Secondary Lobule Research Articles

Treatment of a Wide Neck Middle Cerebral Artery Aneurysm with Secondary Lobule Using Combination Woven EndoBridge and Coil Embolization (P5-5.010)

Treatment of a Wide Neck Middle Cerebral Artery Aneurysm with Secondary Lobule Using Combination Woven EndoBridge and Coil Embolization (P5-5.010)

Abstract 111: Woven Endo Bridge‐Coil Embolization of a Middle Cerebral Artery Bifurcation Aneurysm with Secondary Lobule

Introduction 18‐36% of all intracranial aneurysms are middle cerebral artery(MCA) bifurcation aneurysms. While some are much higher risk than others, they have an overall low estimated annual rupture rate of 0.36%.(1) MCA bifurcation aneurysms have been historically challenging to treat endovascularly given they often have complex morphology and wide necks. The Woven EndoBridge (WEB) is an ellipsoid embolization device designed to provide intrasaccular flow disruption along the aneurysm neck, which has been proven to be an effective method in treating a wide spectrum of wide‐necked bifurcation aneurysms. Thromboembolism and recanalization are the main concerns in treatment with the WEB device, like any aneurysm treatment approach .(2),(3) Occasionally, irregularities and secondary lobules at the base of the primary aneurysm can have persistent filling despite treatment. Methods We present a case of a right MCA bifurcation aneurysm treated by a WEB device and coil embolization. Results 48‐year‐old female with a medical history significant only for active smoking who presented with sudden onset of the worst headache of her life followed by brief loss of consciousness. No neurological evaluation was sought initially, until 2 weeks later as she continued to experience a moderate‐intensity headache associated with nausea and vomiting with frequent falls. On exam, she was alert and oriented, moving all extremities with full strength. CT head revealed an evolving acute to subacute right MCA infarction with adjacent small volume subarachnoid hemorrhage. CTA head revealed a right MCA bifurcation aneurysm measuring 6 x 6 x 7 mm with irregularity of the wall. Multifocal severe stenosis was noted in the right distal right M1 and right M2 divisions. She underwent a diagnostic subtraction angiography which confirmed an irregular right MCA bifurcation aneurysm measuring 4.3 x 4.5 x 5.7 mm (Figure 1 ‐A,B). While it was believed that the subarachnoid hemorrhage was more likely related to the recent infarct, a decision was made to treat the aneurysm given its relatively large size and irregular shape. Embolization was performed with a WEB SL 6 x 4 mm device (Figure 1: C,D ‐blue arrow). Post‐deployment angiograph showed occlusion of the aneurysm dome but persistent filling of the secondary lobule near the base of the aneurysm. Given this residual lobule filling, a decision was made to continue additional embolization with a hyper soft 3D 2 mm X 2 cm coil(Figure 1: C,D ‐ yellow arrow). Final angiography revealed complete occlusion of the aneurysm. Vasospasm of the distal M2 divisions and multiple M3 branches in the right MCA vascular territory was also noted. Therefore, she was treated with 20 mg of intra‐arterial Verapamil with improvement. She was started on Aspirin 325 mg daily. Daily transcranial dopplers were negative for vasospasm. She remained neurologically stable and was discharged home 5 days after admission ambulating independently. Conclusion With modern advances in endovascular devices, many MCA bifurcation aneurysms can be treated minimally invasively. However, there are some limitations to the WEB since every aneurysm is different and there are a finite number of sizes and shapes available for WEB. This case illustrates that adjunctive coil embolization can successfully occlude a residual secondary base lobule after WEB embolization.

A Novel Method for Lung Image Processing Using Complex Networks.

The High-Resolution Computed Tomography (HRCT) detection and diagnosis of diffuse lung disease is primarily based on the recognition of a limited number of specific abnormal findings, pattern combinations or their distributions, as well as anamnesis and clinical information. Since texture recognition has a very high accuracy percentage if a complex network approach is used, this paper aims to implement such a technique customized for diffuse interstitial lung diseases (DILD). The proposed procedure translates HRCT lung imaging into complex networks by taking samples containing a secondary lobule, converting them into complex networks and analyzing them in three dimensions: emphysema, ground glass opacity, and consolidation. This method was evaluated on a 60-patient lot and the results showed a clear, quantifiable difference between healthy and affected lungs. By deconstructing the image on three pathological axes, the method offers an objective way to quantify DILD details which, so far, have only been analyzed subjectively.

Endothelialitis, Microischemia, and Intussusceptive Angiogenesis in COVID-19.

