Site Of Extravasation Research Articles

Probable Mechanisms Involved in Immunotoxin Mediated Capillary Leak Syndrome (CLS) and Recently Developed Countering Strategies.

Antibody-toxin fused agents or immunotoxins, are a newly engineered class of cytotoxic agents consisting of a bacterial or plant toxin moiety hooked up either to a monoclonal antibody or a specific growth factor. Nevertheless, acquiring a full potency in clinic is mostly restricted due to the Capillary leak syndrome (CLS), a serious immune provoked, life-threatening side effect, subsequent to the endothelial damage, resulting in fluid escape from the bloodstream into tissues including lungs, muscle and brain, developing organ failure and eventually death. Proposed underlying mechanisms include direct damage to endothelial cells, acute inflammation, Lymphokine-activated killer (LAK) cells engagement, alteration in cell-cell/cell-matrix connectivities and cytoskeletal dysfunction. Very poor biodistribution and heterogeneous extravasation pattern in tumor site result in accumulation of ITs close to the extravasation site, gradual toxin release and initiation of nearby endothelial cells lysis, secretion of pro-inflammatory cytokines, development of acute inflammation and engagement of Lymphokine-activated killer (LAK) cells. Intrinsic immunogenicity of applied toxin moiety is another important determinant of CLS incidence. Toxins with more intrinsic immunogenicity possess more probability for CLS development. Recently, development of new generations of antibodies and mutated toxins with conserved cytotoxicity has partly tapered risk of CLS development. Here, we describe probable mechanisms involved in CLS and introduce some of the recently applied strategies for lessening incidence of CLS as much as possible.

Infrared Video Thermometry Guidance for Surgical Correction of Chylothorax in Dogs

Background: Macroscopic identification of the extravasation site of chyle in patients with chylothorax is a major challenge. Current forms of identification are invasive and/or expose patients to radiation, as in computerized tomography and radiography. A prototype device that uses infrared video thermometry images to detect temperature increments of 0.1ºC has been developed. This device can process and show real-time images or video on a monitor during surgeries. Therefore, the aim of this work was to report the first successful case in which this innovative device was tested in the transoperative period to identify the thoracic duct and its tributaries in a chylothorax surgery performed in a dog.Case: A 2-year-old male dog of the Shiba Inu breed was presented to the veterinary hospital with exercise intolerance, cough, emaciation, and no history of trauma. Clinical examination was performed along with complete blood count, biochemical analysis, and thoracic radiography. The patient exhibited dyspnea and had diminished breath sounds on chest auscultation. Radiographic images revealed moderate pleural effusion. The dog was anesthetized and submitted to thoracotomy, which enabled visualization of a chylous effusion. A sample of the effusion was collected for cytological and biochemical analyses. Subsequently, pericardiectomy was carried out, and identification of the thoracic duct and its tributaries was guided by an innovative device that generates infrared video thermometry images in real time. The extravasation site of the chylewas visualized on the images shown on a monitor. Consequently, after ligation of the tributary vessel, interruption of chyle overflow could be noticed on the monitor. Thoracotomy was routinely closed, and a drain was placed through an intercostal space after incision. Thirty days after the surgery, the dog exhibited no signs of recurrence. Cytological and biochemical analyses of the effusion revealed an abnormal transudate that had a density of 1,030 g/cm3, alkaline pH, predominance of neutrophils and lymphocytes, and high levels of proteins, triglycerides and cholesterol. These results indicated that the effusion analyzed was chyle.Discussion: Macroscopic aspects of an effusion alone should not be used to make a definitive diagnosis; cytological, physical, and biochemical evaluations are indispensable. The specimen analyzed had a higher concentration of triglycerides than blood, and its cholesterol concentration was lower than that found in blood. Findings like these have already been reported as indicative of chylous effusion. Thoracic duct ligation is the most used technique for correction of chylothorax, and is the technique with better outcomes. Thermometry has already been used for clinical examination in several diseases. However, the innovative device used in this study has the advantage of being noninvasive, and was able to guide the surgeon during the surgery to locate the thoracic duct and precisely identify the tributary lymphatic vessel responsible for the chylous effusion. The physical space occupied by the device did not disturb the surgical team since a small infrared image generator was placed one meter above the patient to take high definition images of the entire animal in the evaluation field. The thermometry device was very useful, non-invasive, and precise to differentiate thoracic structures and to identify the siteof extravasation of chyle. It also allowed a more interactive and precise surgical approach by the surgical team, which was essential to the success of the surgery.Keywords: chyle extravasation, infrared diagnosis, surgery, thorax.

