Rhabdomyolysis caused by interaction between rosuvastatin and vadadustat: a case control study

BACKGROUND

Rhabdomyolysis is a potentially life-threatening disease caused by melting or necrosis of skeletal muscle cells and leakage of muscle components into the bloodstream. It has been reported that the interaction of the HMG-CoA reductase inhibitor rosuvastatin with the renal anemia drug vadadustat increases the blood concentration of rosuvastatin in vitro. In this study, we report a case of suspected rhabdomyolysis caused by the drug interaction of rosuvastatin and vadadustat in clinical practice.

CASE PRESENTATION

A 62-year-old male with medical records of hypertension, myocardial infarction, chronic renal failure, renal anemia, dyslipidemia, and alcoholic liver disease. The patient had been diagnosed with chronic kidney disease (CKD) at the Department of Nephrology, and treated by outpatient care with renal support therapy for the past two years. On X-63 day, his prescription was rosuvastatin (10 mg/day) and a continuous erythrocyte-stimulating agent, epoetin beta pegol (genetical recombination, 100 μg). X-Day 0, blood tests revealed creatine phosphokinase (CPK) 298 U/L, serum creatinine (SCr) 5.26 mg/dL, and hemoglobin (Hb) 9.5 g/dL; thus, the prescription was changed from epoetin beta pegol 100 μg to vadadustat 300 mg/day. On X + day 80, a prescription for a diuretic (azosemide 15 mg/day) was added for swelling of the lower extremities. On X + day 105, we found CPK 16,509 U/L, SCr 6.51 mg/dL, and Hb 9.5 g/dL. The patient was diagnosed as rhabdomyolysis and hospitalized. After hospitalization, rosuvastatin and vadadustat were discontinued and we administered intravenous fluids. Thereafter, CPK and SCr values of the patient improved. On X + day 122, CPK improved to 29 U/L, SCr to 2.6 mg/dL, and Hb to 9.6 g/dL, and he was discharged on X + day 124. At discharge, rosuvastatin 2.5 mg/day was resumed. A blood test on X + day 133 showed CPK 144 U/L and SCr 4.2 mg/dL.

CONCLUSION

We experienced a case of rhabdomyolysis caused by drug interactions between rosuvastatin and vadadustat.

P-138 Transcriptomic signatures in trophectoderm and inner cell mass of human blastocysts with expected pregnancy rates

Study question

Is it possible to identify the molecular factors that contribute to the implantation potential of blastocysts?

Summary answer

Genes correlated with expected pregnancy rate in trophectoderm (TE) and inner cell mass (ICM) respectively were identified, and aneuploidy alone couldn’t predict the pregnancy expectation.

What is known already

The selection of suitable embryos for transfer is critical for achieving successful pregnancy outcomes in assisted reproductive technology (ART). Although pre-implantation genetic testing for aneuploidy (PGT-A) as well as morphological and chronological evaluation of embryos, have been conducted in clinical practice, they do not fully guarantee successful pregnancy. Recently, transcriptional events in early human embryonic development have been analyzed using RNA-sequencing (RNA-seq) and researchers are attempting to apply this information to ART.

Study design, size, duration

To determine the correlation between blastocyst evaluation and pregnancy rate, we retrospectively analyzed 1,890 cases underwent frozen-thawed blastocyst transfer from March 2018 to December 2020. A total of 13 blastocysts that were cryopreserved for clinical use between February 2011 and September 2018, then scheduled for disposal and with consented for research, were subjected to RNA-seq without distinguishing between conventional in vitro fertilization (c-IVF) and intracytoplasmic sperm injection (ICSI).

Participants/materials, setting, methods

Blastocysts were donated by infertile couples undergoing c-IVF or ICSI cycles at the Yamashita Shonan Yume Clinic with informed consent under ethical approval. TE and ICM cells were collected from blastocysts by using a micromanipulator and then subjected to RNA-seq. Gene expression analysis and digital karyotyping using RNA-seq were performed simultaneously for TE and ICM cells, respectively. One-way analysis of variance, chi-square test and Tukey's multiple comparison test were used for this study.

Main results and the role of chance

Blastocysts were classified into three groups to correlate with pregnancy rates based on the diameter of the blastocyst and the time to reach this size: those taking less than 130 h to reach a diameter of > 170 μm (Group 1, n = 676), those taking more than 140 h to reach a diameter of < 180 μm (Group 2, n = 158), and the rest (Group 3, n = 1,056). The pregnancy rates of Groups 1, 2 and 3 were 59.0%, 16.5%, and 34.2%, respectively (p < 0.01). Assessing the differences in overall transcripts correlated between Group 1 (n = 5), Group 2 (n = 4), and Group 3 (n = 4), 26 and 67 differentially expressed genes (DEGs) were identified in ICM and TE cells, respectively. Importantly, downregulated genes in TE of blastocysts with lower expectation of pregnancy included tight junction-related genes, such as CXADR, CLDN10, and ATP1B1, which were implicated in peri-implantation development. Digital karyotyping revealed karyotypic abnormalities and mosaicism in all groups with no common abnormalities observed, suggesting that aneuploidy alone cannot predict the pregnancy expectation.

