Initial Imaging Study Research Articles

Quantitative Liver Imaging in Children.

In children and adults, quantitative imaging examinations determine the effectiveness of treatment for liver disease. However, pediatric liver disease differs in presentation from liver disease in adults. Children also needed to be followed for a longer period from onset and have less control of their bodies, showing more movement than adults during imaging examinations, which leads to a greater need for sedation. Thus, it is essential to appropriately tailor and accurately perform noninvasive imaging tests in these younger patients. This article is an overview of updated imaging techniques used to assess liver disease quantitatively in children. The common initial imaging study for diffuse liver disease in pediatric patients is ultrasound. In addition to preexisting echo analysis, newly developed attenuation imaging techniques have been introduced to evaluate fatty liver. Ultrasound elastography is also now actively used to evaluate liver conditions, and the broad age spectrum of the pediatric population requires caution to be taken even in the selection of probes. Magnetic resonance imaging (MRI) is another important imaging tool used to evaluate liver disease despite requiring sedation or anesthesia in young children because it allows quantitative analysis with sequences such as fat analysis and MR elastography. In addition to ultrasound and MRI, we review quantitative imaging methods specifically for fatty liver, Wilson disease, biliary atresia, hepatic fibrosis, Fontan-associated liver disease, autoimmune hepatitis, sinusoidal obstruction syndrome, and the transplanted liver. Lastly, concerns such as growth and motion that need to be addressed specifically for children are summarized.

Ruptured basilar artery perforator aneurysm mimicking superior cerebellar artery aneurysm

Background and importanceThe diagnosis of basilar artery perforator aneurysm is difficult due to their small size, with high rates of negative angiography. Furthermore, due to the considerable variation of basilar artery perforator (BAP), even if an aneurysm originates from a BAP, it is often difficult to clearly identify its origin on angiography. Clinical presentationA 46-female patient presented with World Federation of Neurological Surgeons Scale 1 subarachnoid hemorrhage. Initial imaging study, including digital subtraction angiography (DSA), revealed no vascular lesions. Two-week after admission, DSA revealed an aneurysm arising from the left superior cerebellar artery (SCA). Endovascular coil embolization was planned first. However, aneurysm selection using microcatheter was failed. Then, surgical approach was done via pre-temporal approach. We identified SCA, but there was no aneurysm. Further dissection revealed an aneurysm arising from basilar artery perforator, which was overlapped by SCA. The parent artery of the aneurysm arose from juxtaproximal to the orifice of left SCA, and crossed SCA at the juxtadistal to the aneurismal sac. Complete clip occlusion was done preserving BAP. After the surgery, the patient developed diplopia without extraoccular movement limitations. Two-month after the surgery, she was fully recovered without any neurologic deficits. ConclusionIt is crucial to adequately consider the possibility of open surgery as a viable option in case that endovascular treatment of aneurysms originated from the distal segment of basilar artery proves unsuccessful.

Growth kinetics of venous tumor thrombus in patients with renal cell carcinoma

Some patients with renal cell carcinoma (RCC) present with venous tumor thrombus (VTT). The extent of the VTT is related to survival, so prompt surgical care is recommended. However, studies evaluating the natural history of VTT in patients with RCC are rare. We sought to evaluate the growth kinetics of VTT in patients with RCC using preoperative cross-sectional images. We identified patients who underwent radical nephrectomy and venous tumor thrombectomy at our institution from 01/2009 to 02/2022. We included those with a minimum of 2 adequate preoperative imaging studies (contrast-enhanced Computerized Tomography (CT), noncontrast Magnetic resonance imaging (MRI), or contrast-enhanced MRI), at least 14 days apart. We measured VTT in each study to calculate growth rate, and evaluated predictors of faster growth (demographics, histology, laterality, tumor diameter, and staging). To assess the relation between clinical variables and VTT growth, we used the Wilcoxon Rank-Sum, Kruskal-Wallis, and Spearman correlation tests. A total of 30 patients were included in the analysis. The median time interval between studies was 33 days. Patients were mostly Caucasian and Males (90% and 70%, respectively). Most patients underwent a CT scan as their initial imaging study (66%), followed with an MRI as second study (73%). The mean venous tumor thrombus growth rate was 0.3 mm/d (standard deviation of 0.5mm), and only rhabdoid/sarcomatoid differentiation showed an association with tumor thrombus growth rate (0.3 vs. 0.63 mm/d, P = 0.038). To the best of our knowledge, this is the first study evaluating the natural growth rate of venous tumor thrombus in patients with renal cell carcinoma. We found that tumor thrombi grew an average of 0.3 mm/d (1.0 cm/month) and that those with sarcomatoid and/or rhabdoid differentiation grew faster (0.63 mm/d). Further studies are needed to validate these results and provide a better understanding of tumor thrombus kinetics.

