Hypodense Areas Research Articles

Gastric carcinoma leading to metastatic spinal cord compression

Gastric cancer is described as a malignancy occurring in the region between the gastroesophageal junction and the pylorus. According to the histology, majority of gastric cancers are classified as adenocarcinomas. The prevalence of bone metastasis in the general population is 2-3%. Here, an unusual case of a 73-year-old male is discussed who presented on September 10, 2023, with symptoms of lower back pain and bowel and urinary incontinence. His MRI results showed mild indentation along with nerve impingement and hypertrophied ligamentum flavum at the level of L5/S1. Within D11 and D12 vertebral bodies, diffuse abnormal signals were appreciated predominantly along posterior corners. CT scan of the abdomen showed sessile hypodense area along the mucosa of the posterior wall of the gastric antrum. Histopathology further confirmed the diagnosis with the appearance of signet ring cells. He was managed with supportive care and palliative radiotherapy. The patient expired on the 28th day of being discharged. Keywords: Stomach Neoplasm, Metastasis, Spinal Cord Compressions, Tumour.

Posterior reversible encephalopathy syndrome after COVID-19 in a patient with chronic renal failure

A 61-year-old man with chronic renal failure had an embolic stroke of undetermined source that was treated with warfarin. Five weeks later, the patient contracted coronavirus disease (COVID-19). Six days after the onset of COVID-19, high blood pressure (>200 ‍mmHg) and consciousness disturbance were reported. CT demonstrated symmetrical hypodensity areas in the bilateral cerebellar hemispheres. MRI revealed hyperintensity lesions in the bilateral cerebellar hemispheres and pons on the T2-weighted and fluid-attenuated inversion recovery images. Moreover, cerebellar lesions appeared as hyperintensity areas on apparent diffusion coefficient mapping. Based on these findings, a diagnosis of posterior reversible encephalopathy syndrome (PRES) was made. The patient was treated with antihypertensive drugs, and the consciousness level improved gradually. MRI after one month showed that the lesions had disappeared. PRES should be considered if the brain CT of patients with COVID-19 shows a low-density lesion, especially in patients with risk factors for PRES such as chronic renal failure or hypertension.

Is the Hyperdensity Areas of the CT Blend Sign Associated with the Fresh Bleeding in Intracerebral Hemorrhage?

Controversies still exist regarding the mechanism formation of the blend sign, defined as hypodensity and hyperdensity regions, in Intracerebral Hemorrhage (ICH), and which region associated with bleeding remains unknown. Spot sign is an independent predictor of hematoma expansion (HE) and indicates persistent bleeding focus in the hematoma. Here, we sought to establish the relationship between the spot sign and the blend sign to gain insights into the formation of the blend sign. Patients were categorized based on the spot sign location within the blend sign in patients with ICH from 2018 to 2023. subjects with a spot sign in the hypodensity region of the blend sign (hypo-spot sign group); subjects with a spot sign in the hyperdensity region of the blend sign (hyper-spot sign group). Subsequently, patients were stratified into two groups based on the presence or absence of HE. Also, we analyzed the relationship between the spot sign and the blend sign, as well as the association between the blend sign and HE. A total of 205 patients were included, including 190 patients (92.7%) who had the spot sign in the hyper-spot sign and 15 patients (7.3%) who had the spot sign in the hypo-spot sign. HE was observed in 60 patients (29.3%), 59 (98.3%) of whom had the spot sign detected in the hyper-spot sign, while only one (1.7%) had the spot sign in the hypo-spot sign. Univariate logistic regression analysis revealed that the hyper-spot sign group (6.305, 1.810-49.072; P < 0.05) was an independent predictor of HE. The hyperdensity area of the blend sign may represent fresh bleeding in ICH rather than the hypodensity area.