Limitations, reasons for caution

Although 93 genes potentially related to implantation have been identified, it is still unclear how these genes are involved in implantation. In vitro implantation models using human embryos and artificial embryos currently under development are expected to contribute to the elucidation of the functions of these genes.

Wider implications of the findings

Our results provide reliable candidates for genes that could allow for non-invasive selection of high-quality blastocysts for ART and add to the knowledge base of transcriptional events in human peri-implantation development.

Trial registration number

not applicable

Clinical usefulness of a novel fluorescence technique for the intraoperative diagnosis of surgical margins in patients with breast cancer

In both 5- and 15-min data, FI was significantly higher in malignant tissues than in benign tissues. The diagnostic accuracy was similar at 5 and 15 min. Therefore, the 5-min FI was enough applying in the further analyses.

O-154 First mitotic spindle formation led by sperm centrosome-dependent microtubule organising centres may cause high incidence of zygotic division errors in humans

Study question

Why do multinucleated blastomeres appear at high frequency in two-cell-stage embryos in humans?

Summary answer

Failure in microtubule assembly during the first mitotic spindle body formation by sperm centrosome-dependent microtubule organising centres (MTOCs) may lead to chromosomal instability.

What is known already

Unlike that in mice, multinucleated blastomeres appear at high frequency in two-cell-stage embryos in humans. However, the underlying mechanism remains elusive. In mice, multiple acentriolar MTOCs appear around the male and female pronuclei after pronuclear disappearance and contribute to dual-spindle formation, engulfing each parental chromosome. This spindle formation may ensure an error-free division, keeping the chromosomes stable during the first cleavage, as observed in mice, but it is unclear whether a similar mechanism exists in humans.

Study design, size, duration

To examine how sperm centrosomes contribute to MTOC formation in humans, two types of 3PN zygotes derived fromeither conventional in vitro fertilization (c-IVF, n = 30) or intracytoplasmic sperm injection (ICSI, n = 10) were used. The zygotes were collected from October 2018 to January 2020. MTOC and mitotic spindle formation at consecutive stages of development during the first cleavage were analysed under static and dynamic conditions using immunofluorescence assay and fluorescent live-cell imaging.

Participants/materials, setting, methods

Under ethics approval, 3PN zygotes were donated by infertile couples undergoing c-IVF or ICSI cycles at the Yamashita Shonan Yume Clinic in Japan. All participants provided informed consent. Immunofluorescence assay was performed using antibodies against α-tubulin, pericentrin, and H3K9me3 after fixation with MTSB-XF solution. Fluorescent live-cell imaging was performed using TagGFP2-H2B mRNA (chromosome marker) and FusionRed-MAP4 mRNA (microtubule marker).

Main results and the role of chance

Immunofluorescence revealed that while 3PN zygotes derived from c-IVF showed four pericentrin dots, those derived from ICSI exhibited two pericentrin dots. In pro-metaphase, an independent group of chromosomes derived from each pronucleus and MTOCs were formed by the sperm centrosome at the core. Microtubules from each MTOC extended toward the chromosomes in the early metaphase; a quadrupolar spindle was formed in the c-IVF-derived zygotes, and a bipolar spindle was formed in the ICSI-derived zygotes by the MTOCs at the zygote apex after chromosome alignment. In pro-metaphase, the microtubules extended from the MTOCs to the nearest chromosome. Since microtubule assembly was found on oocyte-derived chromosomes, we hypothesised that whether a chromosome is surrounded by microtubules depends on the location of the MTOCs, irrespective of its origin. Live-cell imaging of histone H2B and MAP4 revealed that four MTOCs appeared around the three pronuclei just before the disappearance of the pronuclear membrane; microtubules then extended from the MTOCs toward the chromosomes, beginning to form a mitotic spindle as the chromosomes moved to the centre of the oocyte. Interestingly, one of the three assembled chromosome groups showed no microtubule assembly in the pro-metaphase. Similar results were obtained in all six 3PN zygotes subjected.

Limitations, reasons for caution

We demonstrated the high risk of developing bare chromosomes not surrounded by microtubules during the formation of the first mitotic spindle, using human tripronuclear zygotes. However, owing to unavailability of normal fertilized oocytes for this study because of the clinical use, we were unable to confirm this in normal zygotes.

Wider implications of the findings

Although two sperm centrosome-dependent MTOCs are expected to be formed in normal fertilized oocytes, these MTOCs are not sufficient to completely enclose physically separated female and male chromosomes with the microtubules. This explains the high frequency of zygotic division errors that lead to unstable human chromosomes.

Trial registration number

not applicable

P–248 Statistical estimation for incidence of blastocyst trophectoderm vesicles (TVs) and efficacy of assisted hatching (AH)

Study question

The aim of this study is to analyse the association between blastocyst diameter and TVs development, and to examine the efficacy of AH.

Summary answer

Blastocysts with a diameter of more than 170 μm leads to high incidence of TVs and AH applied from the incidence should be effective.