Sudden Sensorineural Hearing Loss from a Jugular Bulb Diverticulum

A 19-year-old woman presented with an 11-month history of sudden-onset left sided hearing loss accompanied by vertigo and headache. Audiometric testing revealed profound left- sided hearing loss. A contrast-enhanced MRI of the internal auditory canal performed 5 months after symptom onset was interpreted as showing a vascular loop, probably the anterior inferior cerebellar artery, abutting and indenting on the left vestibulocochlear nerve; and a prominent and high-riding left jugular bulb. In this study, the internal auditory canals were assessed to be of normal width, with walls that were smooth and sharply defined. A cerebral CT angiogram subsequently performed did not show any abnormal findings related to the previously identified vascular loop. On the basis of these radiologic findings, the patient was advised surgery by physicians at a tertiary- care institution, presumably to address the identified vascular loop. A second opinion was sought by the patient.
 Review of the MRI initially focused on the axial high-resolution T2-weighted sequence (T2-DRIVE), as the fast spin-echo T2-weighted sequence has been recommended as a reliable and cost-effective MR screening protocol for the detection of masses in the IAC.1 In contrast to the official radiology report, stenosis of the left internal auditory canal by a protrusion (Figure 1, white asterisk) originating from the posteromedial wall of the internal auditory canal was noted. This protrusion, which had no MR signal intensity, appeared to abut and compress the cranial nerves within the IAC. Reconstruction of the images in non-orthogonal planes aligned with the orientation and direction of the left 8th cranial nerve showed the protrusion causing upward compression on and distortion of the nerve. (Figure 2, white arrows)
 Attention was directed to the axial high-resolution T1-weighted sequence (T1W-3D FFE), which revealed that the protrusion contained an isointense soft tissue structure (Figure 3, white asterisk) located within the petrous bone medial to the posterior semicircular canal. This structure appeared to be an upward extension of the jugular bulb.
 The axial high-resolution contrast-enhanced T1-weighted sequence (T1W-3D TFE Gd) showed smooth, vivid enhancement of the identified structure (Figure 4, black asterisk), which connected with the sigmoid sinus in lower cuts. This confirmed the presence of a high-riding jugular bulb that encroached on the internal auditory canal.
 Any doubt as to its true nature was dispelled by a review of the temporal bone structures on high-resolution CT which was fortunately available in the cerebral CT angiogram. This revealed a protrusion of the high-riding jugular bulb with a waist-like margin (Figure 5A and B, black arrows), allowing further characterization of the lesion as a jugular bulb diverticulum.2
 A high-riding jugular bulb that projects into the middle ear is not an uncommon anatomic variation. On the other hand, a jugular bulb diverticulum, which is an outpouching of the jugular bulb that can extend superiorly, medially, and posteriorly in the petrous bone, is a true venous anomaly that has been described rarely in the medical literature.3,4 When symptomatic, patients with this anomaly can present with sensorineural hearing loss, tinnitus, vertigo and auricular pain.3-5 Proper identification of a jugular bulb diverticulum in the evaluation of a patient with neurotologic symptoms is necessary to avoid inappropriate medical and surgical intervention.
 As demonstrated in this patient, a jugular bulb diverticulum may not be identified by a screening MRI that utilizes only a T2-weighted sequence. T1-weighted MRI sequences with and without contrast are necessary to demonstrate its soft tissue imaging characteristics. Although not the initial imaging study of choice for sudden sensorineural hearing loss, high-resolution bone-window CT may be necessary to delineate the bony anatomy of the jugular foramen and confirm the presence of this anomaly.

Implementation of ultrasound and fast magnetic resonance imaging pathway reduces computed tomography utilization in children with suspected appendicitis.

Computed tomography (CT) is still used in the imaging diagnosis of acute appendicitis in children at many hospitals. We implemented an ultrasound (US) and fast magnetic resonance imaging (MRI) pathway for suspected appendicitis at our institution with the goal of reducing radiation exposure in children. All children (< 18years old) who underwent appendectomy between January 2011 and July 2021 were reviewed. Data were collected on all imaging studies performed. In December 2015, we initiated an imaging pathway for suspected acute appendicitis. US was the initial imaging study, and a rapid protocol MRI was performed if US was equivocal. Those could not tolerate MRI underwent CT. We evaluated the difference in percentage of patients who underwent CT before and after pathway initiation. 554 patients who underwent appendectomy did not have prior imaging studies on presentation to our hospital and were included in analysis. After initiating the pathway, the use of abdominal US increased from 87% (220 of 254) to 97% (291 of 300, p < 0.0001) and the use of MRI increased by 100% (0 MRIs pre-protocol, 90 of 300 patients post-protocol, p < 0.0001). CT utilization decreased significantly from 32% (82 of 254) to 2% (6 of 300, p < 0.0001). Embracing a new US and rapid MRI pathway to evaluate pediatric patients with suspected acute appendicitis resulted in significant reduction in CT utilization and therefore radiation exposure.

