Initial CT Scan Research Articles

Shattered Kidney After Renal Trauma: Should It Be Classified As an American Association for the Surgery of Trauma Grade V Injury?

To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions. We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups. From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P=.01). Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE.

Embolization of the middle meningeal artery vs. second surgery—treatment response and volume course of recurrent chronic subdural hematomas

BackgroundDespite multiple studies on the embolization of the middle meningeal artery, there is limited data on the treatment response of recurrent chronic subdural hematomas (CSDH) to embolization and on the volume change.MethodsWe retrospectively compared the treatment response and volume change of recurrent CSDHs in a conventional group (second surgery) with an embolization group (embolization as stand-alone treatment) during the time-period from August 2019 until June 2022. Different clinical and radiological factors were assessed. Treatment failure was defined as necessity of treatment for second recurrence. Hematoma volumes were determined in the initial CT scan before first surgery, after the first surgery, before retreatment as well as in an early (1 day–2 weeks) and in a late follow-up CT scan (2–8 weeks).ResultsFifty recurrent hematomas after initial surgery were treated either by second surgery (n = 27) or by embolization (n = 23). 8/27 (26,6%) surgically treated and 3/23 (13%) of the hematomas treated by embolization needed to be treated again. This leads to an efficacy in recurrent hematomas of 73,4% in surgically treated and of 87% in embolized hematomas (p = 0.189). In the conventional group, mean volume decreased significantly already in the first follow-up CT scan from 101.7 ml (SD 53.7) to 60.7 ml (SD 40.3) (p = 0.001) and dropped further in the later follow-up scan to 46.6 ml (SD 37.1) (p = 0.001). In the embolization group, the mean volume did decrease insignificantly from 75.1 ml (SD 27.3) to 68 ml (SD 31.4) in the first scan (p = 0.062). However, in the late scan significant volume reduction to 30.8 ml (SD 17.1) could be observed (p = 0.002).ConclusionsEmbolization of the middle meningeal artery is an effective treatment option for recurrent CSDH. Patients with mild symptoms who can tolerate slow volume reduction are suitable for embolization, whereas patients with severe symptoms should be reserved for surgery.

Preventive Proximal Splenic Artery Embolization for High-Grade AAST-OIS Adult Spleen Trauma without Vascular Anomaly on the Initial CT Scan: Technical Aspect, Safety, and Efficacy-An Ancillary Study.

The spleen is the most commonly injured organ in blunt abdominal trauma. Its management depends on hemodynamic stability. According to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS ≥ 3), stable patients with high-grade splenic injuries may benefit from preventive proximal splenic artery embolization (PPSAE). This ancillary study, using the SPLASH multicenter randomized prospective cohort, evaluated the feasibility, safety, and efficacy of PPSAE in patients with high-grade blunt splenic trauma without vascular anomaly on the initial CT scan. All patients included were over 18 years old, had high-grade splenic trauma (≥AAST-OIS 3 + hemoperitoneum) without vascular anomaly on the initial CT scan, received PPSAE, and had a CT scan at one month. Technical aspects, efficacy, and one-month splenic salvage were studied. Fifty-seven patients were reviewed. Technical efficacy was 94% with only four proximal embolization failures due to distal coil migration. Six patients (10.5%) underwent combined embolization (distal + proximal) due to active bleeding or focal arterial anomaly discovered during embolization. The mean procedure time was 56.5 min (SD = 38.1 min). Embolization was performed with an Amplatzer™ vascular plug in 28 patients (49.1%), a Penumbra occlusion device in 18 patients (31.6%), and microcoils in 11 patients (19.3%). There were two hematomas (3.5%) at the puncture site without clinical consequences. There were no rescue splenectomies. Two patients were re-embolized, one on Day 6 for an active leak and one on Day 30 for a secondary aneurysm. Primary clinical efficacy was, therefore, 96%. There were no splenic abscesses or pancreatic necroses. The splenic salvage rate on Day 30 was 94%, while only three patients (5.2%) had less than 50% vascularized splenic parenchyma. PPSAE is a rapid, efficient, and safe procedure that can prevent splenectomy in high-grade spleen trauma (AAST-OIS) ≥ 3 with high splenic salvage rates.

