Population Structure of Indian Mackerel (Rastrelliger kanagurta) in Java and Bali Island, Indonesia Inferred from Otolith Shape

The Indian mackerel, Rastrelliger kanagurta, is a commercially important resource across Indonesia's archipelagic waters. Despite its essential role in the fisheries industry, information regarding its population structures for management purposes is still limited. The present study investigates the variability of otolith shape as an efficient tool for stock discrimination. A total of 159 pairs of sagittal otolith were sampled at four localities along the southern Java-Bali coastal waters. Otolith outline was modeled by using Wavelet coefficients and was compared between localities using ANOVA-like permutation test, Canonical Analysis of Principal Coordinates (CAP), and classification test performed using linear discriminant analysis. The results showed significant differences in the shape of otolith between populations, reflected explicitly in the morphological feature of the excisura major. The differences in otolith shape were examined from all localities (ANOVA-like, p<0.001, and CAP p>0.05), except those otoliths between Palabuhanratu and Pacitan, thus, a mixed stock may occur in these two locations. These findings were also confirmed by the low classification success rate using LDA 44.26%. These results suggested that at least two distinct stocks potentially contributed to the fishery, impacting species management and conservation.

Changes in Hematological Parameters and Heat Shock Proteins in Juvenile Sablefish Depending on Water Temperature Stress

Juvenile Sablefish Anoplopoma fimbria were used to assess the effects of water temperature (8, 10, 12, 14, 16, 18, and 20°C) on hematological parameters and heat shock proteins 70 and 90 for 4 months. Hematological parameters, including red blood cell count, hematocrit, and hemoglobin, were significantly decreased at 18°C. The inorganic plasma components calcium and magnesium were not altered by water temperature. The organic plasma components glucose and cholesterol were notably elevated at 18°C, whereas total protein was reduced. The enzymatic components, including aspartate aminotransferase, alanine aminotransaminase, and alkaline phosphatase, were notably elevated at 16°C or 18°C. The results of this study indicate that a temperature higher than the proper temperature affects the hematological parameters and heat shock proteins of juvenile Sablefish.

Long-Term Outcomes of Patients with Stent Tips Embedded into Internal Carotid Artery Branches during Aneurysm Coiling

BACKGROUND AND PURPOSE

During stent-assisted coiling of ICA aneurysms, stent tips are sometimes unintentionally embedded into ICA branches. Stent tips can be visualized because they have radiopaque markers. Concerns regarding stent tip misplacement include risks of artery perforation and occlusion. The aim of this study was to evaluate the long-term outcomes of ICA branches with embedded stent tips.

MATERIALS AND METHODS

ICA branches with embedded stent tips were identified among 35 patients with unruptured ICA aneurysms treated with stent-assisted coiling between November 2003 and November 2014. Patient clinical and angiographic outcomes associated with the embedded stent tip were analyzed.

RESULTS

Most of the 35 studied aneurysms were paraclinoid ICA aneurysms (n = 30). The most commonly involved ICA branch was the posterior communicating artery (26 patients, 74.3%), followed by the anterior choroidal artery (8 patients, 22.9%) and ophthalmic artery (1 patient, 2.9%). During the follow-up period (38.6 ± 17.9 months), no new neurologic deficits developed. Neither hemorrhagic nor thromboembolic events occurred. Angiography was performed during the final follow-up evaluation at a mean of 32.7 ± 18.0 months, and all ICA branches with embedded stent tips showed patent blood flow without severe luminal narrowing.

CONCLUSIONS

In our experience, placement of a stent tip into ICA branches during stent-assisted coiling was not associated with any major adverse events.

Pruritic arthropod bite-like papules in T-cell large granular lymphocytic leukaemia and chronic myelomonocytic leukaemia

T-cell large granular lymphocytic leukaemia (T-LGLL) is a clinically indolent mature T-cell neoplasm characterized by a monoclonal population of CD3+ CD8+ cytotoxic T cells, which usually presents as neutropenia, anaemia and thrombocytopenia. Chronic myelomonocytic leukaemia (CMML) is a clonal haematopoietic disorder with features of both a myeloproliferative neoplasm and myelodysplastic syndrome (MDS). Patients with CMML exhibit a persistent peripheral blood monocytosis in addition to myelodysplastic features. Because of the rarity of T-LGLL, its cutaneous manifestations are poorly documented, but include vasculitis, vasculopathy, persistent ulcerations, generalized pruritus and disseminated granuloma annulare. Various types of skin lesions have been observed in patients with CMML and reportedly occur in approximately 10% of cases. We report the extraordinary case of a patient with MDS who developed T-LGLL, and subsequently the MDS progressed to CMML. The patient then developed diffuse arthropod bite-like papules and intractable pruritus.

Growth performance, oxidative stress, and non-specific immune responses in juvenile sablefish, Anoplopoma fimbria, by changes of water temperature and salinity

Juvenile sablefish, Anoplopoma fimbria (mean length 15.5 ± 1.9 cm, mean weight 68.5 ± 4.8 g), were used to evaluate the effects on growth, oxidative stress, and non-specific immune responses by changes of water temperature (8, 10, 12, 14, 16, 18, and 20 °C) and salinity (100 (35.0), 90 (31.5), 80 (28.0), 70 (24.5), 60 (21.0), 50 (17.5), and 40% (14.0) (‰)) for 4 months. The growth performance was significantly increased at the temperature of 12 and 14 °C, and the feed efficiency was notably decreased at the temperature of 18 °C. The growth performance and feed efficiency were also significantly decreased at low salinity. The antioxidant responses such as superoxide dismutase and catalase were significantly increased by the high temperature and decreased by the low salinity. The immune responses such as lysozyme and phagocytosis were elevated by the temperature of 18 °C and decreased by the salinity of 50%. The results of this study indicate that the growth performance of juvenile sablefish, A. fimbria, is influenced by the temperature and salinity, and the excessive temperature and salinity levels can affect the antioxidant and immune responses.

Toxic effects of juvenile sablefish, Anoplopoma fimbria by ammonia exposure at different water temperature

Juvenile sablefish, Anoplopoma fimbria (mean length 17.1±2.4cm, and mean weight 75.6±5.7g) were used to evaluate toxic effects on antioxidant systems, immune responses, and stress indicators by ammonia exposure (0, 0.25, 0.75, and 1.25mg/L) at different water temperature (12 and 17°C) in 1 and 2 months. In antioxidant responses, superoxide dismutase (SOD) and catalase (CAT) were significantly increased by ammonia exposure, whereas glutathione (GSH) was decreased. In immune responses, lysozyme and phagocytosis activity were significantly increased by ammonia exposure. In stress indicators, plasma glucose, heat shock protein 70 (HSP 70), and cortisol were significantly increased. At high water temperature (17°C), alterations by ammonia exposure were more distinctly. The results of this study indicated that ammonia exposure can induce toxic effects in the sablefish, and high water temperature can affect the ammonia exposure toxicity.

