Postprocedural Magnetic Resonance Imaging Research Articles

Percutaneous Sclerotherapy of Large Venous Malformations Using Consecutive Polidocanol and Bleomycin Foam: MR Imaging Volumetric and Quality-of-Life Assessment

PurposeTo retrospectively evaluate sclerotherapy using consecutive polidocanol and bleomycin foam (CPBF) for large untreated venous malformations (VMs) and/or those resistant to prior treatment. Materials and MethodsThis retrospective study included all patients treated with CPBF for untreated VMs larger than 10 mL and/or refractory to treatment between May 2016 and October 2019. Baseline and follow-up VM volumes were measured on fat-suppressed T2-weighted magnetic resonance (MR) imaging. Outcome was evaluated on postprocedural MR imaging volumetry and by a retrospective survey assessing clinical response and adverse events. Imaging response was considered good for volume reduction from 50% to 70% and excellent for volume reduction ≥70%. Symptoms and quality-of-life (QoL) scores were compared before and after CPBF sclerotherapy. ResultsForty-five patients (mean age, 16 years; range, 1–63 years; 25 males) with 57 VMs were analyzed and treated by 80 sclerotherapy. Sixty percent (27 of 45) of patients had undergone prior treatment for VM. Median VM volume was 36.7 mL (interquartile range, 84 mL) on pretherapy MR imaging. Good and excellent results after the last sclerotherapy were achieved in 36% (16 of 45) and 29% (13 of 45) of patients, respectively, corresponding to a decrease of >50% in 60% (34 of 57) of VMs. QoL score increased by at least 3 points, regardless of initial symptoms. Most patients did not desire additional sclerotherapy owing to near complete symptomatic relief, even for patients who did not achieve a good response. Swelling, pain, and motor impairment scores significantly improved after CPBF. Adverse events included fever (44%, 15 of 34) and nausea/vomiting (29%, 10 of 34). ConclusionsCPBF sclerotherapy represents an effective therapy for large and/or refractory VMs with minimal adverse events.

Transuterine Ultrasound-Guided Fetal Embolization of Vein of Galen Malformation, Eliminating Postnatal Pathophysiology.

Transuterine Ultrasound-Guided Fetal Embolization of Vein of Galen Malformation, Eliminating Postnatal Pathophysiology.

Uterine leiomyomas embolization with magnetic resonance imaging follow up

Introduction: Uterine artery embolization (UAE) has been used to treat symptomatic uterine leiomyomas, as women choose to preserve their uterus, uterus sparing techniques such as UAE have been developed. Magnetic resonance imaging (MRI) sequence signal characteristics and the degree of leiomyoma enhancement may be used to predict the response of leiomyoma to UAE. Objective: to investigate role of UAE in different uterine myomas with follow up by MRI. Materials and methods: This prospective observational study was included 40 females with clinical criteria of symptomatic fibroid who weren’t suitable or refuse the other modalities of treatment and underwent UAE. All patients were undergone pre-procedure pelvic ultrasound and pelvic MRI, and post-procedure pelvic MRI. Results: There was a significant decrease in the uterine volume post embolization in all patients with infarction more than 50% occurred in 38 (95%) patients. Bleeding and anemia in patients who had improved were significantly higher than those who were unchanged/recurrent (P value <0.05). Post embolization syndrome occurred in 10 patients (25%), only one patient (2.5%) had puncture site hematoma, two patients (5%) complained with pelvic infection and re-bleeding occurred in 5 (12.55%) patients.

Efficacy and Outcome of Embolization of Intracranial Meningiomas With Minimal Resources

Preoperative embolization of intracranial meningiomas is an accepted treatment modality and offers many advantages for subsequent surgery. It has also been used as a primary therapy without subsequent surgery in selected cases. In this study, the authors share their experience of this procedure with minimal resources carried out in cases where definitive surgery was not advisable. This is a prospective study of 6 cases of meningiomas treated over a period of 11 months (November 2020 to September 2021). None of the cases were fit for prolonged surgery under general anesthesia and also had certain comorbid conditions. Embolization was done in a setup with limited resources without a fully equipped catheterization lab. Post-procedure magnetic resonance imaging (MRI) was done within 48 hours of the procedure. Follow-up was done in the outpatient department. There was complete disappearance of tumor blush in all the 6 cases. Immediate post-procedure MRI revealed significant necrosis of the tumor cavity. Three cases succumbed to their primary comorbid conditions and in the other cases follow-up was uneventful. Following embolization, clinical improvement of presenting symptoms was seen in all 6 cases. In resource-restricted settings, by introducing such innovative methods it is possible to perform selected endovascular procedures. Embolization can be used as a primary treatment modality avoiding subsequent surgery in selected cases with a good outcome.

Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery

The therapeutic efficacy of percutaneous transluminal angioplasty and stenting (PTAS) of post-irradiated stenosis of subclavian artery (PISSA) was not well clarified. This retrospective study was designed to evaluate the technical safety and outcome of the patients of severe symptomatic PISSA accepted PTAS. Between 2000 and 2019, 16 cases with 17 lesions of symptomatic and medically refractory PISSA accepted PTAS were included. We evaluated their technical success, peri-procedural complications and diffusion-weight imaging (DWI) of brain magnetic resonance imaging (MRI), results of symptom relief, and long-term stent patency. The stenosis of the 17 stenotic lesions were 81.2±11.1%. The most common symptom of the 16 patients was dizziness (14/16, 87.5%). All successfully accepted PTAS without neurological complication and had symptom relief after PTAS (17/17, 100%). Of the 12 patients accepted pre-procedural and early post-procedural MRI follow-up, 2 patients had an asymptomatic tiny acute embolic infarct in the territory of vertebrobasilar system. In a 51.9±54.9 months follow-up, all patients had no severe restenosis and no recurrent vertebrobasilar ischemic symptoms. For patients with PISSA and medically refractory ischemic symptoms, PTAS can be an effective alternative management.

Endovascular management of symptomatic stenosis of supra-aortic arteries in patients with Takayasu arteritis.

Endovascular management is used to treat Takayasu arteritis (TA) involving the supra-aortic branches. However, the long-term outcome of this treatment remains unclear. Here, technical safety, outcomes, and restenosis management of supra-aortic arteries in TA patients receiving endovascular treatment were evaluated. TA patients with symptomatic supra-aortic stenosis who underwent percutaneous angioplasty and stenting between 2008 and 2018 at our institute were enrolled in this study. Pre- and post-procedural magnetic resonance imaging (MRI) evaluations, including high-resolution vessel wall imaging (HR-VWI), were performed. Technical efficacy, peri-procedural complications, early post-procedural MRI results, and stent patency were examined. All six patients successfully received stent placement or percutaneous transluminal angioplasty in a total of 22 treated arteries without neurologic complications. During follow-up (mean, 56.3 ± 41.1 months), no recurrent stroke occurred, yet significant restenosis developed in 12 of 22 (54.5%) of the treated arteries. Three of the patients underwent HR-VWI before surgery. Concentric wall thickening and enhancement of the left common carotid artery was detected in one patient, indicating acute inflammation. Angioplasty with drug-eluting balloon (DEB) successfully treated a case of refractory restenosis. Among 10 early post-procedure MRI performed, only two asymptomatic new lesions were detected with diffusion-weighted imaging. Endovascular treatment of supra-aortic arteries of TA patients was safe and effective, yet was associated with a high restenosis rate. Thus, close follow-up is needed. HR-VWI is helpful for pre-procedural selection of patients for percutaneous angioplasty and stenting and drug-eluting balloon angioplasty appears to be a promising treatment for refractory in-stent restenosis.

Silent cerebral embolisation during TAVI: evolution, predictors and neurocognitive effects

Abstract Background Most patients undergoing transcatheter aortic valve implantation (TAVI) develop silent cerebral ischemic lesions (SCIL) detectable at magnetic resonance imaging (MRI). The natural history and clinical relevance of SCIL are not well established. We aimed to assess the characteristics, predictors, evolution, and neurocognitive effects of SCIL. Methods Cerebral MRI was performed within 7 days before TAVI to assess baseline status and age-related white matter changes (ARWMC) score. MRI was repeated postoperatively to assess the occurrence, location, number and dimensions of SCIL. Patients developing SCIL underwent a third MRI at 3–5 months follow-up. A neurocognitive evaluation was performed before TAVI, at discharge and at 3-month follow-up. Results Of the 117 patients enrolled, 96 underwent a postprocedural MRI; SCIL were observed in 76% of patients, distributed in all vascular territories, with a median number of 2 lesions, median diameter 4.5 mm, and median total volume 140 mm3. Independent predictors of SCIL occurrence were a higher baseline ARWMC score and the use of self-expanding or mechanically-expanded bioprostheses. Among 47 patients who underwent follow-up MRI, only 26.7% of postprocedural SCIL evolved into a gliotic scar. SCIL occurrence was associated with a more pronounced transient neurocognitive decline early after TAVI and with a lower recovery at follow-up. Conclusions SCIL occur in the vast majority of patients undergoing TAVR and are predicted by a more diffuse white matter damage at baseline and by the use of non-balloon-expandable prostheses. Although most SCIL disappear within months, their occurrence has a limited but significant impact on neurocognitive function. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): unrestricted grants from Edwards Lifesciences SA, Nyon, Switzerland, and from Medtronic Italia SpA, Milan, Italy

