Negative Angiogram Research Articles

Basilar Artery Perforator Aneurysms and their Contemporary Management

Aneurysms arising in relation to perforators of the basilar artery (basilar perforator aneurysms or BPA) are very rare. Prior literature indicates the need for typically more than one angiogram for diagnosis, and argues for the utility of delayed angiograms in cases of subarachnoid hemorrhage (SAH) with initial negative studies. Different treatment modalities for BPA including endovascular, microsurgical, and conservative management have been described. Contemporary management appears to favor endovascular therapy. We discuss the topic by presenting a case which represents the first instance of BPA diagnosis after a fourth angiogram and subsequent successful endovascular occlusion. A literature review is provided. To discuss the unique presentation and management dilemmas in the rare entity of basilar artery perforator aneurysms by presentation of a case that was managed successfully by endovascular means. We also indirectly highlight the need for multiple follow-up angiograms in initial angiographically negative subarachnoid hemorrhage. We describe a 62-year-old male presenting with good clinical grade SAH and three negative angiograms, whose hospital course was complicated by repeat intraventricular hemorrhage. A fourth angiogram revealed a BPA. Multiple overlapping stents placed in the basilar artery achieved successful aneurysm exclusion. A comprehensive review of the literature was performed on PubMed. Only 57 cases of BPAs have been described in literature. Multiple angiograms may be necessary for diagnosis. These aneurysms present with SAH. Endovascular flow modification is the current treatment of choice by means of overlapping stents or flow diversion.

Serum low density lipoprotein receptor related protein-6 is a discriminator of occluded ‎coronary artery assessed by coronary angiogram

Background: Human lipoprotein receptor-related protein -6 (LRP6) plays a role in the development of coronary artery disease. This study aimed to determine the serum level of the LRP6 in patients referred to the coronary angiogram taking into considerations the findings of ‎coronary angiography, evidence of dyslipidemia, obesity and co-existed diabetes mellitus.
 Methods: This cross-sectional study included 96 patients who referred to coronary angiogram as an interventional diagnostic test for coronary artery disease. The patients were grouped into Group I (negative angiogram); Group IIA (non-obstructed coronary vessels, positive angiogram) and: Group IIB (obstructed coronary vessels, positive angiogram). The anthropometric measurement, blood pressure, and fasting serum lipid profile and glucose were determined. The serum levels of LRP6 were determined by using the Enzyme-Linked ImmunoSorbent Assay (ELISA). 
 Results: A non-significant higher serum level of LRP6 observed in patients with a positive angiogram ‎0.175 ± 0.074 ng/ml (Group IIA) and ‎0.166 ± ‎‎0.063 ng/ml (Group IIB) ‎compared with the negative angiogram (Group I: 0.160 ± 0.019 ng/ml). The area under the curve of LRP6 in patients with positive angiogram was significantly lower than that with a normal angiogram.
 Conclusion: We conclude that the serum level of LRP6 is a good discriminator of patients with coronary ‎artery disease as the area under the curve of the serum levels of LRP6 is significantly decreased as the number of occluded coronary vessels increased.‎

The role of spinal angiography in the evaluation and treatment of pediatric spinal vascular pathology: a case series and systematic review.