Conflict and control in cortical responses to inconsistent emotional signals in a face-word Stroop.

Social communication is fraught with ambiguity. Negotiating the social world requires interpreting the affective signals we receive and often selecting between channels of conflicting affective information. The affective face-word Stroop (AFWS) provides an experimental paradigm which may identify cognitive-affective control mechanisms underpinning essential social-affective skills. Initial functional magnetic resonance imaging (fMRI) study of the AFWS identified right amygdala as driving this affective conflict and left rostral anterior cingulate cortex (rACC) as the locus of conflict control. We employed electroencephalogram (EEG) and eLORETA source localization to investigate the timing, location, and sequence of control processes when responding to affective conflict generated during the AFWS. However we designated affective word as the response target and affective face as the distractor to maximize conflict and control effects. Reaction times showed slowed responses in high vs. low control conditions, corresponding to a Rabbitt type control effect rather than the previously observed Grattan effect. Control related activation occurred in right rACC 96-118 ms post-stimulus, corresponding to the resolution of the P1 peak in the Visual Evoked Potential (VEP). Face distractors elicit right hemisphere control, while word distractors elicit left hemisphere control. Low control trials require rapid "booting up" control resources observable through VEPs. Incongruent trial activity in right fusiform face area is suppressed 118-156 ms post stimulus corresponding to onset and development of the N170 VEP component. Results are consistent with a predicted sequence of rapid early amygdala activation by affective conflict, then rACC inhibition of amygdala decreasing facilitation of affective face processing (however, amygdala activity is not observable with EEG).

Recanalization Rate and Clinical Outcomes of Intravenous Tissue Plasminogen Activator Administration for Large Vessel Occlusion Stroke Patients.

Stroke caused from large vessel occlusion (LVO) has emerged as the most common stroke subtype worldwide. Intravenous tissue plasminogen activator administration (IV-tPA) and additional intraarterial thrombectomy (IA-Tx) is regarded as standard treatment. In this study, the authors try to find the early recanalization rate of IV-tPA in LVO stroke patients. Total 300 patients undertook IA-Tx with confirmed anterior circulation LVO, were analyzed retrospectively. Brain computed tomography angiography (CTA) was the initial imaging study and acute stroke magnetic resonance angiography (MRA) followed after finished IV-tPA. Early recanalization rate was evaluated by acute stroke MRA within 2 hours after the IV-tPA. In 167 patients undertook IV-tPA only and 133 non-recanalized patients by IV-tPA, additional IA-Tx tried (IV-tPA + IA-Tx group). And 131 patients, non-recanalized by IV-tPA (IV-tPA group) additional IA-Tx recommend and tried according to the patient condition and compliance. Early recanalization rate of LVO after IV-tPA was 12.0% (36/300). In recanalized patients, favorable outcome (modified Rankin Scale, 0-2) was 69.4% (25/36) while it was 32.1% (42/131, p<0.001) in non-recanalized patients. Among 133 patients, nonrecanalized after intravenous recombinant tissue plasminogen activator and undertook additional IA-Tx, the clinical outcome was better than not undertaken additional IA-Tx (favorable outcome was 42.9% vs. 32.1%, p=0.046). Analysis according to the perfusion/diffusion (P/D)-mismatching or not, in patient with IV-tPA with IA-Tx (133 patients), favorable outcome was higher in P/ D-mismatching patient (52/104; 50.0%) than P/D-matching patients (5/29; 17.2%; p=0.001). Which treatment tired, P/D-mismatching was favored in clinical outcome (iv-tPA only, p=0.008 and IV-tPA with IA-Tx, p=0.001). The P/D-mismatching influences on the recanalization and clinical outcomes of IV-tPA and IA-Tx. The authors would like to propose that we had better prepare IA-Tx when LVO is diagnosed on initial diagnostic imaging. Furthermore, if the patient shows P/D-mismatching on MRA after IV-tPA, additional IA-Tx improves treatment results and lessen the futile recanalization.

