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Purpose: Pulmonary embolism (PE) represents the most important and fatal complication of deep vein thrombosis (DVT), of which a dislodged thrombus is most commonly derived from the deep venous system of the lower extremity. The aim of this study is to define the incidence and risk factors of PE in DVT patients. Method: We retrospectively reviewed 248 patients with DVT in a lower extremity at Uijeongbu St. Mary's Hospital between January 2000 and August 2008 and they had received additional examinations for making the diagnosis of PE regardless of its symptoms. Result: There were 117 men and 131 women, and their mean age was 59 years old (range: 13∼91) at the time of diagnosis. There were 190 DVT-only patients and 58 patients with PE (the incidence rate of PE in the DVT patients: 23.8%). The gender ratio of the DVT only group was 1:1.3 (males: 83, female: 107) and the gender ratio of the DVT with PE group was 1:0.7 (males: 34, females: 24) (P<0.05). The risk factors of PE in the DVT patients were hypercoagulability (34%), cancer (23%), immobilization (17%), trauma/operation (10%), obesity (10%) and a past DVT history (7%). The idiopathic DVT patients had a relatively high cancer diagnosis rate (18.5%) and the majority of the newly detected cancer were from the chest or abdominal cavity. Conclusion: The incidence of DVT and PE is increasing and 23.8% of the DVT patients showed PE on their chest CT scan. The most significant risk factor for PE in the DVT patients was the male gender, yet an evaluation for cancer should be carefully done for idiopathic DVT patients because of their high rate of having cancer diagnosed.
Objective : The T2*-weighted gradient echo image susceptibility vesselsign (GRE SVS) is a well-known indicator of intraluminal thrombi in acutecerebral infarction. The purpose of this study was to evaluate the relationshipsbetween thrombus size on GRE SVS and recanalization after intravenousadministration of tissue plasminogen activator (IV-tPA). Materials and Methods : Fifty five patients with GRE SVSs on the M1were enrolled. Examination of magnetic resonance image (MRI), includingdiffusion weighted imaging and MR angiography, was performed within20 minutes of admission. Thrombus size on GRE was calculated using thePicture Archiving and Communication System upon initial MRI. Recanalization was assessed with follow-up MRI or transfemoral cerebralangiography within 24 hours of treatment. Results : The patient group consisted of 37 males and 18 females withan average age of 63.74 ± 10.28 years (range: 43 - 77 years). The medianNIHSS score was 13. Fifteen of these patients achieved recanalization(27.3%). The average thrombus cross-sectional area in the recanalizationgroup was 38.54 ± 20.27 mm2, and the corresponding size of thenon-recanalization group was 53.38 ± 24.77 mm2 (p = 0.043). In the receiveroperator characteristic curve for thrombus cross-sectional area in relationto recanalization, the cut-off point was 47.28 mm2. The sensitivityat this cut-off point was 73.3%, the specificity was 60%, and the areaunder the curve was 0.687. Conclusion : Thrombus size on GRE is a simple diagnostic tool that canbe easily measured, and thrombus size on GRE SVS was found to be associatedwith recanalization after IV-tPA.
Objective:The limitations of medical management of symptomatic intracranial arterial stenosis (ICS) have prompted development of new strategies, including endovascular treatment. However, stenting of symptomatic ICS remains investigational. Here, we have reported and analyzed a series of 19 endovascular procedures involving placement of a Wingspan stent. Methods:We conducted a retrospective review of a series of ICS in which patients were treated with percutaneous transarterial balloon angioplasty and stent placement (PTAS). Patients included in the study were diagnosed as symptomatic ICS between May 2010 and September 2011. Results:Nineteen patients (median age, 65 years; 12 males, seven women) were treated with the Wingspan stent system for symptomatic ICS ranging from 50% to 99%. The technical success rate was 100%. The location of ICS included the internal carotid (n = 5; 1 petrous, 3 cavernous, and 1 clinoid segments), vertebral (n = 1; V4 segment), basilar (n = 1), and middle cerebral (n = 12; 9 M1, 3 M2) arteries. There was no occurrence of procedure-related mortality. Periprocedural morbidity occurred in two cases (10.5%), including carotid-cavernous fistula (n = 1) and subarachnoid hemorrhage (n = 1). No ipsilateral stroke was recorded beyond 30 days during a mean follow-up period of 13.2 months (range 9–19 months). Restenosis (> 50%) was observed in one patient (6.3%), who was asymptomatic, on follow-up imaging. Conclusion:Wingspan stent for symptomatic ICS can be performed with a high rate of technical success and acceptable periprocedural morbidity rates. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.
Symptomatic Cerebral Air Embolism During Stent-assistedCoiling of an Unruptured Middle Cerebral Artery Aneurysm:Intraoperative Diagnosis and Management of a RareComplication
Two Cases of Subarachnoid Hemorrhage from Spontaneous Anterior Cerebral Artery Dissection : A Case of Simultaneous Hemorrhage and Ischemia Without Aneurysmal Formation and Another Case of Hemorrhage with Aneurysmal Formation
Spontaneous anterior cerebral artery (ACA) dissection, although extremelyrare, is often associated with severe morbidity and mortality. It could leadto cerebral hemorrhage, ischemic stroke, or, rarely, combination of hemorrhageand ischemia due to hemodynamic changes. Prompt and accuratediagnosis is essential for determining the appropriate management. However, the optimal treatment for ACA dissection remains controversial. Herein, we report on two rare cases of subarachnoid hemorrhage (SAH)caused by ACA dissection; a case presenting with simultaneous SAH andinfarction without aneurysmal formation and another case presentingwith SAH with fusiform aneurysmal formation. A review of the related literatureis provided, and optimal treatments for each type of dissectionare suggested.
