Dark Blood Research Articles

Improved Brain Tumor Conspicuity at 3 T Using Dark Blood, Fat-Suppressed, Dixon Unbalanced T1 Relaxation-Enhanced Steady-State MRI.

Contrast-enhanced magnetic resonance imaging (MRI) is the cornerstone for brain tumor diagnosis and treatment planning. We have developed a novel dual-echo volumetric dark blood pulse sequence called Dixon unbalanced T1 relaxation-enhanced steady-state (uT 1 RESS) that improves the visibility of contrast-enhancing lesions while suppressing the tissue signals from blood vessels and fat. The purpose of this study was to test the hypothesis that Dixon uT 1 RESS would significantly improve the conspicuity of brain tumors compared with magnetization-prepared rapid gradient echo (MPRAGE), as well as to determine potential limitations of the technique. This retrospective study was approved by the hospital institutional review board. Forty-seven adult patients undergoing an MRI scan for a brain tumor indication were included. Contrast-enhanced MRI of the brain was performed at 3 T using both MPRAGE and Dixon uT 1 RESS. To control for any impact of contrast agent washout during the scan procedure, Dixon uT 1 RESS was acquired in approximately half the subjects immediately after MPRAGE, and in the other half immediately before MPRAGE. Image quality, artifacts, and lesion detection were scored by 3 readers, whereas lesion apparent signal-to-noise ratio and lesion-to-background Weber contrast were calculated from region-of-interest measurements. Image quality was not rated significantly different between MPRAGE and Dixon uT 1 RESS, whereas motion artifacts were slightly worse with Dixon uT 1 RESS. Comparing Dixon uT 1 RESS with MPRAGE, the respective values for mean lesion apparent signal-to-noise ratio were not significantly different (199.31 ± 99.05 vs 203.81 ± 110.23). Compared with MPRAGE, Dixon uT 1 RESS significantly increased the tumor-to-brain contrast (1.60 ± 1.18 vs 0.61 ± 0.47 when Dixon uT1RESS was acquired before MPRAGE and 1.94 ± 0.97 vs 0.82 ± 0.55 when Dixon uT 1 RESS was acquired after MPRAGE). In patients with metastatic disease, Dixon uT 1 RESS detected at least 1 enhancing brain lesion that was missed by MPRAGE on average in 24.7% of patients, whereas Dixon uT 1 RESS did not miss any lesions that were demonstrated by MPRAGE. Dixon uT 1 RESS better detected vascular and dural invasion in a small number of patients. In conclusion, brain tumors were significantly more conspicuous at 3 T using Dixon uT 1 RESS compared with MPRAGE, with an approximately 2.5-fold improvement in lesion-to-background contrast irrespective of sequence order. It outperformed MPRAGE for the detection of brain metastases, dural or vascular involvement. These results suggest that Dixon uT 1 RESS could prove to be a useful adjunct or alternative to existing neuroimaging techniques for the postcontrast evaluation of intracranial tumors.

Modeling of factors affecting late gadolinium enhancement kinetics in MRI of cardiac amyloid

BackgroundLate gadolinium enhancement (LGE) is a valuable part of cardiac magnetic resonance imaging (CMR). In particular, inversion-recovery imaging of LGE, with nulling of the signal from reference areas of myocardium, can have a distinctive pattern in some patients with cardiac amyloid, including both diffuse (relatively faint) subendocardial LGE and a relatively dark appearance of the blood. However, the underlying reasons for this distinctive appearance have not previously been well investigated. Pharmacokinetic modeling of myocardial contrast enhancement kinetics can potentially provide insight into the mechanisms of the distinctive LGE appearance that can be seen in cardiac amyloid, as well as why it may be unreliable in some patients. MethodsAn interactive three-compartment pharmacokinetic model of the dynamics of myocardial contrast enhancement in CMR was implemented, and used to simulate LGE dynamics in normal, scar, and cardiac amyloid myocardium; the results were compared with previously published values. ResultsThe three-compartment model is able to capture the qualitative features of LGE, in patients with cardiac amyloid. In particular, the characteristic “dark blood” appearance of PSIR images of LGE in cardiac amyloid is seen to likely primarily reflect expansion of the extravascular extracellular space (EES) by amyloid in the “reference” myocardium; the cardiac amyloid contrast enhancement dynamics also reflect expansion of the body EES. ConclusionThe distinctive appearance of LGE in cardiac amyloid is likely due to a combination of diffuse expansion by amyloid of the EES of the reference myocardium and of the body EES.

Atypical clinical and novel radiological findings in Susac syndrome: Experience from a large monocentric cohort

Susac syndrome (SuS) is a rare immune-mediated endotheliopathy that affects the brain, retina and inner ear and is characterised by the variable clinical triad of encephalopathy, visual and vestibulocochlear dysfunction. Here, we present clinical and paraclinical data of 19 SuS patients followed at Ghent University Hospital and highlight some atypical clinical and novel radiological findings. Our findings suggest that spinal involvement expands the clinical phenotype of SuS. We further introduce dark blood sequences as a more sensitive technique to detect radiological disease activity in SuS. Our data add to the current understanding of the diagnosis, monitoring and treatment of SuS.