Abstract 220: Cerebral Angioedema in a Patient with Refractory Hypertension and Intracerebral Hemorrhage

Introduction/Purpose There is emerging evidence to implicate bradykinin in the development of cerebral edema. In the periphery, its association to the development of angioedema is well known. However, the relationship of peripheral angioedema to the development of cerebral angioedema is not well established. Angioedema may occur in patients receiving antihypertensive medication, and alteplase for acute ischemic stroke (1), however, the concurrent involvement of cerebral vasculature is not well studied. Moreover, the connection with cerebral edema ‐ cytotoxic or vasogenic ‐ remains poorly understood. Here we present a patient with an intracerebral hemorrhage (ICH) in the setting of refractory hypertension, who developed angioedema, and ultimately fulminant cerebral edema. We aim to investigate whether angioedema may extend beyond a systemic response and into the cerebral vasculature, contributing to further neurological compromise. Materials/Methods A retrospective review was conducted for one patient. Data, including history, exam, imaging, and clinical interventions were analyzed. All identifiers were removed. Results A 51‐year‐old African American woman with a medically refractory hypertension on multiple home medications presented with aphasia, and a blood pressure of 220/110 mm Hg. An initial non contrast head CT revealed a 60‐cc left basal ganglia intracerebral hemorrhage. CTA of the head and neck were negative for an underlying structural abnormality. She required intubation soon after presentation due to obtundation. No interval re‐hemorrhage was noted on repeat head CT. A contrast enhanced MRI was also unrevealing. 48 hours later she was noted to have orolingual edema and an angiotensin converting enzyme inhibitor (ACEi) and diltiazem were discontinued. In the ensuing days, due to difficult to control hypertension despite being on multiple antihypertensives, an angiotensin II receptor blocker (ARB) was introduced. However, this was discontinued and reintroduced several days later only to be discontinued again due to orolingual edema. She also had a failed extubation attempt due to hypoxemia and stridor, and received FFP, decadron, and racemic epinephrine. 2 days later she developed bradycardia and had neurologic deterioration progressing from initial right hemiparesis to complete unresponsiveness on examination. A noncontrast head CT showed no interval re‐hemorrhage but did show new areas of hypodensity involving the bilateral occipital lobes, the brainstem, the left temporal lobe, and uncal herniation. Hypertonic saline was started, however the patient progressed to brain death. Conclusion This case highlights the potential link between systemic angioedema, and fulminant cerebral edema and rapid neurologic decline. Previous literature has described potentially parallel mechanisms behind peripheral angioedema and cerebral edema (2). Angioedema may also influence progression from vasogenic to cytotoxic cerebral edema. As vasogenic edema develops, the increased tissue pressure can lead to ischemia and exacerbate cytotoxic edema (3). The significance of posterior circulation involvement is noteworthy, as ischemic infarctions here can lead to neurological deficits and are associated with vasogenic edema due to blood‐brain barrier disruption, such as in posterior reversible encephalopathy syndrome (PRES). Further investigation is required to explore acute intracerebral effects of angioedema. Physicians should consider cerebral angioedema in patients with both peripheral angioedema and neurological deterioration.

Abstract 203: Awake n‐BCA Embolization Of Complex Subcortical AVM In Elderly Patient With Cardiac Comorbidities: Case Report

Introduction Cerebral arteriovenous malformations (AVM) are an abnormal tangle of blood vessels in the brain that connects arteries to veins directly. This can lead to a variety of symptoms, including headaches, hemorrhages, seizures, and progressive neurological deficits. Effective treatment requires a multidisciplinary, individualized approach to maximize positive outcomes. We present the successful case of an 86‐year‐old male with a complex cardiac history who developed acute‐onset weakness and refractory focal motor seizures due to a large subcortical AVM in an eloquent location, treated with n‐Butyl Cyanoacrylate (nBCA) embolization while awake. Results 86‐yo male with a significant cardiac history, including hypertension, persistent atrial fibrillation on Xarelto, and heart failure, presented to the emergency department (ED) two hours after developing left facial droop, dysarthria, followed by a left‐sided focal motor seizure. Computerized tomography (CT) scan of the brain revealed a hypodense area in the right fronto‐parietal lobe, associated with vasogenic edema. Magnetic resonance imaging (MRI) indicated a possible AVM, with subtle nodular enhancement along the cortex and evidence of prior microhemorrhages. A diagnostic cerebral angiogram confirmed the presence of a Spetzler‐Martin grade 2 pial AVM in the posterior right frontal region, with a nidus measuring 6.2 mm by 4.29 mm. The AVM was supplied by the distal arterial pedicle from the inferior branch of the middle cerebral artery (MCA) and drained into the vein of Trolard. No aneurysm, varix, or venous congestion was identified. Following optimization of the patient's heart failure and seizure management, a multidisciplinary team discussed treatment options with the patient and his family. Given the AVM's eloquent location, n‐Butyl Cyanoacrylate (nBCA) embolization was performed while the patient was awake to allow for continuous neurological monitoring. Propofol was slowly injected into the arterial pedicle supplying the nidus, followed by a thorough neurological examination, which revealed no deficits. The nBCA embolization was then completed. Post‐procedural angiography showed significant obliteration of the AVM nidus and reduced arteriovenous shunting. The patient did not experience any parenchymal perfusion defects, thromboembolic complications, or vascular injuries. He was monitored in the neurointensive care unit and exhibited only mild left‐sided weakness and facial droop. Repeat CT imaging was stable. At a five‐month follow‐up, a cerebral angiogram demonstrated complete obliteration of the AVM, with no residual shunting. The patient remained neurologically intact and seizure‐free. A follow‐up angiogram is planned for six to twelve months to monitor for ongoing stability. Conclusion The successful treatment of this complex cerebral AVM using n‐BCA embolization in an awake state underscores the importance of a carefully tailored, multidisciplinary approach to managing such cases. Performing the procedure while the patient is awake allowed for continuous neurological monitoring, significantly reducing the risk of inadvertent damage. This case illustrates that, even in patients with significant comorbidities and high procedural risks, a well‐coordinated, individualized treatment strategy can lead to favorable outcomes. Ongoing follow‐up will be essential to maintain long‐term stability and address any potential complications.