What is known already

TVs are protrusion of trophectoderm cells often observed in expanding blastocyst stages. TVs can be observed in expanding blastocysts regardless of Intracytoplasmic sperm injection (ICSI) and Conventional-IVF (C-IVF), when the internal pressure of blastocysts increase. The rate of TVs incidence in blastocysts inseminated by ICSI is higher than that by C-IVF, due to penetration of the needle into the zona pellucida. Moreover, it has been reported that TVs may inhibit blastocyst hatching. However, the developmental timing of TVs is still unclear, and there is no study that has analysed the association between blastocyst diameter and the incidence of TVs.

Study design, size, duration

1) Diameters and TVs incidence of blastocysts by ICSI and C-IVF were measured, and the cut-off value and the area under the curve (AUC) of the receiver operating characteristic (ROC) curve were calculated to estimate the timing of TV incidence. 2) We analysed the clinical pregnancy rates of blastocysts with TVs treated by AH compared to those of blastocysts by C-IVF not subjected to AH.

Participants/materials, setting, methods

This study included 821 transferred frozen blastocysts ranging from March 2018 to November 2019. The embryos were cultured in a dry incubator after insemination by ICSI or C-IVF. Blastocyst freezing conditions were set at day5 to day7 with a diameter of more than 150 μm in inner diameter of zona pellucida, and this was measured before freezing. The ROC curve was performed using EZR statistical analysis software.

Main results and the role of chance

1) The incidence of TVs in blastocysts by ICSI and C-IVF was 27.5% (117/424) and 14.6% (58/397) respectively. The rate of the incidence of TVs in blastocysts inseminated by ICSI and C-IVF; 8.6% (12/140) and 0.95% (1/105) in 150–159 μm, 12.7% (14/110) and 8.2% (6/73) in 160–169 μm, 40.6% (28/69) and 10.5% (6/57) in 170–179 μm, 55.6% (30/54) and 25.5% (13/51) in 180–189 μm, 66.7% (20/30) and 35.7% (10/28) in 190–199 μm, and 68.4% (13/19) and 26.8% (22/82) in the diameter of more than 200 μm. The cut-off value of the ROC curve was respectively 170 μm (sensitivity 78.6% and specificity 73.0%) and 176 μm (sensitivity 84.5% and specificity 59.6%) in the diameter; the AUC was 0.8 [95%CI:0.752–0.848] and 0.74 [95%CI:0.687–0.793] respectively. 2) The clinical pregnancy rate of TVs blastocyst vs C-IVF blastocyst was 52.7% (88/167) vs 57.8% (37/64) respectively. There is no significant difference between the two clinical pregnancy rates (P = 0.556).

Limitations, reasons for caution

The findings of this study have to be seen in light of some limitations. Since this study aimed to analyse the incidence of TVs based on blastocyst size, we did not take into account the grade according to the Gardner classification and the number of trophectoderm cells.

Wider implications of the findings: Blastocysts inseminated by ICSI and C-IVF were highly likely to have TVs above 170 μm and 176 μm respectively. The clinical pregnancy rates of the blastocyst with TV treated by AH was similar to those of the C-IVF blastocyst.

Trial registration number

Not applicable

Juvenile migration of the exclusively pelagic cyprinid, Gnathopogon caerulescens (Honmoroko) in Lake Biwa, Central Japan

Migration of wild and cultivated juvenile honmoroko Gnathopogon caerulescens of from the spawning and nursery areas in Lake Biwa were investigated, both in the Ibanaiko Lagoon and its outlet to Daido River, using beam-trawl surveys in 2013 and 2014. The study demonstrated migration of G. caerulescens from a nursery lagoon toward Lake Biwa after the juvenile stage. These findings appear to be the first direct evidence for migration of an exclusively pelagic cyprinid species from a littoral nursery to a pelagic adult habitat in a large deep lake.

Additive Value of 3T 3D CISS Imaging to Conventional MRI for Assessing the Abnormal Vessels of Spinal Dural Arteriovenous Fistulae

Introduction:

We investigated the additive value of the 3T 3D constructive interference in steady state (CISS) sequence to conventional MRI for the evaluation of spinal dural arteriovenous fistulae (SDAVF).

Materials and Methods:

We included 16 consecutive patients (15 men, 1 woman; age range 42–81 years; mean 64 years) with SDAVF who underwent 3T MRI and digital subtraction angiography (DSA) before treatment. Two neuroradiologists independently evaluated the presence of abnormal vessels on 3D CISS-, T₂- and T₁-weighted images (T₁WI, T₂WI), and contrast-enhanced T₁WI using a 3-point grading system. Interobserver agreement was assessed by calculating the κ coefficient.

Results:

The SDAVF site was the cervical region in one patient, the thoracic region in 12 patients, the lumbar region in two, and the sacral region in one. For the visualization of abnormal vessels, the mean score was significantly higher for 3D CISS than the other sequences (P < 0.05). In 12 of 16 cases (75%) both readers made definite positive findings on additional 3D-CISS images. Interobserver agreement was excellent for 3D CISS images (κ = 1.0), good for T₁WI (κ = 0.78; 95% confidence interval [CI] 0.54–1.00) and T₂WI (κ = 0.74; 95% CI 0.48–1.00) and moderate for contrast-enhanced T₁WI (CET₁WI) (κ = 0.50; 95% CI 0.21–0.80).