Disease patterns among Saudi children undergoing colonoscopy for lower gastrointestinal bleeding: Single tertiary care center experience.

: The yield of colonoscopy in cases presenting with lower gastrointestinal bleeding (LGIB) in previously published studies varies according to several factors, including endoscopic skills, histopathological experience, and pattern of colonic pathology in different countries. The local literature is limited to a single small 20-year-old study. Our objective was to provide updated data on the diagnostic yield of colonoscopy in Saudi children with LGIB in Saudi Arabia. : This was a retrospective analysis of pediatric patients (0-14 years of age) who underwent colonoscopy for LGIB at the King Fahad Medical City (KFMC), from 2008 to 2018. LGIB was defined as fresh or dark blood per rectum. : During the study period, 175 children underwent colonoscopy for LGIB (99 males, mean age 7.05 ± 3.81 years), which constituted 53.5% of indications for colonoscopy procedures (n = 327) in our center. The terminal ileum was intubated in 81% of the procedures. Overall, inflammatory bowel disease (IBD) was the most commonly identified cause of LGIB (32% ) followed by colonic lymphonodular hyperplasia (CLNH) in 17% and juvenile polyp and rectal mucosal prolapse syndrome (RMPS), 11% each. On sub-analysis, cow's milk protein allergy (CMPA) and CLNH were the most common causes in infants and toddlers, 35% each; IBD (26.5%) and polyps (22.4%) in young children (2-6 years), and IBD (36%), CLNH (14.9%) and RMPS (14%) in older children (6-14 years). In comparing the IBD to the non-IBD group, IBD patients were older (mean 8.37 vs. 6.46 years, P = 0.002) and more likely to have diarrhea, weight loss, high erythrocyte sedimentation rate, anemia, and hypoalbuminemia (odds ratio 24, 11, 10.7, 6.5, and 4, respectively). Colonoscopy had a sensitivity of 97%, specificity of 100%, positive predictive value of 100%, negative predictive value of 81.4%, and accuracy of 97% in diagnosing LGIB. : Colonoscopy is an effective diagnostic tool in children with LGIB with a high diagnostic yield. Besides IBD, CLNH and RMPS are two other important pathologic entities that need to be considered in a child with LGIB.

SJLA_2024_A18: Persistent Complex Seroma Treated by Capsulectomy and Argon Beam Coagulator

Background: Seroma formation is one of the most common events following ventral hernia repair. When mesh is used for the repair of larger and more complex incisional hernias, the risk of seroma formation increases. The mesh onlay technique, which requires more extensive dissection, is associated with an even greater incidence of seroma formation. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant. Methods: The aim of this report is to present a definitive management of a very challenging case of abdominal wall chronic complex seroma following herniorrhaphy with mesh approached by open capsulectomy and scarification of the remnant pseudocapsule. Results: Our patient is a 60 years-old male a status post low anterior resection with covering loop ileostomy for rectal cancer. His diverting stoma was taken off after completing the adjuvant chemotherapy treatment. Seven months later, the patient has developed an enlarging midline incisional hernia. This hernia was subsequently repaired by primary fascial closure with suprafascial onlay polypropylene mesh. Postoperatively, he developed a subcutaneous seroma which was initially treated with an abdominal binder without success. Over the following 3 months of observation, seroma was increasing in size. Discussion: Having recovered his acute condition, surgical intervention was planned. The patient underwent an excision and evacuation of the complex seroma and pseudocapsule. A 12-cm midline incision was made in line with the previous incision used for the hernia repair. The pseudocapsule of the seroma was encountered when the subcutaneous tissue was incised. The incision was carried superior, inferior, and laterally, and the capsule was exposed. The seroma opening sinus was expanded and fluid was evacuated. There were some fibrous dead tissues and coagulated dark blood. The anterior and lateral aspects of the pseudo capsule were excised. Furthermore, the posterior aspect was cleaned carefully using the curettage instrument without affecting the integrity of the mesh which was looking healthy and intact and without causing injury to the intraabdominal contents. Argon beam coagulator was used to scarify the remaining posterior aspect attaching to the mesh. Hemostasis was secured, and the wound was closed over a Jackson–Pratt drain. A pressure dressing and abdominal binder were applied. Conclusion: Factors leading to seroma following incisional herniorrhaphy are poorly understood. Many options are available for treating complicated abdominal wall seroms. capsulectomy and scarification of the remnant pseudocapsule were good option for the treatment of persistence complex seroma.