A Rare Case of Dizzines

Case History: Female patient, 50 yrs, came to ED for vertiginous syndrome and weight loss. She reported gradual postural instability, dizziness and vomiting for about three months. Headache and dizziness persisted, so she carried out haematochemical examination and brain CT scan without contrast medium, which showed multiple areas of tissue hypodensity surrounded by digitiform oedema suspicious for metastasis. Assuming a metastatic oncological pathology, she was admitted to Internal Medicine department for further investigation: new haematochemical examinations, which showed lymphocytopenia (400 u/L), oncomarkers dosage and total body CT scan with contrast medium. Due to the lymphocytopenia, haematochemical tests to exclude an infectious origin of brain lesions, were needed. It resulted positive for HIV-Ab and IgG for Cytomegalovirus and toxoplasma. CT images were reassessed and considering HIV-Ab positivity, the suspicion of Toxoplasma gondii brain abscesses was raised. So, she started empirical antibiotic therapy with Cotrimoxazole, carried out an MRI and then transferred to the Infectious Diseases Department, where after 10 days of empirical antibiotic treatment, she started HAART therapy. Discussion: T. gondii is a parasite that can infect humans in various ways including ingestion of raw meat or water contaminated with cat faeces. Toxoplasmosis in HIV-positive patients is usually a consequence of reactivation of the parasite’s tissue cysts, and cerebral toxoplasmosis is a major cause of morbidity and mortality in HIV-infected patients.

A Rare Case of Tentorial Sinus Thrombosis in a Patient with Sickle Cell Disease

Background: The reported incidence of venous thromboembolism in sickle cell disease patients is approximately 12% before the age of 40, accompanied by an additional 5-10% incidence of cerebral venous sinus thrombosis. Tentorial sinuses are venous structures in the posterior cranial fossa, draining the occipital and temporal lobes and the superior part of the cerebellum. Here, we describe a rare case of lateral tentorial sinus thrombosis in a patient with sickle cell disease. Methods: Case report and review of the available literature Results: A 26-year-old woman with sickle cell disease presented with a 2-day history of headache, nausea, and vomiting. Neurological exam was normal. CT brain revealed hyperdensity in the right occipital region and subtle area of hypodensity in the right medial occipital lobe. MRI/MRV brain showed right lateral tentorial sinus and occipitobasal vein thrombosis in addition to right medial occipital lobe venous infarct. The patient was started on therapeutic heparin initially, then transitioned to apixaban. Hemoglobin electrophoresis revealed a HbS fraction of 80.6% and HbF 16.6%. The patient received an exchange transfusion and was discharged home in stable condition. Conclusions: In patients with symptoms concerning for cerebral venous thrombosis, attention is usually directed to the traditional dural venous sinuses and cortical veins, while other venous structures can be overlooked. Although, in this particular case, it was clear on imaging, tentorial sinus thrombosis can easily be missed if not associated with brain edema or venous infarct.