While it has been extensively studied in adults, the role of spinal angiography in children with suspected spinal vascular malformations is not fully characterized. With special implications regarding technique, radiation dose, and pathology, we sought to review our single-center experience with pediatric spinal vascular pathology and use a systematic review of the literature to further identify its role in pediatrics. A retrospective chart review was conducted under IRB approval for all patients age 0-18years old who underwent spinal angiography at our institution between 2007 and 2018 for concern for spinal vascular pathology. A simultaneous systematic review was conducted via dedicated search terms in two distinct databases and reviewed to identify all studies referring to spinal angiography or angiograms in pediatric patients. Six patients were included. Three patients (50%) had vascular malformations confirmed on diagnostic angiography and underwent subsequent endovascular treatment. Two patients (33.3%), one with hematomyelia and one with spinal cord infarction, had negative diagnostic angiograms. One patient (16.7%) had a spinal tumor and underwent angiography for further evaluation preoperatively. Spinal angiography was used to aid in diagnosis, preoperative planning, and treatment in these cases. It was demonstrated to be safe in this patient population, with no untoward events, minimal radiation dose, and possible therapeutic applications in select cases. The systematic review identified 11 studies regarding pediatric spinal angiography. These ranged from single case reports to case series of up to 38 patients and highlighted the role of spinal angiography in diagnosis, endovascular treatment, preoperative planning, and postoperative follow-up. Spinal angiography may be used in a variety of scenarios to better understand the architecture of vascular spinal lesions and facilitate endovascular intervention. While its application in both adult and pediatric pathology is limited to select cases, spinal angiography remains a key diagnostic procedure when approaching vascular lesions or tumors of the spine, assessing for etiology of spinal cord infarcts, and in the evaluation of unexplained hemorrhage in the spinal canal.

Post paracentesis deep circumflex iliac artery injury identified at angiography, an underreported complication

BackgroundThough injury to the inferior epigastric artery (IEA) is reported to be the most common source of hemorrhagic complications from paracentesis, we wish to present our experience involving deep circumflex iliac artery (DCIA) injuries that in our experience is the artery most frequently injured during paracentesis.MethodsSixteen patients with clinically significant hemorrhage following paracentesis were referred to our Interventional Radiology service for trans-catheter embolization. Patterns of hemorrhage from diagnostic cross-sectional imaging and subsequent angiographic findings and management were investigated.Results8/16 patients (50%) had angiographic evidence of injury to the DCIA and 4/16 patients (25%) had evidence of injury to the IEA, with two of these patients demonstrating hemorrhage from both the DCIA and IEA; 3/16 patients had injuries to subcostal and/or intercostal arteries; while 3/16 patients had negative angiograms. All patients underwent embolization of the identified injured arteries, and empiric embolization was performed of the DCIA and/or IEA in the three patients with negative angiograms. Fourteen of sixteen patients stabilized post embolization, while two patients required a second embolization procedure to achieve hemostasis; all patients were subsequently discharged home in stable condition.ConclusionBoth the IEA and the lesser known DCIA need to be considered when performing paracentesis and at subsequent angiography for post paracentesis iatrogenic hemorrhage. Knowledge of both of these at-risk abdominal wall arteries may help minimize hemorrhagic complications from paracentesis.

SAT-623 Acute Bradycardia Secondary to Worsening of Hypothyroidism Post-Iodine Contrast

BACKGROUNDPatient with history or risk of developing thyroid disorder can develop worsening of overt hypothyroidism after exposure to iodine containing contrast. We report a case of bradycardia requiring CCU treatment due to worsening of hypothyroidism due to iodine contrast.CASE DETAILSA 68 years old female with history of heart failure, coronary artery disease, hypertension, diabetes mellitus and hypothyroidism presented to ED for chest pain and dyspnea. She was taking L-thyroxine 100mcg with other medications at home. CT angiography was negative and coronary angiogram was unremarkable. Her symptoms were alleviated and she was discharged home next day. Her discharge vitals included heart rate within normal limit. After 3 days she presented to ED for dizziness and weakness. Her vitals included heart rate of 51 and BP of 105/50. EKG showed sinus bradycardia. She was not taking medications that could potentially cause bradycardia, including beta-blockers. She was discharged next day without change in medications. She again presented to the hospital next day due to dizziness, fatigue and bradycardia. Vitals signs showed BP of 91/48 with heart rate of 37. She was admitted to CCU and treated with dopamine drip. Her TSH was 11.90(0.35-5.5 uIU/ml) and free T4 0.69(0.76-1.46ng/dl). She was started on 125mcg of L-thyroxine and was discharged home on this dose. After 2 days of discharge patient again presented to ED for the 4th time for dizziness and bradycardia. EMS details regarding vitals and EKG were not available but document did include atropine given en route, suggesting likely bradycardia of <40. On arrival to ED, Heart rate was 52 with BP 120/59. TSH done this visit was reported 26.40. Patient confided not taking 125mcg of L-thyroxine but continuing 100mcg, the dose she was on before first admission. Patient was again started on 125mcg of levothyroxine in hospital and observed for 3 days. Patient’s symptoms were resolved, and her heart rate was >60/min on the day of discharge.DISCUSSION Association of iodine contrast with hypothyroidism has been less studied compared to that with hyperthyroidism. Risk factors such as pre-existing sub-clinical hypothyroidism and hashimoto thyroiditis has been identified in some studies. It is postulated that in presence of excess iodine, iodine internalization into the thyrocyte and iodine organification is suppressed, also known as Wolff-Chaikoff effect. In most of the reported cases and studies, transient changes in thyroid function after exposure to iodine contrast rarely resulted change in management. Our case is unique in the sense that patient needed treatment in cardiac critical care including chronotropic agent. As use of iodine contrast in acute care setting has been on rise since last few decades, a hospital clinician needs to be vigilant about this phenomenon.

