Utility of digital subtraction angiography-based collateral evaluation in medically treated acute symptomatic basilar artery stenosis

BACKGROUND AND PURPOSE

Although a stroke from atherosclerosis in the basilar artery (BA) often presents with mild initial stroke severity, it has heterogeneous clinical courses. We investigated the efficacy of digital subtraction angiography (DSA)-based collateral perfusion evaluation in association with long-term outcomes of medically treated symptomatic basilar artery stenosis.

METHODS

From a registry database of all consecutive patients with stroke, we included 98 medically treated patients (due to mild initial stroke severity) [National Institute of Health Stroke Scale (NIHSS) scores ≤ 4; symptomatic basilar artery stenosis, 70-99%] with available initial diagnostic DSA. Basilar collateral scoring was performed via the DSA, using a modified version of the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system in both the superior cerebellar artery and anterior/posterior-inferior cerebellar artery territories (score 0-8). The outcomes were designated as the 90-day modified Rankin Scale (mRS90) score (poor, 3-6). Student's t-test, chi-square test and logistic regression analyses were used to identify factors associated with a poor outcome.

RESULTS

The median initial NIHSS score was 2 [interquartile range (IQR), 0-3], median posterior circulation Alberta Stroke Program Early CT Score was 8 (IQR, 7-10), median collateral score was 7 (IQR, 7-8) and 20 (20.4%) had poor mRS90 scores. In multivariate analysis, poorer collateral scores (P = 0.003), higher NIHSS scores (P = 0.005) and lower posterior circulation Alberta Stroke Program Early CT Score (P = 0.017) were independently associated with a poor mRS90 score.

CONCLUSIONS

The DSA-based collateral scoring of the BA large branches might predict long-term outcome in medically treated symptomatic basilar artery stenosis with mild initial severity. Evaluation of BA collateral perfusion status might be useful to determine appropriate treatment strategies.

Efficacy and Safety of Modified Pranlukast (Prakanon(®)) Compared with Pranlukast (Onon(®)): A Randomized, Open-Label, Crossover Study

INTRODUCTION

Pranlukast is a leukotriene receptor antagonist (LTRA) that is used as an additional controller of mild to moderate asthma. This study compared the efficacy and side effects of two bioequivalent preparations of pranlukast: original pranlukast (Onon(®); Ono Pharmaceutical, Japan) and a modified formulation of pranlukast (Prakanon(®); Yuhan Co, Korea) in patients with mild to moderate asthma.

METHODS

Of the 34 subjects screened, 30 patients who were using standard medication to control asthma and scored less than 20 points on the Asthma Control Test(™) (ACT) were assigned randomly to one of the two groups in a prospective, open label, crossover study: group 1 received Prakanon(®) (150 mg/day) and group 2 received Onon(®) (450 mg/day) for 8 weeks each; after a 1-week rest period, the groups were switched to the alternative medication for further 8 weeks and monitored for 2 more weeks without study medication. Evaluation parameters included the ACT, quality of life questionnaire adult Korean asthmatics (QLQAKA), pulmonary function tests, peripheral blood tests, vital signs, and adverse events.

RESULTS

Thirty patients were enrolled and 21 completed the trial: 10 in group 1 and 11 in group 2. The baseline data of the two groups did not differ. No statistical significant differences were observed in efficacy and lung function at each time and in changes from baseline value between the two kinds of pranlukast. The final asthma control rate was 81% with Prakanon(®) and 76% with Onon(®). There were no differences in vital signs and laboratory data at each time and in changes from baseline value between the two drugs. There were no differences in adverse events between the two drugs. The most common side effect was abdominal pain. Drug compliance was high, without differences between the two drugs.

CONCLUSION

These findings suggest that Prakanon(®) which is an improved formulation of pranlukast at a lower dose than the original formulation, Onon(®), has a similar efficacy and side effect profile in the control of persistent asthma.

Pulmonary nodule size evaluation with chest tomosynthesis and CT: a phantom study

OBJECTIVE

We compared digital tomosynthesis (TOMO) and chest CT in terms of assessing the sizes of nodules located in zones where evaluation by simple radiography is limited.