COVID-19 has been associated with a range of illness severity-from minimal symptoms to life-threatening multisystem organ failure. The severe forms of COVID-19 appear to be associated with an angiocentric or vascular phase of the disease. In studying autopsy patients succumbing to COVID-19, we found alveolar capillary microthrombi were 9 times more common in COVID-19 than in comparable patients with influenza. Corrosion casting of the COVID-19 microcirculation has revealed microvascular distortion, enhanced bronchial circulation, and striking increases in intussusceptive angiogenesis. In patients with severe COVID-19, endothelial cells commonly demonstrate significant ultrastructural injury. High-resolution imaging suggests that microcirculation perturbations are linked to ischemic changes in microanatomic compartments of the lung (secondary lobules). NanoString profiling of these regions has confirmed a transcriptional signature compatible with microischemia. We conclude that irreversible tissue ischemia provides an explanation for the cystic and fibrotic changes associated with long-haul COVID-19 symptoms.

A reaction-diffusion model to understand granulomas formation inside secondary lobule during tuberculosis infection

Mycobacterium tuberculosis (Mtb) is the causative agent for tuberculosis, the most extended infectious disease around the world. When Mtb enters inside the pulmonary alveolus it is rapidly phagocytosed by the alveolar macrophage. Although this controls the majority of inhaled microorganisms, in this case, Mtb survives inside the macrophage and multiplies. A posterior chemokine and cytokine cascade generated by the irruption of monocytes, neutrophils and posteriorly, by T-cells, does not necessarily stop the growth of the granuloma. Interestingly, the encapsulation process built by fibroblasts is able to surround the lesion and stop its growing. The success of this last process determines if the host enters in an asymptomatic latent state or continues into a life-threatening and infective active tuberculosis disease (TB). Understanding such dichotomic process is challenging, and computational modeling can bring new ideas. Thus, we have modeled the different stages of the infection, first in a single alveolus (a sac with a radius of 0.15 millimeters) and, second, inside a secondary lobule (a compartment of the lungs of around 3 cm3). We have employed stochastic reaction-diffusion equations to model the interactions among the cells and the diffusive transport to neighboring alveolus. The whole set of equations have successfully described the encapsulation process and determine that the size of the lesions depends on its position on the secondary lobule. We conclude that size and shape of the secondary lobule are the relevant variables to control the lesions, and, therefore, to avoid the evolution towards TB development. As lesions appear near to interlobular connective tissue they are easily controlled and their growth is drastically stopped, in this sense secondary lobules with a more flattened shape could control better the lesion.

RP EBUS as a guide for transbronchial pulmonary biopsy in the diagnosis of organizing pneumonia.

Diffuse parenchymal lung diseases (DPLDs) include a wide variety of manifestations characterized by different degrees of inflammation and fibrosis with various patterns of secondary lobule alterations, such that the diagnosis often requires histopathological confirmation in addition to clinical and radiological data. Radial probe endobronchial ultrasonography (RP EBUS) can be used as a guide for transbronchial pulmonary biopsy (TBPB) to obtain tissue samples, and thus can be a useful tool in the diagnostic management of peripheral pulmonary lesions. Organizing pneumonia (OP) is a particular type of DPLD characterized by lung inflammation and scarring that obstruct the small airways and air sacs of the lung. In this study, we describe how and when RP EBUS can be used to guide TBPB and significantly help in the diagnosis of OP.

Ultra-high-resolution computed tomography can demonstrate alveolar collapse in novel coronavirus (COVID-19) pneumonia.

PurposeTo review the chest computed tomography (CT) findings on the ultra-high-resolution CT (U-HRCT) in patients with the Novel coronavirus disease 2019 (COVID-19).Materials and MethodsIn February 2020, six consecutive patients with COVID-19 pneumonia (median age, 69 years) underwent U-HR CT imaging. U-HR-CT has a larger matrix size of 1024 × 1024 thinner slice thickness of 0.25 mm and can demonstrate terminal bronchioles in the normal lungs; as a result, Reid’s secondary lobules and their abnormalities can be identified. The distribution and hallmarks (ground-glass opacity, consolidation with or without architectural distortion, linear opacity, crazy paving) of the lung opacities on U-HRCT were visually evaluated on a 1 K monitor by two experienced reviewers. The CT lung volume was measured, and the ratio of the measured lung volume to the predicted total lung capacity (predTLC) based on sex, age and height was calculated.ResultsAll cases showed crazy paving pattern in U-HRCT. In these lesions, the secondary lobules were smaller than those in the un-affected lungs. CT lung volume decreased in two cases comparing predTLC.ConclusionU-HRCT can evaluate not only the distribution and hallmarks of COVID-19 pneumonia but also visualize local lung volume loss.