Evaluation of lateral lymph node metastasis in mid-low rectal cancer and planning of multi-disciplinary treatment

After the implementation of neoadjuvant chemoradiotherapy and total mesorectal excision, lateral local recurrence becomes the major type of local recurrence after surgery in rectal cancer. Most lateral recurrence develops from enlarged lateral lymph nodes on an initial imaging study. Evidence is accumulating to support the combined use of neoadjuvant chemoradiotherapy and lateral lymph node dissection. The accuracy of diagnosing lateral lymph node metastasis remains poor. The size of lateral lymph nodes is still the most commonly used variable with the most consistent accuracy and the cut-off value ranging from 5 to 8 mm on short axis. The morphological features, differentiation of the primary tumor, circumferential margin, extramural venous invasion, and response to chemoradiotherapy are among other risk factors to predict lateral lymph node metastasis. Planning multiple disciplinary treatment strategies for patients with suspected nodes must consider both the risk of local recurrence and distant metastasis. Total neoadjuvant chemoradiotherapy is the most promising regimen for patients with a high risk of recurrence. Simultaneous Integrated Boost Intensity-Modulated Radiation Therapy seemingly improves the local control of positive lateral nodes. However, its impact on the safety of surgery in patients with no response to the treatment or regrowth of lateral nodes remains unclear. For patients with smaller nodes below the cut-off value or shrunken nodes after treatment, a close follow-up strategy must be performed to detect the recurrence early and perform a salvage surgery. For patients with stratified lateral lymph node metastasis risks, plans containing different multiple disciplinary treatments must be carefully designed for long-term survival and better quality of life.

Accuracy of Ultrasound Imaging Findings in Diagnosis of Adnexal Masses: A Cross-sectional Study

Introduction: Adnexal mass lesions are common among women of all age groups. Precise preoperative estimation of the benign or malignant nature of an adnexal mass is important to avoid additional surgical treatment. Sonography is the initial imaging study of choice in the evaluation of women with suspected adnexal masses. Assiut scoring model is a simpler model for differentiation of adnexal masses into benign and malignant using various ultrasonographic parameters. Aim: To assess the accuracy of ultrasound in differentiating benign from malignant adnexal masses using Assiut scoring model. Materials and Methods: This cross-sectional study was conducted in Department of Radiodiagnosis at Christian Medical College and hospital (tertiary care hospital), Ludhiana, Punjab, India, from November 2018 to January 2021. The study included 80 cases of adnexal masses. An Ultrasound (USG) diagnosis was made based on tumour volume, type of mass, papillary projections, septae and vessel location and Assiut score was obtained. Histopathological examination was carried out following surgery or biopsy. The diagnostic accuracy of USG (with histopathology as gold standard) was determined. Sensitivity, specificity, positive predictive value and negative predictive value of USG was assessed for predicting malignancy taking histopathology as gold standard. The p-value &lt;0.05 was considered statistically significant. Results: Most numbers of patients (33 patients, 41.25%) belonged to age group 21-30 years. Mean age of study subjects was 35.35±12.8 years. Majority (60, 75%) of patients were benign and 20 (25%) were malignant. The USG findings showed good agreement with histopathology (kappa=0.76, p-value&lt;0.0001). Sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for correctly predicting malignant lesions being 90%, 90%, 75% and 96.43% respectively. Median Assiut score in malignant was significantly higher as compared to benign (9.95 vs 3.47, p-value&lt;0.0001). Characteristics such as central or septal vascularization, presence of thick septa, papillary projections, multilocularity and high tumour volume (especially above 500 mL) showed a significant association with malignancy (p-value&lt;0.0001). Conclusion: The USG based Assuit scoring model is a good tool in differentiating benign from malignant adnexal masses with high sensitivity and specificity.

Clinical and Brain Imaging Findings of Children with Acute Ataxia: Ten Years of Experience at a Major Pediatric Referral Center