Clinical and Imaging Features of Pulmonary Nodular Lymphoid Hyperplasia.

To investigate the clinical and radiographic features of PNLH and the relationship with pathologic features. A total of 11 patients in whom PNLH was confirmed in our department were retrospectively studied. The clinical and radiographic features were extracted and analyzed, and we also discussed the relationship between radiologic and pathologic features. Of the 11 patients with PNLH, 5 were discovered incidentally, while 4 presented with chest symptoms. Laboratory tests showed no specificity and the lesions were located under the pleura with an adjacent pleural indentation. Most lesions were solid, with some showing signs of spiculation or spiculate protuberance. In some cases, hypodense areas and vocules were visible. The enhanced scan showed marked enhancement, but most had no lymph node enlargement, and there was no pleural effusion. The clinical manifestations of PNLH are nonspecific and the imaging features overlap with those of malignant lung tumors, and the diagnosis depends on pathologic examination.

Beaten to Blindness: Battered Baby Syndrome

Introduction: A battered child is one who sustains repetitive physical injuries due to non-accidental violence inflicted by a parent or guardian. Child abuse encompasses behaviors exposing the child to various forms of physical or sexual abuse, neglect, or emotional misconduct. Typically, battered child syndrome is diagnosed through a disparity between the history provided by the child's caregivers and the findings of clinical examination. Case details: An 18-month-old girl child was admitted to a tertiary care hospital, presenting with a four-day history of fever, vomiting for two days and a seizure episode. The child had a history of head injury one week ago, resulting in transient unconsciousness. Upon examination, multiple healed and fresh injuries were observed on the face, hands, and right thigh. CT brain revealed hypodensity areas with a mildly displaced fracture of the left frontal bone. Fundus examination identified bilateral multiple intraretinal hemorrhages and papilledema. X-ray showed a fracture of the right proximal tibia. The child required ventilator support during the hospital stay, and subsequently, developed retinal blindness. The child was managed accordingly. Discussion: The classical feature of Battered Baby Syndrome is the discrepancy between the nature of injuries and the history provided, and the delay between the injury and medical attention. The parental risk factors for child abuse are poverty, social isolation, drug addiction, violent environment, family history of abuse, communication skills deficit and the child related risk factors are children with special needs, children with behavior problems, bonding deficit. etc. Conclusion: The current case sheds light on the unfortunate prevalence of this condition within the Indian context, urging point-of-care health providers to stay vigilant and informed about child abuse patterns in the community. It serves as a crucial reminder of the responsibility we all share in safeguarding the well-being of children.

Pediatric Case of Autoimmune Cerebellitis with Positive Anti-GAD Antibodies and Accidental Finding of Roth Spots

Abstract We present a pediatric case of autoimmune cerebellitis, which was distinguished by the presence of positive anti-glutamic acid decarboxylase (anti-GAD) antibodies. The patient, a young child, presented with a four-day history of progressively worsening headaches, coupled with persistent vomiting. These symptoms prompted immediate medical evaluation. Initial computed tomography (CT) imaging revealed a hypodense area in the left cerebellum and mild hydrocephalus, indicating fluid accumulation in the brain. Subsequent magnetic resonance imaging (MRI) provided more detailed visualization, confirming the diagnosis of acute cerebellitis, which was characterized by bilateral enlargement of the cerebellum and an associated mass effect that exerted pressure on the adjacent brain structures. The medical team initiated a comprehensive treatment regimen that included antibiotics to address any potential bacterial infection, antivirals to counter possible viral etiologies, immunoglobulin therapy to modulate the immune response, and corticosteroids to reduce inflammation. The patient responded well to this treatment protocol, with follow-up imaging showing a significant reduction in cerebellar swelling and overall improvement in clinical symptoms. The detection of elevated anti-GAD antibodies, along with anti-thyroglobulin antibodies, indicated an autoimmune origin of the cerebellitis. This autoimmune response can lead to the body’s immune system mistakenly attacking healthy brain tissue. Moreover, the incidental finding of a Roth spot, a retinal hemorrhage with a white center, during a routine eye examination suggested potential systemic involvement, possibly indicating a broader immune-mediated condition.