Conclusion:

For the assessment of abnormal vessels of SDAVF, the 3T 3D CISS sequence adds value to conventional MRI.

Genetic diversity and population structure of Hyporhamphus sajori (Beloniformes: Hemiramphidae) inferred from mtDNA control region and msDNA markers

This paper presents preliminary data on the genetic diversity and population structure of Hyporhamphus sajori by analysing a 510 bp sequence in the mitochondrial DNA (mtDNA) control region and eight polymorphic microsatellite DNA loci. The H. sajori individuals from different locations were indistinguishable from one another based on mtDNA variation, as demonstrated with a neighbour-joining tree and minimum spanning network analysis. Low level of genetic diversity and the absence of population structure in H. sajori from the north-west Pacific Ocean, combined with negative indices for neutral evolution in these populations, suggest that H. sajori underwent a population expansion after a recent bottleneck. The Structure analysis, discriminant analysis of principal components (DAPC) and the pair-wise Φ_ST values after Bonferroni correction using eight microsatellite loci provided no clear inference on the genetic differentiation and thus no evidence of population structure of H. sajori. The genetic connectivity among locations might be due to fairly high gene flow via transport of eggs and larvae by the Kuroshio and Tsushima warm current. This study revealed low levels of genetic diversity and suggested high level of contemporary gene flow among populations of H. sajori in the East (Japan) Sea and the Pacific Ocean.

Foramen Magnum Dural Arteriovenous Fistulae with Repeated Subarachnoid Haemorrhage

We report a patient who had dural arteriovenous fistulae in the region of the foramen magnum with repeated subarachnoid haemorrhage. Magnetic resonance imaging revealed abnormal vascular structures on the right side of the medulla oblongata in an extra-axial portion.

Angiographic findings showed that the lesion was supplied from the meningeal arteries and drained directly into the subarachnoid vein. There was venous dilatation. Embolisation was performed via the transarterial approach using a micro coil and liquid material.

Three years after treatment, the patients' condition is good and follow-up angiograms confirmed the stability of the treatment outcome. While dural arteriovenous fistulae of the foramen magnum are rare, this malformation results in a high rate of bleeding and requires treatment.

Strategy for endovascular coil embolization of a penetrating vertebral artery injury

Background:

Penetrating vertebral artery injuries (VAIs) are even rarer than carotid artery injuries. For anatomical reasons, the surgical management of VAI is difficult, and endovascular management often yields a good outcome. We report our strategy for the endovascular treatment of a patient with a penetrating VAI at the V2 segment of the left vertebral artery.

Case Description:

In a fall on a large rake, a 76-year-old man was stabbed in the left neck by three tines. Although he manifested no neurological deficits, computed tomography (CT) suggested penetrating VAI. Digital subtraction angiography confirmed VAI and extravasation, and he underwent endovascular coil embolization. Two microcatheters, inserted proximal and distal to the injury sites, were used for successful endovascular coil embolization. Postoperative magnetic resonance imaging - and single photon emission CT studies denied cerebral infarction and a decrease in cerebral perfusion. The patient exhibited no neurological deficits and was able to leave the hospital on foot.

Conclusion:

This is the rare documentation of a patient whose penetrating VAI was treated by simultaneous coil embolization and foreign body removal. Imaging studies confirmed the patency and perfusion of the intracranial artery. Our treatment strategy produced a good outcome in this unusual patient.

Evaluation of Intracranial Dural Arteriovenous Fistulas: Comparison of Unenhanced 3T 3D Time-of-flight MR Angiography with Digital Subtraction Angiography

PURPOSE

We compared gross characterization of intracranial dural arteriovenous fistulas (DAVFs) between unenhanced 3-tesla 3-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) and digital subtraction angiography (DSA).

METHODS

We subjected 26 consecutive patients with intracranial DAVF to unenhanced 3T 3D TOF MRA and to DSA. Two independent sets of observers inspected the main arterial feeders, fistula site, and venous drainage pattern on MRA and DSA images. Interobserver and intermodality agreements were assessed by k statistics.

RESULTS

Interobserver agreement was excellent for fistula site (κ = 0.919; 95% confidence interval [CI], 0.805 to 1.000), good for main arterial feeders (κ = 0.711; 95% CI, 0.483 to 0.984), and very good for venous drainage (κ = 0.900; 95% CI, 0.766 to 1.000). Intermodality agreement was excellent for fistula site (κ = 0.968; 95% CI, 0.906 to 1.000) and good for main arterial feeder (κ = 0.809; 95% CI, 0.598 to 1.000) and venous drainage (κ = 0.837; 95% CI, 0.660 to 1.000).

CONCLUSION

Gross characterization of intracranial DAVF was similar for both imaging modalities, but unenhanced 3T 3D TOF MRA cannot replace DSA.

Diel patterns of larval drift of honmoroko Gnathopogon caerulescens in an inlet of Ibanaiko Lagoon, Lake Biwa, Japan

Diel drift patterns of larvae of the endangered cyprinid Gnathopogon caerelescens in an inlet of the Ibanaiko Lagoon, connected to Lake Biwa in Japan, were assessed in April 2012. Peak occurrence of yolk-sac larvae was within a few hours after dark. Drift of newly hatched larvae is considered to be an important biological mechanism that ensures larval dispersal and recruitment from the inlets (spawning grounds) to the lagoon which functions as a nursery ground.