Background: Ataxia is a symptom of a wide range of disorders, which manifests as a lack of coordinated movements. It is commonly associated with cerebellar disorders. Objectives: To evaluate the neuroimaging findings of children with acute ataxia (AA) and to identify the association between these findings and clinical results. Patients and Methods: This cross-sectional study was conducted using the electronic medical records of patients, presenting to a major pediatric referral center over 10 years from March 2009 to February 2020. Patients were included in the study if they were younger than 18 years, were diagnosed with AA (&lt; 30 days), and underwent magnetic resonance imaging (MRI), computed tomography (CT) scan, or both. The exclusion criteria were as follows: A history of neurological or medical disorders, explaining ataxia; pseudo-ataxia; a traumatic brain injury; severe loss of consciousness; and missing key information in the medical records (e.g., no brain imaging findings). Patient data, including the demographic data, clinical history, laboratory findings, imaging results, and in-hospital outcomes, were collected. A P-value less than 0.05 was considered statistically significant, and the confidence interval was set at 95%. Results: A total of 119 patients were included in this study (51% female; mean age, 4.9 years). Clinically urgent neurological pathology (CUNP) was detected in 37 (31.09%) patients. The most common pathologies on images were tumors, acute disseminated encephalomyelitis (ADEM), and stroke. However, the most common diagnosis was acute post-infectious cerebellar ataxia (APCA) (24.4%), followed by brain tumors (16.8%) and Guillain-Barre syndrome (GBS) (15.1%), respectively. Overall, 11 variables were significantly different between patients with and without CUNP. Most notably, the duration of symptoms (P &lt; 0.01), ophthalmoplegia (odds ratio [OR] = 13.93; 95% confidence interval [CI]: 3.5 - 54.7), focal neurologic deficit (OR = 7.26; 95% CI: 2.6 - 20.5), and fever (OR = 3.33; 95% CI: 1.1 - 9.8) were associated with a higher risk of CUNP. On the other hand, some features, such as a recent history of febrile illness (presence of fever or body temperature above 38°C in the last month) (OR = 0.36; 95% CI: 0.16 - 0.8) and hyporeflexia (P &lt; 0.01), were associated with a lower risk of CUNP. Conclusion: Acute post-infectious cerebellar ataxia was the most common diagnosis of AA in children, undergoing neuroimaging studies in our center. Nevertheless, tumor was the most common pathology detected on the images of patients with CUNP. Some pathologies might not be detected by some imaging modalities. Considering the associations identified in this study, patients with risk factors, such as a longer duration of symptoms, ophthalmoplegia, focal neurologic deficit, and fever, need to undergo another imaging modality with higher sensitivity if there are no positive findings in the initial imaging study. On the other hand, patients with protective factors, such as hyporeflexia and a recent history of febrile illness, could benefit more from other diagnostic modalities.

Downstream imaging following abnormal molecular breast imaging, lessons learned and suggestions for success

ObjectivesMolecular breast imaging (MBI) is a supplemental screening modality that assists in detection of breast cancer. Objectives were to investigate how abnormal MBI findings were further evaluated on subsequent imaging studies and assess outcomes. MethodsRetrospective single-institution review included patients who underwent supplemental screening MBI between October 2018 and October 2021, utilizing 300 MBq (8 mCi) 99mTc-sestamibi as radiotracer. Patients with abnormal MBI were assessed for subsequent imaging, biopsies, or surgeries performed. Outcome metrics included recall rate, cancer detection rate, and positive predictive values for recall (PPV1) and biopsy (PPV3); 95% confidence intervals calculated via Wilson score interval. All tests were two-sided; p < 0.05 considered statistically significant. ResultsTotal of 716 MBI exams performed, 93 of which were read as abnormal with ultimate detection of 11 malignancies. Recall rate was 13.0%, cancer detection rate was 15.4/1000 (invasive: 11.2/1000), PPV1 was 11.8%, and PPV3 was 27.5%. Of 11 malignancies, 7 (63.6%) were not visible on concurrent or most recent mammogram. Initial subsequent imaging study detected a correlate for mass uptake in 20/22 (90.9%) cases compared to 42/70 (60.0%) for nonmass uptake (p < 0.007), with correlates for nonmass uptake seen on ultrasound or mammogram in only 5/19 (26.3%). MRI was utilized in 63 (8.8%) cases overall. ConclusionScreening MBI afforded a high cancer detection rate, yet lower detection of nonmass uptake on subsequent ultrasound/mammography resulted in increased usage of MRI compared to prior reports. As utilization of MBI increases, more reported experiences are needed to establish best practices and understand effects of implementation.

Disparities in the Management of Pediatric Breast Masses

IntroductionDisparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass. MethodsA retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses. ResultsA total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis. ConclusionsWe found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Renal arterial embolization: Indications, angiographic findings, and outcomes in a series of 170 patients.

The lack of overall experience and reporting on angiographic findings in previously published studies of renal arterial embolization (RAE) compelled us to report our overall experience on a series of patients. A retrospective study was performed analyzing data of patients enrolled for RAE between 2010 and 2019. History, physical examination, and laboratory data were reviewed for all patients. Abdominal ultrasound was the initial imaging study, and all patients underwent subsequent computed tomography or magnetic resonance imaging. The outcome of RAE was determined based on radiographic and clinical findings. Data from 202 patients were analyzed, with a mean age of 45 ± 15 years, and 71.3% of patients were male. Iatrogenic injury was the most common indication for RAE (54%), followed by renal tumors, trauma, and spontaneous, in 27.7%, 10.4%, and 8.4% of patients, respectively. Renal angiography revealing pseudoaneurysm alone or with other pathology in the lower pole of the kidney was the most common finding (40.6%), whereas no lesions were identified on angiography in 32 patients (15.8%), after which RAE was subsequently aborted. Renal arterial embolization was successful in 158 of 170 patients (92.9%) after 1 or more trials (maximum of 4). Microcoil alone or with other embolic materials was the most commonly used material for embolization (85%). Iatrogenic injury was the most common indication for RAE. Pseudoaneurysm alone or with other lesions was the most common lesion on renal angiography; however, angiography showed a negative result in 16% of patients, even those with symptoms. When lesions are present on angiography, the overall success of repeated trials of RAE reached 92.9%.