Single-shot simplified cardioneuroablation

Abstract Introduction Cardioneuroablation (CNA) is a promising therapy of a spectrum of arrhythmias dependent on increased activity of parasympathetic tone. The right anterior ganglionated plexus (RAGP), localized paraseptally between right atrium and right superior pulmonary vein, is frequently a primary target for CNA. Methods are sought to determine exact locations of RAGP to minimize ablation lesion set during CNA. Immediate and accurate intraprocedural visualization of RAGP area in patients undergoing CNA is desirable. Methods Consecutive patients who underwent right-atrial CNA for reflex syncope, symptomatic bradycardia or vagal atrial fibrillation were included into the study. After venous contrast injection a 3-dimensional rotational atrial scan (3DRAS) was used to obtain digital images. Next, manual segmentation (MS) of hypodense areas between the right atrium (RA) and the right superior pulmonary vein (RSPV) was performed to reconstruct RAGP. Using 3-dimensional mapping system such created 3D RAGP area visualisation was automatically synchronized with fluoroscopy and these sites were targeted for CNA. Heart rate (HR) acceleration ≥30% and ultra-short-term deceleration capacity (UST-DC) were used for determination of acute CNA outcomes. Results Five patients (3 males, age 37±17) underwent 3DRAS and MS of RAGP area during CNA. A single radiofrequency lesion was delivered in each patient (mean RF time - 33±15s, power - 25W). The mean procedure time was 40±13 minutes. Targeted HR acceleration was achieved in all patients (baseline HR vs post-CNA HR, 57±8bpm vs 93±11bpm; p=0.0007; mean HR acceleration 65±15%). UST-DC significantly decreased after CNA (pre-CNA UST-DC vs post-CNA UST-DC, 13.6ms vs 3.2ms, p=0.00096). There were no complications. Conclusions Single-shot simplified CNA is feasible. Visualization of RAGP area using 3DRAS and MS is safe, effective and can very rapidly delineate CNA target.Figure

Inflammatory myofibroblastic tumor of the liver after adrenal neuroblastoma surgery: a case report

A boy aged 55 months was diagnosed with stage IV Neuroblastoma (NB) of the right adrenal gland 2 years ago. Preoperative chemotherapy was given and he was then treated with retroperitoneal tumor resection and lymph node dissection. After surgery, the children were transferred to the Hemato-Oncology Department for chemotherapy according to the high-risk group NB, with outpatient follow-up every 6 months. In the second postoperative year, abdominal computed tomography (CT) scan revealed a rounded hypodense area in the upper part of the right posterior lobe of the liver, with marked inhomogeneous enhancement in the venous phase after enhancement, which was surgically resected, and postoperative pathology confirmed inflammatory myofibroblastic tumor (IMT) of liver. The patient was not given any special treatment after surgery. In this study, whole transcriptome sequencing was performed on the postoperative specimen of adrenal NB and the specimen of IMT of liver. This unusual case emphasizes the need for close monitoring of second tumor development in NB survivors even in the absence of known predisposing factors.

A RARE CASE OF TYPE A AORTIC DISSECTION PRESENTING AS ACUTE STROKE: A DIAGNOSTIC CHALLENGE

Abstract A 60–year–old woman presented to the emergency department with acute left hemiplegia, not chest pains. Past medical history was significant for family history of aortic aneurysm, arterial hypertension. At brain–CT was reported hypodensity areas in posterior arm of the right internal capsule and in right tempero–polar lobe, confirmed on brain–MRI, and compatible with acute ischemic injury. Echocolor–dopper of epiaortic vessels documentated ulcerated plaque into the right common carotid artery (CCA). Selective catheterization found focal dissection obstructing the flow, treated with self–expanding stent. On echocardiography evalutation for suspiction of TAAD: dilatation of ascending aorta with flap oscillation, severe arotic regurgitation, pericardial effusion (Fig. 1). CT–Angiography was performed with evidence of type A dissection extending superiorly to the right CCA and inferiorly to the iliac bifurcation. For coma state, the patient was mechanically ventilated, and seriate CTs showed new ischemic lesions and hemorrhagic infarction of previous. Because of contraindication for cardiac surgery due neurological state, the patient was referred at medical therapy as bridge to hybrid aortic arc substitution at resolution of intracranial hemorrhages. In the next days there was progressive improvement neurological status with restoration of sensory and autonomic breathing with hemodynamic stability. Aortic dissection (AD) is defined as a disruption of the medial layer leading to the formation of two lumens separated by an intimomedial flap. AD is a critical diagnosis to make due to life–threatening outcomes and its non–specific presentation as in the case of our patient where the management of AD was delayed due to an unusual initial clinical presentation. Multimodality imaging approach has been fundamental for correct diagnosis and risk stratification. A limited number of studies have reported cases with stroke as the first symptom with concomitant TAAD. Concomitant intracerebral hemorrhage and TAAD is a very rare presentation and the optimal timing of surgery in these patients is unknown. In our opinion, patients who presents acute stroke should be carefully evaluated using multimodal imaging to exclude TAAD before administering reperfusion therapy. In addition, performing CAS before surgery for TAAD is challenging but might be a valid treatment option to maintain good brain perfusion and improve prognosis, but further investigations are needed.