Antioxidant Responses, Neurotoxicity, and Metallothionein Gene Expression in Juvenile Korean Rockfish Sebastes schlegelii under Dietary Lead Exposure

This study was conducted to assess toxic effects of dietary lead (Pb) exposure on Korean Rockfish Sebastes schlegelii. Juvenile rockfish were used to evaluate the oxidative stress, neurotoxicity, and metallothionein (MT) gene expression after dietary exposure to lead (as Pb²⁺; 0, 30, 60, 120 and 240 mg/kg). Superoxide dismutase (SOD) activity, a measure of oxidative stress, was substantially elevated in the livers and gills of fish given dietary Pb greater than 60 mg/kg. Glutathione S-transferase (GST) activity in the liver and gill was significantly increased by dietary Pb > 60 mg/kg. A significant decrease in glutathione (GSH) level was observed in fish liver after exposure to dietary Pb > 30 mg/kg and in the gill after treatment with dietary Pb > 120 mg/kg. Acecyltholinesterase (AChE) was noticeably decreased in the brain by dietary Pb > 120 mg/kg and in the muscle by dietary Pb > 60 mg/kg. Metallothionein gene expression in the liver was stimulated significantly by the Pb exposure. Because dietary Pb exposure had a toxic effect on antioxidant responses, a neurotransmitter, and a specific immune expression in rockfish, the results of this study can be used to determine potential useful markers of Pb toxicity. Received June 11, 2016; accepted March 10, 2017.

Evaluating augmentation with calcium phosphate cement (chronOS Inject) for bone defects after internal fixation of proximal tibial fractures: A prospective, multicenter, observational study

INTRODUCTION

Managing subchondral bone defects in proximal tibia fractures after plateau reduction is an important consideration. ChronOS Inject is a recently developed calcium phosphate bone substitute that shows relatively fast osteointegration.

HYPOTHESIS

Using chronOS Inject during internal fixation of proximal tibial fractures provides a satisfactory treatment option that is both clinically and radiologically safe.

PATIENTS AND METHODS

Patients enrolled in this study were treated with chronOS Inject bone void filler, during internal fixation of proximal tibial fractures. Patients were evaluated preoperatively and at 6 weeks, 6 and 12 months postoperative. Radiographic union was assessed using plain films supplemented by CT scans. Pain, function and adverse events were collected at all visits. A total of 36 patients were enrolled in the study and treated according to a predetermined protocol. Seven of the 36 patients (19.4%) were lost to follow-up.

RESULTS

Successful radiographic union was achieved in 27/29 (93.1%) of patients at final follow-up. Articular subsidence of>2mm only occurred in one patient. Statistical analysis showed significant improvements both in leg pain and knee function. Progress in knee function was observed in 93.1% (27/29) of patients from 6 weeks to 12 months. No product-related complications were reported.

CONCLUSIONS

Successful union was achieved based on radiographic criteria as well as clinical outcomes. When managing bone defects after internal fixation of proximal tibial fractures, the use of chronOS Inject resulted in significant improvement of knee function and reduction of leg pain.

LEVEL OF EVIDENCE

Level IV, prospective observational study.

Prophylactic Antiplatelet Medication in Endovascular Treatment of Intracranial Aneurysms: Low-Dose Prasugrel versus Clopidogrel

BACKGROUND AND PURPOSE

Prophylactic antiplatelet medication is beneficial in decreasing thromboembolic complications during endovascular treatment of unruptured intracranial aneurysms. The efficacy may be limited by variability of individual response to antiplatelet medication, especially clopidogrel. We compared the efficacy of 2 antiplatelet medications, low-dose prasugrel and clopidogrel, in patients undergoing endovascular treatment of unruptured aneurysms.

MATERIALS AND METHODS

From November 2014 to July 2015, 194 patients with a total of 222 unruptured aneurysms underwent endovascular treatment at a single institution. Laboratory and clinical data from the prospectively maintained registry were used in this study. Antiplatelet medication was given the day before endovascular treatment (prasugrel 20 mg or 30 mg or clopidogrel 300 mg). Response to the antiplatelet medication was measured by the VerifyNow system. Periprocedural adverse event rates between the 2 groups were compared.

RESULTS

There were no significant differences in the baseline characteristics of patients and aneurysms between the 2 groups. The P2Y12 reaction unit values were lower (clopidogrel group versus prasugrel group, 242.7 ± 69.8 vs 125.7 ± 79.4; P < .0001) and percentage inhibition values were higher (22.1% ± 19.7% vs 60.2 ± 24.7%; P < .0001) in the prasugrel group. There were no thromboembolic events, but there was 1 procedural bleed in each group, without any clinical consequences.

CONCLUSIONS

The prasugrel group showed more effective and consistent platelet inhibition. We may omit the antiplatelet response assay with the low-dose prasugrel premedication before the endovascular treatment of patients with unruptured aneurysms. Further study is required to determine whether there is benefit of this strategy regarding clinical outcome.

Sargaquinoic acid attenuates inflammatory responses by regulating NF-κB and Nrf2 pathways in lipopolysaccharide-stimulated RAW 264.7 cells

Myagropsis myagroides, a brown alga, showed strong anti-inflammatory activities in the previous studies. In this study, we isolated a strong anti-inflammatory compound, sargaquinoic acid (SQA), from M. myagroides and investigated the anti-inflammatory action using lipopolysaccharide (LPS)-stimulated RAW 264.7 cells. SQA suppressed the production of inducible nitric oxide synthase and cyclooxygenase-2 in LPS-stimulated cells as well as that of reactive oxygen species. As a result, SQA inhibited the production of NO, prostaglandin E2, and pro-inflammatory cytokines. LPS-induced transcriptional activation of nuclear factor-κB (NF-κB) was remarkably inhibited by SQA treatment through the prevention of inhibitor κB-α degradation. The regulation of NF-κB activation was also mediated by the phosphorylation of ERK and Akt in LPS-stimulated RAW 264.7 cells. Moreover, SQA induced the production of heme oxygenase 1 via activation of transcription factor Nrf2. These results indicate that SQA inhibits the LPS-induced expression of inflammatory mediators via suppression of ERK and Akt-mediated NF-κB pathway as well as up-regulation of Nrf2/HO-1 pathway, indicating that SQA has a potential therapeutic and preventive application in various inflammatory diseases.