Impact of Magnetic Resonance Imaging (MRI) Findings on Management of Symptomatic Patients Following Radiofrequency Ablation (RFA) of Osteoid Osteoma (OO)

The purpose of this study is to assess the impact of MRI findings on management of symptomatic patients following RFA of OO. Retrospective review of 43 patients with RFA for OO between June 2010 and June 2017 was performed. Patient, nidus, and ablation data were reviewed. Pre- and 6–8 weeks post-procedural MRI (n = 32) were compared for coverage of nidus by ablation zone, bone marrow edema, nidus hyperintensity, and other findings. Baseline pain levels and analgesic use were compared with post-procedural follow-up visit at 6–8 weeks. Three groups of clinical and MRI outcomes of complete (CR), partial (PR), and no response (NR) were defined. A weighted kappa statistic was used to assess for agreement. Clinical responses were CR in 34/43 (79.1%, 95% CI: 64.0–90.0%), PR in 8/43 (18.6%), and NR in 1/43 (2.3%) patients. All 19/32 patients with MRI CR experienced clinical CR. One patient with MRI NR had clinical NR. All 7/32 patients with clinical PR had MRI PR. All 4/43 complications were in MRI PR or NR groups. Substantial agreement was observed between MRI and clinical outcomes (kappa: 0.69, 95% CI: 0.45–0.95). MRI helped determine etiologies in all symptomatic patients and their management (n = 8). MRI is recommended for symptomatic patients after ablation.

Predicting outcomes after acute reperfusion therapy for basilar artery occlusion.

Basilar artery occlusion (BAO) leads to high rates of morbidity and mortality, despite successful recanalization. The discordance between flow restoration and long-term functional status clouds clinical decision-making regarding further aggressive care. We sought to develop and validate a practical, prognostic tool for the prediction of 3-month favorable outcome after acute reperfusion therapy for BAO. This retrospective, multicenter, observational study was conducted at four high-volume stroke centers in the USA and Europe. Multivariate regression analysis was performed to identify predictors of favorable outcome (90-day modified Rankin scale scores 0-2) and derive a clinically applicable prognostic model (the Pittsburgh Outcomes after Stroke Thrombectomy-Vertebrobasilar (POST-VB) score). The POST-VB score was evaluated and internally validated with regard to calibration and discriminatory ability. External validity was assessed in patient cohorts at three separate centers. In the derivation cohort of 59 patients, independent predictors of favorable outcome included smaller brainstem infarct volume on post-procedure magnetic resonance imaging (P<0.01) and younger age (P=0.01). POST-VB score was calculated as: age+(10×brainstem infarct volume). POST-VB score demonstrated excellent discriminatory ability [area under the receiver-operating characteristic curve (AUC)=0.91] and adequate calibration (P=0.88) in the derivation cohort (Center A). It performed equally well across the three external validation cohorts (Center B, AUC=0.89; Center C, AUC=0.78; Center D, AUC=0.80). Overall, a POST-VB score<49 was associated with an 88% likelihood of favorable outcome, as compared to 4% with a score≥125. The POST-VB score effectively predicts 3-month functional outcome following acute reperfusion therapy for BAO and may aid in guiding post-procedural care.