Contrast Media Extravasation in CT and MRI - A Literature Reviewand Strategies for Therapy.

Contrast extravasation events in daily radiological routine may lead to serious complications, especially during CT examinations. The resulting symptoms may vary from local pain up to skin ulcers, necrosis or even acute compartment syndrome.There are no uniformly accepted radiological guidelines or recommendations regarding detection and treatment of extravasation events and immanent complications in a timely manner. Systematic literature research considering the last 35 years via PubMed using search terms "contrast medium extravasation/paravasation". In the literature, there are conservative management approaches of contrast media extravasation without major evidence base, such as unguent dressings, cooling or splinting. This therapy is mostly symptomatic. Additionally, various invasive techniques are described. We discuss these techniques in the context of contemporary literature, such as the hyaluronidase Injection into the site of extravasation, suction/aspiration technique including flushing of the affected tissue areas and the squeezing technique. However, most citations lack scientific evidence: many articles include anecdotal enumerations, case studies or cite publications from the era, when ionic high osmolar contrast media was state-of-the-art. Besides, many authors derive their extravasation management from studies, where agents other than contrast media were investigated. After detailed literature review, we suggest early (plastic) surgical consultation when non-ionic, low-osmolar contrast medium extravasation is about 150 cc or more. In case of extravasation less than 150 cc but in presence of additional symptoms such as impaired perfusion or altered sensibility, the (plastic) surgeon should also be consulted instantly. We do not recommend any invasive first line therapy when contrast media extravasation is less than 150 cc and the patient presents no additional symptoms, besides swelling and local pain. Nevertheless continuous monitoring and accurate conservative management such as active cooling and elevation, splinting of the affected extremity are mandatory as early detection of critical symptoms helps to initiate prompt surgical intervention and avoid sequelae. · Morbidity after contrast media extravasation is extremely rare.. · Predicting sequelae after contrast extravasation is difficult at first sight.. · Treatments such as hyaluronidase injection, suction/aspiration, squeeze technique have been described.. · Surgical consultation is recommended for extravasation > 150 cc or when additional symptoms occur.. · Mandlik V, Prantl L, Schreyer AG. Contrast Media Extravasation in CT and MRI - A Literature Review and Strategies for Therapy. Fortschr Röntgenstr 2019; 191: 25 - 32.

Clinical outcome and subsequent sequelae of cement extravasation after percutaneous kyphoplasty and vertebroplasty: a comparative review.

Background Injection of cement during vertebroplasty and kyphoplasty can leak into surrounding structures and could be symptomatic. Purpose To identify the sites and incidence of cement extravasation after kyphoplasty and vertebroplasty, and to evaluate their impacts on clinical outcomes. Material and Methods A retrospective review of 316 patients treated with kyphoplasty and vertebroplasty; 411 cases were included (223 kyphoplasty and 188 vertebroplasty). Cement extravasation was evaluated postoperatively by computed tomography (CT) scan of the spine. Clinical outcomes were assessed by visual analog scale (VAS) and Oswestry Disability Index (ODI). Results There was a statistically significant difference in the incidence rate of cement extravasation between vertebroplasty and kyphoplasty groups ( P < 0.04). The most common site of cement extravasation was in paravertebral soft tissues for vertebroplasty (n = 33, 40.7%) and for kyphoplasty (n = 30, 30%). In the subgroup where cement leaked into the intradiscal space, adjacent vertebral body fractures occurred in 3/26 vertebrae (11.5%) in the vertebroplasty group and in 2/18 vertebrae (11.1%) in the kyphoplasty group. Both groups showed a statistically significant decrease in both VAS ( P < 0.001) and ODI scores ( P < 0.001). There was no significantly difference in patient satisfaction between those who had cement extravasation and those who did not, in both groups. Conclusion Kyphoplasty has an advantage in terms of less risk of cement extravasation. However, this factor did not reflect on subsequent sequelae or final clinical outcomes. This study did not find a distinct correlation between intradiscal cement extravasation and increased risk of adjacent vertebral fractures.