Steerable pencil beams for multi-Gbps indoor optical wireless communication

We report a novel optical wireless communication (OWC) system solution that supports multi-Gbps (Gigabit-per-second) capacity for indoors. Narrow beams, termed as pencil beams, are directed to wireless users using a tunable laser and a passive diffractive optical element. This enables a wide coverage of ultra-high-capacity communication links to serve multiple network users simultaneously. Experimental results demonstrating data rates of up to 10 Gbps, with on-off keying modulation format, over a distance of more than 2.5 m, are reported. Error-free links beam-steered over a total wavelength range of 130 nm, with steering angle of 17.16°, have been achieved. This system is proposed for short-range OWC and is promising for seamless integration in in-building optical networks.

Toward multi-Gbps indoor optical wireless multicasting system employing passive diffractive optics

This Letter presents the evaluation and demonstration of an optical free-space (FS) multicasting system for multi-Gigabits-per-second (multi-Gbps) indoor transmission. These simultaneous line-of-sight links are formed by infrared beams and are beam-steered using a passive diffraction grating. The experiment has resulted in error-free links (bit error rate <10(-9) at 2.5 Gbps on-off keying) and is scalable to support higher data rates. This system is proposed for short-range optical wireless communication and can be seamlessly integrated in in-building fiber networks.

The characteristics and risk factors of headache development after the coil embolization of an unruptured aneurysm

BACKGROUND AND PURPOSE

Development of a headache after aneurysm coil embolization is not uncommon but has received little attention. The authors prospectively analyze the characteristics and risk factors of a headache after coiling in patients treated for an unruptured cerebral aneurysm.

MATERIALS AND METHODS

Ninety patients treated for an unruptured cerebral aneurysm over a period of 1 year, and without a headache history within a month before coiling, were enrolled in this study. All coilings were successfully performed without neurologic complications. After coiling, headache development and intensities were recorded.

RESULTS

Fifty (55.6%) patients experienced a headache (VAS score, 4.5 ± 2.02) at 7.9 (range, 0-72) hours, on average, after coiling, and all headaches resolved within an average of 73.0 (range, 3-312) hours. Univariate analysis showed that the following were significantly associated with the development of a headache: age ≤ 50 years (OR 4.636, 95% CI, 1.414-15.198), hypertension (OR 0.232, 95% CI, 0.095-0.571), a packing attenuation of >25% (OR 3.619, 95% CI, 1.428-9.174), and a previous headache history (OR 2.769, 95% CI, 1.120-6.849). However, binary logistic regression showed that only a packing attenuation of >25% (P = .013, adjusted OR 3.774, 95% CI, 1.320-10.790) and no history of hypertension (P = .019, adjusted OR 3.515, 95% CI, 1.233-10.021) were independently associated with the development of a headache.

CONCLUSIONS

A headache frequently developed after the coiling of unruptured aneurysms. However, headaches were relatively benign and resolved within several days. The present study shows that no hypertension history and a packing attenuation of >25% are risk factors of headache development.

Comparison of 2-year angiographic outcomes of stent- and nonstent-assisted coil embolization in unruptured aneurysms with an unfavorable configuration for coiling

BACKGROUND AND PURPOSE

Stents are known to have hemodynamic and biologic effects in addition to their mechanical scaffold effect. To determine whether stents affect long-term outcomes after coiling of unruptured aneurysms, we compared angiographic outcomes at 2 years postembolization for stent- and nonstent-assisted coiled unruptured aneurysms.

MATERIALS AND METHODS

Stent-assisted coiling was used in unruptured aneurysms unfavorable for simple coiling (neck size >4 mm and dome-to-neck ratio <1.5) in our practice. Therefore, 126 coiled unruptured aneurysms in total (40 [31.7%] stent group and 86 [68.3%] nonstent group) with these conditions were selected for this study. The nonstent group aneurysms were treated with multiple microcatheter technique (53 cases) or balloon-assisted technique (33 cases). Self-expandable stents were used for coiling in stent group aneurysms. No significant difference in aneurysmal characteristics (aneurysm type [sidewall/bifurcation], diameter, neck size, and dome-to-neck ratio) or angiographic outcome at embolization (packing attenuation, obliteration grade, and contrast filling) were observed between the 2 study groups.

RESULTS

At 2-year follow-up visits, rates of progressive occlusion (stent group, 17/40 [42.5%] versus nonstent group, 34/86 [39.5%]) and recanalization (7/40 [17.5%] versus 18/86 [21.0%]) did not show a statistically significant difference between the 2 groups (P = .895).

CONCLUSIONS

The present study did not show that additional hemodynamic and biologic effects of stents designed for neck remodeling were enough to enhance progressive occlusion and prevent the recanalization of unruptured aneurysms. Our finding suggests that stent placement provides no better long-term angiographic outcomes for unruptured aneurysms with an unfavorable configuration for coiling.

Intra-arterial nimodipine infusion for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage

This study evaluated the efficacy of intra-arterial nimodipine infusion for symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Clinical data collected from 42 consecutive patients with symptomatic vasospasm after aSAH were retrospectively reviewed. Forty-two patients underwent 101 sessions of intra-arterial nimodipine infusion. Angiographic response, immediate clinical response, and clinical outcome were evaluated at discharge and six months later. Angiographic improvement was achieved in 82.2% of patients. The immediate clinical improvement rate was 68.3%, while the deterioration rate was 5.0%. A favorable clinical outcome was achieved in 76.2% at discharge and 84.6% six months. Vasospasm-related infarction occurred in 21.4%. There was no drug-related complication. The nimodipine group showed satisfactory outcomes. Nimodipine can be recommended as an effective and safe intra-arterial agent for the treatment of symptomatic vasospasm after aSAH.

Endovascular treatment for unruptured intracranial aneurysms in elderly patients: single-center report

BACKGROUND AND PURPOSE

The optimal management of patients with unruptured intracranial aneurysms remains controversial in elderly populations. The aim of this study was to evaluate technical results and clinical outcomes in a single center of consecutive elderly patients with unruptured intracranial aneurysms treated with endovascular embolization.