Heart attacks triggered by huge mud slides in mountain regions and severe flooding in inhabited areas

BACKGROUND

On July 12, 2012, heavy rains struck southwest Japan, particularly in the Mount Aso area. Huge mud slides in the mountains destroyed houses, and heavy rains caused severe flooding in the inhabited areas. We investigated the incidence of cardiovascular events after the disaster.

METHODS

We investigated patients who were admitted to the emergency department (ED) from July 12 to August 31 in 2012. We reviewed all patients with cardiovascular events, including acute myocardial infarction (AMI), angina attack, worsening of congestive heart failure (CHF), cardiopulmonary arrest (CPA), arrhythmias, tako-tsubo cardiomyopathy (TC), and symptomatic venous thromboembolism (VTE).

RESULTS

The total number of cardiovascular events was 28 (14 supraventricular arrhythmias, 3 angina attacks, 1 AMI, 1 VTE, 4 CHF, 1 TC and 4 CPA). There was a significant increase in cardiovascular events during the follow-up period in 2012 in comparison with the average number of these events over the same time period during the prior 2 years (16.8 vs. 5.1/month, p<0.01). There was a sharp increase in cardiovascular events in the first week after the disaster. A second peak was observed 7 weeks after the disaster. Two patients with angina attack were previously diagnosed as having vasospastic angina. The incidence rate of AMI did not increase.

CONCLUSION

An increase in cardiovascular events was observed after severe rainfalls and mud slides. Prevention of disaster-induced cardiovascular events should be a priority regardless of the magnitude of the disaster.

Abstract T P18: Development of A SPECT-Based Objective Evaluating System for Therapeutic Effect of Acute Endovascular Therapy

Background: and purpose Endovascular therapies (EVT) are increasingly preformed among patients with acute ischemic stroke in whom alteplase failed to recanalize or contraindicated. However, it is difficult to prove its efficacy by a randomized controlled study. Thus, we developed a SPECT-based objective evaluating system using a relative threshold value of cerebral blood flow (CBF) measured within the first 6 hours of onset.

Methods: Between 2010 and 2012, 27 patients with supratentorial embolic stroke presented within 6 hours and contraindicated for intravenous rt-PA (16 men, 11 women, 74+/-12 years old, NIHSS median 19) were enrolled. After obtaining informed consent, all patients’ pre-treatment CBF was measured by 99mTc-HMPAO SPECT (tracer injection: median 361 min). All SPECT images were co-registered to individual FLAIR images and analyzed using the software developed for exclusive use (FusionViewer, Nihon Medi-Physics Co., Ltd, Japan). A predicted infarct size (x) was obtained 3-dimensionally as the sum of voxel sizes exhibiting <64% CBF of symmetrical voxel. Final infarct volume (y) was calculated on CT at 24 hours. A significant infarct size reduction was defined if final infarct volume was smaller than the lower 95% C.I. of the regression line [Y=0.8914X+3.742]. This study was approved by each IRB.

Results: EVT was performed in 3 patients: 1 with localized intra-arterial thrombolysis (LIT), 1 with mechanical clot disruption (MCD) and 1 with LIT+MCD. A complete recanalization of M1/ M2 was obtained in 2 patients, while the other patient’s M1 recanalized partially. Median recanalization time was 5.1 (range 2.8~5.7) hours. All EVT patients had achieved significant infarct size reduction (predicted size: 121.9+/-47.1 cm3, final infarct size: 51.8+/-58.8 cm3). On the other hand, none of 24 patients without EVT showed significant infarct size reduction (predicted size: 97.2+/-74.6 cm3, final infarct size: 118.3+/-115.1 cm3).

Conclusion: We confirmed the significant infarct size reduction obtained by EVT. This CBF based surrogate measure could be applied to the evaluation of various interventional therapies.

Successful treatment using high-dose intravenous immunoglobulin in a patient with rapidly progressive interstitial pneumonia associated with dermatomyositis

Abstract A 36-year-old male patient with dermatomyo-sitis (DM) associated with rapidly progressive interstitial pneumonia (IP) was successfully treated by high-dose intravenous immunoglobulin (IVIG). He suffered from myopathy, skin lesions, and IP. In spite of the treatment with a high-dose corticosteroid, IP progressed rapidly. Then high-dose intravenous immunoglobulin (20 g/day, 4 days) was administered. The skin lesions, myopathy, and pulmonary lesions improved. High-dose IVIG was considered to be a relatively safe and effective treatment for progressive IP associated with DM.

Manual external carotid artery manipulation for failed device advance through the stent in carotid artery stent placement. A technical note

We report herein the usefulness of a manual external carotid artery manipulation for failed advancement of devices through the stent in carotid artery stent (CAS) placement with open cell type stent and filter type distal protection device. In all, 22 consecutive patients underwent CAS with filter type protection device between April 2008 and December 2009 in our institution, and failed advancement of the devices through the stent occurred in 4 patients (18%). For all the 4 patients, the devices could be navigated normally through the stent under the manual external carotid artery manipulation. In cases with failed device advance in CAS, this maneuver would be one of the methods to resolve this.

