, and ADC.

Effect of cilostazol in preventing restenosis after carotid artery stenting using the carotid wallstent: a multicenter retrospective study

BACKGROUND AND PURPOSE

Restenosis after CAS is a postoperative problem, with a reported frequency of approximately 2%-8%. However differences in stent design, procedure, and the antiplatelet agent appear to affect the incidence of restenosis. We assessed the frequency of restenosis and the effect of the antiplatelet agent CLZ in preventing restenosis after CAS by the standard procedure using the CWS.

MATERIALS AND METHODS

Between May 2010 and October 2011, 62 lesions in 60 consecutive patients underwent CAS using the CWS at 4 medical institutions, and all patients were followed clinically and assessed by sonography, 3D-CTA, or angiography at 3 and 6 months postoperatively. Restenosis was defined as ≥50% stenosis. The incidence of restenosis and the variation in the incidence of restenosis by the difference in type of antiplatelet agent between the CLZ group (n = 30; aspirin, 100 mg, and CLZ, 200 mg) and the non-CLZ group (n = 32; aspirin, 100 mg, and clopidogrel, 75 mg [n = 29]; or ticlopidine, 100 mg [n = 2] or 200 mg [n = 1]) were retrospectively investigated. Two antiplatelet agents were given starting 1 week preoperatively until at least 3 months postoperatively.

RESULTS

Restenosis occurred in 5 patients (8.3%), but all were cases of asymptomatic lesions in the follow-up period. All 5 patients with restenosis were in the non-CLZ group, with no cases of restenosis in the CLZ group; the difference was significant (P = .0239).

CONCLUSIONS

The restenosis rate after CAS by using the CWS was 8.3%. CLZ was associated with significant inhibition of restenosis.

Diffuse dermal angiomatosis

Diffuse dermal angiomatosis (DDA) is characterized clinically by painful erythematous lesions with ulcers and histologically by a benign, diffuse, and self-limited proliferation of tiny blood vessels in the superficial layers of the reticular dermis. Here we describe a case of DDA with leg ulcer. Erythematous lesions presented around the ulcer and angiogram revealed an occlusion of the superficial femoral artery. The erythematous lesions disappeared after revascularization. Although DDA is extremely rare, early correction of the ischemia in the peripheral artery should be taken into consideration.

Transient hyperintensity in the subthalamic nucleus and globus pallidus of newborns on T1-weighted images

BACKGROUND AND PURPOSE

In the brains of newborns, changes in signal intensity in most structures can be explained by the development of myelination. However, there are some structures for which signal intensity changes cannot be accounted for by myelination alone. We examined the STN and globus pallidus signal intensities and tried to determine whether a relationship exists between the signal intensity and the postnatal age or the gestational age at the examination.

MATERIALS AND METHODS

We examined T1WI and T2WI obtained from 79 neonates who showed normal development at their 2-year follow-up examinations. We performed both qualitative and quantitative (signal intensity ratio to the thalamus) evaluation of the STN and globus pallidus signals, and we examined the correlation between signal intensity changes and the age of neonates.

RESULTS

With increasing postnatal age at examination, the high signal intensity on the T1WI for both STN and globus pallidus diminished. Although the disappearance of this hyperintensity was well correlated with the postnatal age at examination for both the qualitative and quantitative studies, there was no correlation with gestational age at examination. For the T2WI, there was no correlation with either the postnatal age or the gestational age at examination.

CONCLUSIONS

Signal intensity on T1WI in the STN and globus pallidus is not related to the gestational age at examination; instead, signal intensities on T1WI seem to be more dependent upon the postnatal age at examination.

Phase I/II study of transcatheter arterial chemoembolization with cisplatin powder and degradable starch microspheres for unresectable hepatic metastases from colorectal cancer refractory to systemic standard chemotherapy

577

Background: We conducted a phase I/II study of novel transcatheter arterial chemoembolization with cisplatin powder and degradable starch microspheres (DSM) to determine the recommended dose (RD) and to assess the efficacy and safety.