MATERIALS AND METHODS

Between May 2003 and February 2010, 96 patients older than 70 years (men, 16 patients; women, 80 patients; mean age, 73 years) with 122 saccular unruptured intracranial aneurysms were treated in our hospital with an endovascular approach. The endovascular procedures and technique, angiographic follow-up, and complications were evaluated.

RESULTS

Successful embolizations without complications were completed in 95.9%. Five patients had procedure-related events, including thromboembolism in 1 patient, aneurysm perforation during the procedure in 1, and 3 postoperative transient minor symptoms (headache, otalgia, and trigeminal pain) in 3. The degree of occlusion of the treated aneurysm was complete in 46.7%; there was a small neck remnant in 40.9% and residual filling in 12.2%. Imaging (MR angiography) follow-up was performed in 68.7% of the patients. The mean follow-up duration was 19.4 months (range, 5-57 months). Fifty-five patients (93.9%) showed no interval change of the residual neck. Four (6%) demonstrated recanalizations, all of which were successfully recoiled.

CONCLUSIONS

Endovascular treatment of unruptured intracranial aneurysms in patients older than 70 years of age appears to be safe. Favorable outcomes with low morbidities may replace surgery or conservative treatment as an active management alternative.

Is fasting necessary for elective cerebral angiography?

BACKGROUND AND PURPOSE

In order to prevent unexpected events such as aspiration pneumonia, cerebral angiography has been performed under fasting in most cases. We investigated prospectively the necessity of fasting before elective cerebral angiography.

MATERIALS AND METHODS

The study is an open-labeled clinical trial without random allocation. In total, 2554 patients who underwent elective cerebral angiography were evaluated on development of nausea, vomiting, and pulmonary aspiration during and after angiography. Potential risks and benefits associated with fasting were provided in written documents and through personal counseling to patients before the procedure. The patients chose their fasting or nonfasting option. No restriction in diet was given after angiography. The patients were observed for 24 hours. Nausea and vomiting during and within 1 hour after angiography was considered as a positive event associated with cerebral angiography.

RESULTS

The overall incidence of nausea and vomiting during and within 1 hour after angiography was 1.05% (27/2554 patients). There was no patient with pulmonary aspiration. No statistical difference in nausea and vomiting development between the fasting and the diet groups was found.

CONCLUSIONS

The incidence of nausea and vomiting associated with cerebral angiography is low and not affected by diet or fasting. Pulmonary aspiration had no difference between the diet and the fasting group. Our study suggests that fasting may not be necessary for patients who undergo elective cerebral angiography.

Two-year follow-up of contrast stasis within the sac in unruptured aneurysm coil embolization: progressive thrombosis or enlargement?

BACKGROUND AND PURPOSE

The fate of contrast stasis within an aneurysmal sac after coiling has not been established. We followed and evaluated the potential risks of recanalization of unruptured aneurysms embolized with BPCs for 2 years.

MATERIALS AND METHODS

A total of 301 unruptured aneurysms in 252 patients were treated with BPCs. Contrast stasis was observed on initial postembolization angiograms in 104 (34.6%) of these aneurysms. For follow-up, skull images by an angiographic unit (at 3, 9, 15, and 21 months), CE-MRA including TOF source images (at 6, 12, and 18 months), and DSA (at 24 months) were used.

RESULTS

In 89 (85.6%) of the 104 aneurysms with contrast stasis, the stasis disappeared on 6-month MRAs and occlusions remained unchanged without recanalization for 2 years. In the remaining 15 (14.4%), recanalization occurred during follow-up. The presence of contrast stasis was not found to be associated with the obliteration rate (P = .641) or packing attenuation (aneurysms without contrast stasis 30.7% ± 11.18 versus aneurysms with contrast stasis 33.0% ± 12.11, P = .113). Contrast stasis was not found to be a risk factor for recanalization (15/104 [14.4%] versus 29/197 [14.7%], P = 1.000).

CONCLUSIONS

Contrast stasis is a benign angiographic finding that can disappear within 6 months on follow-up MRA. In addition, contrast stasis was not found to be associated with a low obliteration rate or packing attenuation or to be a risk factor for recanalization. The present study shows that aneurysms with contrast stasis on initial postembolization angiograms are no more likely to recanalize than aneurysms without contrast stasis.

Intracranial stent placement for recanalization of acute cerebrovascular occlusion in 32 patients

BACKGROUND AND PURPOSE

Stents have been reported as an option for improvement of the recanalization rate in AIS. The authors have also used intracranial stents in failed cases of IAT with pharmacologic and mechanical methods since 2004. We retrospectively reviewed our cases of intracranial stent use for IAT of AIS for recanalization and as a rescue procedure for iatrogenic intracranial vascular dissection during IAT.

MATERIALS AND METHODS

Thirty-two patients, who were diagnosed with AIS, were treated with intracranial stents (28 balloon-mounted and 7 self-expandable stents) at our neurovascular center between April 2004 and December 2008. The stent use for all 32 patients was the final attempt to recanalize occluded vessels after various trials of pharmacologic or mechanical thrombolysis or to treat iatrogenic vascular dissection.

RESULTS

Among the 32 patients, immediate poststenting angiographic recanalization was achieved in 100% with TIMI/TICI 2 (15 of 32 lesions, 46.9%) or TIMI/TICI 3 (17 of 32 lesions, 53.1%). However, complication rates were also high. Major symptomatic intracerebral hemorrhage (1 case of procedural symptomatic hemorrhage and 3 cases of delayed symptomatic hemorrhage) occurred in 4 (12.5%); intracranial vascular dissection, in 4 (12.5%); extracranial vascular dissection, in 3 (9.4%); immediate IST, in 4 (12.5%); subacute (within 1 week) IST, in 2; late (>1 week) IST, in 1, and 1 case of in-stent restenosis occurred twice (at 5 and 17 months).

CONCLUSIONS

Intracranial stent placement for AIS management has an excellent recanalization rate. However, it is associated with high complication risks as our series showed. We believe that the decision to treat AIS with intracranial stent placement should be made after careful consideration of potential benefits and risks.

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.

Endovascular coil embolization of 435 small asymptomatic unruptured intracranial aneurysms: procedural morbidity and patient outcome

BACKGROUND AND PURPOSE

Whether treatment of small asymptomatic aneurysms is appropriate or not remains controversial. We performed a retrospective study on the procedural morbidity and mortality of coil embolization of small asymptomatic unruptured intracranial aneurysms (UIAs) to obtain a more generalized estimate of procedural risk.