Clinical outcomes of a CT protocol for simultaneous examination of the aorta and coronary artery in patients with aortic aneurysm.

In patients with aortic aneurysm (AA), coronary artery disease (CAD) increases the risk of perioperative complications and even asymptomatic CAD isassociated with adverse clinical outcomes. We aimed to compare coronary-aorta CT (CACT) with thoracoabdominal CT angiography (Aorta CT) for CAD management and clinical outcomes in these patients. We enrolled 479 patients undergoing CACT and 693 patients undergoing Aorta CT as an initial CT scan for AA. The primary outcome was a composite of all-cause death or myocardial infarction (MI) at 3 years after CT. The secondary outcomes were subsequent CAD management and invasive coronary angiography (CAG). After index CT scan, the CACT group had a significantly higher rate of coronary revascularization compared with the Aorta CT group (10.7% vs. 3.8%, p < 0.001) but a lower probability of diagnostic CAG among total invasive CAG (32% vs. 55%, p < 0.001). At 3 months after the CT scan, the prescription rates of statins (65.8% vs. 44.6%, p < 0.001) and antiplatelet agents (57.6% vs. 43.9%, p < 0.001) were higher in the CACT group. During follow-up, the CACT group had a significantly lower incidence of the composite outcome of all-cause death or MI (adjusted HR 1.72, 95% CI 1.07-2.78, p = 0.027) than the Aorta CT group. Among patients with AA, CACT was associated with a higher rate of subsequent CAD management and a lower risk of all-cause death or MI compared to Aorta CT. When evaluating with AA using CT, simultaneous coronary and aortic evaluation using CACT would be recommended over Aorta CT.

Comparison of Lung CT Scan Findings upon Admission and Three Months after the Discharge of Patients with COVID-19

Background and Objective: There is not enough information about the long-term pulmonary complications of patients with COVID-19. This prospective study aimed to compare the findings of lung CT scan upon admission and three months after the discharge of patients with COVID-19. Materials and Methods: This prospective study was conducted on 60 patients with COVID-19 hospitalized in Shahid Beheshti and Sina hospitals in Hamadan, Iran, in 2020-2021. The lung CT scan results of the patients upon admission and three months later were assessed and compared by an experienced radiologist quantitatively and qualitatively after obtaining and recording the demographic characteristics, risk factors, and clinical findings. Results: The mean score of lung involvement upon hospitalization of the patients was 3.7±1.4, and three months after discharge, it was determined at 1.1±1.2. The most frequent findings in the initial CT scan of the patients were ground-glass opacification, mixed GGO, and bands with frequencies of 60%, 36.7%, and 18.3%, respectively. After three months, CT scan results of 32 (53.3%) patients showed lung involvement and an abnormal finding in the lung, the most common of which were ground-glass opacification, mixed GGO, and bands with frequencies of 30%, 13.3%, and 10.0%, respectively. Patients who had pulmonary involvement three months after discharge had a higher average lung involvement score during hospitalization (4.4±1.5 vs. 2.9±0.7, P=0.001). Conclusion: Abnormal CT scan results of the lung three months after discharge is common in COVID-19 patients, among whom patients with more pulmonary involvement during hospitalization have more abnormal findings

Potential of Satellite Sign for Prediction of Hematoma Expansion in Small Spontaneous Hematoma within 7 Days' Follow-Up.