Young male with heart failure and negative angiogram

A young previously well male presented with features of acute coronary syndrome and heart failure. ECG showed inferior ST elevations but his cardiac markers and angiogram was negative. He was found to have a large abdominal paraganglioma with normal adrenal glands. He had a successful excision of the tumor and is now under life- long surveillance. He is awaiting genetic testing.

04:03 PM Abstract No. 245 Impact of vital signs and delay following positive diagnostic imaging in predicting positive angiogram for gastrointestinal hemorrhage

To evaluate the utility of vital signs and delay between positive diagnostic imaging and angiogram in predicting active extravasation on angiogram in patients with GI hemorrhage. A single-institution retrospective chart review identified patients with GI bleeding over a 10-year period. Vital signs in the 4 hours preceding angiogram, diagnostic studies, and angiographic studies were reviewed. Variables were compared using univariate statistics. A total of 272 patients were identified. Of the 384 total angiograms, 109 were performed after a positive diagnostic imaging study. Mean time from diagnostic imaging completion to the start of angiogram was 124 ± 77 minutes for positive angiograms and 191 ± 105 minutes for negative angiograms (p=0.001). Angiograms performed < 2 hours after positive imaging were positive for active hemorrhage in 22/41 (54%) patients, while those performed >2 hours after imaging were positive in only 13/68 (19%) patients. Vital signs in the 4 hours prior to the angiogram were available for 198/384 angiograms and are compared between patients with positive and negative angiograms in the table. While all are statistically significantly different between groups, this is likely of little clinical significance given the similar absolute values. The intermittent nature of GI hemorrhage results in a high rate of negative angiograms. Minimizing delays between positive diagnostic imaging and angiogram increased the likelihood of visualizing a culprit vessel to be targeted for treatment. Though vital signs were statistically different between patients with positive and negative angiograms, the clinical significance of these differences is questionable as no vital sign appears to reliably identify patients with subsequent positive angiogram.Tabled 1Positive AngiogramNegative AngiogramP ValueHR at angiogram start92.1 ± 17.785.2 ± 18.50.009BP at angiogram start122.9 ± 23.9139.7 ± 26.1<0.00166.8 ± 12.472.4 ± 13.10.003Maximum HR106.3 ± 20.297.2 ± 20.70.002Minimum BP97.9 ± 24.5111.8 ± 25.7<0.00155.8 ± 12.260.4 ± 12.30.01 Open table in a new tab

The effect of donor age on posttransplant mortality in a cohort of adult cardiac transplant recipients aged 18-45.