Anesthesia in Low-Resourced Settings. Near Misses and Lessons Learned

Physician training requires the highest intelligence quotient of all professions to assimilate the vast amounts of complex knowledge required. The most critical decision-making medical specialty is anesthesiology, which requires much art of practicing medicine. That art is acquired via experience from years of medical practice.Clinical experience can also be gleaned from studying these 90 case reports in Brock-Utne’s book, Anesthesia in Low-Resourced Settings. These cases are from third-world countries, but any of these situations could also occur in American Ivy League University hospitals.Limited hospital night staff can be overwhelmed by a sudden influx of gunshot trauma cases and force one to care for emergency patients outside one’s regular working expertise. Another time one could be working remote from the hospital’s fully equipped main operating room complex in a small-case specialty single operating room. Then a crisis arises needing additional drugs and devices taking 20 min to be transported to that remote venue. Innovative temporary medical measures will be required. Power failures can occur without backup electricity. Suction systems can fail. Gas delivery can fail. An anesthesia machine can fail. A device may develop a problem not foreseen by its designers. Low-resourced settings can occur in a flash moment anywhere in the world, even in rich countries.This book’s cases challenge anesthesiologists’ training, intellect, and resourcefulness. This book is rich in wisdom. Before doing “mission medical work,” all anesthesiologists should read this book. There is a summarizing list of pearls of wisdom in the book. Reading that list may save one patient’s life in your career. I read the book in 2 days. Reading this book should be mandatory for anesthesia trainees nearing graduation. Anesthesiologists at any career point will read lessons echoing some anesthesia mishap they have experienced and wish they had read this book earlier in their careers.The deficient resources can be:This is the most valuable case in the book.A 29-yr-old woman fell off a moving train. When she arrived at a midsize Somali hospital, she was hypotensive, in pain, and tachycardic. She had fractures of the T10 vertebra, right humerus, the pelvis, and five right-side ribs with a right-side hemopneumothorax. A large-bore right subclavian multi-lumen access cordis venous cannula and an intercostal chest drain were immediately inserted. The pleural cavity drained 1,500 ml of blood. Additional peripheral venous access catheters were inserted.The anesthesiologist administered 4 units of blood. The blood pressure improved, but the centralized venous pressure measured via the subclavian cannula stayed at zero. Intercostal blood continued to drain and worried the thoracic surgeon, who urgently wanted to operate to stop the bleeding. The international normalized ratio (INR) test for clotting, of a sample withdrawn for the right-subclavian vein cannula, measured 2.3 (N = less than 1.1 when not on warfarin).The anesthesiologist worried about the darkness of the ongoing draining chest blood and the inexplicable high INR test result. The thoracotomy found no active bleeding source. A repeat INR test sample drawn from the femoral vein revealed a normal INR test of 1.1. The right subclavian cannula was intrapleural, and the persistent draining dark blood was subclavian catheter transfused blood. The first INR test had been done on the trauma intrapleural blood.A patient underwent general anesthesia with intubation using a wire-reinforced flexible endotracheal tube. On awakening, the patient bit firmly on the tube and occluded it, bending the reinforcing wire. After the biting relaxed, the tube was still entirely blocked from the crimping of the reinforcing wire. The patient’s chest started to heave as he struggled to breathe past the sustained endotracheal tube obstruction.Fully deflate the endotracheal tube cuff. That frees up about 40% of the cross-sectional area of the trachea for the patient to breathe past the outside of the endotracheal tube.Soon this patient woke up and was safely extubated. The problem is preventable by initially placing a bite-block or a Guedel airway in the mouth beside the endotracheal tube.After reading this book, many will recall many forgotten pearls of wisdom. Dr. Brock-Utne is a rare and superbly trained physician anesthesiologist who has worked extensively in third-world circumstances. He is an Emeritus full clinical professor from Stanford University in California. He is the epitome of a clinically expert scientist. His book is recommended to read.

Haematocolpos and Secondary Hematometra Due to Imperforate Hymen: Diagnosis and Treatment

BackgroundImperforate hymen is an uncommon congenital anomaly of the female genital tract and is rarely diagnosed in newborns. An imperforate hymen is a cause of primary amenorrhea. Case DescriptionA 12-year-old girl was admitted to the pediatric outpatient clinic with cyclic abdominal pain for eight days. She had lower abdominal pain with dysuria and constipation for the previous six weeks. There is a bulging mass on the perineal that appears when straining. Fever, nausea, vomitus, abdominal enlargement, and leucorrhea were denied; breast enlargement since 12 years old with no history of menarche. The patient vital signs were normal. On physical examination obtained, lower abdominal pain and tender suprapubic mass were palpable. The pubertal status was normally secondary sexual characteristics. An interlabial mass was found protruding from the introitus vagina and the hymen intact on inspection of the external genitalia. Laboratory and urinalyses revealed normal. Hematometra and hematocolpos were found on abdominal ultrasonography, which led to the diagnosis of imperforate hymen. Therefore, a hymenectomy was performed and evacuated 520 ml of dark red blood. The patient’s condition was good, and she had regular menstruation. ConclusionsImperforate hymen is an easy diagnosis, but sometimes clinicians are oblivious to including this in the differential diagnosis of lower abdominal pain in pubescent girls with primary amenorrhea. Also, a lack of awareness about the importance of external genitalia examination as part of routine physical examination in children and adolescents makes this diagnosis easily missed or delayed.