Three-dimensional quantitative MRI of aerosolized gadolinium-based nanoparticles and contrast agents in isolated ventilated porcine lungs.

The objective of this study is to evaluate the suitability and performance of ultra-short echo time (UTE) sequences for imaging and quantifying the deposition of nebulized MRI contrast agents in human-sized lungs. Nebulization of clinically used contrast agent or gadolinium-based nanoparticles were performed using a commercial jet nebulizer in isolated and ventilated porcine lungs connected to a 3D-printed human upper airways replica. MR images of isolated lungs were acquired on a 3T clinical MR scanner using 3D UTE sequences at different flip angles. 3D acquisitions with isotropic millimetric resolution were obtained in less than 4 min. Images exhibit homogeneous and large MR signal enhancement (above 200%) following nebulization of both types of aerosols. Deposition of aerosol down to the level of the bronchi of secondary lobules was visualized. T1 values and the concentration of nanoparticles obtained by MRI were found to correlate with the amount of nebulized gadolinium3+ ions. The distribution of aerosolized gadolinium-based contrast agent or nanoparticles can be visualized and quantified using UTE MRI in large animal ventilated lung model on a clinical MRI scanner. This protocol can be used for assessing and quantifying aerosol regional deposition with high spatial resolution (1 mm 3D isotropic) without ionizing radiation and could be applied in the future for diagnostic or therapeutic applications in patients.

ATTACK OF THE FOAMY MACS: DIFFUSE PANBRONCHIOLITIS IN A CAUCASIAN WOMAN

SESSION TITLE: Pulmonary Pathology II SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Diffuse Panbronchiolitis (DPB) is a rare condition most commonly seen in patients of Asian descent (1). We identified a Caucasian patient with alpha-1antitrypsin (α1AT) MS genotype, who was diagnosed with DPB after multi-disciplinary discussion (MDD). CASE PRESENTATION: A 41 y/o woman with a diagnosis of hypersensitivity pneumonitis (HP) was referred for environmental exposure evaluation by an occupational/environmental pulmonologist to find the cause of her HP. She had presented five years previously with cough productive of yellow sputum. She reported a history of seasonal allergies. Her cough did not improve with bronchodilator use. Prednisone did provide some relief at a dose of 40 mg daily but was discontinued due to insomnia and edema. Her chest CT showed tubular bronchiectasis in both lower lobes and peribronchial thickening with peripheral infiltrates. Surgical lung biopsy demonstrated features thought to be consistent with HP. Comprehensive environmental exposure history was unrevealing. Physical exam revealed intermittent coughing, diffuse crackles and expiratory low-pitched wheezing. Due to discordance between her clinical & exposure history, chest imaging and pathology, her case was presented at MDD conference. During this MDD, thoracic radiology impression was that her imaging represented an airways-centered process such as bronchiolitis. Thoracic pathology review found bronchiolocentric lymphocytic infiltrations with germinal centers distributed in the middle of the secondary lobule, interstitial lymphocytes, and foamy macrophages in the interstitium, sparing the alveolar spaces. The massive lymphocytic infiltration in a bronchiolocentric pattern along with interstitial foamy macrophages was consistent with the unique pathologic pattern of DPB. Additional laboratory tests found normal α1AT level (125), but abnormal genotype (MS). CFTR gene sequencing and autoimmune antibodies were normal. CBC showed no leukocytosis or eosinophilia. She was treated with erythromycin and noted improvement in cough. DISCUSSION: DPB can be a rare cause of cough in non-Asian patients. α1AT MS genotype has been associated with airway disease and may be the reason for this patient’s presentation (2). Here, MDD yielded a refinement in clinical diagnosis, which led to alteration in care. Treatment for DPB includes chronic macrolide use, a therapy different from traditional therapies for HP, and would have not been instituted without this diagnostic refinement. CONCLUSIONS: This case highlights the utility of MDD approach in increasing diagnostic confidence of rare pulmonary diseases. Reference #1: Poletti V, et al. Diffuse panbronchiolitis. Eur Respir J 2006; 28:862. Reference #2: Sandford AJ, et al. Z and S mutations of the α1-antitrypsin gene and the risk of chronic obstructive pulmonary disease. Am J Respir Cell Mol Biol 1999; 20: 287–291. DISCLOSURES: No relevant relationships by Cheryl Augenstein, source=Web Response grant recipient relationship with Department of Defense, Department of Veterans Affairs, CDC Please note: >$100000 Added 03/18/2019 by Stella Hines, source=Web Response, value=Grant/Research Support No relevant relationships by Mary Richert, source=Web Response No relevant relationships by Bethany Weiler-Lisowski, source=Web Response No relevant relationships by Sarah Williams, source=Web Response