Hearts from older donors are increasingly utilized for transplantation due to unmet demand. Conflicting evidence exists regarding the prognosis of recipients of advanced age donor hearts, especially in young recipients. A retrospective analysis was performed on 11433 patients aged 18 to 45 who received a cardiac transplant from 2000 to 2017. Overall, 10279 patients received hearts from donors less than 45 and 1145 from donors greater than 45. Recipients of older donors were older (37 vs. 34years, P<.01) and had higher rates of inotropic dependence (48% vs. 42%, P<.01). However, groups were similar in terms of comorbidities and dependence on mechanical circulatory support. Median survival for recipients of older donors was reduced by 2.6years (12.6 vs. 15.2, P<.01). Multivariable analysis demonstrated donor age greater than 45 to be a predictor of mortality (HR 1.18 [1.05-1.33], P=.01). However, when restricting the analysis to patients who received a donor with a negative preprocurement angiogram, donor age only had a borderline association with mortality (HR 1.20 [0.98-1.46], P=.06). Older donor hearts in young recipients are associated with decreased long-term survival, however this risk is reduced in donors without atherosclerosis. The long-term hazard of this practice should be carefully weighed against the risk of waitlist mortality.

Subarachnoid Hemorrhage of Unknown Origin at Initial Imaging Investigation

In some patients with spontaneous subarachnoid hemorrhage(SAH), initial imaging investigations may not be able to detect a bleeding source;repeat imaging may be necessary to reveal these lesions. We reviewed a consecutive series of 45 patients with SAH and negative initial digital subtraction angiograms(DSA)during a 15-year period. The aims were to document the frequency and reason for the negative initial investigations, to determine the appropriate modality and timing of repeat examinations, and to investigate the identified bleeding sources. Twenty-eight(62%)patients underwent repeat DSA, 35(78%)underwent magnetic resonance imaging(MRI), and 33(73%)underwent computed tomography angiography(CTA). Nine lesions(5 small aneurysms, 2 craniocervical junction arteriovenous fistulas, 1 arteriovenous malformation, and 1 internal carotid artery dissection)were identified on subsequent DSA after 2-3 weeks. Most aneurysms were identified on an atypical vascular tree. CTA or MRI alone were unable to disclose the culprit lesions. In retrospect, human errors including oversight were the major reasons for the negative initial investigation results. It is, however, difficult to search for a tiny vascular lesion that might be anywhere in the cranium. Repeat DSA is still the gold standard for the inspection of hidden bleeding sources in patients with SAH of unknown origin.

Subarachnoid Hemorrhage Caused by an Extramedullary Intradural Foramen Magnum Cavernous Malformation

Objective: Pure subarachnoid hemorrhage (SAH) secondary to spine cavernous malformation is rare. Method: Female, 41 year old, with a massive intraventricular and SAH secondary to a extramedullary intradural foramen magnum cavernous malformation. The patient developed a sudden headache and drowsiness without neurological deficits. A CT scan revealed a massive SAH without intraparenchymal blood. Angiogram was negative for aneurysm or vascular malformation. A MRI showed an extramedullary intradural mass in the foramen magnum. She underwent a neurosurgical resection of the mass. Results: No complications due to resection and the pathological test revealed a cavernous malformation. Conclusion: This is the second case of foramen magnum cavernous malformation reported in literature. It should be considered a differential diagnosis of SAH with negative angiogram and surgical treatment usually provides good outcomes.

Functional Outcomes and Delayed Cerebral Ischemia Following Nonperimesencephalic Angiogram-Negative Subarachnoid Hemorrhage Similar to Aneurysmal Subarachnoid Hemorrhage