Radiation-induced inflammatory cascade and its reverberating crosstalks as potential cause of post-radiotherapy second malignancies.

The disease-free survival following radiotherapy is often limited by the development of second/secondary cancers. This significant impediment to effective cancer treatment implicated even in the modern-day radiotherapy needs to be countered effectively. Critical analysis reveals that besides achieving effective tumor control, radiotherapy elicits certain cellular and systemic inflammatory events in tumor infiltrate, which remain relatively stable and tend to facilitate "in-field" or "out of field" oncogenesis in due course of time. Acute pro-inflammatory cytokines generated as a result of radiation-induced oxidative insult and DNA damage induce genetic instability that contributes to tumor heterogeneity and plasticity. The reverberating crosstalks between radiation-targeted tumor and its microenvironment in turn initiate inflammatory loops that feedback the immune system to manifest as systemic consequences. An "inflammatory switchover" within the tumor microenvironment is thus induced by cumulative radiation exposure, initiating pro-tumor events that can severely limit the outcome of radiotherapy. Various pro-survival tumorigenic pathways activated as a result regulate radiation-induced hypoxia, ECM remodeling, angiogenesis/vasculogenesis, and immune suppression/evasion within the tumor microenvironment. NF-κB, HIF and STAT are identified as central regulating mediators among others that orchestrate inflammatory switchover from apoptosis-mediated tumor surveillance to radiation-induced carcinogenesis. Radiation-induced interleukins stimulate recruited macrophages and endothelial cells to promote intravasation, which is further aided by release of chemokines favoring extravasation and secondary site lesions. We hence propose that delineating the inflammatory signaling network emanating from irradiation of complex tumor tissue is critical for devising suitable therapeutic strategies to prevent post-radiotherapy second cancers or metastasis. Graphical Abstract ᅟ.

Focal Cutaneous Squamous Cell Carcinoma Following Radium-223 Extravasation

Long-term sequelae due to extravasation of intravenous radioisotopes resulting in radiation injuries are rarely reported. As the use of radioactive isotopes for the treatment of osteoblastic metastases increases, information regarding the prevention, treatment, and long-term monitoring of suspected extravasation injury will become increasingly important. We present a patient with no previous history of skin cancer who developed an aggressive cutaneous squamous cell carcinoma at the site of prior radium-223 extravasation. We recommend that patients who experience extravasation of therapeutic radioisotopes be monitored by dermatologists for long-term sequelae. Cutaneous squamous cell carcinoma should be recognized as a rare but potential adverse event following cutaneous extravasation of radium-223 and is likely a side effect that is severely underreported.

Prehospital Dextrose Extravasation Causing Forearm Compartment Syndrome: A Case Report

Case: A 57-year-old woman was found at home by paramedics to be hypoglycemic with altered mental status. She had multiple attempts at IV access and eventually a 22G IV was established and D50 was infused into her right forearm. Extravasation of the dextrose was noted after approximately 12 g of the medication was infused. She was given a dose of glucagon intramuscularly and her mental status improved. Shortly after her arrival to the emergency department, she was noted to have findings of compartment syndrome of her forearm at the site of the dextrose extravasation. She was evaluated by plastic surgery and taken to the operating room for emergent fasciotomy. She recovered well from the operation. Discussion: D50 is well known to cause phlebitis and local skin necrosis as a complication. This case illustrates the danger of compartment syndrome after D50 extravasation. It is the first documented case of prehospital dextrose extravasation leading to compartment syndrome. There may be safer alternatives to D50 administration and providers must be acutely aware to monitor for D50 infusion complications.