Background Hematoma expansion (HE) is the most important modifiable predictor that can change the clinical outcome of intracerebral hemorrhage (ICH) patients. The study aimed to investigate the potential of satellite sign for prediction of HE in spontaneous ICH patients who had follow-up non-contrast computed tomography (NCCT) within 7 days after the initial CT scan. Methods We retrospectively reviewed data and NCCT from 142 ICH patients who were treated at our hospital at Bangkok, Thailand. All included patients were treated conservatively, had baseline NCCT within 12 hours after symptom onset, and had follow-up NCCT within 168 hours after baseline NCCT. HE was initially estimated by two radiologists, and then by image analysis software. Association between satellite sign and HE was evaluated. Results HE occurred in 45 patients (31.7%). Patients with HE had significantly higher activated partial thromboplastin time ( p = 0.001) and baseline hematoma volume ( p = 0.001). The prevalence of satellite sign was 43.7%, and it was significantly independently associated with HE ( p = 0.021). The sensitivity, specificity, and accuracy of satellite sign for predicting HE was 57.8, 62.9, and 61.3%, respectively. From image analysis software, the cutoff of greater than 9% relative growth in hematoma volume on follow-up NCCT had the highest association with satellite sign ( p = 0.024), with a sensitivity of 55%, specificity of 64.6%, and accuracy of 60.5%. Conclusion Satellite sign, a new NCCT predictor, was found to be significantly associated with HE in Thai population. With different context of Thai population, HE was found in smaller baseline hematoma volume. Satellite sign was found more common in lobar hematoma. Further studies to validate satellite sign for predicting HE and to identify an optimal cutoff in Thai population that is correlated with clinical outcomes are warranted.

Abstract P4-07-24: Circulating tumor cells enumeration and Health Related Quality of Life of patients treated with first-line chemotherapy for HER2 negative metastatic breast cancer

Abstract Background: In patients with metastatic breast cancer (mBC), Circulating Tumor Cells (CTC) counts have a strong prognostic impact on progression free survival (PFS) and overall survival (OS). Changes 4 weeks after the start of a new line of therapy, inform on treatment efficacy. Despite improvements in systemic treatment, metastatic BC remains mainly uncurable with alteration of health-related quality of life (HRQOL) during the course of the disease. The aim of this work was to assess impact of clinical factors and biological factors as CTC on HRQOL. Methods: The French cohort COMET is a prospective study including first line HER2 negative patients receiving weekly paclitaxel and bevacizumab according to EMA approved combination. The aim of this cohort was to evaluate clinical, biological and radiological parameters associated with patients’ outcome (CTC, CEC, serum markers, ctDNA, pharmacogenomic polymorphisms, metabolomic parameters, visceral fat assessed by initial CTscan, serum estradiol level, and quality of life). HRQOL was assessed at baseline, at every cycle until progression and then every 3 months up to death using the EORTC QLQ-C30 questionnaire and its breast cancer specific module, the EORTC QLQ-BR23. Five dimensions of HRQOL were analyzed for the primary analyses: Global health status (GHS), physical functioning (PF), Emotional functioning (EF), fatigue (FA) and pain (PA). Time until definitive deterioration (TUDD) in HRQOL was defined as the interval between inclusion and the first decrease in HRQOL score ≥ 5 compared to baseline HRQOL score with no further improvement or in case of death. CTC counts were determined using the standard CellSearch system [Menarini Silicon Biosystems]. Results: Out of 510 patients included in COMET study, 432 patients with available HRQOL data were analyzed in this study. At baseline, patients reported a mean score for GHS of 57.6 (SD=22.7), for PF of 75.8 (23.2), for EF of 62.2 (25.8), for FA of 42.2 (29.60) and for PA of 38.1 (31.5). The Median TUDDs for the 5 targeted dimensions was 10.1 months [7.5-16.9] for GHS, 6.1 months [4.1-8.9] for PF, 21.6 [18.7-31.2] for EF, 10.8 [6.2-16.6] for FA and 13.6[10.1-22.5] months for PA. CTC counts were available in 261 patients at base line and in 229 patients after 4 weeks of treatment, before second cycle of chemotherapy. CTC high count was independent of main clinical and biological characteristics except lobular subtype. We confirmed the poor outcome of patients with high CTC count at base line and after one cycle of treatment with the threshold of &amp;gt; 4CTC/7.5 ml of blood. Out of the 5 dimensions of HRQOL, TUDD of EF was significantly correlated with a high CTC level at base line (p=0.0262) and even more with still an elevated count of CTC after one cycle of chemotherapy(p=0.0137). There was no association of CTC with the other dimensions of HRQOL. Conclusion: This is the first study ever reporting an analysis of QoL and CTC. We observed an association of high CTC count with one component of HRQOL scale. This suggests that CTC could be complementary to clinical factors that could influence HRQOL in HER2 negative metastatic BC treated with first line chemotherapy. Citation Format: Jean-Yves Pierga, Oumar Billa, Sandrine Dabakuyo, Jérôme Lemonnier, Frédérique Berger, Olivier Trédan, William Jacot, Anthony Gonçalves, Marc Debled, Christelle Levy, Christelle Jouannaud, Marie-Ange Mouret-Reynier, Jean-Marc Ferrero, Florence Dalenc, Fatima-Zohra Toumi, Franck Bonnetain, Francois-Clement Bidard, Shufang Renault. Circulating tumor cells enumeration and Health Related Quality of Life of patients treated with first-line chemotherapy for HER2 negative metastatic breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-24.