The angiogram-negative subarachnoid hemorrhage (SAH) literature includes patients with perimesencephalic hemorrhage, which is recognized to have a much better outcome than aneurysmal SAH. To evaluate the clinical outcomes of Nonperimesencephalic Angiogram-Negative SAH (NPAN-SAH). A prospective, spontaneous SAH database of 1311 patients that accrued between April 2006 and December 2014 was screened. All patients with NPAN-SAH and 2 consecutive negative cerebral angiograms were included. We identified 191 (11%) from a total of 1311 patients with spontaneous SAH. Amongst angiogram-negative patients, 83 (4.9%) were adjudicated to have NPAN-SAH. Patient characteristics were similar across the groups, except NPAN-SAH patients were more likely to be men and had higher rates of diabetes. In a multivariable logistic regression model, NPAN-SAH patients were less likely to develop vasospasm, after adjusting for Fisher grade, sex, and diabetes (odds ratio [OR]: 0.197, 95% confidence interval [CI; 0.07-0.55], P = .002). In another adjusted model accounting for Hunt and Hess clinical grade, NPAN-SAH patients were also less likely to develop vasospasm (OR: 0.2, 95% CI [0.07-0.57], P = .002). We found no statistical significance between 2 groups for rebleed, developing hydrocephalus, seizures, or delayed cerebral ischemia. NPAN-SAH patients were equally associated with poor functional outcome (modified Rankin scale ≥3; OR: 1.16, 95% CI [0.615-2.20], P = .6420), and death (OR: 1.22, 95% CI [0.362-4.132], P = .7455) compared to aneurysmal SAH. Although the risk of vasospasm may be lower, patients with NPAN-SAH are equally associated with delayed cerebral ischemia, poor outcome, and death as compared to patients with aneurysmal SAH. Furthers studies may be necessary to further clarify these findings.

4:03 PM Abstract No. 108 Analysis of the outcome and secondary intervention for patients with rebleed following mesenteric angiogram for acute lower gastrointestinal bleed

To analyze the outcome and secondary intervention for patients with rebleed following mesenteric angiogram for acute lower GI bleed. This retrospective study reviewed 82 patients who underwent mesenteric angiograms performed for acute lower GI bleed in our institution between 2011 and 2016. 26 patients had a rebleeding episode after mesenteric angiography. Total of 82 procedures were done for patients with acute lower GI bleed. 26 patients had a rebleeding episode after mesenteric angiography. Of the 26 patients, 15 had negative prior mesenteric angiograms while 9 were positive cases. The results are summarized in the table. Rebleed after mesenteric angiograms in our study was 32% (26/82). The most common secondary intervention was surgery and endoscopy with diverticulosis and hemorrhoids being the most common underlying etiologies.

A Novel Technique to Measure the Intensity of Abnormality on GI Bleeding Scans: Development, Initial Implementation, and Correlation With Conventional Angiography.

Develop a technique to quantify intensity of lower gastrointestinal bleeding (LGIB) on Tc-labeled red blood cell (RBC) scintigraphy, correlate with angiography, and determine the tool's predictive value. An IRB-approved, single institution database query of GI bleeding scans performed between January 2013 and December 2015. Reports from all studies and imaging from all positive studies were reviewed. A technique was developed for scan analysis, allowing for calculation of percent increase of activity in the region of interest (ROI, area of bleeding) and ROI in the aorta and liver (controls). Database query determined which patients underwent angiography, and which had positive angiograms. Median ROI percent increase in patients with positive scintigraphy and positive angiography was compared to those with positive scintigraphy and negative angiography. Of 194 bleeding scans performed during the study period, 71 were positive for active LGIB, 37 had angiography, and 9 had active contrast extravasation. The new tool was used to analyze the 37 cases with positive nuclear scans sent for angiography. Median percent increase in ROI activity was 50% in those with positive scan and positive angiogram and 26.8% in those with positive scan but negative angiogram. Using ROI percent change quartiles, we observed a statistically significant association between percent increase in ROI activity from baseline and the probability of having a positive angiogram (Cochran-Armitage trend test, P = 0.01), such that there are no positive angiogram cases when ROI change was <20% and a majority of the positive angiogram cases (67%) in the highest quartile. Utilization of processing protocol to determine percent increase in activity from baseline within ROI of active LGIB on scintigraphy has predictive value in determining which patients will not benefit from conventional angiography.