Methods: Cisplatin powder and DSM mixing solution was administered followed by the injection of DSM alone via hepatic artery every 4 weeks. In phase I, cohorts of 3 patients received escalating dose of cisplatin (50, 65 and 80mg/m2), and RD was estimated during the first cycle. In the phase II, more RD patients were added to assess tumor response, toxicity, hepatic progression free survival (H-PFS) and 6-month overall survival (OS) rate.

Results: A total of 24 patients (male 16, female 8; mean age 63.0, range 45-79; colon 15, rectal 9) were enrolled in this study. FOLFOX had previously been administered to all patients, irinotecan-containing regimen to 12 and bevacizumab and/or cetuximab to 14. During phase I (n= 9 patients), maximum tolerated dose was not reached and cisplatin 80 mg/m2 was recommended for a phase II. Phase II enrolled 15 patients. The following grade 3 toxicities were observed: platelets reduction 16.6%, aspartate transaminase elevation 38.8%, alanine transaminase elevation 16.6%, hyponatremia 11.1%, cholecystitis 5.5%. The tumor response rate was 53.3% (CR 0, PR 8, SD 6, and PD 1). The median H-PFS was 6.3 months (95% CI; 2.71 to 9.88) and 6 -month OS rate was 86.7%.

Conclusions: This phase I/II study demonstrates that novel transcatheter arterial chemoembolization with 80 mg/m2 cisplatin powder and DSM is well tolerable, and can produce a high response rate with encouraging survival duration. Further clinical trials are warranted.

No significant financial relationships to disclose.

Phase II study of segmental transcatheter arterial chemoembolization using ethiodized oil mixed with cisplatin powder for unresectable hepatocellular carcinoma

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Background: Conventional transcatheter arterial chemoembolization (TACE) using with ethiodized oil mixed with epirubicin or doxorubicin hydrochloride mainly has been widely adapted for intermediate-stage hepatocellular carcinoma (HCC). However, cisplatin has stronger effect for HCC than epirubicin and in the recent years cisplatin powder was commercially available in Japan and then we can use cisplatin powder mixed with ethiodized oil for HCC. We conducted a phase II study to assess the safety and efficacy of segmental or subsegmental (Seg/Subseg) TACE using a suspension of cisplatin powder mixed with ethiodized oil for unresectable HCC.

Methods: Twenty patients with single-nodule HCC that was not indicated for surgical treatment or local ablation therapy were enrolled in this study. Seg/Subseg-TACE was performed by using a 2-F tip microcatheter at a distal portion of the subsegmental artery supplying the tumor. Subsequently, the feeding artery was embolized with gelatin sponge particles. The suspension was prepared by mixing 100 mg of cisplatin powder with 10 ml of ethiodized oil. Primary endpoint of this phase II trial was 2-year local disease free survival (DFS); secondary endpoints evaluated were the safety, time to progression (TTP), and 2-year overall survival (OS) rate.

Results: A total of 20 patients (male 15, female 5; mean age 72.4, range 62-83; Child Pugh's A 20) were treated single nodule HCC with Seg/subseg TACE. Median tumor size was 2.6cm (range1.2-5.0cm). The 2-year local DFS was 63.2 %. The following grade 3 or 4 toxicities were observed: platelets reduction 5%, aspartate transaminase elevation 55%, alanine transaminase elevation 40% and alkaline phosphatase elevation 5%. The median TTP was 17.6 months (95%CI, 5.25 to 29.9) and the 2-year OS rate was 94.7%.

Conclusions: This phase II study demonstrates that segmental or subsegmental transcatheter arterial chemoembolization using a suspension of cisplatin powder mixed with ethiodized oil is well tolerable, and may achieve significant local tumor control and prolong survival. Further clinical trials are warranted.

No significant financial relationships to disclose.

Phase I/II study of arterial infusion with 5-fluorouracil combined with systemic gemcitabine for unresectable pancreatic cancer

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Background: Unresectable pancreatic cancer is poorly responsive to conventional therapies. We conducted a phase I/II study to ascertain the recommended dose (RD) of 5-fluorouracil (5-FU) in arterial infusion chemotherapy combined with systemic gemcitabine in unresectable pancreatic cancer and to evaluate the safety and efficacy.