Left posterior cerebral artery occlusion following minor head trauma: a case report

A 17-year-old male patient who received a punch behind the left ear 2 days ago, was admitted to the emergency room with a headache and dizziness. His neurological examination was normal. Brain CT images demonstrated diffuse hypodense areas and sulcus deletion in the left occipital lobe. On MR images, diffusion restriction for acute ischemia in the left PCA watershed area was determined, and hospitalization was recommended. However, he and his relatives left the hospital. Through the electronic information system called “e-nabız”, it was learned that the patient was hospitalized in an external center and treated with antiplatelet and anticoagulant regimens for ten days due to an acute thrombus at the left PCA P1 distal-P2 level observed on the brain CT and MR angiography images. In our clinic, his neurological examination was completely normal thirty days later. Still, a visual field examination revealed a total quadrianopsy in the upper temporal pole on the right and left eyes. An encephalomalacia in the left PCA watershed area was observed on CT images. The findings of this case showed that minor head trauma in children can cause large vessel occlusion and therefore close follow-up of these children for a certain time would be appropriate.

CBCT-3D radiographic analysis of an infected radicular cyst of the upper jaw: a case report

Objectives: The purpose of this case report is to find out the function of CBCT that can analyze in detail a radicular cyst case where CBCT has the ability to determine the density of a lesion. An overview of the density pattern of a radicular cyst can help determine the lesion and its margins. Case Report: : A 40-year-old patient complained of swelling in the palate that had been felt for about a year with a history of trauma due to an accident fifteen years ago. The patient underwent CBCT examination with the results of a hypodense area compared to the surrounding bone in the maxillary anterior area involving teeth 11,21,22 to 23 accompanied by a discontinuity of the cortical plate of the palatal bone and extending to involve the base of the nasal cavity. Part of the lesion is clearly demarcated, while the other side is diffuse. The suspected radiodiagnosis of the case was a moderately aggressive radicular cyst with a differential diagnosis of an odontogenic tumor. Conclusion: The final diagnosis of this case was a radicular cyst with chronic granulomatous inflammation, based on a combination of radiographic findings, clinical findings, and histopathological examination.

Anaesthetic Management for Rt Emphysematous Pyelonephritis with Grade I Hydroureteronephrosis with Perinephric Abscess with Left Lobar Pneumonia