Changes in sensorimotor network activation after botulinum toxin type A injections in patients with cervical dystonia: a functional MRI study

Botulinum toxin type A (BoNT) is considered an effective therapeutic option in cervical dystonia (CD). The pathophysiology of CD and other focal dystonias has not yet been fully explained. Results from neurophysiological and imaging studies suggest a significant involvement of the basal ganglia and thalamus, and functional abnormalities in premotor and primary sensorimotor cortical areas are considered a crucial factor in the development of focal dystonias. Twelve BoNT-naïve patients with CD were examined with functional MRI during a skilled hand motor task; the examination was repeated 4 weeks after the first BoNT injection to the dystonic neck muscles. Twelve age- and gender-matched healthy controls were examined using the same functional MRI paradigm without BoNT injection. In BoNT-naïve patients with CD, BoNT treatment was associated with a significant increase of activation in finger movement-induced fMRI activation of several brain areas, especially in the bilateral primary and secondary somatosensory cortex, bilateral superior and inferior parietal lobule, bilateral SMA and premotor cortex, predominantly contralateral primary motor cortex, bilateral anterior cingulate cortex, ipsilateral thalamus, insula, putamen, and in the central part of cerebellum, close to the vermis. The results of the study support observations that the BoNT effect may have a correlate in the central nervous system level, and this effect may not be limited to cortical and subcortical representations of the treated muscles. The results show that abnormalities in sensorimotor activation extend beyond circuits controlling the affected body parts in CD even the first BoNT injection is associated with changes in sensorimotor activation. The differences in activation between patients with CD after treatment and healthy controls at baseline were no longer present.

PECULIARITIES OF THYMUS STROMA AND ITS VASCULARIZATION DURING EARLY STAGES OF HUMAN PRENATAL ONTOGENESIS (REVIEW OF LITERATURE)

Analysis of literature sources on morphogenesis peculiarities of thymus in human fetuses was conducted. Features of stroma formation and development of thymus angioarchitectonic during 4-10 weeks of prenatal development have been examined. Research has also studied terms of epithelial cords formation, and formation of stromal components of primary and secondary lobules in thymus. Mesenchyme value in processes of thymus’ connective tissue capsule forming and providing vascularization was studied.

Magnetic resonance imaging in the evaluation of idiopathic pulmonary fibrosis: a real possibility, or an attractive challenge?

Magnetic resonance imaging in the evaluation of idiopathic pulmonary fibrosis: a real possibility, or an attractive challenge?

Interstial Lung Disease – How Do I Differentiate it?

Differentiation of various interstitial lung diseases with CT is made from the point of both the pattern recognition and the location of abnormalities in lobules. Patterns of abnormalities include linear and reticular opacities, nodules, parenchymal opacification, cysts, and decreased lung attenuation. From the point of the locations in secondary lobules, abnormalities on CT were categorized centrilobular, perilobuloar, panlobular, and random distributions. In this lecture, the clues for the differentiation of various interstitial lung diseases will be mentioned from above two points views. Then, precise radiologic-pathologic correlation of various interstitial abnormalities will be shown in order to let you understand characteristic CT findings of various interstitial lung diseases

Diffuse Cystic Lung Disease. Part I.

The diffuse cystic lung diseases (DCLDs) are a group of pathophysiologically heterogenous processes that are characterized by the presence of multiple spherical or irregularly shaped, thin-walled, air-filled spaces within the pulmonary parenchyma. Although the mechanisms of cyst formation remain incompletely defined for all DCLDs, in most cases lung remodeling associated with inflammatory or infiltrative processes results in displacement, destruction, or replacement of alveolar septa, distal airways, and small vessels within the secondary lobules of the lung. The DCLDs can be broadly classified according to underlying etiology as those caused by low-grade or high-grade metastasizing neoplasms, polyclonal or monoclonal lymphoproliferative disorders, infections, interstitial lung diseases, smoking, and congenital or developmental defects. In the first of a two-part series, we present an overview of the cystic lung diseases caused by neoplasms, infections, smoking-related diseases, and interstitial lung diseases, with a focus on lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis.

New species of Simulium (Nevermannia) from Korea, with reference to its allied species in the S. vernum species group (Diptera: Simuliidae) in Korea and Japan

AbstractThe larvae and pupae of a new species, Simulium (Nevermannia) immaculatum sp. nov., are described from Korea. Descriptions are supplemented with photographs of larvae and pupae and habitat information. The new species can be distinguished from other Asian members of the S. vernum group by the cephalic plate and thorax of the pupa devoid of tubercles, 4 pupal gill filaments lying close together, larva with postgenal cleft shorter than postgenal bridge, spot under ocellus absent, and rectal papillae with three simple lobes with single digit‐like small secondary lobule basally.