517 RIGHT ATRIAL THROMBUS IN A PATIENT WITH CARDIAC AMYLOIDOSIS: A MULTIMODALITY IMAGING APPROACH

Abstract Case Presentation A 47-year-old man was referred to our outpatient clinic for dyspnea and chest pain. His past medical history was remarkable for an admission of acute congestive heart failure, occurred two weeks before presentation. On that occasion, the patient was discharged after a few days of diuretic therapy. Diagnostic Workup at presentation, the patient was symptomatic for dyspnea with signs of systemic congestion. The ECG showed sinus rhythm, inferolateral negative T waves and absent progression of R wave in precordial leads. Transthoracic echocardiography revealed markedly thickened left ventricular (LV) walls (maximum interventricular septum dimension 19 mm) with a granular-sparkling appearance of the myocardium, bi-atrial enlargement, preserved LV ejection fraction, restrictive mitral flow pattern thickened interatrial septum and atrio-ventricular valves. No significant valvular regurgitations were detected. Global LV longitudinal strain was significantly reduced (-9.4%), with relative apical sparing. Given the high suspicion for infiltrative disease we performed further investigations. The cardiac computed tomography (CCT) excluded significant coronary artery disease, but it raised the suspicion of a thrombus at the level of the right atrial appendage, that was confirmed by a transesophageal echocardiography showing a mobile round mass of 14×12 mm. Finally, tissue characterization by cardiac magnetic resonance exhibit a diffuse myocardial delayed enhancement, with a dark blood pool and, an increase in extracellular volume and T1 mapping values (1266.3 ms). Laboratory tests showed increased levels of creatinine, BNP and, lambda light chains. Bone scintigraphy imaging didn't identify any uptake of radiotracers at myocardial level. These findings were suggestive for cardiac light-chain (AL) amyloidosis. Accordingly, a treatment with warfarin, beta-blockers, steroid, and diuretics was initiated. Conclusions cardiac amyloidosis is an infiltrative disease characterized by the deposition of aggregates of amyloid fibrils in the myocardium. Multimodality imaging is pivotal to determine the diagnosis, assess the potential complications, and stratify the patients’ prognosis. Our case demonstrates that cardiac AL amyloidosis is associated with an increased thromboembolic risk, irrespective of the presence of atrial fibrillation. Moreover, although the left atrial appendage is most frequently the site of thrombus formation, it is advised to look for them also in uncommon sites as the right atrial appendage.

A success story of modified Sugiura technique surgery in a non-cirrhotic portal hypertension (NCPH)

Background: Non-cirrhotic portal hypertension refers to elevated portal vein pressure in the absence of liver cirrhosis. Surgery could be an effective procedure for patients with recurrent variceal bleeding who fail to respond to pharmacotherapy or endoscopic therapy. We report a success story of modified Sugiura technique in managing a patient with non-cirrhotic portal hypertension. Case presentation: A male, 24-year-old, complained of recurrent vomiting of dark red blood color for six months. Anemic conjunctiva and splenomegaly were discovered during a physical examination. Pancytopenia and normal hepatobiliary function were revealed in the laboratory examination. Ultrasonography of the abdomen demonstrates nonspecific splenomegaly. An abdominal computerized tomography scan revealed hepatosplenomegaly and pelvic fluid accumulations. Grade IV esophageal varices and mild portal hypertensive gastropathy were observed during endoscopic examination. Active bleeding still presented despite initiation of medical treatment and endoscopic ligation. Finally, a surgical procedure using the Sugiura technique was performed. The patient was recovered, no recurrent symptom of hematemesis was reported after one year of follow-up. Conclusion: Modified Sugiura technique is a useful treatment of choice in non-cirrhotic portal hypertension patients who failed to respond other medical treatments. However, comprehensive assessment is critical prior to choose this procedure.

Pathological changes in an Alsatian dog following Amitraz and Sniper (dichlorvos) exposure

Amitraz and Sniper (dichlorvos) are known ectoparasiticides of dogs in Nigeria. Although reports of their toxicosis exist, information on the pathological presentations of their combined toxicosis is scanty hence the present case report. Two dogs both had Amitraz bath with simultaneous fumigation of their immediate environment with Sniper (diclorvos). Excessive salivation, staggering gait, and respiratory distress were observed shortly thereafter with the prompt administration of atropine sulphate which ameliorated it, but a particular dog progressively became weak, inactive and off feed. A vomitus, dark watery stool and blood spots were observed within its kennel before death. The post-mortem examination revealed emaciated, dehydrated and tick infested carcass with pale ocular and oral mucous membranes. There was also ileocolic intestinal intussusception characterized by anal intussusceptum protrusion, congested liver and pulmonary peribronchial haemorrhage with inter-alveoli cellular infiltration including haemorrhagic enteritis. Death might have been due to hypovolemic shock following the observed dehydration, pallor, haematochezia, peritoneal fluid exudation, hepatic congestion, pneumonia characterized by peribronchial haemorrhages, and haemorrhagic enteritis. The observed intussusception was a rare occurrence in a dog following Amitraz and Sniper poisoning in Abuja, Nigeria, which highlighted the need for their cautious and professional use.