ntroduction: A perinephric abscess is usually a complication of urologic infection which results from fat necrosis. Before the era of antibiotics, perinephric abscesses were due to prolonged bacteremia. More than 3/4 of perinephric abscesses are now due to complications of urinary tract infections. Case Report: We present a 71 year old female case with Right Emphysematous Pyelonephritis Grade I Hydroureteronephrosis with left perinephric abscess, left lobar pneumonia posted for bilateral DJ stenting with perinephric drain placement under continuous spinal anesthesia. Presented with H/o lower back pain, associated with fever since 3 days and H/o burning micturition, since 6 months. She is known case of Type 2 DM since 23 years and on Inj. Biphasic Insulin, Tablet vildagliptin, Tablet Dapaglifazone, known case of hypothyroidism and on tablet Thyroxin 50 mg OD in morning. H/o stroke 20 years back right side Upper &amp; lower limb affected. H/o previous appendectomy 20 years back, CT–KKUB suggestive of Emphysematous Pyelonephritis, right side with grade I HUN, left perinephric fat with ill diffused hypodense area in upper lobe of left kidney. Non obstructive left renal calculus 4.0mm. ECG shows RBBB, Saturation was 92% on Roomair, On ABG analysis severe metabolic acidosis found. We planned to administer continuous spinal anesthesia. Patient was explained about the continuous spinal anesthesia &amp; written informed consent was taken. Tablet Alprazolam 0.25 mg, and tablet Rantac, 15 was given previous night and in morning on the day of surgery. Nil per oral is maintained 8 hours before surgery. A 18 Gauge IV cannula was secured, a 5 lead Electrocardiogram, Pulse Oximeter, NIBP and ETCo2 monitoring was done. Under strict aseptic precautions, L3 L4 space was identified and using 18G tuhoy needle, Lumbar puncture is done. Injection Bupivacaine 0.8cc given, block is achieved till T8 level. Surgery was lasted for one and half hour. Vitals were stable. Patient shifted to recovery room and was under observation for an hour, patient was shifted to post operative ward. Conclusion: This is an Original case report, which provide a successful management of anesthesia, of bilateral DJ stenting with perinephric drain placement under continuous spinal anesthesia. Anesthesia Management for Right Emphysematous Pylonephritis with grade I HUN. With perinephric abscess with left lobar Pneumonia.

Otic Capsule Demineralization and Hearing Outcome of Stapes Surgery for Osteogenesis Imperfecta in Comparison With Otosclerosis.

To assess the location/number of otic capsule demineralization and hearing outcomes of stapes surgery (SS) for osteogenesis imperfecta (OI) compared with otosclerosis (OS). This study included 11 and 181 consecutive ears from 6 and 152 patients with OI and OS, respectively. Demineralization loci observed as hypodense area of the otic capsule were examined using high-resolution computed tomography. All patients underwent SS. Locations of the hypodense areas were classified into the anterior oval window, anterior internal auditory canal, and pericochlear area. The location/number of hypodense areas and preoperative/postoperative hearing parameters were correlated. Postoperative hearing outcome was evaluated 12 months after surgery. Hypodense area was more frequently observed in OI (9 of 11 ears [81.8%]) than in OS (96 of 181 ears [53.0%]), with significant differences. Multiple sites were involved in 81.8% OI and 18.8% OS patients, showing significant differences. Preoperative air conduction (AC), bone conduction, and air-bone gap (ABG) were 48.9 ± 17.8, 28.0 ± 11.3, and 20.7 ± 8.4 dB, respectively, in OI and 56.2 ± 13.5, 30.5 ± 9.9, and 26.4 ± 9.7 dB, respectively, in OS, demonstrating greater AC and ABG in OS than in OI. Postoperative AC (31.3 ± 20.5 dB), ABG (10.6 ± 10.0 dB), and closure of ABG (12.1 ± 4.7 dB), that is, preoperative ABG minus postoperative ABG of OI, were comparable to those of OS (AC, 30.9 ± 13.3 dB; ABG, 7.0 ± 7.4 dB; closure of ABG, 20.1 ± 11.6 dB). OI ears showed more severe demineralization of otic capsule than OS ears. However, favorable hearing outcomes could be obtained through SS for OI and OS ears.

Assessing EUS-guided radiofrequency ablation in unresectable pancreatic ductal adenocarcinoma: a single-center historic cohort study

/aims: Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as an alternative for the local treatment of unresectable pancreatic ductal adenocarcinoma (PDAC). We aim to assess the feasibility and safety of EUS-RFA in patients with unresectable PDAC. The following was a historic cohort compounded by locally advanced (LA) and metastatic (m) PDAC naïve patients, who underwent EUS-RFA between October 2019 to March 2022. EUS-RFA was performed with a 19-g needle electrode with a 10 mm active tip for energy delivery. Study primary endpoints were feasibility, safety, and clinical follow-up; secondary endpoints were performance status (PS), local control (LC) and overall survival (OS). Twenty-six patients were selected: 15/26 LA-PDAC and 11/26 mPDAC. Technical success was achieved in all patients with no major adverse events. Six months after EUS-RFA, OS was 11/26 (42.3%), with significant PS improvement (P=.03). LC was achieved, with tumor reduction from 39.5 to 26 mm (P=.04). Post-treatment hypodense necrotic area was observed at six-month follow-up in 11/11 alive cases. Metastatic disease was a significant factor for OS worsening (HR 5.021; IC 95% 1.589 - 15.87; P=.004) CONCLUSIONS: EUS-RFA of pancreatic adenocarcinoma is a minimally invasive and safe technique that may have an important role as targeted therapy for local treatment of unresectable cases, as well as an alternative for poor surgical candidates. Also, RFA may play a role in downstaging cancer with potential OS increase in non-metastatic cases. Large prospective cohorts are required to evaluate this technique in clinical practice.