The clinical and radiological importance of extraarticular contrast material leakage into adjacent synovial compartments on ankle MR arthrography in patients with OCD and anterolateral impingement

PurposeTo evaluate the tibiotalar joint capacity and the localisation, frequency and amount of extravasation in patients with extraarticular contrast material leakage into adjacent synovial compartments on ankle magnetic resonance (MR) arthrography. Materials and methodsSites of extravasation were determined in the ankle MR arthrograms of 69 patients. Thirty-four patients without extraarticular contrast material leakage into locations unrelated to the injection path were included as a control group. Volumetric measurements of extraarticular contrast material leakage and the tibiotalar joint capacity were performed on a three dimensional (3D) volume measurement workstation. ResultsExtravasation of contrast material occurred through the anterior, posterior, and anterolateral recesses of the tibiotalar joint. The most common site of extravasation was along the flexor hallucis longus tendon synovium (24.6%). The amount of extravasation was significantly higher in patients with ankle osteochondritis dissecans (OCD) than in patients with a different diagnosis (p=0.039). Loose bodies were detected in all OCD’s patients with insufficient tibiotalar joint distention. ConclusionsConnections between the ankle joint and neighboring synovial compartments can decrease the diagnostic value of ankle MR arthrography examinations due to inadequate joint distention. Large injection volumes should be used for ankle MR arthrography of patients with OCD (especially OCD’s patients with loose body) and impingement syndrome.

Lymphatic Intervention Techniques: Look Beyond Thoracic Duct Embolization

In this issue of the Journal of Vascular and Interventional Radiology, Baek et al ( 1 Baek Y. Won J.H. Chang S.J. et al. Lymphatic embolization for the treatment of pelvic lymphoceles: preliminary experience in five patients. J Vasc Interv Radiol. 2016; (May 27, 2016. www.jvir.org; published online. http://dx.doi.org/10.1016/j.jvir.2016.04.011) PubMed Google Scholar ) and Hur et al ( 2 Hur S. Shin J.H. Lee I.J. et al. Early experience in the management of postoperative lymphatic leakage using lipiodol lymphangiography and adjunctive glue embolization. J Vasc Interv Radiol. 2016; 27: 1177-1186 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar ) describe successful treatment of series of patients with lymphatic leaks by using two relatively new lymphatic embolization techniques. The first is a direct injection of N-butyl cyanoacrylate (NBCA) glue into the site of lymph extravasation (also called “lymphatic pseudoaneurysm” by Hur et al [2]). The second technique embolizes the lymph flow proximal to the leak by injecting N-BCA glue into the lymph node upstream of the leak. Lymphatic Embolization for the Treatment of Pelvic Lymphoceles: Preliminary Experience in Five PatientsJournal of Vascular and Interventional RadiologyVol. 27Issue 8PreviewTo retrospectively assess the outcome of lymphatic embolization in the treatment of pelvic lymphoceles. Full-Text PDF

Ozone Ameliorates Doxorubicine-Induced Skin Necrosis - results from an animal model.

Doxorubicin (DXR) extravasation result with serious morbidity like skin ulceration and necrosis. The purpose of this study is to determine the protective effects of ozone, olive oil, dimethyl sulfoxide (DMSO), and coenzyme Q10 in the treatment of DXR-induced skin ulcers on rats. After an intradermal injection of DXR on a basis of an animal extravasation model, the materials were topically applied. The ulcer sizes were measured, and a punch biopsy was taken from the extravasation site in which the skin ulcers formed at the end of the experiment. The samples were analyzed for tumor necrosis factor alpha (TNF-α), interleukin 1-beta (IL1β), malondialdehyde (MDA), superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px) enzymes, and examined histopathologically. The ulcer sizes clearly decreased in the study groups, including DMSO, olive oil, ozone plus coenzyme Q10, and ozone plus olive oil groups in comparison with the control group with the exception of the coenzyme Q10 group. The malondialdehyde levels were lower in the DMSO, olive oil, ozone plus olive oil, and ozone plus coenzyme Q10 groups than they were in the control group, but they were not significantly different. The TNF-α level was lower in the DMSO, ozone plus olive oil, coenzyme Q10, and ozone plus coenzyme Q10 groups in comparison with the control group. There was no significant change in the SOD, GSH-Px, and IL1β levels in the study groups in comparison with the control and the sham groups. The ozone plus olive oil group could be considered to be an alternate therapy for skin ulcers due to DXR extravasation.

Effect of (18)F-fluorodeoxyglucose extravasation on time taken for tumoral uptake to reach a plateau: animal and clinical PET analyses.