Methods: 5-FU was administered through the pancreatic and hepatic arteries via the port system as a 5-hour infusion on days 1, 8, and 15 every 4 weeks for 5 cycles. Gemcitabine was administered in 30-minute intravenous infusion at the same days. In phase I, escalating 5-FU doses for level 1 and 2 was set at 750mg and 1,000mg/m2, respectively. Dose of coadministered gemcitabine (1,000 mg/m2) was fixed. Using a 3+3 study design, dose-limiting toxicity (DLT) was assessed, and RD was estimated in the first cycle. In phase II, more RD patients were added to assess tumor response, toxicity, overall survival and progression-free survival.

Results: During the phase I, 7 patients were enrolled. DLT was not observed. One patient dropped out of this study because of insufficient drug distribution via the port system. Assuming RD at 1,000mg/m2 of 5-FU, the phase II enrolled a total of 16 patients (metastatic, 14; local advanced, 2). The tumor response rate was 68.8% (CR 0, PR 11, SD 2, PD 3). The grade 3 toxicities of neutropenia (6%) and thrombocytopenia (6%) were observed. Median overall and progression-survival times (all patients) were 9.8 and 6.2 months, respectively.

Conclusions: Arterial infusion 5-FU 1,000mg/m2 combined with full-dose systemic gemcitabine was tolerable and can produce a high response rate with encouraging survival duration for unresectable pancreatic cancer.

No significant financial relationships to disclose.

Fractional anisotropy--threshold dependence in tract-based diffusion tensor analysis: evaluation of the uncinate fasciculus in Alzheimer disease

BACKGROUND AND PURPOSE

Tract-based analysis can be used to investigate required tracts extracted from other fiber tracts. However, the fractional anisotropy (FA) threshold influences tractography analysis. The current study evaluated the influence of the FA threshold in measuring diffusion tensor parameters for tract-based analysis of the uncinate fasciculus in subjects with Alzheimer disease (AD).

MATERIALS AND METHODS

Subjects included 30 patients with AD and 10 healthy controls. We acquired tractographies of the uncinate fasciculus by using different FA thresholds. We measured mean FA and the apparent diffusion coefficient (ADC) along the uncinate fasciculus for different FA thresholds and evaluated the correlation between diffusion tensor parameters (FA, ADC) and the Mini-Mental State Examination (MMSE) scores.

RESULTS

The uncinate fasciculus showed lower mean FA and higher mean ADC values in cases with more severe AD. A higher FA threshold led to a lower mean ADC value and a higher mean FA value along the uncinate fasciculus, whereas the relative order of measured values according to the severity of AD was not influenced by the FA threshold. An FA threshold of 0.2 showed higher correlation between mean ADC values and MMSE scores. FA thresholds of 0.15 and 0.20 showed higher correlation between mean FA values and MMSE scores.

CONCLUSIONS

Appropriate selection of the FA threshold leads to higher correlation between diffusion tensor parameters and the severity of AD. For tract-based analysis of degenerative diseases such as AD, appropriate selection of the FA threshold for tractography is important.

Diffusion tensor tractography of the Meyer loop in cases of temporal lobe resection for temporal lobe epilepsy: correlation between postsurgical visual field defect and anterior limit of Meyer loop on tractography

BACKGROUND AND PURPOSE

Visual field defects sometimes occur after temporal resection surgery. Our purpose was to evaluate the correlation between visual field defects caused by temporal lobe resection and the degree of resection of the Meyer loop, as assessed by diffusion tensor tractography.

MATERIALS AND METHODS

We examined 14 patients who underwent temporal resection for temporal lobe epilepsy. We obtained presurgical tractographies and then measured the distance between the temporal tip and the anterior limit of the Meyer loop (T-M distance). The degree of resection of the Meyer loop was defined as the distance from the anterior limit of the Meyer loop to the posterior limit of the temporal lobe resection (M-R distance). This was calculated by subtracting the T-M distance from the measured distance between the temporal tip and the posterior limit of the resection (T-R distance).

RESULTS

The mean T-M distance was 36.6 mm. The interindividual variation of the distance ranged from 30.0 to 43.2 mm. Although there was no statistically significant correlation between the extent of the visual field defect and the T-R distance, there was a statistically significant correlation between the degree of the visual field defect and the M-R distance.