MR Multitasking-based multi-dimensional assessment of cardiovascular system (MT-MACS) with extended spatial coverage and water-fat separation.

To extend the MR MultiTasking-based Multidimensional Assessment of Cardiovascular System (MT-MACS) technique with larger spatial coverage and water-fat separation for comprehensive aortocardiac assessment. MT-MACS adopts a low-rank tensor image model for 7D imaging, with three spatial dimensions for volumetric imaging, one cardiac motion dimension for cine imaging, one respiratory motion dimension for free-breathing imaging, one T2-prepared inversion recovery time dimension for multi-contrast assessment, and one T2*-decay time dimension for water-fat separation. Nine healthy subjects were recruited for the 3T study. Overall image quality was scored on bright-blood (BB), dark-blood (DB), and gray-blood (GB) contrasts using a 4-point scale (0-poor to 3-excellent) by two independent readers, and their interreader agreement was evaluated. Myocardial wall thickness and left ventricular ejection fraction (LVEF) were quantified on DB and BB contrasts, respectively. The agreement in these metrics between MT-MACS and conventional breath-held, electrocardiography-triggered 2D sequences were evaluated. MT-MACS provides both water-only and fat-only images with excellent image quality (average score=3.725/3.780/3.835/3.890 for BB/DB/GB/fat-only images) and moderate to high interreader agreement (weighted Cohen's kappa value=0.727/0.668/1.000/1.000 for BB/DB/GB/fat-only images). There were good to excellent agreements in myocardial wall thickness measurements (intraclass correlation coefficients [ICC]=0.781/0.929/0.680/0.878 for left atria/left ventricle/right atria/right ventricle) and LVEF quantification (ICC=0.716) between MT-MACS and 2D references. All measurements were within the literature range of healthy subjects. The refined MT-MACS technique provides multi-contrast, phase-resolved, and water-fat imaging of the aortocardiac systems and allows evaluation of anatomy and function. Clinical validation is warranted.

Methaemoglobinemia: a diagnosis of surprise with recent literature review and management

BackgroundMethaemoglobinemia (MetHb) is a rare entity in clinical practice which often goes undiagnosed and keeps both the anaesthesiologist and attending surgeon under tension during surgery on seeing dark or chocolate-coloured blood in the surgical field. A low oxygen saturation (SpO2) will further panic us to search for a cause but may end futile. To add further, SpO2 may not rise significantly with adequate oxygenation and may not reach 100 with a fraction of inspired oxygen (FiO2) of 1 which keeps us searching further for a cause. An arterial blood gas (ABG) finally clinches our diagnosis. It is often missed in the pre-anaesthetic evaluation due to its rarity and the patient being asymptomatic most of the time.Case presentationWe present a case of a 61-year-old man, a reformed smoker and hypertensive on regular medication was evaluated for laparoscopic partial nephrectomy for right renal cell carcinoma. MetHb was diagnosed preoperatively in the midst of the COVID pandemic when we had all our patients’ room air SpO2 recorded and thus helped us in the smooth and hassle-free management with vitamin C preoperatively for 5 days and an uneventful perioperative period.ConclusionsMetHb is an uncommon and potentially reversible cause of hypoxia. A simple bedside SpO2 evaluation may give a hint to the diagnosis along with a high haematocrit which urges us to order for an ABG when no other cause is attributable. A preoperative diagnosis can lead to an effective and simple management with vitamin C which often reduces methaemoglobin to significantly low levels and to have a favourable outcome. According to the literature, any level of less than 20% does not have much clinical significance in asymptomatic patients and surgery need not be deferred.

S2600 Gastric Mucormycosis: A Case of a Rare Infectious Cause of Upper GI Bleeding