The present study aimed to investigate the effect of (18)F-fluorodeoxyglucose (FDG) extravasation on the time taken for tumoral uptake to reach a plateau. For the animal experiment, FDG extravasation was conducted in the tails of HCT116 tumor-bearing xenograft mice models in three groups (no extravasation, 40% extravasation, and 80% extravasation; n=5, each). Dynamic positron emission tomography (PET) images were acquired over a period of 2h following injection. Time-activity curves for FDG in the tails and tumors were calculated. For the clinical experiment, 22 patients (male:female, 14:8; age range, 70.8±9.2years) were subjected to PET/computed tomography (PET/CT) 1h after the injection of FDG. The inclusion criteria were as follows: (1) submitted to both whole-body and subsequent regional scanning; (2) entire extravasation activity visualized in the whole-body images; (3) tumor visualized on both whole-body and additional regional images; and (4) status of tumor either confirmed by biopsy or clinically suspected for malignancy. The standardized uptake values (SUVs) of the tumors (on the whole-body and additional PET images) and extravasation sites were recorded. There were no significant differences in the time taken for tumoral uptake to reach a plateau and that to reach minimum activity at the extravasation site among the three groups of mice. However, the mean tumoral activity and activity at the extravasation site were negatively correlated at 1h post-injection. According to the clinical PET findings, the differences in SUV between the whole-body and regional images were not significantly correlated with the interval between injection of FDG and start of whole-body scanning, interval between the start of whole-body scanning and start of regional scanning, extravasation volume, maximum SUV of the extravasation site, or total activity at the extravasation site. The time taken for tumoral uptake to reach a plateau is not affected by extravasation, even at extensive degrees. Thus, in routine practice, the imaging time of approximately 60min post-injection need not be modified even if extravasation is identified. However, tumor SUV may be underestimated in cases of extravasation.

Platelets Guide Leukocytes to Their Sites of Extravasation.

Effective immune responses require the directed migration of leukocytes from the vasculature to the site of injury or infection. How immune cells “find” their site of extravasation remains largely obscure. Here, we identified a previously unrecognized role of platelets as pathfinders guiding leukocytes to their exit points in the microvasculature: upon onset of inflammation, circulating platelets were found to immediately adhere at distinct sites in venular microvessels enabling these cellular blood components to capture neutrophils and, in turn, inflammatory monocytes via CD40-CD40L-dependent interactions. In this cellular crosstalk, ligation of PSGL-1 by P-selectin leads to ERK1/2 MAPK-dependent conformational changes of leukocyte integrins, which promote the successive extravasation of neutrophils and monocytes to the perivascular tissue. Conversely, blockade of this cellular partnership resulted in misguided, inefficient leukocyte responses. Our experimental data uncover a platelet-directed, spatiotemporally organized, multicellular crosstalk that is essential for effective trafficking of leukocytes to the site of inflammation.

Percutaneous Transhepatic Biliary Drainage in the Management of Post-surgical Biliary Leaks.

The aim of this study was to evaluate the efficacy of percutaneous transhepatic biliary drainage (PTBD) in the treatment of post-surgical biliary leaks and its efficacy in restoring the integrity of bile ducts. One hundred and fifty-seven patients with a post-surgical biliary leak were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to laparoscopic procedures in 114 patients, while 43 patients had postoperative leak following open surgery. Percutaneous transhepatic biliary drainage was performed with an 8- to 10-F catheter, with the side holes positioned proximal to the site of extravasation to divert bile flow away from the leak site. The established biliary leaks at the site of origin were diagnosed at an average of 7days (range 2-150days) after surgery. In all cases, percutaneous access to the biliary tree was achieved. In 62 patients, biliary leak completely healed after drainage for 10-50days (mean, 28days) while 89 patients underwent surgical reconstruction subsequently. PTBD is a feasible, effective, and safe procedure for the treatment of post-surgical biliary leaks. It is therefore a reliable alternative to surgically repair smaller biliary leaks, while in patients with large defects, it helps prepare patients for surgical reconstruction.