Young Female with Recurrent Spontaneous Cervical Artery Dissection

Previous neurosonological study demonstrated the value of neurosonology in daily monitoring of the cervical artery dissection. This study showed rate of recurrence of 27 % in unaffected arteries. There are two group of recurrences, early and late. Early spontaneous cervical artery dissection (sCAD) recurrences are not uncommon and usually involve arteries previously unaffected by dissection. They are oligosymptomatic (headache or neck pain) or asymptomatic and might be correlated with a transient arterial disorder. Late sCAD recurrences are rare and can occur at site of previous sCAD and might be indicative of an underlying persistent connective tissue weakness. In this case report we present a 31- year old female patient who presented to emergency room because of headache and pain in the neck which started 3 days before. Initial brain CT scan and CT-angiography were normal. Next day she became disoriented and complained of headache, vertigo, nausea. Magnetic resonance of the brain showed little hematoma in quadrigeminal cistern and left vertebral artery dissection in V2 segment. Initial neurovascular ultrasound (nUS) showed dissection in V2 segment left vertebral artery. Next nUS after five days showed new dissection in V1 and V2 segment in right vertebral artery. Following nUS showed initial regression hematoma in both vertebral arteries. To conclude, early sCAD recurrences are not uncommon and usually involve arteries previously unaffected by dissection. Because of that it is important to daily neurosonology monitoring of the dissection.

Abstract WMP4: Bridging Thrombolysis In Stroke Patients With Low Aspects Prior To Endovascular Thrombectomy

Background: In stroke patients with large vessel occlusion and extensive early ischemic change, the role of bridging thrombolysis prior to endovascular thrombectomy (EVT) is still to be determined. Aim: To examine the impact of ischemic change on the efficacy and safety of bridging thrombolysis in patients treated with EVT. Methods: Consecutive anterior circulation EVT patients from a prospectively collected registry were included in this retrospective analysis. Alberta stroke programme early CT scores (ASPECTS) were evaluated from initial non-contrast CT scan with lower score indicating larger areas of early ischemic change. Outcome measures included symptomatic intracranial hemorrhage and functional independence (modified Rankin scale score 0-2) at day 90. Multivariable logistic regression models with interaction terms between ASPECTS and bridging thrombolysis were created. ASPECTS was treated as numeric variable in the primary analysis and trichotomized (ASPECTS ≤5, 6-8, 9-10) in a sensitivity analysis. Results: 872 EVT patients (384 female, mean ± SD age of 67 ± 15, baseline NIHSS 16 [IQR 11-20], median ASPECTS 8 [range 2-10]) were included. 436 (50%) received bridging intravenous thrombolysis with alteplase. There was no significant main effect of ASPECTS on sICH (main effect OR 0.73 95%CI 0.45-1.21, p=0.24) and no modifying effect of thrombolysis (interaction p=0.65). With decreasing numeric ASPECTS, the probability of functional independence reduced (main effect OR 1.34 95%CI 1.20-1.49, p&lt;0.001), and this the reduction was steeper in those without bridging thrombolysis (interaction p=0.035). The interaction was not significant when ASPECTS was split into the 3 categories (p=0.28). Conclusion: In anterior circulation patients treated with EVT, bridging thrombolysis was associated with a higher probability of functional independence in those with more extensive early ischemia as determined by ASPECTS. These results suggest patients with large ischemic cores may still benefit from bridging thrombolysis, but this will need to be evaluated in further studies.