Surveillance After Ureteroneocystostomy: Is it Necessary?

ObjectiveTo determine the utility of post-operative imaging after ureteroneocystostomy and whether long-term symptom or radiographic surveillance aided in the detection of recurrent obstruction. Materials and MethodsAdult patients were identified who underwent a ureteroneocystostomy with or without psoas hitch or Boari flap between January 2012 and June 2021. Patients who underwent a bilateral procedure, had active malignancy or immediate failure, or did not have 6 months of follow-up with 2 imaging studies were excluded. Using the initial imaging study after stent removal, patients were categorized into normal and equivocal groups according to predefined radiologic criteria. Patients were followed longitudinally to determine whether they subsequently developed radiographic evidence of obstruction. Follow up visits were reviewed for patient symptoms suggestive of post-operative obstruction, defined as flank pain, hematuria, or pyelonephritis. ResultsOne hundred and twelve patients met criteria. Normal and equivocal initial imaging was seen in 99 and 13 patients, respectively. At a mean radiologic follow-up of 32 months, stricture recurrence was identified in 3 patients with normal initial imaging. No patients with initial equivocal imaging demonstrated recurrent obstruction at mean radiologic follow-up of 29 months. All patients with recurrent stricture presented with symptoms of obstruction. Of patients who developed symptoms after ureteroneocystostomy, 13.6% had recurrent stricture. ConclusionAsymptomatic patients after ureteroneocystostomy who had either normal or equivocal post-operative imaging did not benefit from additional radiologic testing in this cohort. All patients that demonstrated failure presented with symptomatic obstruction that warranted imaging. Surgeons may consider restricting surveillance imaging to symptomatic patients after the initial post-operative period.

Predictors of very early stroke recurrence in the POINT trial population

BackgroundRecent trials of acute secondary prevention in patients with minor ischemic stroke or transient ischemic attack (TIA) have demonstrated high rates of early recurrence within days of the initial event. Identifying clinical features associated with early recurrence may guide focused management.MethodsUsing logistic regression applied to the data of the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, we evaluated what baseline clinical factors predict outcome events occurring within 7 days of randomization.ResultsIn the POINT trial, 181 subjects (3.7%) had early recurrence, defined as primary outcome events within 7 days of trial entry, whereas only 100 outcome events occurred over the remainder of the 90 day trial. Protective effects of dual antiplatelet therapy with clopidogrel plus aspirin were seen only as a reduction in these early recurrences, without any impact on later events. In univariate analysis, systolic blood pressure, diastolic blood pressure, serum glucose, initial carotid imaging results, study cohort (minor stroke or TIA), and treatment assignment were significantly associated with early recurrence. Multivariate logistic regression analysis identified a number of factors with significant independent associations with early recurrence, including carotid stenosis or occlusion (Odds Ratio [OR] 2.77; 95% confidence interval [CI] 1.78–4.31), cohort (minor stroke versus TIA) (OR 1.86; 95% CI 1.33–2.58), race (OR 1.57; 95% CI 1.10–2.25), baseline statin use (OR 0.68; 95% CI 0.49–0.95), systolic blood pressure (OR 1.10; 95% CI 1.03–1.18), serum glucose (OR 1.03; 95% CI 1.01–1.05), and age (OR 1.02; 95% CI 1.00–1.03). Receiver Operator Characteristic (ROC) analysis showed a 70% accuracy of the resulting logistic model in predicting early recurrence.ConclusionsEarly recurrence is high, and is concentrated in the first 7 days, in patients with minor stroke or TIA. A number of baseline clinical factors, including carotid disease, presentation with minor stroke rather than TIA, race, absence of statin usage, systolic blood pressure, and serum glucose, are independently associated with early event recurrence in the POINT trial population.

The Chain of Adherence for Incidentally Detected Pulmonary Nodules after an Initial Radiologic Imaging Study: A Multisystem Observational Study.