Abstract TMP93: Severe Non-Contrast CT Hypodensity Modifies EVT Treatment Effect and is Associated With Worse Outcomes Independent of Ischemic Core Volume: A Secondary Analysis of the SELECT2 Trial

Introduction: Endovascular thrombectomy (EVT) reduces disability in patients with large ischemic core stroke. Increasing core volume is prognostic but does not modify treatment effect. CT hypodensity can vary within an area of core. We assessed the relationship between the severity of CT core hypodensity and clinical outcome in the SELECT2 trial. Methods: Non-contrast CT ischemic core was drawn manually by two blinded investigators with consensus review by a third investigator. An absolute Hounsfield unit (HU) threshold for severe hypodensity was set at the lower 99% confidence interval [CI] for normal contralateral thalamic grey matter. Outcomes assessed included ordinal mRS, functional independence (mRS 0-2), independent ambulation (mRS 0-3), and mortality at 90 days. The association between the volume of severe hypodensity and outcome was adjusted for age, baseline NIHSS, and total baseline core volume, via logistic and proportional odds models with treatment*hypodensity interaction. Results: Of 317 assessable patients, the median hypodensity of ischemic core was 31HU (IQR 28-33). Median density of normal thalamus was 38HU. The severe hypodensity threshold (lower 99% CI) was 26HU with median volume affected 14mL (IQR 5.6-29.2) or median 19% (IQR 9-35%) of the total hypodensity volume. The volume of core ≤26HU (per 1 mL increase) was associated with a 90-day mRS shift towards worse outcomes in EVT patients (n=161, adjusted common odds ratio, acOR 1.03, 95%CI 1.01-1.05) but not medical management ([MM], n=156, acOR 1.00, 95%CI 0.98-1.02, p-interaction 0.005); lower functional independence in EVT (aOR 0.96 95%CI 0.93-0.99) but not MM (aOR 1.02, 95%CI 0.99-1.06, p-interaction 0.004); lower independent ambulation in EVT (aOR 0.97, 95%CI 0.94-0.99) but not MM (aOR 1.01, 95%CI 0.98-1.04, p-interaction 0.002) and higher mortality in EVT (aOR 1.03, 95%CI 1.01-1.05) but not MM (aOR 1.00, 95%CI 0.98-1.02, p-interaction 0.02). Conclusion: In patients with large ischemic core, areas of significant CT hypodensity are associated with worse clinical outcomes after EVT but not MM. This is independent of total core volume and modifies the treatment effect of EVT. This may improve prognostic decision-making and drive developments in automated image processing.

One Fell Swoop: Septic Muscle Embolism and Central Venous Catheter Infection Imaged with [18F] Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

We describe the case of a 43-year-old female with hereditary hemochromatosis, previously without cardiac issues, who presented with a severe fever (>40 to 41 °C) to our hospital. Initial assessments, including transthoracic echocardiography, showed no typical signs of infective endocarditis. A contrast-enhanced CT scan revealed a hypodense area in the right subscapular muscle, alongside pleural thicknesses. Due to the critical condition, a central venous catheter (CVC) was implanted for immediate intravenous treatment. Subsequent blood cultures, positive for Staphylococcus aureus, and transesophageal echocardiography led to a diagnosis of multivalvular infective endocarditis (MIE). Subsequently, the patient underwent positron emission tomography/computed tomography (PET/CT) with [18F]Fluorodeoxyglucose ([18F]FDG), which detected increased tracer incorporation in the muscle lesion, CVC, and pleural thicknesses. The final diagnosis was CVC infection and septic embolism to the subscapular muscle in a patient with pleuritis. This case showcases the critical role of [18F]FDG PET/CT as whole-body imaging modality in diagnosing and managing complex infective cases.