Prediction of Severity and Adverse Outcomes Associated with Perforation in Patients Presenting to the Emergency Department with Esophageal Injury

Background/Aims: Esophageal perforation is associated with high mortality and morbidity in patients presenting to the emergency department (ED) with esophageal injury. We investigated the effectiveness of initial CT scan in patients with esophageal injury to determine the risk factors for complications.Methods: Patients admitted through the ED for evaluation of esophageal injuries between January 2001 and May 2020, were investigated. Demographic data, etiological factors, comorbidities, treatment administered, and outcomes were collected. Esophageal injury was graded based on the following CT criteria: (a) normal, (b) pneumomediastinum, (c) mediastinitis, fluid collection, abscess, or overt esophageal wall injury, and (d) pleural effusion, subcutaneous emphysema, or pneumothorax. Grade 2 was defined as microperforation and grades 3 and 4 as overt perforation.Results: Of 281 patients with esophageal injury, 38 had CT-documented overt perforations and 20 had microperforations. Foreign body-induced injury (n=37), Boerhaave syndrome (n=12), and chemical injury (n=3) were common causes of esophageal injury. Complications occurred in 24 (8.5%) patients. Risk factors for complications were age ≥65 years (OR 4.14, 95% CI 1.18~14.56, P=0.027), cerebrovascular disease (OR 8.58, 95% CI 1.13~65.19, P=0.038), Boerhaave syndrome (OR 12.52, 95% CI 2.07~75.68, P=0.006), chemical injury (OR 15.72, 95% CI 3.67~67.28, P&lt;0.001), and CT-documented grade 4 perforation (OR 15.75, 95% CI 4.39~56.55, P&lt;0.001).Conclusions: Initial CT-based grading in the ED are useful for predicting potential complications and for managing patients with esophageal injury and suspected perforation.

Role of NOS3 894G&gt;T Gene Polymorphism in Traumatic Cerebral Hemorrhagic Contusion Khartoum, Sudan, 2020-2021

The nitric oxide produced by the endothelial nitric synthase (NOS3) gene helps to maintain cerebral blood flow (CBF) after traumatic brain injuries (TBI). The aim is to determine the prognostic role of NOS3 894 G&gt;T gene in traumatic hemorrhagic contusion and outcome. A cross-sectional study was conducted for 90 patients who attended the National Centre for Neurological Sciences, Khartoum, Sudan. Non-Sudanese patients, hemorrhagic contusions associated with other types of brain bleeding, and patients with chronic disease were excluded. An initial CT scan was used upon admission to detect brain edema, anatomical site, and the number of contusions. The Glasgow coma scale (GCS) was used upon admission to assess the trauma severity. The Glasgow outcomes scale (GOS) was used upon discharge to assess the outcome. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used for NOS3 genotyping. The result shows that 93.3% of patients were male, while 32.2% of them were female. It further indicates that 58.9 % had a mild injury; 60% of the patients were presented with frontal lobe injury, 14.4% had multiple sites injury, and 22.2% had brain edema. The number of deaths was 8 (8.9%). The genotyping of NOS3 revealed that 94.4% of patients had homozygous GG and 5.6% heterozygous GT. G allele represented 97.2% of NOS3 alleles. NOS3 894 G&gt;T genotypes were not significantly associated with patients, linguistic afflation’ and outcome. The study concluded that NOS3 894G&gt;T gene has no prognostic role in traumatic hemorrhagic contusion and outcome. Keywords: Nitric oxide synthase gene, Traumatic brain injury, Glasgow coma scale, Glasgow outcomes scale.