P472Cerebral thromboembolic risk in atrial fibrillation ablation: a direct comparison of vitamin K antagonists versus non-vitamin K-dependent oral anticoagulants

Abstract Aims Cerebral thromboembolic events are well-known complications of pulmonary vein isolation (PVI) and can manifest as stroke or silent cerebral embolic lesions. Over the last years, the preferred oral anticoagulation in atrial fibrillation (AF) shifted from vitamin K antagonists (VKA) to non-vitamin K-dependent oral anticoagulants (NOAC). The aim of this study was to compare the incidence of cerebral embolic lesions after AF ablation in patients on VKA versus patients on NOAC, and to identify corresponding clinical and procedural risk factors. Methods A total of 421 patients undergoing PVI (by radiofrequency catheter or cryoballoon) were prospectively included into the study. Of these, 43.7% were on VKA and 56.3% on NOAC treatment. In the NOAC group 38% of patients had an interruption of anticoagulation for 24-36 hours. All patients underwent pre- and postprocedural cerebral magnetic resonance imaging. Results Periprocedural cerebral lesions occurred in 13.1% overall. Of these, three (0.7%) resulted in symptomatic cerebrovascular accidents. Incidence of cerebral lesions was significantly higher in patients on NOAC compared to VKA (16% vs. 9.2% respectively, p = 0.04), as well as in patients that had intraprocedural cardioversions compared to no cardivoersions (19.5% vs. 10.4% respectively, p = 0.03). In multivariate analysis both parameters were found to be independent risk factors for cerebral embolism. No significant difference between interrupted and uninterrupted NOAC administration could be detected. Conclusions In patients undergoing AF ablation, we identified the use of NOAC and intraprocedural cardioversion as independent risk factors for the occurrence of periprocedural cerebral embolic lesions. Abstract Figure. Incidence of cerebral embolic lesions

P564Silent cerebral ischemic lesions after left-sided ablation for paroxysmal supraventricular tachycardia

Abstract Pulmonary vein isolation is associated with silent cerebral ischemic lesions detected by diffusion-weighted magnetic resonance imaging (MRI), with an incidence between 1% and 40%. Recent studies have shown that these cerebral lesions can occur after radiofrequency ablation for left ventricular extrasystole. Risk of these lesions in conventional ablation has not been evaluated. Aim of this study was to investigate silent cerebral ischemic lesions following left-sided conventional ablation. In a prospective study 296 consecutive patients scheduled for paroxysmal supraventricular tachycardia (PSVT) ablation were screened, and 26 patients meeting study criteria were enrolled. Patients were excluded for age under 18 years or over 80 years, clinically significant neurovascular or valvular disease, proven left atrial thrombus, thrombophilia, previous pacemaker or ICD implantation, documented paroxysmal atrial fibrillation, or any contraindication to MRI. Participants underwent cerebral MRI 24 hours prior and after the ablation, in case of new ischemic lesions a repeated MRI was planned within 3-6 months. Two sequences were used, a 3D T2-weighted fluid-attenuated inversion recovery (FLAIR) and an axial diffusion-weighted (DW) sequence. By definition acute lesions appear as hyperintensities on the postprocedural diffusion-weighted images which correlate with the hypointense signals on the apparent diffusion map and can not be detected on the preprocedural images. Patients were planned to be divided into three groups patients with and without silent cerebral ischemic lesions who underwent left-sided ablation, and a control group undergoing only right-sided ablation. Groups were compared based on clinical and procedural characteristics. The mean age was 43.9 ± 17.3 years, 42% (n = 11) were men, 35% (n = 9) had a history of hypertension. In all groups radiofrequency energy was used and the ablation was performed with a 4 mm tip non-irrigated catheter. In case of a left-sided procedure left atrium was approached by transseptal puncture controlled by intracardiac echocardiography. Before the transseptal puncture intravenous heparin was administered. Activated clotting time was aimed to be 200-300 seconds. None of the postprocedural MRI in the left-sided or the right-sided group revealed any evidence of new cerebral ischemic lesions. Mean procedural time of left-sided ablations was 176.9 ± 74.7 minutes which was significantly longer (p = 0.0077) compared to the right-sided procedures with 132 ± 72.2 minutes total time. Mean left atrial procedural time was 69.1 ± 7.8 minutes, average ACT was 265 ± 28.2 seconds. No silent ischemic cerebral lesions were detected by MRI after catheter ablation of left-sided PSVT substrate in comparison with the historical population undergoing ablation for atrial fibrillation or ventricular extrasystole. Presumably, cerebral lesions occur at a lower rate or might not appear at all after these less complex procedures.