Rationale: Millions of people are diagnosed with incidental pulmonary nodules every year. Although most nodules are benign, it is universally recommended that all patients be assessed to determine appropriate follow-up and ensure that it is obtained. Objectives: To determine the degree of concordance and adherence to 2005 Fleischner Society guidelines among radiologists, clinicians, and patients at two Veterans Affairs healthcare systems with incidental nodule tracking systems. Methods: Trained researchers abstracted data from the electronic health records of patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. We classified radiology reports and patient follow-up into three categories. Radiologist-Fleischner adherence was the agreement between the radiologist's recommendation in the computed tomography (CT) report and the 2005 Fleischner Society guidelines. Clinician/patient-Fleischner concordance was agreement between patient follow-up and the guidelines. Clinician/patient-radiologist adherence was agreement between the radiologist's recommendation and patient follow-up. We evaluated whether the recommendation or follow-up was more (e.g., sooner) or less (e.g., later) aggressive than recommended. Results: After exclusions, 4,586 patients with 7,408 imaging tests (n = 4,586 initial chest CT scans; n = 2,717 follow-up chest CT scans; n = 105 follow-up low-dose CT scans) were included. Among radiology reports that could be classified in terms of Fleischner Society guidelines (n = 3,150), 80% had nonmissing radiologist recommendations. Among those reports, radiologist-Fleischner adherence was 86.6%, with 4.8% more aggressive and 8.6% less aggressive. Among patients whose initial scans could be classified, clinician/patient-Fleischner concordance was 46.0%, 14.5% were more aggressive, and 39.5% were less aggressive. Clinician/patient-radiologist adherence was 54.3%. Veterans whose radiology reports were adherent to Fleischner Society guidelines had a substantially higher proportion of clinician/patient-Fleischner concordance: 52.0% concordance among radiologist-Fleischner adherent versus 11.6% concordance among radiologist-Fleischner nonadherent. Conclusions: In this multi-health system observational study of incidental pulmonary nodule follow-up, we found that radiologist adherence to 2005 Fleischner Society guidelines may be necessary but not sufficient. Our results highlight the many facets of care processes that must occur to achieve guideline-concordant care.

Flow Diverter Treatment of Ruptured Basilar Artery Perforator Aneurysms

PurposeRuptured basilar artery perforator aneurysms (BAPAs) represent a very rare cause of subarachnoid hemorrhage and an under-reported subtype of cerebral aneurysm. There is no consensus for the optimal treatment strategy (conservative vs. surgical vs. various endovascular approaches). We aim to present a multicenter experience of BAPA treatment using flow-diverter (FD) stents.MethodsAt five tertiary neurovascular centers, all cases of ruptured BAPAs treated by FD were retrospectively collected. Baseline imaging and clinical characteristics, complications, as well as early and long-term angiographic and clinical outcome (mRS) were analyzed.ResultsEighteen patients (mean age, 57 years; SD, ±10.7 years) with acute SAH related to a BAPA were treated using 18 FD stents. Aneurysms were detected on initial imaging study in 28%; delayed diagnosis was triggered by clinical deterioration due to rebleeding in 15%. No rebleeding after FD was seen, 28% developed FD-related ischemic complications. At long term (n = 16), overall mortality was 13% (2/16), and favorable outcome (mRS 0–2) was 81% (13/16). All BAPAs (n = 13) were completely occluded at long-term angiographic follow-up.ConclusionIn our multicenter experience, FD treatment of ruptured BAPAs appears to have comparable safety and efficacy outcomes to FD treatment of other ruptured posterior circulation aneurysms as well as to the conservative management of BAPAs. This treatment strategy for a ruptured BAPA achieved a high rate of angiographic occlusion and favorable clinical outcome; however, as the conservative management also seems to offer similar clinical outcomes an individualized treatment decision is warranted. Future prospective studies comparing both approaches are required.

Central Nervous System Tumors in Children.

Central Nervous System Tumors in Children.

Spontaneous Regression of Disc Prolapse – An Underlooked Phenomena: A Case Report and Literature Review