CONTRAST-ENHANCED ULTRASOUND IN PEDIATRIC ABDOMINAL TRAUMA

Abstract Introduction Evaluation of the use of contrast-enhanced ultrasound (CEUS) in patients with abdominal trauma. Methods Retrospective study of patients with grade III or higher abdominal trauma, according to the American Association of Surgical Association (AAST) severity scale. All patients underwent an initial CT scan, mode B ultrasound before discharge and a second-generation contrast-enhanced ultrasound (CEUS) one month after the trauma (contrast dose=0.03 ml/kg). Results From January 2017 to December 2021, a total of 36 patients (2–15 years) with abdominal trauma were collected. 18 hepatic, 8 splenic, 8 renal and 2 pancreatic traumas. Of these, 8 patients required urgent embolization due to active bleeding or pseudoaneurysm and 1 patient required urgent surgical intervention. CEUS at 1 month showed: complete resolution in 22 patients, 2 residual hematomas, 1 patient with urinoma and devascularized area, 3 pseudoaneurysms, 7 with persistence of lacerations resolved at 2 weeks and 1 patient with 2 pancreatic cysts. Conclusions CEUS allows evaluation of parenchymal injuries of abdominal organs, as well as the presence of residual hematomas, active bleeding, pseudoaneurysms, urinomas and/or devascularized areas, therefore, it can be a useful tool for follow-up and monitoring of abdominal trauma. The absence of irradiation and its great accessibility allow it to be repeated as often as desired; and the confirmation of resolution enables an earlier return to daily life.

Neurological Outcome Prediction in Patients with Subarachnoid Hemorrhage Using a Model Based on Initial CT Scan, Clinical Data and Neural Networks.

Neurological Outcome Prediction in Patients with Subarachnoid Hemorrhage Using a Model Based on Initial CT Scan, Clinical Data and Neural Networks.

Impact of Multifidus Muscle Morphometry on the Clinical Evolution of Chronic Low Back Pain

Purpose: The multifidus muscle is an important extensor muscle of the lumbar spine. It plays a major role in the stability and realization of axial rotation movements of the thoraco-lumbar spine. Its atrophy by fatty degeneration would be at the origin of the occurrence of chronic low back pain which constitutes a public health problem in Senegal. Taking into account its anatomy is essential for the etiopathogenic analysis and the treatment of low back pain. The purpose of our work was to investigate the impact of multifidus muscle morphometry on the anatomy-clinical evolution of low back pain. Material and method: this was a prospective study over a period of 30 months from November 2019 to May 2022. It involved 100 patients seen in the neurology department of Fann Hospital for chronic low back pain and who had already had a scanner falling within the criteria for low back pain. We used 3D Slicer, SPSS 20, Excel 2016 software to model and analyze the morphometric data of the multifidus muscle after physiotherapy and control lumbar scans. Results: The sex ratio was 2.23. The average age of the patients was 45 ± 7 years. On the initial CT scan, according to the Hadar classification, we noted a predominance of grade 2 with 56% in L5/S1, followed by grade 1 with 32% and grade 3 with 14%. In L4/L5, the majority of patients, 67%, had grade 1. A conflicting circumferential disc bulge with the roots predominating in L5/S1 was present in 94% of men (p-value = 0.02). Before physiotherapy, the average volume of the multifidus was 193 mm3 ± 39, after physiotherapy it was 203 mm3 ± 42 with a progression rate of 5.2%. Clinically, severe type pain had regressed from 86% before physiotherapy to 0% after physiotherapy (p-value = 0.03). Conclusion: Taking into account the morphometry of the multifidus is an essential element in the management of chronic low back pain.

Difference of mean Hounsfield units (dHU) between follow-up and initial noncontrast CT scan predicts 90-day poor outcome in spontaneous supratentorial acute intracerebral hemorrhage with deep convolutional neural networks