Precise Localization of Occult Gastrointestinal Hemorrhage Using Dynamic SPECT/CT

Active but intermittent gastrointestinal (GI) bleeding can be readily detected with dynamic planar scintigraphic imaging. This is a case of a 48-year-old woman who presented from an outside institution with active GI bleeding on 99mTc-labeled RBC (99mTc-RBC) scintigraphy, but the upper and lower GI evaluations failed to subsequently localize the site of persistent bleeding. Repeat 99mTc-RBC planar scintigraphy identified a focus of active extravasation in the right lower quadrant of the abdomen. Dynamic SPECT/CT imaging was immediately performed and further identified the ileocecal valve region as the precise site of active extravasation, which was confirmed at surgery.

Neonatal Urinary Ascites: A Report of Three Cases

Urinary ascites in neonates is not a common condition. Three cases of urinary ascites are presented and each of them has a different aetiology. Neonates with urinary ascites usually present as clinical emergency, requiring resuscitation, ventilator support, and subsequent drainage of urine. The ultimate management depends on the site of extravasation and the underlying cause.

Development of chemotherapy-induced extravasation management algorithm to facilitate and improve care of cancer patients.

224 Background: Chemotherapy administration has up to a 6% incidence of extravasation, which can cause ulcer formation, tissue necrosis and loss of limb function, requiring surgical intervention (debridement and skin grafting). Because of its rare occurrences and the lack of uniform consensus on management strategies, much time is spent on decision making process by the patient care team and treatments are often delayed. To facilitate and improve the care of cancer patients in cases of chemotherapy extravasation, a task force was created to develop chemotherapy extravasation management algorithm. Methods: Chemotherapy extravasation management task force comprised of oncology pharmacy and oncology nursing leaderships. Literature search (limited to English language) was performed in PubMed (through April 2014) and of 34 “hits”, 13 articles on management of chemotherapy extravasation were reviewed. An algorithm was developed which contained 7 distinct intervention pathways dependent upon the drug involved in extravasation. The treatment algorithm was adopted after review by the cancer institute’s QI committee and oncology pharmacy and therapeutics subcommittee. Results: Chemotherapy extravasation algorithm provides the following guidance to nurses and providers: (1) Initial steps for nurses to follow in case of chemotherapy extravasation; (2) Chemotherapeutic agent-specific recommendations for cold or hot compress with antidote if indicated; (3) Nursing instruction for documentation of the adverse event and recommendation to photograph the site of extravasation; (4) Preparation and administration instruction of the antidotes (hyaluronidase, dexrazoxane, sodium thiosulfate, and DMSO). Finalized chemotherapy extravasation algorithm was made available in all oncology treatment areas and included in each extravasation kit. Conclusions: The development of algorithm for chemotherapy extravasation management provides clear and comprehensive instructions to oncology nurses and oncology providers on management and shortens the time to initiate management, thereby minimizing the risk of potentially debilitating sequelae from delayed management.

Indocyanine green video angiography predicts outcome of extravasation injuries.

BackgroundExtravasation of cytotoxic drugs is a serious complication of systemic cancer treatment. Still, a reliable method for early assessment of tissue damage and outcome prediction is missing. Here, we demonstrate that the evaluation of blood flow by indocyanine green (ICG) angiography in the extravasation area predicts for the need of surgical intervention.MethodsTwenty-nine patients were evaluated by ICG angiography after extravasation of vesicant or highly irritant cytotoxic drugs administered by peripheral i.v. infusion. Tissue perfusion as assessed by this standardized method was correlated with clinical outcome.ResultsThe perfusion index at the site of extravasation differed significantly between patients with reversible tissue damage and thus healing under conservative management (N = 22) versus those who needed surgical intervention due to the development of necrosis (N = 7; P = 0.0001). Furthermore, in patients benefiting from conservative management, the perfusion index was significantly higher in the central extravasation area denoting hyperemia, when compared with the peripheral area (P = 0.0001).ConclusionsIn this patient cohort, ICG angiography as indicator of local perfusion within the extravasation area was of prognostic value for tissue damage. ICG angiography could thus be used for the early identification of patients at risk for irreversible tissue damage after extravasation of cytotoxic drugs.

Extra-articular contrast material leaks into locations unrelated to the injection path in shoulder MR arthrography.