Intracranial dural arteriovenous fistulas: evaluation with 3-T four-dimensional MR angiography using arterial spin labeling

PURPOSE

To evaluate whether 3-T four-dimensional (4D) arterial spin-labeling (ASL)-based magnetic resonance (MR) angiography is useful for the evaluation of shunt lesions in patients with intracranial dural arteriovenous fistulas (AVFs).

MATERIALS AND METHODS

Institutional review board approval and prior written informed consent from all patients were obtained. Nine patients with intracranial dural AVF (seven men, two women; age range, 52-77 years; mean age, 63 years) underwent 4D ASL MR angiography at 3 T and digital subtraction angiography (DSA). Spin tagging was with flow-sensitive alternating inversion recovery with Look-Locker sampling. At 300-millisecond intervals, seven dynamic images with a spatial resolution of 0.5 × 0.5 × 0.6 mm(3) were obtained. The 4D ASL MR angiographic and DSA images were read by two sets of two independent readers each. Interobserver and intermodality agreement was assessed with the κ statistic.

RESULTS

On all 4D ASL MR angiographic images, the major intracranial arteries were demonstrated at a temporal resolution of 300 milliseconds. Interobserver agreement was excellent for the fistula site (κ = 1.00; 95% confidence interval [CI]: 1.00, 1.00), moderate for the main arterial feeders (κ = 0.53; 95% CI: 0.08, 0.98), and good for venous drainage (κ = 0.77; 95% CI: 0.35, 1.00). Intermodality agreement was excellent for the fistula site and venous drainage (κ = 1.00; 95% CI: 1.00, 1.00) and good for the main arterial feeders (κ = 0.80; 95% CI: 0.58, 1.00).

CONCLUSION

The good-to-excellent agreement between 3-T 4D ASL MR angiographic and DSA findings suggests that 3-T 4D ASL MR angiography is a useful tool for the evaluation of intracranial dural AVFs.

Tumor consistency of pituitary macroadenomas: predictive analysis on the basis of imaging features with contrast-enhanced 3D FIESTA at 3T

BACKGROUND AND PURPOSE

Preoperative evaluation of pituitary macroadenoma tumor consistency is important for neurosurgery. Thus, we aimed to retrospectively assess the role of contrast-enhanced FIESTA in predicting the tumor consistency of pituitary macroadenomas.

MATERIALS AND METHODS

Twenty-nine patients with pituitary macroadenomas underwent conventional MR imaging sequences and contrast-enhanced FIESTA before surgery. Two neuroradiologists assessed the contrast-enhanced FIESTA, contrast-enhanced T1WI, and T2WI. On the basis of surgical findings, the macroadenomas were classified by the neurosurgeons as either soft or hard. Finally, Fisher exact probability tests and unpaired t tests were used to compare predictions on the basis of the MR imaging findings with the tumor consistency, collagen content, and postoperative tumor size.

RESULTS

The 29 pituitary macroadenomas were classified as either solid or mosaic types. Solid type was characterized by a homogeneous pattern of tumor signal intensity without intratumoral hyperintense dots, whereas the mosaic type was characterized by many intratumoral hyperintense dots on each MR image. Statistical analyses revealed a significant correlation between tumor consistency and contrast-enhanced FIESTA findings. Sensitivity and specificity were higher for contrast-enhanced FIESTA (1.00 and 0.88-0.92, respectively) than for contrast-enhanced T1WI (0.80 and 0.25-0.33, respectively) and T2WI (0.60 and 0.38-0.54, respectively). Compared with mosaic-type adenomas, solid-type adenomas tended to have a hard tumor consistency as well as a significantly higher collagen content and lower postoperative tumor size.

CONCLUSIONS

Contrast-enhanced FIESTA may provide preoperative information regarding the consistency of macroadenomas that appears to be related to the tumor collagen content.

Comparison of dynamic contrast-enhanced 3T MR and 64-row multidetector CT angiography for the localization of spinal dural arteriovenous fistulas

BACKGROUND AND PURPOSE

For the localization of spinal dural arteriovenous fistulas, it is not determined whether dynamic contrast-enhanced MRA is more reliable than multidetector CTA. The aim of this study was to compare the agreement between intra-arterial DSA, dynamic contrast-enhanced MRA at 3T, and 64-row multidetector CTA for the localization of spinal dural arteriovenous fistulas.

MATERIALS AND METHODS

We enrolled 12 consecutive patients (11 men, 1 woman; age range, 46-83 years; mean, 65 years) who underwent preoperative dynamic contrast-enhanced MRA at 3T and 64-row multidetector CTA. The spinal dural arteriovenous fistula location was confirmed by intra-arterial DSA as the reference standard. Two reviewers independently evaluated the level of the artery feeding the spinal dural arteriovenous fistula on the basis of continuity between the feeder and abnormal spinal vessels on 3T dynamic contrast-enhanced MRA and 64-row multidetector CTA images. Interobserver and intermodality agreement was determined by calculation of the κ coefficient.