MATERIALS AND METHODS

A total of 435 small (maximum diameter < or = 7 mm) asymptomatic UIAs in 370 patients were treated by coil embolization. Aneurysm sizes were determined by using 3D angiograms. We assessed procedure-related morbidity and mortality, immediate postprocedural angiographic results, short-term imaging follow-up results, and clinical outcomes.

RESULTS

Initial aneurysm occlusion was complete in 334 aneurysms, near complete in 78, and incomplete in 22. One internal carotid artery (ICA) aneurysm that ruptured during the procedure was treated with parent artery occlusion. Two hundred wide-neck aneurysms were coiled with the aid of various neck-remodeling techniques. The 44 procedure-related complications were the following: 24 thromboembolisms, 11 coil protrusions or prolapses into the parent vessel, 4 intraprocedural ruptures, 3 device-related complications, and 2 femoral-access complications. We had a total of 44 (10.1%) procedure-related complications with only 1 leading to persistent neurologic deficit. Procedure-related permanent morbidity and mortality were 0.27% (1/370) and 0%, respectively.

CONCLUSIONS

In this series of small unruptured asymptomatic aneurysms, endovascular treatment was achieved with good short-term angiographic outcome and low permanent neurologic impairment. The goal of this study was not to provide a conclusion about treatment guidelines for small UIA but rather to help guide future recommendations by presenting a more generalized estimate of endovascular treatment risk than is currently available.

Reproduction and growth of the freshwater prawn, Palaemon paucidens (Decapoda: Palaemonidae) in a lake of Korea

This study analyzed the reproduction and growth of freshwater prawn, Palaemon paucidens De Haan 1844 from Suk-dang lake(Korea). The analysis of the sex ratio showed a higher proportion of males than that of females. The average size of the eggs was 6.12 (+/-0.55) mm3 in the non-eyed stage (stageA) and 7.20 (+/-0.86)mm3 in the eyed stage (stage B). The reproductive output (RO) calculated with the dried-body weight of an incubating female and the weight of the eggs in dried condition was 26.97% (n = 17) of the average females weight. Incubating prawn appeared in April, and the gonadosomatic indices(GSI) showed the highest value during three months from January to March. Based on the month when there was a high proportion of incubating females with a high GSI, the estimated spawning season of P. paucidens was April. The maturity of the female was evaluated by the development of the ovaries and the existence of eggs. The average body length when 50% of the females in the group reached maturity was 8.55 (+/-2.74) mm. The analysis of the length-frequency distribution showed that the life span of P. paucidens ranged from 12 to 13 months. Females mature faster than males.

Hyperventilation-induced nystagmus in peripheral vestibulopathy and cerebellopontine angle tumor

OBJECTIVE

To determine the incidence and characteristics of hyperventilation-induced nystagmus (HIN) in cerebellopontine angle (CPA) tumors and unilateral peripheral vestibulopathy (UPV), and to elucidate differential contribution of hyperventilation to bring out vestibular asymmetry between acute and chronic phases of UPV.

METHODS

We recorded horizontal HIN in 33 patients with CPA tumors and 145 with UPV. The UPV included patients of either acute (7 days or less from symptom onset, n = 47) or chronic (more than 7 days from symptom onset, n = 98) phases.

RESULTS

The incidence of HIN was higher in the CPA tumor than in the UPV group (82 vs 34%, p < 0.01) and was also higher in the acute than in the chronic UPV group (60 vs 21%, p < 0.01). Furthermore, HIN was more commonly ipsilesional (i-HIN) in the CPA tumor than in the UPV group (52 vs 8%, p < 0.01) and more commonly ipsilesional in the acute than in the chronic UPV group (21 vs 1%, p < 0.01). The patients with i-HIN and acoustic neuroma had a tendency to harbor smaller tumors and to have less severe caloric asymmetry.

CONCLUSIONS

The contribution of hyperventilation on vestibular nystagmus differs depending on the disease phase or underlying pathologies. Our study demonstrates that hyperventilation-induced nystagmus (HIN) beating to the side of reduced caloric response, hearing impairment, or abnormal auditory brainstem response responses may be a valuable sign for bedside detection of cerebellopontine angle (CPA) tumors. CPA tumor should be a prime suspicion in patients with acute vertigo and ipsilesional HIN, especially when the vertigo accompanies hearing impairments.

Embolization of wide-necked aneurysms with using three or more microcatheters

BACKGROUND

A new and relatively simple endovascular technique, in which more than three microcatheters are used for endovascular treatment of cerebral aneurysms for the first time, is described.

METHOD

Eight patients with wide necked aneurysms were successfully treated with detachable coils using the multiple microcatheter technique. Three patients presented with subarachnoid haemorrhage and five were unruptured. The aneurysm locations were superior hypophyseal artery (2), posterior communicating artery (2), middle cerebral artery bifurcation (1), distal anterior cerebral artery (1), basilar artery (1) and vertebral artery (1). The average neck size was 7.4 +/- 2.8 mm (3.5-12 mm), average width of the aneurysms was 10.6 +/- 5.7 mm (6.2-23 mm) and depth was 8.9 +/- 5.8 mm (3-22 mm). Three microcatheters (7 patients) and four microcatheters (1 patient) were introduced and used for coil delivery. Three or four coils were deployed and intermingled to stabilize the whole coil mass as well as to occupy the aneurysmal sac. When a relatively stable coil frame was formed, one coil was detached and subsequent coils were inserted. After the coil mass became more stable, other coils were also detached and all microcatheters were used for subsequent coil deployment.

FINDINGS

All aneurysms were successfully treated without complications. Postemboilzation angiograms showed no contrast filling in 5 cases (100% occlusion) and a very small residual neck in 3 cases. There was no procedure related complication.

CONCLUSION

The multiple microcatheter technique can be one technical option for the endovascular treatment of wide necked aneurysms.

Clinical analysis of vertebrobasilar dissection

BACKGROUND

The natural history of vertebrobasilar artery dissection (VAD) is not fully known. The purpose of this study was to review the clinical outcome of the patients with VAD, then to propose an appropriate management strategy for VAD.

METHOD

From 1992 to 2004, 35 VAD patients admitted to our institutes were retrospectively reviewed. There were 28 men and 7 women, whose age ranged from 4 to 67 years with a mean age of 44 years. Angiography was assessed to document the shape, and location of the dissecting aneurysm with respect to the posterior inferior cerebellar artery (PICA). A modified Rankin score was assigned for functional outcome. The functional outcome scores were analyzed according to the patient's age, gender, hypertension history, the pattern of initial manifestation, angiographic shape of VAD, angiographic location of VAD, treatment modality.