Introduction: Gastric mucormycosis is a rare clinical entity that mandates upper endoscopic evaluation and specific histopathologic findings for a diagnosis. Due to its non-specific clinical presentation, it poses a diagnostic challenge for providers. We present a case of gastric mucormycosis in a critically ill and immunosuppressed patient that was discovered in the setting of evaluation of upper gastrointestinal bleeding. Case Description/Methods: A 66-year-old man with a history of a kidney transplant two years prior, with a recent diagnosis of post-transplant lymphoproliferative disorder (PTLD) and who had recently undergone an initial round of R-CHOP chemotherapy four weeks prior was admitted to the hospital with altered mentation and neutropenia. His hospital course was prolonged with multiple cardiac arrests in the setting of septic shock from his profound neutropenia. He was noted to have dark blood from his nasogastric tube and a concomitant drop in his hemoglobin, for which the Gastroenterology service was consulted. He underwent urgent upper endoscopic evaluation and was found to have both significant clot in his stomach and an ulcerated fungating lesion along the greater curvature of the stomach which was biopsied. Pathology results showed fungal organisms with special GMS stain showing morphologic features consistent with mucormycosis. The Infectious Diseases service was urgently consulted and he was started on triple anti-fungal therapy with amphotericin, micafungin and posaconazole. Otolaryngology evaluated the patient due to these endoscopic findings, with laryngoscopy negative for head and neck involvement of this infection. Surgery was consulted for evaluation of subtotal gastrectomy, but he was deemed an unsuitable surgical candidate. The patient eventually succumbed to this and passed away during his hospitalization. Discussion: Gastric mucormycosis is a rare infection that often manifests in the setting of immunosuppression as seen in solid organ transplant recipients or in patients with diabetes. The most often clinical manifestation is upper gastrointestinal bleeding, and thus endoscopic evaluation is part of the work-up to exclude other diseases that could mimic its presentation. This diagnosis often results in fatal outcomes, so early recognition is critical for both medical management with anti-fungal therapy, along with surgical management given the high failure rate of medical management alone for this diagnosis.

S1912 A Rare Case of Recurrent Hemosuccus Pancreaticus

Introduction: Hemosuccus pancreaticus is a rare cause of GI bleeds characterized by intermittent bleeding from the major duodenal papilla. Chronic pancreatitis, via arterial wall necrosis, can form a visceral pseudoaneurysm in 10% of cases. Here is a rare case of recurrent hemosuccus pancreaticus caused by a gastroduodenal artery (GDA) pseudoaneurysm, despite repeated embolization. Case Description/Methods: A 65-year-old man with alcoholic pancreatitis and pancreaticoduodenal pseudoaneurysm status post embolization in 2019 was being evaluated for hematochezia for 6 months. The patient underwent several negative EGDs and colonoscopies. Video capsule endoscopy showed scant blood streaking in proximal small bowel. Initial CT showed an enlarged pancreas with dilated pancreatic duct. EUS showed a 3x2.5cm well-defined cystic lesion at the pancreatic head with an anechoic center with vascular flow. Repeat CT showed a 1.6cm saccular aneurysmal dilation of the superior pancreaticoduodenal artery (SPDA). Prior to follow-up, he was admitted with hematochezia, with his hemoglobin down from 12 to 7.8. EGD showed blood in the second part of duodenum with fresh oozing from ampulla. An aortogram showed a non-bleeding pseudoaneurysm of the GDA, which was successfully embolized. One month later, he presented again with hematochezia. CTA showed a recurrent 1.5cm pseudoaneurysmal dilation of the SPDA and possible lower GI bleed. Colonoscopy showed dark red blood mixed with stool. NM scan showed a slow bleed from left common/internal iliac artery. An angiogram showed extravasation from the GDA, which was embolized along with the recurrent pseudoaneurysm. Seen 45 days after discharge, the patient was asymptomatic (Figure). Discussion: Hemosuccus pancreaticus caused by GDA pseudoaneurysm is reported in less than 2% of population. Successful embolization in the first 6 months is estimated to be 67%, with rebleeding risk at 37%. Rebleeding is thought to be due to collateral vessels, but in this case, no extravasation was seen after each embolization. Our patient developed recurrent symptoms with development of an aneurysm involving the same artery 1 month later. Recurrence or formation of new pseudoaneurysms usually occur within the first 6 months after embolization. This case is unique in that the patient initially had a successful embolization in 2019 of an aneurysm involving the same artery without any bleeding for 2 years, showing that hemosuccus pancreaticus can recur even after the initial 6 month period after a successful embolization.Figure 1.: A: EGD showing bleeding from ampulla. B: Angiogram of celiac trunk with GDA pseudoaneurysm. C: CTA showed 1.5cm saccular pseudoaneurysmal dilatation of the superior pancreaticoduodenal artery. D: EUS showed a 3.4 x 2.5 cm cystic lesion with anechoic center.

S2558 An Unusual Cause of Upper Gastrointestinal Bleed: Temporary Epicardial Pacing Wire