Th17 immune responses in Brazilian dyslipidemic patients with atherosclerosis

Lymphocytes, macrophages, and immunological mediators are critical in atherogenesis, but Th17 cells are still little studied. We investigated blood lymphocyte profiles, cytometric changes in blood Th17 cells, and production of Th17-associated cytokines by peripheral blood mononuclear cells (PBMCs) stimulated with phytohemagglutinin (PHA) in dyslipidemic patients. Forty-nine Brazilian dyslipidemic patients, including 14 with negative coronary angiograms (CAs) and 35 with positive CAs (atherosclerosis), were classified into groups G1 and G2, respectively, and 27 healthy individuals without dyslipidemia were included in the control group (HI). In all participants, lipid profiles, CVD risk factors, atherogenic risk indexes, cytometry of blood T lymphocytes (CD4+ T, CD8+ T, and Th17 cells), and Th17 cytokine production were determined. Production of interleukin (IL)-17A, IL-17F, IL-21, and IL-22 was measured in culture supernatants of PHA-stimulated PBMCs. Patients with atherosclerosis exhibited low levels of high-density lipoprotein cholesterol and apolipoprotein A and showed increased atherogenic risk indexes and a higher frequency of prior acute myocardial infarction (AMI). CD8+ T-cell counts were lower in patients with previous AMI and higher in dyslipidemic obese individuals. Th17 cell frequency was increased in dyslipidemic women with atherosclerosis. PBMCs from patients with atherosclerosis produced less IL-17A and IL-21, but more IL-22. IL-17F production was unaltered. In summary, cytometric changes in CD8+ T and Th17 lymphocytes and altered production of Th17-associated cytokines were observed in these individuals and were related to endocrine factors, obesity, and AMI. The practical implications of these findings need to be investigated in future studies.

Double Trouble: Acute Pulmonary Embolism in a Patient With Acute Inferior Wall Stemi

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary embolism (PE) and myocardial infarction are two of the most feared medical emergencies. Both carry a high mortality, demand radically different interventions, yet are often indistinguishable. Differentiating between a right ventricular myocardial infarction and PE is a challenging clinical scenario; however, correctly ascertaining the pathologic process is imperative, as decision making drastically impacts patient outcome. There have been a few case reports of PE masquerading as a myocardial infarction; however, we report the first ever case of a PE that presented with inferior wall STEMI and how it offered a uniquely difficult clinical dilemma in determining which intervention would confer survivability for our patient. CASE PRESENTATION: This is a 72-year-old male with hypertension, IDDM and recent cholecystectomy who presented with lower extremity edema, dyspnea and hypoxia. An EKG showed ST elevation in leads II, III, and aVF with reciprocal ST depression in aVL and lead I. The troponin was 1.770 with a BNP of 3546. A CT chest angiography demonstrated an acute PE with an RV:LV of 1.32. An echocardiogram demonstrated severe hypokinesis of the base, mid-to-distal-inferior and inferolateral walls. After considerable interdisciplinary debate, a decision was made to perform a coronary angiogram, which demonstrated 99% stenosis of the mid right coronary artery, resulting in drug-eluting stent deployment. Subsequently, the patient underwent successful catheter-directed intra-arterial thrombolysis. A repeat echocardiogram with agitated saline demonstrated a right to left shunt with persistent inferior wall motion abnormalities, suggesting a parodoxical thromboembolism through a pre-existing patent foramen ovale. DISCUSSION: Three proposed mechanisms can possibly explain the co-existing processes. An existing plaque could have ruptured from increased myocardial demand resulting from the PE or profound hypoxia generated a catecholamine surge triggering myocardial ischemia. However, only one mechanism fully accounts for the concurrence of both pathologies: a paradoxical thromboembolism propagating through the patent foramen ovale resulting in acute RCA stenosis. CONCLUSIONS: There have been cases of a PE that have mimicked a STEMI, but yielded negative coronary angiograms for significant obstructive coronary artery disease.1,2 Only Goslar et al. reported a paradoxical thromboembolism from a PE into the conus artery, resulting in an antero-septal myocardial infarction; however, the initial transthoracic echocardiogram findings could not be explained independently by the two processes.3 Therefore, our case demonstrates that a PE and STEMI can occur simultaneously and present identically, resulting in a complicated clinical picture that demands timely decision making. Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264717/ Reference #2: https://www.ncbi.nlm.nih.gov/pubmed/25414218 Reference #3: https://cardiovascularultrasound.biomedcentral.com/articles/10.1186/1476-7120-8-50 DISCLOSURE: The following authors have nothing to disclose: Shahniwaz Labana, Marwah Hussein, Sandip Saha, Mohammad Khan No Product/Research Disclosure Information