FINDINGS

There was no statistically significant difference between the functional outcome with age, gender, trauma history and past medical history of hypertension. Of 35 patients, 22 presented with SAH, 11 with ischemic symptoms and 2 were incidentally detected. The patients without SAH had a better functional outcome than those with SAH (p = 0.029). There was statistical significance between Hunt-Hess (H-H) grade and clinical outcome (p = 0.032). The shape and location of VAD was not significantly related to the functional outcome (p = 0.294, 0.840). But all the cases of rebleeding and mortality (except one case with initially poor H-H grade) developed exclusively in patients with aneurysms. There was no statistically significant correlation between the treatment modality and the outcome (p = 0.691).

CONCLUSION

The VAD patients with SAH would be recommended to be managed by either surgical or endovascular treatment, but those without SAH, could be managed conservatively with antiplatelet therapy and/or anticoagulation.

Anatomical and clinical outcomes after endovascular treatment for unruptured cerebral aneurysms. A single-center experience

SUMMARY

To describe the immediate and follow-up anatomical outcomes as well as procedure-related morbidity after endovascular procedures for unruptured cerebral aneurysms, we reviewed 68 patients with 78 unruptured aneurysms treated with detachable coils from may 1996 to february 2002. Angiograms were retrospectively reviewed for the nature of the aneurysms and the degree of therapeutic obliteration. Periprocedural complications, immediate clinical outcome and longterm neurological status were analyzed. Immediate anatomical outcomes were complete in 35 aneurysms (45%); residual neck in 24 (31%), partial contrast filling in 17 (22%), and failed embolization in two (2%). Of 27 aneurysms with follow-up angiography, 12 of the 13 aneurysms that were completely occluded in the initial treatment were still completely occluded at the end of a mean follow-up period of 17 months. Periprocedural complications were thromboembolic (n=6), haemorrhagic (n=3), coil protrusion (n=7) and other unrelated complications (n=3). Only two patients, with thromboembolic complications were moderately disabled with permanent neurological deficits in immediate clinical outcome, and their condition improved to independent in 1.5 and three months each. Small aneurysms and posterior circulation location showed more protective immediate results than aneurysms of large and anterior circulation after endovascular treatment (p values: 0.01 and 0.02). Our experiences of endovascular treatment for unruptured cerebral aneurysms were comparable to the results of recent series. Endovascular treatment for small posteriorly located aneurysms produced significantly better results than for large anteriorly located lesions.

Procedure-related haemorrhage in embolisation of intracranial aneurysms with Guglielmi detachable coils

We reviewed the haemorrhagic complications of the endovascular treatment of intracranial aneurysms, in terms of frequency, pre-embolisation clinical status, clinical and radiological manifestations, management and prognosis. In 275 patients treated for 303 aneurysms over 7 years we had seven (one man and six women--2.3%) with haemorrhage during or immediately after endovascular treatment. All procedures were performed with a standardised protocol of heparinisation and anaesthesia. Four had ruptured aneurysms, two at the tip of the basilar artery, and one ach on the internal carotid and posterior cerebral artery, treated after 12, 5, 14, and 2 days, respectively, three were in Hunt and Hess grade 2 and one in grade 1. Bleeding occurred during coiling in three, after placement of at least four coils, and during manipulation of the guidewire to enter the aneurysm in the fourth. Haemorrhage was manifest as extravasation of contrast medium, with a sudden rise in systolic blood pressure in three patients. The other three patients had unruptured aneurysms; they had stable blood pressure and angiographic findings during the procedure, but one, under sedation, had seizures immediately after insertion of four coils, and the other two had seizures, headache and vomiting on the day following the procedure. Heparin reversal with protamine sulphate was started promptly started when bleeding was detected in four patients, and the embolisation was completed with additional coils in three. Emergency ventricular drainage was performed in the two patients with ruptured aneurysm and one with an unruptured aneurysm who had abnormal neurological responses or hydrocephalus. The bleeding caused a third nerve palsy in one patient, which might have been due to ischaemia and progressively improved.

Aplasia of the internal carotid artery

BACKGROUND

The majority of previous reports on this rare agenesis of the internal carotid artery (ICA) have been limited to reporting upon its association with other congenital anomalies case by case. In order to collectively summarize this congenital anomaly of ICA, we have reviewed nine cases of ICA aplasia and their associated abnormalities.

METHODS

Nine cases of ICA aplasia were reviewed. The diagnosis of aplasia or agenesis of the ICA was based on angiographic findings and the presence of an absent or hypoplastic bony carotid canal by temporal bone computed tomography (TBCT). Their presumable embryological aetiologies, initial presenting symptoms, unusual collateral circulations, as demonstrated by angiographies, and various associated anomalies are reviewed.

FINDINGS

The initial presentations were; subarachnoid haemorrhage in three patients, headache in one patient and ischemic symptoms and signs in three patients. The remaining two cases were found incidentally during angiography for other diseases. Collateral circulations to the middle cerebral artery ipsilateral to the ICA aplasia were via posterior communicating artery (P-com) or anterior communicating artery (A-com). On TBCT, all cases but one demonstrated agenesis of the bony carotid canal and the remaining case showed a hypoplastic canal. Cerebral aneurysms were found in six patients, four with A-com aneurysm, one with a basilar bifurcation aneurysm, and one with both a right P-com and a left cavernous ICA aneurysm; two incidentally found cases had no aneurysm. Other associated abnormalities were found in four cases; one case of hypoplasia of the common carotid artery (CCA) with an arachnoid cyst at the temporal pole, one case of abnormal origin of the right CCA from the aorta and the right subclavian artery from the descending aorta, one case of congenital temporomandibular joint (TMJ) ankylosis, and one case of nasopharyngeal angiofibroma with atresia of the upper basilar artery. Except for the atresia of the upper basilar artery, all such abnormalities were found on the same side as the ICA aplasia.

INTERPRETATION

Agenesis or aplasia of ICA may be entirely harmless. However, associated conditions such as cerebral aneurysm or abnormal collateral channels should alert clinicians to the possibility of deterioration to life-threatening conditions, such as subarachnoid haemorrhage or irreversible ischemia. Other associated anomalies are commonly depicted on the same side as the ICA aplasia and may also give rise to issues of clinical importance.

Childhood meningioma: unusual location, atypical radiological findings, and favorable treatment outcome

OBJECTS

To investigate the characteristics of childhood meningioma, especially, locations, radiological findings, pathological features (including proliferative potential) and outcome, 11 children with meningiomas were retrospectively analyzed.