A Pathologist’s View of Airway Obstruction in Chronic Obstructive Pulmonary Disease

The boundary between purely conducting airways and gas exchanging tissue is formed by the terminal bronchioles as they divide into transitional bronchioles where alveolar openings first appear (1). The numbers of alveolar openings increase with each successive generation of branching until they take up the entire luminal surface in the alveolar ducts and the ducts branch for several more generations before ending blindly in alveolar sacs (2). McDonough and colleagues recently used a combination of multidetector computed tomography (MDCT) and micro-CT to show that there are about 44,510 ± 15,574 (± SD) terminal bronchioles/lung pair (3), a number that compares favorably to a mean of 44,500 ± 18,574 (± SD) obtained in four separate studies of individual lung casts (1, 4–6). Each terminal bronchiole supplies a unit of lung termed the acinus, and a secondary lobule refers to a group of acini that are either surrounded by a connective tissue septum (Figure 1A) when examined by histology (2), or where bronchioles cluster only millimeters apart (Figure 1B) when examined in a bronchogram (7).

CT findings of hypersensitivity pneumonitis

CT findings of 22 cases of hypersensitivity pneumonitis (HP) were evaluated on 1 cm slices. All cases were diagnosed by transbronchial lung biopsy and clinical information. The study population included 8 men and 14 women with a mean age of 43 years. The causative antigens were considered to be so-called summer type in 17 cases, air humidifier in 1, pigeon in 1 and paint spray (isocyanate was suspected) in 3. CT examination were performed at a mean of 1.5 weeks after admission. In conclusion, characteristic CT findings of HP include combination of small nodular shadows and slight elevation of lung density. The size of nodular shadows was usually within 1 cm diameter, and their distribution was considered to be a centrilobular pattern, representing alveolitis and granuloma formation in a secondary lobule. It was though that the slight elevation of lung density developed when the disease extended all over the secondary lobule and the nodules developed when the disease was limited to the centrilobular lesion. In most cases, significant changes in proximal bronchi and pulmonary vasculatures could not be detected. The presence of segmental or lobar distribution of the shadows was also suggested. In addition to the typical findings, various other findings were also revealed; irregular shaped dense shadows, subpleural curvilinear shadow and honeycombing formation, especially in chronic cases. These findings have caused some difficulty in distinguishing HP from other interstitial diseases. More precise information can probably be obtained by thin slice CT than by 1 cm slice thicknesses, nevertheless, the standard method of CT should yield a useful diagnostic imaging.

Thin-Section CT of the Secondary Pulmonary Lobule: Anatomy and the Image—The 2004 Fleischner Lecture

The secondary pulmonary lobule is a fundamental unit of lung structure, and it reproduces the lung in miniature. Airways, pulmonary arteries, veins, lymphatics, and the lung interstitium are all represented at the level of the secondary lobule. Several of these components of the secondary lobule are normally visible on thin-section computed tomographic (CT) scans of the lung. The recognition of lung abnormalities relative to the structures of the secondary lobule is fundamental to the interpretation of thin-section CT scans. Pathologic alterations in secondary lobular anatomy visible on thin-section CT scans include interlobular septal thickening and diseases with peripheral lobular distribution, centrilobular abnormalities, and panlobular abnormalities. The differential diagnosis of lobular abnormalities is based on comparisons between lobular anatomy and lung pathology.

Pictorial Essay: Multinodular Disease

The evaluation of patients presenting with multinodular pulmonary disease provides an important clinical challenge for physicians. The differential diagnosis includes an extensive list of benign and malignant processes making the management of these cases frequently problematic. With the introduction of high-resolution CT (HRCT) scanning, the ability to assess various patterns of diffuse multinodular disease has evolved into an essential part of the diagnostic process. The purpose of this article is to develop an approach to the diagnosis of multinodular parenchymal disease using HRCT scan pattern recognition as a point of departure.

A new sorediate, fumarprotocetraric acid‐producing lichen species of Menegazzia (Parmeliaceae, Ascomycota) from New Zealand

A new sorediate lichen, Menegazzia hypernota Bjerke, is described from New Zealand. This new species is characterised by convex, crescent‐shaped to fabi‐form soralia that are occasionally associated with perforations; apothecia with 2‐spored asci; the small perforations; the numerous secondary lobules; the presence of inconspicuous, yellow spots in the internal cavity; and fumarprotocetraric acid as principal medullary constituent. Menegazzia caliginosa, a species associated with M. hypernota, is reported for the first time from the Auckland Islands.