CONCLUSION

The range of interindividual variation for the position of the Meyer loop was rather large, indicating that this variation is the key factor in visual field defects after temporal lobectomy, and the visual field defect appears to be predicted by presurgical tractography. Evaluation of the Meyer loop through the use of tractography seems to be a feasible method, which can be used to predict the visual field defect after temporal lobe resection.

Parasagittal Arachnoid Markings on the Inner Skull on Three-Dimensional CT: Relation between Hydrocephalus and Arachnoid Granules

The purpose of the study was to evaluate the number and size of arachnoid markings on the inner plate of the skull on 3D-CT. The subjects included 16 hydrocephalus and 26 non-hydrocephalus cases. We evaluated the correlation between age and both the number and sizes of the arachnoid markings, and compared them between hydrocephalus and non-hydrocephalus cases. We also evaluated cases exhibiting a “smooth cranium” that had no arachnoid markings at all on the inner plate. There was a positive correlation between age and the number of the arachnoid markings. There were no statistically significant differences in arachnoid markings between hydrocephalus and non-hydrocephalus cases, while, there were statistically significant differences in the frequency of “smooth cranium” findings in the population under ten years old. The “smooth cranium” can only be seen in hydrocephalus cases. These findings may be a clue to the morphological or functional changes of the arachnoid villi in hydrocephalus cases.

Global and region-specific analyses of apparent diffusion coefficient in dentatorubral-pallidoluysian atrophy

BACKGROUND AND PURPOSE

Dentatorubral-pallidoluysian atrophy (DRPLA) is an autosomal dominant spinocerebellar ataxia. Techniques for the quantitative assessment of neurodegenerative lesions remain to be established in this disease. We attempted to quantify global and region-specific neurodegeneration in DRPLA using analysis of apparent diffusion coefficient (ADC) maps.

METHODS

Diffusion-weighted images (b = 1000 s/mm(2)) by echo-planar sequences were obtained with the use of a 1.5T clinical scanner. Whole-brain histogram and region of interest (ROI) analyses of ADC values as well as conventional MR imaging studies were performed in 6 patients with genetically confirmed DRPLA.

RESULTS

Histograms demonstrated significantly higher mean ADC values in the patients than in age- and sex-matched control subjects (P < .01). ROI analysis revealed that the patients had significantly higher ADC values in the cerebellum and globus pallidus, preferentially affected regions (P < .05), but not in the thalamus, the region relatively spared in this disease. ADC values in the white matter were higher only in patients with adult-onset disease. Histogram analyses could more sensitively identify abnormalities than ROI analyses, because the former avoided errors associated with setting ROIs and thus had smaller P values on statistical analysis than the latter.

CONCLUSIONS

Histogram ADC analyses were more sensitive for the detection of neurodegeneration in DRPLA than ROI analyses, whereas ROI analyses revealed regional alterations reflecting the distribution of pathologic changes. Thus, histogram and ROI analyses complement each other and may permit the sensitive, quantitative evaluation of neurodegeneration in DRPLA, especially that involving the globus pallidus showing normal T2 signals.

Diffusion anisotropy and diffusivity of white matter tracts within the temporal stem in Alzheimer disease: evaluation of the "tract of interest" by diffusion tensor tractography

PURPOSE

Our aim was to determine whether diffusion anisotropy and diffusivity of white matter tracts of the temporal stem in patients with Alzheimer (AD) can be evaluated independently by using diffusion tensor tractography.

MATERIALS AND METHODS

Subjects included 15 patients with AD (11 women and 4 men; mean age, 74 years) and 15 age-matched control subjects (11 women and 4 men; mean age, 72 years). Diffusion tensor images were acquired by using echo-planar imaging. We drew tractographies of the uncinate fasciculus, inferior occipitofrontal fasciculus, and Meyer's loop, with diffusion tensor analysis software. We measured diffusion anisotropy, diffusivity, and the number of voxels along the "tracts of interest" and used the Student t test to compare results between patients with AD and controls.