METHODS

A total of 48 images comprising phantom nodules of four sizes in six different locations were used. Nodule size measurement errors for measurements using TOMO and CT images compared with the actual size from each observer were calculated. The inter- and intraobserver repeatability of the measured values and the agreement between the two techniques were assessed using the method described by Bland and Altman.

RESULTS

The mean measurement errors for all of the nodules and four observers were -0.84 mm [standard deviation (SD), 0.60 mm] on TOMO and -0.18 mm (SD, 0.71 mm) on CT images. The mean measurement errors for the different observers ranged from -1.11 to -0.55 mm for TOMO and from -0.39 to 0.08 mm for CT. Assessing the agreement between nodule size measurements using TOMO and CT resulted in mean measurement errors of -0.65 mm, with a 95% limit of agreement of -2.53 to 1.22 mm for comparison of TOMO with CT.

CONCLUSION

Our results suggest that nodule sizes obtained using TOMO and chest CT are comparable, even for nodules located in areas where the size measurement is limited on simple radiography.

ADVANCES IN KNOWLEDGE

TOMO and CT can be used interchangeably, even for nodules located in a blind area on simple radiography.

Angiosarcoma presenting with spontaneous hydropneumothorax: report of a case and review of the literature

Angiosarcoma is a rare malignant tumor of soft tissue. Because angiosarcoma originates from endothelial cells, it can occur in any organ and shows aggressive clinical features. Most commonly, angiosarcoma initially presents as a cutaneous lesion. Lung metastasis from scalp angiosarcoma can develop pneumothorax. We report a case of multiorgan involvement of an angiosarcoma, including the scalp, initially presenting with hydropneumothorax. Immunohistochemistry analysis of the cells obtained from the study confirmed the pleural invasion of the angiosarcoma.

Clinical outcomes and prognostic factors in patients with tuberculous destroyed lung

OBJECTIVE

To characterise the prognosis and identify factors contributing to mortality in patients with tuberculous destroyed lung (TDL).

DESIGN

Following a retrospective review of clinical data and radiographic findings, 169 patients with TDL were enrolled in this study. All patients were graded on a 4-point scale (field score 1-4) based on the extent of destroyed lung parenchyma on chest radiography.

RESULTS

The mean patient age was 64 years (range 33-90); 103 (61%) were male. The median number of hospitalisations was 1 (range 0-11) during follow-up, with a mean duration of 31 months (range 0-172). Pneumonia developed in 96 patients (57%), while 50 patients (30%) developed acute respiratory failure requiring mechanical ventilation, 37 (22%) haemoptysis, 24 (14%) spontaneous pneumothorax and 22 (13%) reactivation of tuberculosis. Overall mortality was 28% (47/169), with a median survival of 39 months (range 0-176) after diagnosis. TDL-related mortality was 19% (32/169), and a field score ≥ 3 was the only independent predictor of shorter survival based on a Cox proportional hazards model (HR 3.520, 95%CI 1.51-8.20, P = 0.004).

CONCLUSION

TDL has a poor prognosis, particularly in patients with more extensive lung destruction.

Novel influenza A (H1N1) infection: chest CT findings from 21 cases in Seoul, Korea

AIM

To retrospectively evaluate the computed tomography (CT) appearances of novel influenza A (H1N1) infection.

MATERIALS AND METHODS

Chest CT images obtained at clinical presentation in 21 patients (eight men, 13 women; mean age, 37 years; age range, 6-82 years) with confirmed novel influenza A (H1N1) infection were assessed. The radiological appearances of pulmonary parenchymal abnormalities, distribution, and extent of involvement on initial chest CT images were documented. The study group was divided on the basis of age [group 1, patients <18 years old (n=8); group 2, patients ≥ 18 years old (n=13)]. Medical records were reviewed for underlying medical conditions and laboratory findings. The occurrence of recognizable CT patterns was compared for each group using the images from the initial CT examination.