RESULTS

Unusual location, large size, frequent calcification, and cyst formation were characteristic radiological findings. Gross total resection was achieved in 8 patients, and there was recurrence in 2. Gamma knife radiosurgery was performed on residual and recurrent tumors. MIB-1 indices tended to be high in large tumors. Nine patients had a Karnofsky Performance Scale of more than 70 during the follow-up period of 10 months to 19.5 years. Surgical treatment rendered 4 of 5 epileptic patients seizure free. The childhood meningiomas examined had unusual locations, atypical radiological findings, and various proliferative potentials.

CONCLUSIONS

Complete resection is the treatment of choice. Gamma knife radiosurgery can be a good alternative for residual tumors and small recurrent tumors. The outcome of childhood meningiomas is good after surgery.

Induction of a senescence-like phenotype in bovine aortic endothelial cells by ionizing radiation

Treatment of confluent monolayers of bovine aortic endothelial cells (BAEC) with gamma rays resulted in the delayed appearance of cells with an enlarged surface area that were morphologically similar to senescent cells. The majority of these cells stained positively for senescence-associated beta-galactosidase (SA-beta-gal), indicating that these cells are biochemically similar to senescent cells. The incidence of the senescence-like phenotype increased with dose (5-15 Gy) and time after irradiation. Cells with a senescence-like phenotype began to appear in the monolayer several days after irradiation. The onset of the appearance of this phenotype was accelerated by subculturing 24 h after irradiation. This acceleration was not entirely due to stimulation of progression through the cell cycle, since a high percentage of the senescent-like cells that appeared after subculture were not labeled with BrdUrd during the period after subculture. Prolonged up-regulation of expression of CDKN1A (also known as p21(CIP1/WAF1)) after irradiation was noted by Western blot analysis, again suggesting a similarity to natural senescence. Phenotypically altered endothelial cells were present in the irradiated monolayers as long as 20 weeks after irradiation, suggesting that a subpopulation of altered endothelial cells that might be functionally deficient could persist in the vasculature of irradiated tissue for a prolonged period after irradiation.

Early stage onychomadesis presenting as painful swellings of proximal nail folds

Two Korean men complained of painful erythematous swellings of the proximal nail folds. When we removed the overlying nail plates, we observed new ones growing under the old ones. These painful swellings disappeared after the affected nails were extracted. We found typical onychomadesis in another finger during the follow-up, suggesting that the initial condition marked the onset of onychomadesis. Because both patients had plaster casts removed recently and histories of trauma, it was hypothesized that trauma might be responsible for this peculiar condition.

Primary unreamed intramedullary nailing for open fractures of the tibia

Forty-six open tibial fractures (42 patients) were treated by primary unreamed intramedullary nailing, with debridement of open wounds and treatment of soft tissue. According to Gustilo-Anderson classification there were 18 grade I cases, 18 grade II cases and 10 grade III cases. The incidence of infection was low with two cases of superficial infection and one of deep infection. The mean time for union was 21.9 weeks and the rate of nonunion was 10.8%. There was no significant difference in the mean time to union, infection rate and rate of nonunion with different site and grade of fracture, but there was a longer union time and a higher rate of nonunion in complex and comminuted fractures. Unreamed intramedullary nailing, with appropriate soft tissue treatment, gives good results in the treatment of open tibial fractures including grade III.

Expression of the cyclin-dependent kinase inhibitor p27 in keratoacanthoma

BACKGROUND

Keratoacanthomas are characterized by initial rapid enlargement followed by clinical regression. A series of cyclin and cyclin-dependent kinase complexes regulate cell cycle progression. p27(kip) inhibits a variety of cyclin-cyclin-dependent kinase complexes in vitro and may act to hold eukaryotic cells in a quiescent state (G0).

OBJECTIVE

We examined expanding and regressing keratoacanthomas for expression of p27(kip).

METHODS

An immunohistochemical method was used to visualize and count p27(kip)-labeled cells in 5 expanding and 15 regressing keratoacanthomas.

RESULTS

In normal epidermis p27(kip) was found overlying the nuclei of suprabasilar keratinocytes. In expanding keratoacanthoma there was little expression of p27(kip) in nuclei of atypical keratinocytes composing the tumor (1.25 +/- 2.1 labeled cells per high-power field); in regressing keratoacanthoma the nuclei of most suprabasilar keratinocytes in atypical tumor aggregates contained p27(kip) (55.1 +/- 28.6 labeled cells per high-power field). The difference was significant at P values of less than.001.

CONCLUSION

The identification of p27(kip) in regressing keratoacanthoma but not in expanding keratoacanthoma suggests that p27(kip) may be playing a role in promoting regression of keratoacanthoma and is a potential target for pharmacologic intervention.

Fracture separation of the distal humeral epiphysis in children younger than three years old

This study evaluated the change of carrying angle and the causes of cubitus varus after the fracture separation of the distal humeral epiphysis in young children. Twelve cases of fracture separation of distal humeral epiphysis were treated from January 1995 to July 1997. The age of all patients was younger than 3 years old. A metaphyseal fragment was seen in all cases (Salter-Harris type II), but the size of the metaphyseal fragment was either a very small flake or a large Thurston-Holland fragment. Posteromedial displacement was seen in all cases. There were three treatment groups: closed reduction with percutaneous pinning, closed reduction with cast, and cast without reduction. Follow-up period averaged 23.5 months (range, 12-40). Cubitus varus deformity was seen in seven cases, and six of them had a partial defect of the medial condyle that was avascular necrosis. The methods of treatment, age of injury, and the type of epiphyseal injury had no influence on the development of cubitus varus, but avascular necrosis of the medial condyle was related to the cubitus varus deformity (p<0.05). The results of this study suggest that fracture separation of distal humeral epiphysis in young children is likely to produce cubitus varus deformity with the development of avascular necrosis of the medial humeral condyle.

Percutaneous gallbladder drainage for delayed laparoscopic cholecystectomy in patients with acute cholecystitis

BACKGROUND

Many studies have concluded that delayed or interval laparoscopic cholecystectomy (LC) in patients with acute cholecystitis (AC) demonstrated higher conversion rates and complication rates compared with early LC. However, if the acutely inflamed gallbladder is decompressed by emergent percutaneous gallbladder drainage (PGBD), it may decrease the technical difficulty of LC allowing successful delayed LC when the patient is in better condition. The purpose of this retrospective study was to assess the outcomes of delayed LC following PGBD in patients with AC.