ObjectivesThis study aimed to investigate the usefulness of a new non-contrast CT scan (NCCT) sign called the dHU, which represented the difference in mean Hounsfield unit values between follow-up and the initial NCCT for predicting 90-day poor functional outcomes in acute supratentorial spontaneous intracerebral hemorrhage(sICH) using deep convolutional neural networks. MethodsA total of 377 consecutive patients with sICH from center 1 and 91 patients from center 2 (external validation set) were included. A receiver operating characteristic (ROC) analysis was performed to determine the critical value of dHU for predicting poor outcome at 90 days. Modified Rankin score (mRS) >3 or >2 was defined as the primary and secondary poor outcome, respectively. Two multivariate models were developed to test whether dHU was an independent predictor of the two unfavorable functional outcomes. ResultsThe ROC analysis showed that a dHU >2.5 was a critical value to predict the poor outcomes (mRS >3) in sICH. The sensitivity, specificity, and accuracy of dHU >2.5 for poor outcome prediction were 37.5%, 86.0%, and 70.6%, respectively. In multivariate models developed after adjusting for all elements of the ICH score and hematoma expansion, dHU >2.5 was an independent predictor of both primary and secondary poor outcomes (OR = 2.61, 95% CI [1.32,5.13], P = 0.006; OR = 2.63, 95% CI [1.36,5.10], P = 0.004, respectively). After adjustment for all possible significant predictors (p < 0.05) by univariate analysis, dHU >2.5 had a positive association with primary and secondary poor outcomes (OR = 3.25, 95% CI [1.52,6.98], P = 0.002; OR = 3.42, 95% CI [1.64,7.15], P = 0.001). ConclusionsThe dHU of hematoma based on serial CT scans is independently associated with poor outcomes after acute sICH, which may help predict clinical evolution and guide therapy for sICH patients.

Food Bolus Ileus as a Cause of High-Grade Bowel Obstruction: A Case Report

Small bowel obstruction is often caused by previous surgical scar or cancer. High grade bowel obstruction secondary to food bolus impaction is very rare especially in a young patient who has otherwise no medical or surgical history. We are presenting a unique case in a young male who presented with acute abdomen with initial CT scan suggestive of Meckel’s diverticulitis. During exploratory laparotomy, patient was found to have a severe degree of bowel obstruction with one definitive transition point caused by food bolus impaction. Food bolus ileus is a rare cause of bowel obstruction requiring surgical intervention. However, definitive intervention should not be delayed when patients present with concerning clinical signs.

Systemic thrombo-embolic events in a middle-aged male with Loeffler endocarditis without peripheral eosinophilia—a case report

BackgroundLoeffler-endocarditis (LE) is considered a chronic restrictive cardiomyopathy and manifestation of eosinophilic myocarditis characterized by eosinophilic infiltration. LE is a rare underdiagnosed disease and associated with high morbidity and mortality.Case presentationWe report a case of a 46-year-old man suffering from LE associated with thromboembolic events without peripheral eosinophilia. The patient presented with typical clinical signs of acute onset of limb ischaemia, predominantly on the right limb, indicating immediate iliacal thrombectomy and due to a severe compartment syndrome additional fasciotomy. Total occlusion also of left popliteal artery suggesting an impaired chronic and aggravated impaired perfusion indicated also urgent left sided revascularization. Subsequent echocardiography revealed severe left ventricular dysfunction with a striking amount of spontaneous echo-contrast, noticeable in the left ventricular cavity. Furthermore the initial CT scan demonstrated asymptomatic left kidney- and brain infarctions. Diagnostic workup including endomyocardial biopsy (EMB) of the left ventricle, uncovered an underlying LE without peripheral eosinophilia.ConclusionsThis case demonstrates and highlights the findings, treatment and outcome of a patient with LE and associated thrombo-embolic events without peripheral eosinophilia and emphazises the importance of awareness for LE in patients presenting with an acute cardiac decompensation and thrombo-embolic events. EMB should be performed early in unstable patients unsuitable for cardiovascular magnetic resonance imaging.

HPB P60 Pancreatic Carcinosarcoma as a rare cause of upper gastrointestinal bleeding requiring resection