RESULTS

The most common CT pattern observed in all patients was ground-glass attenuated (GGA) lesions (20/21, 95%). Bronchial wall thickening (9/21, 43%) was the second most common CT finding. Other common CT findings were consolidation (6/21, 29%), pleural effusion (6/21, 29%), pneumothorax or pneumomediastinum (5/21, 24%), and atelectasis (5/21, 24%). Among these, atelectasis and pneumomediastinum (pneumothorax) were only observed in group 1. The GGA lesions showed predilections for diffuse multifocal (10/20, 50%) or lower zone (8/20, 40%) distribution. Involvement of central lung parenchyma (12/20, 60%) was more common than a mixed peripheral and central pattern (6/20, 30%) or a subpleural pattern (2/20, 10%) at the time of presentation. Patchy GGA lesions were more frequent (18/20, 90%) than diffuse GGA lesions, and 75% (15/20) of these lesions had a bronchovascular distribution. Bilateral disease was present in all patients with GGA lesions. Bronchial wall thickening was predominantly centrally located and the distribution of the consolidation was non-specific.

CONCLUSION

The predominantly centrally located GGA lesions, with common multifocal or bilateral involvement, peribronchovascular distribution, and patchy appearance are the more distinctive CT findings of novel influenza A (H1N1) infection. Pneumomediastinum and atelectasis resulting from this disease are more common in young patients under the age of 18 years.

Impaired expression of Toll-like receptor 2 in nontuberculous mycobacterial lung disease

The aims of the present study were to investigate the expression of Toll-like receptor (TLR)2 on the peripheral blood monocytes of patients with nontuberculous mycobacterial (NTM) lung disease and healthy controls, and to assess the responses of these monocytes to TLR2 agonists such as Mycobacterium avium and lipoteichoic acid (LTA). Reverse transcriptase-PCR was used to analyse TLR2 mRNA expression in peripheral blood monocytes from 17 NTM patients and 10 healthy controls. mRNA and protein secretion levels were also determined for the cytokines interleukin (IL)-12 p40 and tumour necrosis factor (TNF)-alpha. Expression of TLR2 mRNA by peripheral blood monocytes after stimulation with M. avium or LTA was lower in NTM patients than in healthy controls. IL-12 p40 and TNF-alpha mRNA and cytokine secretion levels were also lower in patients than in healthy controls. Treatment with anti-TLR antibody decreased M. avium- and LTA-induced IL-12 p40 and TNF-alpha production in healthy controls, but not in NTM patients. The present results suggest that the downregulation of Toll-like receptor 2 and the resulting decreased production of interleukin-12 p40 and tumour necrosis factor-alpha following Mycobacterium avium or lipoteichoic acid stimulation may contribute to host susceptibility to nontuberculous mycobacterial lung disease.

Use of silicone stents for the management of post-tuberculosis tracheobronchial stenosis

The role of bronchoscopic management in post-tuberculosis tracheobronchial stenosis is not well defined. To investigate the role of bronchoscopic intervention, including silicone stenting, in the management of post-tuberculosis tracheobronchial stenosis, the current retrospective study was conducted at a tertiary referral hospital. Under rigid bronchoscopy, 80 patients underwent ballooning, neodymium-yttrium aluminium garnet laser resection and/or bougienation as first-line methods of airway dilatation between January 2000 and December 2003 inclusive, and were followed for a median of 41 months. Silicone stents were required in 75 out of 80 (94%) patients to maintain airway patency. Bronchoscopic intervention provided immediate symptomatic relief and improved lung function in 88% of the patients. After airway stabilisation, stents were removed successfully in 49 out of 75 (65%) patients at a median of 14 months post-insertion. Three patients out of 75 (4%) eventually underwent surgical management. Acute complications included: excessive bleeding (n = 1); pneumothorax (n = 5); and pneumomediastinum without mortality (n = 2). Stent-related late complications, such as migration (51%), granuloma formation (49%), mucostasis (19%) and re-stenosis (40%), were controllable during a median follow-up of 41 months. In conclusion, bronchoscopic intervention, including silicone stenting, could be a useful and safe method for treating post-tuberculosis tracheobronchial stenosis.