RESULTS

On DSA, the vessel feeding the spinal dural arteriovenous fistula was the intercostal artery (7 cases), the lumbar artery (3 cases), and the internal iliac artery or the ascending pharyngeal artery (1 case each). For the fistula level, interobserver agreement was excellent for 3T dynamic contrast-enhanced MRA (κ = 0.97; 95% CI, 0.92-1.00) and very good for 64-row multidetector CTA (κ = 0.84; 95% CI, 0.72-0.96). Intermodality agreement with DSA was good for 3T dynamic contrast-enhanced MRA (κ = 0.78; 95% CI, 0.49-1.00) and moderate for 64-row multidetector CTA (κ = 0.41; 95% CI, 0.020-0.84).

CONCLUSIONS

For the localization of spinal dural arteriovenous fistulas, 3T dynamic contrast-enhanced MRA may be more reliable than 64-row multidetector CTA.

[Computer-aided detection of metastatic brain tumors in magnetic resonance images]

The fact that accurate detection of metastatic brain tumors is important for making decisions on the treatment course of patients prompted us to develop a computer-aided diagnostic scheme for detecting metastatic brain tumors. In this paper, we first describe how we extracted the cerebral parenchyma region using a standard deviation filter. Second, initial candidates for tumors were decided by sphericity and cross-correlation value with a simulated ring template. Third, we made true positive and false positive templates obtained from actual clinical images and applied the template matching technique to them. Finally, we detected metastatic tumors using these two characteristics. Our improved method was applied to 13 cases with 97 brain metastases. Sensitivity of detection of metastatic brain tumors was 80.4%, with 5.6 false positives per patient. Our proposed method has potential for detection of metastatic brain tumors in brain magnetic resonance (MR) images.

A 6-fr guiding catheter (slim guide(®)) for use with multiple microdevices. An experimental study

A modified technique is required in patients with wide-necked aneurysms whose treatment by the single microcatheter technique is difficult. We developed a 6-Fr guiding catheter (Slim Guide(®)) that features a large lumen (0.072 inch) for performing the modified technique. To evaluate the usefulness of Slim Guide(®) we carried out experiments using three types of 6-Fr guiding catheter. In experiment 1, the shaft hardness and kink resistance were compared among three different guiding catheters (Slim Guide(®), Launcher(®), Envoy(®)). In experiment 2, we inserted a microballoon catheter and a microcatheter into the three different guiding catheters and recorded the maximal infusion pressure. In experiment 3, we inserted 13 different types of microdevices into the three different guiding catheters and evaluated the resistance of the microdevices. Although the shaft of the Slim Guide(®) was softer than that of the other two guiding catheters, its kink resistance was comparable. The maximal infusion pressure was significantly lower than with Launcher(®) or Envoy(®) catheters. Furthermore, with Slim Guide(®), in 136 of 143 microdevice combinations examined (95.1%) there was no resistance; this was true for 125 (87.4%) and 116 (81.1%) combinations using the Launcher(®) - and the Envoy(®) guiding catheters, respectively. There was a significant difference between Slim Guide(®) and the other two guiding catheters with respect to their accommodation of double microsystems (p<0.05). Although the inner diameter of Slim Guide(®) is slightly larger than of the other two guiding catheters, it significantly increased the combination of microdevices that could be used for the coil embolization of difficult aneurysms.

Hyperperfusion syndrome after stent placement for subclavian artery stenosis: case report

A 60-year-old woman presented with a rare case of hyperperfusion syndrome after stent placement for subclavian artery stenosis manifesting as dizziness due to vertebrobasilar insufficiency. Three days after undergoing stent placement to treat the severely stenotic (90%) right subclavian artery, she suffered intracranial hemorrhage related to hyperperfusion syndrome. Preoperative single-photon emission computed tomography findings of low cerebral perfusion and poor perfusion reserve might indicate the possibility of hyperperfusion syndrome after stenting in patients with subclavian artery stenosis.

Outer-diameter narrowing of the internal carotid and middle cerebral arteries in moyamoya disease detected on 3D constructive interference in steady-state MR image: is arterial constrictive remodeling a major pathogenesis?

BACKGROUND

To obtain information on affected vessels in moyamoya disease (MMD), we analyzed the vascular morphological characteristics of MMD using three-dimensional (3D) constructive interference in steady-state (CISS) magnetic resonance imaging (MRI).

METHODS

The population of this 3D-CISS MRI study consisted of 51 patients with MMD: 16 patients with atherosclerotic middle cerebral artery (MCA) stenosis or occlusion, 42 MRI control patients, and 28 control digital subtraction angiography (DSA) patients. We measured the outer diameters of the terminal portion of the internal carotid artery (ICA) and the proximal portion of the MCA (M1 portion). We evaluated the inner diameter as the relative value (%) obtained from magnified DSA images and analyzed these data.

RESULTS

The outer diameters of the ICA and M1 portions were significantly smaller in the MMD group than in the other two groups, while the M1 outer diameter of the atherosclerosis group was not significantly different compared to the control (ICA: MMD, 2.61 ± 0.46 mm vs. control, 4.04 ± 0.50 mm and M1: MMD, 1.92 ± 0.43 mm vs. control, 3.34 ± 0.54 mm vs. atherosclerosis, 3.45 ± 0.56 mm). Furthermore, in MMD patients, the outer diameter was unrelated to the progression of the luminal stenosis grade estimated by DSA.