Abstract Background Pancreatic carcinosarcoma is a rare malignant neoplasm and has a very poor prognosis. Diagnosis is mainly by pathological examination including immunohistochemistry (IHC) of the biopsy or resected specimen. Due to the rarity of the cancer, information regarding clinical presentation, pathology and management is limit to a few case reports. Methods We report a 61-year-old fit and healthy male, who presented to the emergency department with melaena and syncope. Initial CT scan showed a pancreatic body/tail tumour, likely pancreatic cancer without nodal or intra-abdominal metastasis. Upper GI endoscopy revealed a lesion in the second part of the duodenum, with a visible vessel, and evidence of recent bleeding . Two clips were applied, and a biopsy of the lesion showed ulcer slough only. Tumour markers and IgG4 levels were normal. An MRI pancreas showed no definite pancreatic mass, features of chronic pancreatitis and irregular bile ducts. HPB MDT consensus was to proceed for EUS, which confirmed a hypoechoic, vascular, 3cm mass lesion in D1-D2. Biopsies again, showed ulcer slough. A PET CT scan showed avidity in the second part of the duodenum and pancreatic head, neck and distal body. The patient presented to the surgical emergency unit twice during this time with symptoms of anaemia requiring IV iron and blood transfusions, and with early signs of obstruction, which settled with conservative management. Interval MRI showed increase in size of the duodenal mass, and stable appearance of the lesion in the head of the pancreas. Eventually, semi-emergency total pancreaticoduodenectomy and splenectomy was undertaken. Results Intraoperatively, a large D2 tumour was found extending into the pancreatic head posteriorly, compressing but not infiltrating the IVC. The rest of the pancreas was hard in consistency and nodular. Soft lymph nodes were found at the aorto-caval, common hepatic and around the SMA. There was no obvious intra-abdominal metastasis. The final histopathology showed a malignant, biphasic tumour favouring pancreatic carcinosarcoma staged pT3 N0 (0/29) L1 V1 R1 (posterior and SMV). On molecular cytogenetic analysis there was no evidence of rearrangement associated with synovial sarcoma in the cells examined. He recovered well post operatively and has commenced adjuvant chemotherapy of modified Folfirinox. Conclusions Pancreatic carcinosarcoma is a rare entity, which due to its unusual presentation, can be challenging to manage. Prompt MDT discussion is instrumental in such cases. The assessment of different radiological modalities, showing progressive increase in the size of the lesion within a short time period, raised the suspicion of an aggressive mitotic lesion, with the repeat biopsies unlikely to yield diagnosis in an otherwise operable lesion. Ultimately, the patient underwent a semi-emergency, total pancreaticoduodenectomy and splenectomy due to ongoing bleeding and the rapidly growing tumour size. In this case, surgery followed by adjuvant chemotherapy has been adopted as the optimum management strategy, for both bleeding control, and oncological benefit.

Lung CAncer SCreening in French women using low-dose CT and Artificial intelligence for DEtection: the CASCADE study protocol

IntroductionLung cancer screening (LCS) using low-dose CT has been demonstrated to reduce lung cancer-related mortality in large randomised controlled trials. Moving from trials to practice requires answering practical questions about...

Abstract 14471: Cardiac Sarcoidosis Presenting With Hiccups - A Case Report

Introduction: Sarcoidosis is a multi-system disorder of unknown etiology that is commonly associated with hilar lymphadenopathy and granulomas. Cardiac involvement is less common, however, sarcoidosis is a known cause of restrictive cardiomyopathy. It typically presents as new-onset arrhythmias or heart failure, although cases of sudden cardiac death have been reported. Case presentation: We present a case of a 56-year-old male with a known history of pulmonary sarcoidosis, not on any active treatment, who presented to the emergency department with one week of continuous hiccups every few seconds associated with non-exertional dyspnea. Initial CT scan of the chest showed multiple stellate-like ground-glass opacities and progression of bronchiectasis. Troponins were negative. On the initial EKG, he was found to be in atrial flutter and was admitted to the general medical floor. He was given baclofen and the hiccups resolved over the next 24 hours. Cardiology was consulted for suspected cardiac sarcoidosis and they recommended transferring the patient to the tertiary care center for further evaluation. Upon arrival, the patient underwent catheter ablation for atrial flutter and he returned to the sinus rhythm after the procedure. The initial nuclear scan with gallium was not suggestive of cardiac sarcoidosis, however, subsequent cardiac MRI showed cardiac involvement. Due to the high risk of arrhythmias, the patient was scheduled for implantable cardioverter defibrillator placement before discharge. Treatment with steroids was deferred until after the PET scan could be completed. The patient was discharged in stable condition and interrogation of the device found it to be well functioning and with no significant arrhythmias noted. Conclusions: Presentation of cardiac sarcoidosis can be variable and should be considered in any patient with a known history of sarcoidosis who presents with atypical symptoms at or above the level of the diaphragm, such as hiccups or with new-onset arrhythmias.