RESULTS

Values of diffusion anisotropy of the bilateral uncinate fasciculus and left inferior occipitofrontal fasciculus were significantly lower for patients with AD than for controls. Also, values of diffusivity in the bilateral uncinate fasciculus were significantly greater for patients with AD than for controls. There was no significant difference in diffusion anisotropy or diffusivity along Meyer's loop between the 2 groups. There was no significant difference in the number of voxels included in all constructed tracts between patients with AD and controls.

CONCLUSION

White matter tracts of the temporal stem can be evaluated independently by using diffusion tensor tractography, which appears to be a promising technique for determining changes in white matter in degenerative diseases.

Successful treatment of acute Budd-Chiari syndrome with percutaneous transluminal angioplasty

A 26-year-old man developed progressive, massive ascites and hematemesis due to rupture of esophageal varices. Combination diagnostic modalities of color doppler ultrasonography, enhanced computed tomography, and magnetic resonance imaging led to the case being diagnosed as acute Budd-Chiari syndrome with severe stricture of the intrahepatic inferior vena cava. Percutaneous transluminal angioplasty this resulted in great improvement of the clinical manifestations.

Borderline Brenner tumor of the ovary: MRI findings

Ovarian Brenner tumor is an uncommon epithelial tumor that accounts for 1.5% to 2.5% of all ovarian neoplasms. These tumors are usually benign. Whereas the magnetic resonance imaging features of benign Brenner tumors have been described, reports of malignant findings are limited. We report a case of borderline malignant Brenner tumor that imaged as a cystic lesion with papillary projections and solid elements.

The transradial approach for selective carotid and vertebral angiography

PURPOSE

The transradial approach is not so popular in cerebral angiography. The purpose of this study was therefore to present our experience of success rate and safety of this method.

MATERIAL AND METHODS

From December 1998 to June 2001, 526 carotid and vertebral angiographies with DSA were performed via the radial artery. A 1.4-mm catheter was used through a 1.4-mm introducer sheath. We evaluated the procedure as successful if sufficient images for diagnosis were obtained of the bilateral carotid arteries and unilateral vertebral artery. Each patient was reassessed for any complications, occurring until the next morning. The length of time needed for an examination was measured in the last 10 cases.

RESULTS

In all but 5 cases, the procedures were evaluated as successful (99.0%). Unsuccessful cases manifested severe pain at the radial puncture, angiospasm at the radial artery, loop formation at the radial artery, occlusion at the subclavian artery, and an aberrant right subclavian artery. No severe complications including neurological ones were encountered. Minor complications were noted in 17 cases (3.2%): 4 cases of thrombus at the ulnar artery, 1 angiospasm at the radial artery, and 12 cases of small hematoma at the puncture site. The radial approach took 14 min less in the common carotid study and 3 min 30 s less in the internal carotid study than by the femoral approach.

CONCLUSION

The transradial approach enabled selective studies for carotid and vertebral angiography with a high success rate and safety with few complications.

The transradial approach for selective carotid and vertebral angiography

PURPOSE

The transradial approach is not so popular in cerebral angiography. The purpose of this study was therefore to present our experience of success rate and safety of this method.

MATERIAL AND METHODS

From December 1998 to June 2001, 526 carotid and vertebral angiographies with DSA were performed via the radial artery. A 1.4-mm catheter was used through a 1.4-mm introducer sheath. We evaluated the procedure as successful if sufficient images for diagnosis were obtained of the bilateral carotid arteries and unilateral vertebral artery. Each patient was reassessed for any complications, occurring until the next morning. The length of time needed for an examination was measured in the last 10 cases.

RESULTS

In all but 5 cases, the procedures were evaluated as successful (99.0%). Unsuccessful cases manifested severe pain at the radial puncture, angiospasm at the radial artery, loop formation at the radial artery, occlusion at the subclavian artery, and an aberrant right subclavian artery. No severe complications including neurological ones were encountered. Minor complications were noted in 17 cases (3.2%): 4 cases of thrombus at the ulnar artery, 1 angiospasm at the radial artery, and 12 cases of small hematoma at the puncture site. The radial approach took 14 min less in the common carotid study and 3 min 30 s less in the internal carotid study than by the femoral approach.

CONCLUSION

The transradial approach enabled selective studies for carotid and vertebral angiography with a high success rate and safety with few complications.