Introduction: Intervertebral disc prolapse is a very common abnormality found in the population, that can manifest in a variety of complaints like back pain, radiculopathy, and even to the extent that it might lead to more adverse neurological deficits. Symptoms improve in majority of patients only with conservative treatment. However, some patients may require surgical intervention. In some cases, spontaneous regression of herniated disc can be seen. Thus, the interest in the phenomenon of spontaneous resorption of the herniated discs has increased, which raised the controversy regarding managing such patients. Here, we report a case of a huge lumbosacral spontaneous disc resolution at the level of L5-S1 in which clinical improvement was associated with a significant decrease in the size of a huge, herniated disc. In addition, we performed a comprehensive review of literature of all reported cases of spontaneous disc resolution to provide an updated discussion of such an underlooked phenomena.&#x0D; Case Report: A 53-year-old female not known to have any medical illness presented at the Neurosurgery Clinic with complaints of chronic back pain for six years which was progressing and radiating to both of her lower extremities (right more than left) and had become more intense in the last year. It was slightly relieved by simple analgesics and aggravated by sitting or lying down. There was no history of trauma, weaknesses, or sphincteric disturbances. Upon evaluation in our clinic, local exam revealed lower back midline tenderness at the level of L5-S1 vertebrae. No tenderness was observed in the paravertebral area or facets. Straight leg raising test was positive at 70º in the right side and 90º in the left, normal power, intact sensation, normal tone, and reflexes. Negative Babinski and clonus was noted in both limbs. MRI lumbar spine showed significant right paracentral L5-S1 disk prolapse indenting the thecal sac compressing the root. A full-course and effective medical treatment was initiated as the patient was never treated properly before for her back pain, along with physical therapy and regular OPD follow-ups. A follow-up MRI a year later revealed significant reduction in the size of the disk prolapse as compared to the initial imaging study. Overall, patient’s symptoms significantly improved, and she was kept on conservative management.&#x0D; Conclusion: To conclude, the case presented here shows the efficacy and validity of conservative management for patients who are diagnosed with a herniated disc in the absence of neurological deficits. This shows the importance of not pushing surgical treatment for patient with lumbar disc herniation without neurological deficits, each patient should receive a trial of conservative therapy and close OPD follow-ups and repeated MRI scans for further assessment of any advancement or improvement, because herniated discs can regress spontaneously. Radiological changes alone should not be the main target for assessing improvement, what matters more is clinical and symptomatic improvement. Surgical management remains an important therapeutic option for patients who failed conservative management and patients who have severe neurological deficits.

MP61-09 INITIAL MANAGEMENT OF INDETERMINATE RENAL MASSES IN A STATEWIDE COLLABORATIVE:A MUSIC-KIDNEY ANALYSIS

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging/Surveillance III (MP61)1 Sep 2021MP61-09 INITIAL MANAGEMENT OF INDETERMINATE RENAL MASSES IN A STATEWIDE COLLABORATIVE:A MUSIC-KIDNEY ANALYSIS Mohit Butaney, Amit Patel, Brian Lane, Ji Qi, Anna Johnson, Craig Rogers, and for the Michigan Urological Surgery Improvement Collaborative Mohit ButaneyMohit Butaney More articles by this author , Amit PatelAmit Patel More articles by this author , Brian LaneBrian Lane More articles by this author , Ji QiJi Qi More articles by this author , Anna JohnsonAnna Johnson More articles by this author , Craig RogersCraig Rogers More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002101.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The widespread use of imaging has led to the increasing detection of incidental renal lesions. Although some may be accurately classified as suspicious (renal cell carcinoma) and others as benign (Bosniak I-IIF cysts or angiomyolipomas), other lesions are best initially characterized as ‘indeterminate’, for example when they cannot be determined to be enhancing without additional imaging sequences. Optimal management is not well understood. We assess the use of follow up imaging in the management of indeterminate renal lesions(IRL). METHODS: The Michigan Urological Surgery Improvement Collaborative—Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and follow-up data at 13 diverse practices. At initial evaluation, data was recorded regarding the radiologist interpretation of each imaging study (suspicious, indeterminate, benign) as well as the clinician’s assessment. Patients with complete data were assessed at 120 days after initial evaluation as to whether observation or treatment was performed. RESULTS: 19.6% (472/2413) patients(pts) were recorded as having an IRL at their initial imaging study, of which 36% had non-contrast imaging. 23.9% (113/472) of pts with IRL underwent subsequent imaging(SI), of which 59.3% (67/113) were re-classified as solid enhancing lesions, 20.4% as benign lesions, with only 20.4% IRL remaining. Of these 113 pts with repeat imaging, 17 underwent biopsy (15 malignant, 1 benign, 1 indeterminate) and 10 of 15 patients with cancer on biopsy underwent treatment, while the remaining selected surveillance. Pts with initial IRL reclassified to suspicious were less likely to have benign histology at pre-treatment biopsy (8.7% vs. 9.7%) or surgery (6.1% vs. 10.5%) compared with lesions initially characterized as suspicious, but these did not reach statistical significance. CONCLUSIONS: Until now, outcomes of indeterminate renal masses have been poorly understood. About 80% of patients with indeterminate renal lesions can be reclassified with subsequent dedicated imaging. Patients with benign renal lesions, including Bosniak I-IIF cysts, T1a AMLs, and other non-enhancing lesions or pseudotumors can be reassured and should not undergo intervention. Initial contrast axial imaging, the addition of further imaging and consideration of biopsy more fully characterizes an indeterminate renal lesion, often affecting subsequent management. Source of Funding: Funding from Blue Cross Blue Shield of Michigan © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1086-e1086 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohit Butaney More articles by this author Amit Patel More articles by this author Brian Lane More articles by this author Ji Qi More articles by this author Anna Johnson More articles by this author Craig Rogers More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement Loading ...