Left ventricular dysfunction causing ischemia in patients with patent coronary arteries.

New onset of heart failure (HF) is an indication for the assessment of coronary artery disease. The aim of this study was to clarify the mechanistic causes of new onset HF associated with ischemic electrocardiograph (EKG) changes and chest pain in patients with patent or minimally diseased coronary arteries. Twenty consecutive patients (Group A) were retrospectively reviewed if they had an history of new onset of HF, chest pain, electrocardiographic changes indicating ischemia (ST depression or T wave inversion in at least two consecutive leads and a negative coronary angiogram [CA]) and did not require percutaneous coronary intervention or coronary artery bypass grafting. A 1:1 matched cohort (Group B) was adopted to validate the results. All patients had a negative CA. The majority of subjects in Group A had a higher left ventricular end diastolic pressure (LVEDP) when compared to the control group (p<0.05). Similarly, the aortic diastolic (AOD) pressure was lower in Group A than in Group B (p<0.05). In patients with elevated LVEDP and low AOD, with a coronary perfusion pressure (CPP) <20 mmHg, deep T wave inversion in two consecutive leads were more frequently observed. When the CPP was between 20-30 mmHg, a mild ST depression were more frequently recorded (p<0.05). Conversely, when the CPP was >30 mmHg, only mild non-specific ST-T changes or normal EKG were observed. In patients with HF and EKG changes suggestive of ischemia in at least two consecutive leads, a lower AOD could aggravate ischemia in patients with elevated left ventricular end diastolic pressure.

Analysis of 30 Spinal Angiograms Falsely Reported as Normal in 18 Patients with Subsequently Documented Spinal Vascular Malformations.

The early diagnosis of spinal vascular malformations suffers from the nonspecificity of their clinical and radiologic presentations. Spinal angiography requires a methodical approach to offer a high diagnostic yield. The prospect of false-negative studies is particularly distressing when addressing conditions with a narrow therapeutic window. The purpose of this study was to identify factors leading to missed findings or inadequate studies in patients with spinal vascular malformations. The clinical records, laboratory findings, and imaging features of 18 patients with spinal arteriovenous fistulas and at least 1 prior angiogram read as normal were reviewed. The clinical status was evaluated before and after treatment by using the Aminoff-Logue Disability Scale. Eighteen patients with 19 lesions underwent a total of 30 negative spinal angiograms. The lesions included 9 epidural arteriovenous fistulas, 8 dural arteriovenous fistulas, and 2 perimedullary arteriovenous fistulas. Seventeen patients underwent endovascular (11) or surgical (6) treatment, with a delay ranging between 1 week and 32 months; the Aminoff-Logue score improved in 13 (76.5%). The following factors were identified as the causes of the inadequate results: 1) lesion angiographically documented but not identified (55.6%); 2) region of interest not documented (29.6%); or 3) level investigated but injection technically inadequate (14.8%). All the angiograms falsely reported as normal were caused by correctible, operator-dependent factors. The nonrecognition of documented lesions was the most common cause of error. The potential for false-negative studies should be reduced by the adoption of rigorous technical and training standards and by second opinion reviews.

Management of Spontaneous Subarachnoid Hemorrhage Patients with Negative Initial Digital Subtraction Angiogram Findings: Conservative or Aggressive?