Treatment of giant intracranial aneurysms, via either surgical or endovascularapproaches, is associated with a high level of technical difficulty aswell as a high rate of treatment-related morbidity and mortality. Flow-divertingstents, such as the Pipeline embolization device (PED), have drasticallyaltered the therapeutic strategies for the treatment of giant aneurysms. Gaining endovascular access using a microcatheter to the portion of theparent artery distal to the aneurysm neck is requisite for safe and effectivestent deployment. Giant aneurysms are often associated with vasculartortuosity, which necessitates significant catheter support systems to enablemaneuvering of PEDs across the aneurysm neck. This is also requiredin order to reduce the probability of stent herniation within giantaneurysms. We report on a case of a giant supraclinoid internal carotidartery (ICA) aneurysm which was treated successfully with a PED utilizinga balloon anchor technique to facilitate direct microcatheter access acrossthe aneurysm neck.
Objective:This study was conducted to assess the efficacy and safety of endovascular mechanical thrombectomy (EMT) for patients diagnosed with basilar artery (BA) occlusion. Materials and Methods : We retrospectively analyzed clinical and imaging data of 16 patients diagnosed with BA occlusion who were treated with endovascular intervention from July 2012 to February 2013. Direct suction using the Penumbra system and thrombus retrieval by the Solitaire stent were the main endovascular techniques used to restore BA flow. The outcomes were evaluated based on rate of angiographic recanalization, rate of improvement of National Institutes of Health Stroke Scale (NIHSS) score, rate of modified Rankin Scale (mRS) at discharge and after 3 months, and rate of cerebral hemorrhagic complications. Successful recanalization was defined as achieving Thrombolysis In Cerebral Infarction (TICI) of II or III. Results : Sixteen patients received thrombectomy. The mean age was 67.8 ± 11 years and the mean NIHSS score was 12.3 ± 8.2. Eight patients treated within 6 hours of symptom onset were grouped as A and the other 8 patients treated beyond 6 hours (range, 6-120) were grouped as B. Successful recanalization was met in six patients (75%) for group A and 7 (87.5%) for group B. Favorable outcome occurred in 4 patients (50%) for group A and 5 (62.5%) for group B. Conclusion : Our study supports the effectiveness and safety of endovascular mechanical thrombectomy in treating BA occlusion even 6 hours after symptom onset.
Objective:The increased use of bypass surgery in the treatment of ischemic cerebrovascular diseases requires a better understanding of the superficial temporal artery (STA) anatomy. This study is to describe the gross anatomy of STA in adult Korean population with respect to cranial surgery and to provide basic anatomic data for bypass surgery. Methods:The study evaluated retrospectively 35 patients who visited the neurosurgery department at a single institution. For each patient, both the left and right STA (70 vessels) were evaluated by a 3-dimensional computed tomographic angiogramfor diameter and anatomic relationships to external landmarks. Results:Of 70 STAs, 69 had a bifurcation. Among these, 57 (82.6%) were above the superior margin of the zygomatic arch. The STA bifurcation was 53.2 ± 5.9 mm posterior to the keyhole, 9.5 ± 5.3 mm anterior to the posterior margin of condylar process of the mandible, and 21.7 ± 15.8 mm superior to the superior margin of the zygomatic arch. The inner diameter of the STA was 1.8 ± 0.5 mm at the superior margin of the zygomatic arch, and 1.4 ± 0.4 mm and 1.4 ± 0.5 mm for frontal and parietal branches, respectively. The 75.7% of frontal and 66.7% of parietal branches were suitable for microvascular anastomosis. Conclusion:This present study demonstrated the STA in Korean adults, which may benefit the clinician in dealing with the surgical procedures related to this STA.
Intraosseous arteriovenous malformation (AVM) in the craniofacial region is rare. When it occurs, it is predominantly located in the mandible and maxilla. We encountered a 43-year-old woman with Klippel-Trenaunay syndrome affecting the right lower extremity who presented with a left orbital chemosis and proptosis mimicking the cavernous sinus dural arteriovenous fistula. Computed tomography angiography revealed an intraosseous AVM of the sphenoid bone. The patient's symptoms were completely relieved after embolization with Onyx. We report an extremely rare case of intraosseous AVM involving the sphenoid bone, associated with Klippel-Trenaunay syndrome.
Intracranial embolization usually arises from the heart, a vertebrobasilar artery, a carotid artery, or the aorta, but rarely from the distal subclavian artery upstream of an embolus. We report on a patient who experienced left shoulder and forearm pain with weak blood pressure and pulse followed by concurrent onset of left hemiplegia. This case is a rare example of multiple cerebral embolic infarctions, which developed as a complication of distal subclavian artery thrombosis possibly associated with protein S deficiency.