Introduction: A temporary epicardial pacing wire (TEPW) is frequently placed during cardiac surgery to treat postoperative arrhythmias. Gastrointestinal (GI) complications from TEPW are rare, and only a few have been described. Here we describe a rare case of upper GI bleed from TEPW traversing the stomach. Case Description/Methods: A 76-year-old male with a past medical history of coronary artery disease (CAD) status posts two stents, myocardial infarction, chronic kidney disease, hypertension, and stroke presented to the emergency department with chest pain. The patient had a non-ST-elevation myocardial infarction (NSTEMI); coronary angiography showed multivessel CAD. He underwent coronary artery bypass grafting (CABG), following which the patient had 1200cc dark blood drained through the nasogastric tube. The patient underwent esophagogastroduodenoscopy (EGD), which showed a significant amount of fresh blood (Figure A) and a suspicious linear object entering and exiting the gastric body (Figure B). He underwent a celiac and left gastric artery angiogram with embolization of the injured branch of the left gastric artery. The foreign body removed from the stomach was identified as right ventricle TEPW. Repeat EGD showed no active bleeding. Discussion: Epi-myocardium of the atria and ventricle are common sites for TEPW placement during cardiac surgery. They are tunneled to the outside through the left subcoastal margin. Poor sensing or capture, dislodgement, or retention are the most common complications. Other complication include bleeding from the right ventricular laceration with tamponade, avulsion of a side branch from a saphenous vein coronary bypass graft, and perforation of the superior epigastric artery. GI complications from this procedure are rare. Few reports of bowel perforation presenting as acute abdomen have been described. A case of dyspepsia due to gastric wall injury caused by the migration of TEPW into the gastric cavity has been described. To our knowledge, no case of upper GI bleed secondary to pacemaker wire misplacement has been described. Post-cardiac surgery patients are usually in the ICU. Therefore, if signs of GI bleeding are present in the postoperative period, EGD should be performed for diagnostic purposes. However, rarely displaced pacemaker wire may be one of the causes of GI bleeding, which should be on the physician's radar.Figure 1.: (A) EGD showing pooled blood in stomach giving definitive evidence of upper GI bleed. (B) EGD showing pacemaker wire traversing the stomach.

CNNT DB-LGE: free-breathing dark blood late enhancement imaging using the convolutional neural network transformer speeds acquisition by 50%

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported in part by the Division of Intramural Research of the National Heart, Lung, and Blood Institute, National Institutes of Health (grants Z1A-HL006214-05 and Z1A-HL006242-02). Background Dark blood late gadolinium enhancement (DB-LGE) imaging shows superior delineation of myocardial infarction (MI), especially at the sub-endocardial boundary. Our previous study [1] developed a free-breathing DB-LGE with the single shot SSFP readout, phase sensitive inversion recovery (PSIR) reconstruction, and respiratory motion corrected averaging. To compensate the potential signal-to-noise ratio loss, our previous DB-LGE doubled the measurements, thereby increasing the acquisition time. Purpose In this study, we developed a deep learning image enhancement model using a novel neural network architecture called the convolutional neural network transformer (CNNT) to improve the image quality of DB-LGE and to reduce the acquisition time by decreasing the number of measurements. Methods A novel image enhancement model was developed using a novel network architecture called the Convolutional Neural Network Transformer (CNNT) proposed by us. This architecture is suitable for the 2D+Time CMR acquisition, by exploiting the temporal correlation between images over multiple averages. The evaluation was first retrospectively conducted on a cohort of 12 patients acquired with the original protocol [1] using the full 16 measurements. For every subject, a complete short-axis stack (typically 12 slices) was acquired to cover the entire left ventricular. The imaging data was reconstructed in three ways. Original: using all acquired 16 measurements. This is our base-line protocol. Original 50%: using only the first 8 measurements. CNNT 50%: using only the first 8 averages, but performing the CNNT deep learning image enhancement before MOCO PSIR reconstruction. Two experienced imaging researchers (PK and MF, >10 years of experience for both) scored all DB-LGE images for the overall quality, diagnostic confidence and delineation of MI/boundaries (5 = excellent, 4 = good, 3 = fair, 2 = poor, and 1 = non-diagnostic). The CNNT DB-LGE was deployed to the MR scanner using the Gadgetron InlineAI [2]. Results Figure 1 gives examples of DB-LGE with three reconstruction methods. The CNNT image has higher SNR and well delineated MI. The Original images with the longest acquisition have good quality and the Original-50% acquired with 8 measurements are good quality but have reduced SNR. The mean scores for overall image quality, diagnostic confidence and MI delineation of two reviewers were 4.88±0.23, 4.88±0.23, 4.83±0.25 for CNNT and 4.96±0.14, 4.96±0.14, 4.67±0.39 for the original approach. No significant differences were found between the original and the CNNT (P>0.15 for all). Figure 2 shows an acute MI patient prospectively acquired with the 50% scan time reduction, with and without the CNNT enhancement. The resulting PSIR images well delineate the MVO due to the acute MI, with improved SNR. Conclusion A novel CNNT model was proposed and evaluated to speed up the free-breathing MOCO DB LGE by 50% without sacrificing image quality.

Dark Blood: An Analysis of Slaves in the Family (Slavernes slægt)

The article presents an analysis of the Danish documentary series, Slaves in the Family. It demonstrates how an analytics of hybridity can unpack the naturalizations and denaturalizations of categories of purity, arguing that it is vital to capture the unstable tension between understanding “hybridity” as a mixing of elements on the one hand, and as a displacement of categories on the other. Slaves in the Family criticizes and destabilizes ideas of purity by rearticulating the story of Danish colonial history and of Danish national identity. However, the article argues that the series’ narrative about family and race is uneasily situated between the two conceptions of hybridity. Consequently, notions of purity are reinstalled by the way the series articulates “kinship” as the basis of true relations and authentic identity.