METHODS

A total of 72 LC for AC were divided into PGBD (n = 27) and non-PGBD groups (n = 45). The PGBD group had delayed LC (after 72 hours of admission). Thirty-two non-PGBD patients had early LC (within 72 hours of admission) and 13 non-PGBD had delayed LC. Outcome of delayed LC for the PGBD group was assessed by LC time, conversion rate, morbidity rate, and hospital stay, and compared with that of the non-PGBD group.

RESULTS

Compared with early and delayed LC of the non-PGBD group, the PGBD group showed longer LC time (median 110 minutes versus 87.5 minutes versus 85 minutes, P <0. 05), a little lower conversion rate (15% versus 25% versus 23%), similar morbidity rate (15% versus 9% versus 15%), and prolonged hospital stay (13 days versus 7 days versus 10 days).

CONCLUSIONS

PGBD did not significantly improve the outcome of LC for AC as assessed by conversion and morbidity rate and hospital stay compared with no PGBD. Thus, we can conclude that although PGBD is a safe and effective emergency procedure for AC, it should be limited to higher risk groups such as elderly or critically ill patients and to acalculous cholecystitis.

Clinical characteristics of vertebrobasilar artery dissection

Sixteen patients with the diagnosis of vertebral or basilar artery dissection who were admitted at the Seoul National University Hospital from 1972 to 1996 are described. During the same period, we encountered 76 patients with posterior circulation aneurysms, so the vertebrobasilar artery dissection was 21% of posterior circulation aneurysms. The mean age was 44 years, and male predominated. Nine patients presented with subarachnoid hemorrhage (SAH) and seven with ischemic symptoms. The characteristic angiographic finding of patients with SAH was aneurysmal dilatation (pseudoaneurysm) in eight of nine cases. In cases of ischemic symptoms, only one case had aneurysmal dilatation. Some other angiographic findings were demonstrated such as string sign, tapered narrowing, complete occlusion, or double lumen. Clinical course of SAH group was much different from that of ischemic group. Rebleeding occurred in three patients of SAH group; immediately after the rebleeding all patients became comatose, but after extraventricular drainage, all patients with rebleeding recovered rapidly. In SAH group, four of nine cases died but there was no mortality in the ischemic group. These four patients showed signs of stem failure, when computed tomography (CT) demonstrated no evidence of additional bleeding and follow-up CT showed the infarction at a part of stem and/or cerebellum. Vasospasm or sudden extensive extension of dissection could be the cause of death. Surgical management was performed in three patients, endovascular intervention in four, and conservative management in two. The patients with incomplete embolization or conservative management had poor outcome. In ischemic group, all underwent conservative management including anticoagulation and/or antiplatelet therapy. On follow-up, most of the patients with ischemic symptoms made complete or very good recoveries.

A case of nodular cystic fat necrosis: the end stage lesion showing calcification and lipomembranous changes

Nodular cystic fat necrosis, first described by Przyjemski et al. in 1978, is a distinct, benign subcutaneous lesion characterized histologically by encapsulated fat necrosis. We report a case of nodular cystic fat necrosis in a 22-year-old man who had had two mobile, rice-sized, deep-seated papules on his right shin for ten years after trauma. Histologically, the excised mass showed encapsulated fat necrosis, calcification, and lipomembranous changes. The encapsulation of necrotic tissue may prevent further extension of adiponecrosis. The subcutaneous fat is prone to trauma or ischemia. The observation of lipomembranous changes in nodular cystic fat necrosis seems to support the concept that lipomembranous change is a nonspecific pattern of the fat necrosis due to multiple local or systemic events causing a compromise in the blood supply of the subcutaneous tissue.

Moyamoya disease in adults: characteristics of clinical presentation and outcome after encephalo-duro-arterio-synangiosis

To determine the clinical characteristics and the effectiveness of encephalo-duro-arterio-synangiosis (EDAS) in adulthood-onset Moyamoya disease (MMD), the authors retrospectively reviewed 26 patients suffering from MMD who were admitted to Seoul National University Hospital between 1987 and 1995. When they showed major symptoms, all were more than 16 years-old. The most common presenting symptom was intracranial hemorrhage (ICrH), found in 12 patients or 46% of the total; the second was infarction and transient ischemic attack, each found in seven or 27% of them. Only one patient was found to have seizures, which were associated with a cerebral infarction. The Suzuki angiographic stage 3 and less than stage 3 accounted for 73% of all 52 hemispheres. A total of 15 patients underwent single photon emission computed tomography (SPECT) preoperatively. When the derangement of cerebral perfusion was estimated with four SPECT grades (SG), 70% of their hemispheres revealed normal (SG1) or localized decreased-perfusion (SG2). The other 30% had extensive decreased-perfusion or localized perfusion defects (SG3). There was no case who had extensive perfusion defects (SG4). A total of 17 patients underwent EDAS operations (EDAS group) and nine did not undergo any operation (no-op group). The EDAS group had significantly better clinical outcomes than the no-op group after a 12-month median follow-up period (P < 0.05). The angiographic and SPECT follow-up studies comprised six and seven cases, respectively. There was also satisfactory angiographic revascularization in all follow-up cases and improvement in cerebral perfusion at SPECT follow-up in six of seven cases. It is concluded that the involvement of posterior circulation of MMD is not frequent and cerebral perfusion is preserved in adulthood-onset MMD patients. These findings may explain the reason why hemorrhages are frequent and the late onset of symptoms in adulthood-onset MMD. Surgical treatment with EDAS seems to be effective in adulthood-onset MMD in terms of clinical improvement.

A case of estrogen dermatitis

A 29-year-old Korean woman had erythematous papular patches on her face for six months. The eruptions recurred in a cyclic fashion along with her menstruation. The patient responded positively to an intradermal skin test for estrogen and showed marked improvement with the antiestrogen drug, Tamoxifen. We concluded that sensitivity to her own estrogen caused this dermatitis, that an intradermal skin test with progesterone and estrogen should be carried out routinely in patients with cyclic premenstrual flares, and that tamoxifen can be used as a specific therapy. To the best of our knowledge, this woman is the first patient with estrogen dermatitis reported in Korea.

A case of bleomycin-induced scleroderma

The association of exposure to bleomycin with the development of scleroderma-like cutaneous abnormalities has been reported. We experienced a case of scleroderma involving the hands, feet, and forearms after bleomycin chemotherapy. The present report supports the possible causal relation of bleomycin with scleroderma. Regarding the widespread use of bleomycin, this complication is thought to be under appreciated.