To evaluate the localisation, frequency and amount of extravasation in patients with extra-articular contrast material leak into locations unrelated to the injection path in shoulder magnetic resonance (MR) arthrography and associated shoulder disorders. The sites of extravasation were determined on the shoulder MR arthrography of 40 patients. The extravasations were measured on three vertical planes of the MR arthrography. Sufficient joint distension was assessed according to the transverse diameters of the axillary recess on coronal MR images. Extravasation of the contrast material occurred through the subscapular recess, the synovium of the biceps, and the axillary recess. In four cases, extravasations were observed in more than one anatomic location. The most common site of extravasation was along the subscapularis muscle. Superior labrum anterior-posterior (SLAP) lesions were found to be most frequently associated with extravasations. The amount of extravasation was significantly higher in patients with adhesive capsulitis compared with the patients with a different diagnosis (p = 0.022). The extravasations adjacent to the axillary recess do not always indicate glenohumeral ligament pathology. Massive subscapular extravasations were most frequently associated with adhesive capsulitis and SLAP lesions, and might be considered in the MR arthrography report. • Contrast material extravasation may reduce the diagnostic value of shoulder MR arthrography. • The extravasations may occur into locations unrelated to the injection path. • The extravasations adjacent to axillary recess can be misleading for HAGL lesion. • Massive subscapular extravasations were frequently associated with adhesive capsulitis and SLAP lesions.

Quantitative analysis applied to contrast medium extravasation by using the computed-tomography number within the region of interest

The present study was carried out to present a method to analyze extravasation quantitatively by measuring the computed tomography (CT) number after determining the region of interest (ROI) in the CT images obtained from patients suspected of extravasation induced by contrast medium auto-injection. To achieve this, we divided the study subjects into a group of patients who incurred extravasation and a group of patients who underwent routine scans without incurring extravasation. The CT numbers at IV sites were obtained as reference values, and CT numbers at extravasation sites and hepatic portal veins, respectively, were obtained as relative values. Thereupon, the predicted time for extravasation (TEP) and the predicted ratio for extravasation (REP) of an extravasation site were obtained and analyzed quantitatively. In the case of extravasation induced by a dual auto-injector, the values of the CT numbers were confirmed to be lower and the extravasation site to be enlarged when compared to the extravasation induced by a single autoinjector. This is because the physiological saline introduced after the injection of the contrast agent diluted the concentration of the extravasated contrast agent. Additionally, the TEP caused by the auto-injector was about 40 seconds, and we could perform a precise quantitative assessment of the site suspected of extravasation. In conclusion, the dual auto-injection method, despite its advantage of reducing the volume of contrast agent and improving the quality of images for patients with good vascular integrity, was judged to be likely to increase the risk of extravasation and aggravate outcomes for patients with poor vascular integrity by enlarging extravasation sites.

Evolution of Computed Tomography Angiography Spot Sign Is Consistent With a Site of Active Hemorrhage in Acute Intracerebral Hemorrhage

CT angiography spot sign predicts hematoma expansion in patients with acute intracerebral hemorrhage (ICH). The spot sign may represent a site of active extravasation, a locus of arrested hemorrhage forming fibrin globes, or represent associated epiphenomena such as hypertensive microaneurysms. We sought to describe the evolution of spot signs over 60 seconds in acute ICH using dynamic CT angiography and determine whether they grow and diffuse into the hematoma as would be expected with active extravasation. We prospectively identified consecutive patients presenting with spontaneous ICH<6 hours from symptom onset that completed dynamic CT angiography imaging over a 60-second acquisition protocol. We determined spot positivity, quantified spot volumes, and then used repeated-measures ANOVA to assess changes in spot volume over time. We collected data on 35 patients; 13 of 35 (37%) patients were spot-positive. Spot-positive patients had larger median ICH volume compared with spot-negative patients (median 10.7 versus 49.2 mL; P=0.007). Maximal spot sign volumes ranged from 0.02 to 2.8 mL (median 0.17 mL). Spot sign volumes increased significantly with time (P<0.001) and seemed to disperse into the hematoma in all cases. Three of 13 (23%) spot-positive patients presented with 2 distinct spot signs, but the remaining patients either had only 1 spot sign or different contiguous components of an irregularly shaped spot sign. In this dynamic CT angiography study of ICH, spot signs evolve consistent with sites of active extravasation.