Background. The ideal management of SAH patients with negative initial DSA findings remains unresolved. Objective. (i) To present risk factors, clinical courses, and outcomes in different types of SAH patients with negative DSA findings; (ii) to explore the differences of basal vein between aSAH patients and NASAH patients; and (iii) to evaluate the value of repeated DSA for these patients. Methods. All SAH patients with negative initial DSA findings between 2013 and 2015 in our hospital were enrolled and were further categorized as perimesencephalic SAH (PMN-SAH) or nonperimesencephalic SAH (nPMN-SAH). Risk factors, clinical courses, outcomes, and the basal vein drainage patterns were compared. Results. A total of 137 patients were enrolled in the present study. The PMN-SAH group had better GOS and mRS values at 1-year follow-up. Moreover, the nPMN-SAH group had a higher rate of complications. The basal vein drainage pattern showed significant difference when comparing each of the NASAH subtypes with aSAH groups. There was a significant higher rate of a responsible aneurysm in nPMN-SAH group upon repeated DSA. Conclusions. SAH patients with negative initial DSA findings had benign clinical courses and outcomes. Repeated DSA studies are strongly advised for patients with the nPMN-SAH pattern.

Interventional Radiology: Interventions and Techniques in Trauma

The purpose of the review was to describe how interventional radiology procedure contribute in the management of the trauma patient, distinguish the situations where evidence has demonstrated improved outcomes with its use, acknowledge the limitations and controversies of the techniques and their place on management algorithms, and mention some particular situations where, despite lack of evidence, the procedures are commonly employed. CT seems to be a better indicator of significant vascular injury with the associated high risks when compared to a discordant negative conventional angiogram. Empiric embolization of the injured segments might improve outcomes in these settings. Finding a subcapsular splenic hematoma in CT is an independent risk factor associated with high rates of NOM failure. Prophylactic interventions are recommended, even in low grade splenic injuries, when a subcapsular splenic hematoma is present. In liver trauma, the injured liver is more susceptible to ischemic injury from arterial embolization with subsequent infarct, biloma, and abscess formation. When needed, angio-embolization should be performed as selective as possible. Subsequent surveillance for ischemic liver injury complications should be instated and, if required, timely therapeutic interventions considered. The initial CT scan findings of “contrast blush” and high-grade solid organ injury are some of the best early predictors for failure of the non-operative management (NOM) in the trauma patient. Endovascular interventions improve the outcomes of NOM when clinical or imaging findings indicate a high risk for continued or delayed hemorrhage. Angio-embolization improves the outcomes of unstable hemorrhagic pelvic fractures and is useful as complement of damage control surgeries or when the surgical interventions fail to control vascular injuries.

Risk of pulmonary embolism after a prior negative CT pulmonary angiogram

ContextWith increasing utilization of computed tomography pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE), many patients undergo repeat CTs. ObjectiveThe aim of this study is to identify the rate of positive subsequent CTPAs after an initial negative CTPA and whether there is a risk-free period after a negative CTPA. MethodsWe evaluated 318 patients with at least 1 subsequent CTPA after an initial negative CTPA, with 786 total CTPAs. We also evaluated a control group of 200 unselected CTPAs. ResultsThe positive rate in the repeat group was 7% at the first repeat CTPA and 10% per-patient within 1000 days. The positive rate in the control group was 9% (P= not significant). No risk-free period was seen, with a positive rate of 5% within 2 weeks after a negative CTPA. The number of prior negative CTPAs showed a trend towards decreasing rate of the subsequent CTPA being positive, but this did not meet statistical significance. DiscussionThere is no risk-free period after an initial negative CTPA, and therefore, patients with clinical suspicion of PE should be rescanned even after a recent negative study. Even patients with multiple negative prior CTPAs have a measurable risk of subsequent PE. Established clinical prediction scoring systems must be used to triage the patients who need CTPAs.