Saturation-pulse prepared heart-rate independent inversion-recovery (SAPPHIRE) biventricular T1 mapping: inter-field strength, head-to-head comparison of diastolic, systolic and dark-blood measurements

BackgroundTo assess the feasibility of biventricular SAPPHIRE T1 mapping in vivo across field strengths using diastolic, systolic and dark-blood (DB) approaches.Methods10 healthy volunteers underwent same-day non-contrast cardiovascular magnetic resonance at 1.5 Tesla (T) and 3 T. Left and right ventricular (LV, RV) T1 mapping was performed in the basal, mid and apical short axis using 4-variants of SAPPHIRE: diastolic, systolic, 0th and 2nd order motion-sensitized DB and conventional modified Look-Locker inversion recovery (MOLLI).ResultsLV global myocardial T1 times (1.5 T then 3 T results) were significantly longer by diastolic SAPPHIRE (1283 ± 11|1600 ± 17 ms) than any of the other SAPPHIRE variants: systolic (1239 ± 9|1595 ± 13 ms), 0th order DB (1241 ± 10|1596 ± 12) and 2nd order DB (1251 ± 11|1560 ± 20 ms, all p < 0.05). In the mid septum MOLLI and diastolic SAPPHIRE exhibited significant T1 signal contamination (longer T1) at the blood-myocardial interface not seen with the other 3 SAPPHIRE variants (all p < 0.025). Additionally, systolic, 0th order and 2nd order DB SAPPHIRE showed narrower dispersion of myocardial T1 times across the mid septum when compared to diastolic SAPPHIRE (interquartile ranges respectively: 25 ms, 71 ms, 73 ms vs 143 ms, all p < 0.05). RV T1 mapping was achievable using systolic, 0th and 2nd order DB SAPPHIRE but not with MOLLI or diastolic SAPPHIRE. All 4 SAPPHIRE variants showed excellent re-read reproducibility (intraclass correlation coefficients 0.953 to 0.996).ConclusionThese small-scale preliminary healthy volunteer data suggest that DB SAPPHIRE has the potential to reduce partial volume effects at the blood-myocardial interface, and that systolic SAPPHIRE could be a feasible solution for right ventricular T1 mapping. Further work is needed to understand the robustness of these sequences and their potential clinical utility.

Випадок нетравматичної субдуральної гематоми

The risk for the development of subacute or chronic subdural hematoma is associated with the widespread use of anticoagulant therapy for both prophylactic and therapeutic purposes. Therefore, the purpose of the study was to carry out clinical and morphological analysis of the case of chronic subdural hematoma associated with the use of antithrombotic therapy to substantiate the pathogenetic links of their relationship. Materials and methods. The case report. The body of a woman with signs of bodily injuries was found in the apartment at the place of residence. The autopsy along the entire length of the vertebral canal revealed a draining thin-layer subdural hemorrhage in the form of layers of liquid dark red blood, which effortlessly filled all the free spaces between the dura mater and arachnoid mater. The bones of the vault, the base and the frontal skeleton of the skull were intact. The dura mater was moderately tense, grayish in color, with the bones of the skull tightly fused in all parts of the skull. On the convex and basal surfaces of both hemispheres of the brain with spread between the hemispheres of the brain, around the cerebellum and trunk with penetration into the large occipital foramen, subdural hemorrhage in the form of layers of thick dark red blood was found. Forensic histological examination of pieces of internal organs revealed hemorrhage under the dura mater of the brain and spinal cord with reactive inflammatory changes, deposition of hemosiderin granules. Forensic toxicological analysis of blood, urine, stomach and small intestine contents, liver and gallbladder and kidneys revealed diclofenac and an unknown substance that might be an anticoagulant; however, it could not be identified by the approved methods due to the limited number of comparison samples. Examination of the corpse in the apartment revealed blisters and ampoules of various drugs in the largest amount of diclofenac, warfarin. Results and discussion. The analysis of the data obtained on the scene, as well as from the medical history, records in the available medical documentation, morphological characteristics of detected hemorrhages, results of forensic toxicological and forensic histological studies have established that hemorrhages might have occurred due to uncontrolled use of diclofenac and warfarin. Conclusion. Subdural hematomas are currently the topical medical and social issue due to the significant growing rate of its incidence. Based on this case, it can be stated that the development of chronic subdural hematoma is caused by the combination of mild trauma and inflammatory response in the damaged dura mater with potentiation of hematoma formation through the use of antithrombotic drugs

Imperforate hymen associated with constipation and acute urinary retention

A 14-year-old patient with primary amenorrhea presented with acute abdominal pain, severe constipation, and urinary retention. A computed tomography scan of the abdomen or pelvis revealed a hematocolpos with distension of the vagina up to 7.4 cm in diameter and a proximal hematometra (Figure 1). Exam findings revealed a bulging hymen with a purple hue (Figure 2). A hymenectomy was performed with evacuation of 500 mL of dark blood. The hymenal tissues were surgically corrected to maintain patency (Figure 3).