CONCLUSIONS

This is the first report that the outer diameters of both the ICA and M1 decrease in MMD patients. Our findings suggest that the vascular constrictive changes of the affected arteries are an important phenomenon reflecting MMD pathology.

Usefulness of 3D DSA-MR fusion imaging in the pretreatment evaluation of brain arteriovenous malformations

RATIONALE AND OBJECTIVES

For the evaluation of patients scheduled for the treatment of brain arteriovenous malformations (AVMs), accurate anatomical information is essential. The purpose of this study was to assess the usefulness of three-dimensional (3D) digital subtraction angiography (DSA)-magnetic resonance (MR) fusion imaging for the pretreatment evaluation of AVMs.

MATERIALS AND METHODS

The study population consisted of 11 consecutive patients (7 males, 4 females; age 10-72 years; mean 45 years) with brain AVMs. All prospectively underwent pretreatment MR imaging (MRI), MR angiography (MRA), and two-dimensional (2D) and 3D DSA. The 3D DSA and MR images were semiautomatically fused with fusion software on a workstation. In the delineation of AVM nidus, feeder, drainer, and relationship between AVM and the adjacent brain structures, two radiologists independently evaluated MRA and MRI, three-dimensional (3D) DSA, and MRI, and 3D DSA-MR fusion images using a 4-point scoring system. The referring neurosurgeons were asked whether the information provided by 3D DSA-MR fusion images was helpful for treatment decisions.

RESULTS

For all four items, the delineation was significantly better with the 3D DSA/MRI or 3D DSA-MR fusion images than the MRA/MRI images. Although the delineation for the nidus, feeder, and drainer were not significantly different between the 3D DSA/MRI and 3D DSA-MR fusion images, 3D DSA-MR fusion imaging were significantly better for the relationship between AVM and the adjacent brain structures than 3D DSA/MR imaging (P = .0047). The information provided by 3D DSA-MR fusion images was helpful for treatment decisions in all cases.

CONCLUSION

3D DSA-MR fusion images are useful for the pretreatment evaluation of brain AVMs.

Prolonged and regionally progressive symptomatic cerebral hyperperfusion syndrome after superficial temporal artery-middle cerebral artery anastomosis in a patient with moyamoya disease

Background:

The incidence of symptomatic hyperperfusion syndrome after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis for patients with moyamoya disease (MMD) approaches 30%. In most cases, hyperperfusion occurs in a localized area and disappears within 1-2 weeks.

Case Description:

A 59-year-old female diagnosed with asymptomatic MMD for 4 months became rapidly symptomatic with transient ischemic attacks (TIAs). After left STA-MCA anastomosis surgery, she developed symptomatic hyperperfusion, initially (1-2 weeks after surgery) manifesting with severe headache and lesions located in the left basal ganglia. She then developed (2-5 weeks after surgery) aphasia and right hemiparesis caused by new hyperperfusion lesions located in the left frontal area. At discharge (7 weeks after surgery), she recovered fully without any remaining neurologic deficit and no ischemic lesions.

Conclusion:

This report details a rare case of a patient with MMD who presented with regionally progressive hyperperfusion lesions after STA-MCA anastomosis and symptoms that persisted for 5 weeks following surgery. Results from this case suggest that regional differences exist in the functional recovery of cerebrovascular reactivity (CVR) in a patient with rapidly progressive MMD.

Can 3T MR angiography replace DSA for the identification of arteries feeding intracranial meningiomas?

BACKGROUND AND PURPOSE

For identifying the arterial feeders of meningiomas, the usefulness of 3D TOF MRA at 3T has not been systematically investigated. This study was intended to assess whether unenhanced 3D TOF MRA at 3T can replace DSA for the identification of arteries feeding intracranial meningiomas and whether it is useful for assessing their dural attachment.

MATERIALS AND METHODS

Twenty-one consecutive patients with intracranial meningiomas (18 women, 3 men; aged 42-77 years, mean 57 years) underwent DSA, conventional MR imaging, and 3D TOF MRA. Two neuroradiologists independently evaluated the primary and secondary feeders of each tumor on maximum-intensity-projection and source MRA images. They also identified the location of dural attachments based on information from MR imaging/MRA images. Interobserver and intermodality agreement was determined by calculating the κ coefficient.

RESULTS

For the identification of primary and secondary feeders on MRA images, interobserver agreement was very good (κ=0.83; 95% CI, 0.66-1.00) and moderate (κ=0.58; 95% CI, 0.34-0.82) and intermodality agreement (consensus reading of MRA versus DSA findings) was excellent (κ=0.94; 95% CI, 0.84-1.00) and good (κ=0.72; 95% CI, 0.51-0.93), respectively. With respect to the dural attachment of meningiomas, interobserver agreement was very good (κ=0.95; 95% CI, 0.84-1.00). The agreement in the diagnosis between MR imaging/MRA and surgery was excellent (κ=1.00).

CONCLUSIONS

Unenhanced 3D TOF MRA at 3T cannot at present supplant DSA for the identification of the feeding arteries of intracranial meningiomas. This information may be useful for evaluating their dural attachment.