Evolution, Predictors, and Neurocognitive Effects of Silent Cerebral Embolism During Transcatheter Aortic Valve Replacement

ObjectivesThe aim of this study was to assess the characteristics, predictors, evolution, and neurocognitive effects of silent cerebral ischemic lesions (SCILs). BackgroundMost patients undergoing transcatheter aortic valve replacement (TAVR) develop SCILs detectable on magnetic resonance imaging (MRI). The natural history and clinical relevance of SCILs are not well established. MethodsCerebral MRI was performed within 7 days before TAVR to assess baseline status and age-related white matter change score. MRI was repeated post-operatively to assess the occurrence, location, number, and dimensions of SCILs. Patients developing SCILs underwent a third MRI examination at 3- to 5-month follow-up. A neurocognitive evaluation was performed before TAVR, at discharge, and at 3-month follow-up. ResultsOf the 117 patients enrolled, 96 underwent post-procedural MRI; SCILs were observed in 76% of patients, distributed in all vascular territories, with a median number of 2 lesions, a median diameter of 4.5 mm, and a median total volume of 140 mm3. Independent predictors of SCIL occurrence were higher baseline age-related white matter change score and the use of self-expanding or mechanically expanded bioprostheses. Among 47 patients who underwent follow-up MRI, only 26.7% of post-procedural SCILs evolved into gliotic scar. SCIL occurrence was associated with a more pronounced transient neurocognitive decline early after TAVR and with lower recovery at follow-up. ConclusionsSCILs occur in the vast majority of patients undergoing TAVR and are predicted by more diffuse white matter damage at baseline and by the use of non-balloon-expandable prostheses. Although most SCILs disappear within months, their occurrence has a limited but significant impact on neurocognitive function.

Interim results of bleomycin-polidocanol foam sclerotherapy as a highly efficient technique for venous malformations

ObjectiveThe objective of this study was to retrospectively review the clinical and radiographic outcomes of patients with venous malformations (VMs) treated with bleomycin-polidocanol foam (BPF) sclerotherapy. MethodsThe Institutional Review Board waived ethical approval for this retrospective review in which 55 patients (31 female and 24 male patients; mean age, 18.8 years; range, 2-60 years) were treated with BPF sclerotherapy. The stability (half-life) of BPF compared with polidocanol foam was studied. Standard sclerotherapy techniques were used. A total of 111 sclerotherapy sessions were performed, with a mean of 2.0 treatments per patient (range, 1-6). An average of 10 mL of BPF was used per procedure, with the total amount ranging from 2.5 to 30 mL. Symptoms before and after treatment, follow-up time, complications, and volume reduction on magnetic resonance imaging were recorded. ResultsThe median half-lives of the BPF and polidocanol foam were 238.25 ± 3.86 seconds and 194.33 ± 3.5 seconds, respectively. A t-test indicated significant differences between the groups (P < .01). The mean follow-up was 14 months (range, 6-24 months). All 55 patients (100%) reported improvement in symptoms. The total excellent and good response rate was 94.6%. An excellent response was achieved in 32 cases (58.2% [32/55]), a good response in 20 cases (36.4% [20/55]), and a poor response in 3 cases (5.4% [3/55]). Postprocedural magnetic resonance imaging demonstrated volume reduction of treated lesions in 54 of 55 patients (98%), with a mean lesion volume reduction of 84.6%. Postprocedure complications were minor in 13 of 111 procedures (12%) that were performed on 10 of 55 patients (18.2%), and no major complications occurred. ConclusionsBPF sclerotherapy of VMs is safe and effective. BPF sclerotherapy can be a promising first-line treatment of VMs.

Magnetic Resonance Imaging Assessment After Therapy in Prostate Cancer

Prostate cancer is the fifth leading cause of death worldwide. A variety of treatment options is available for localized prostate cancer and may range from active surveillance to focal therapy or whole gland treatment, that is, surgery or radiotherapy. Serum prostate-specific antigen levels are an important tool to monitor treatment success after whole gland treatment, unfortunately prostate-specific antigen is unreliable after focal therapy. Multiparametric magnetic resonance imaging of the prostate is rapidly gaining field in the management of prostate cancer and may play a crucial role in the evaluation of recurrent prostate cancer. This article will focus on postprocedural magnetic resonance imaging after different forms of local therapy in patients with prostate cancer.

Endoscope-Assisted Minimally Invasive Interlaminar Lumbar Decompression for Spinal Stenosis

Background: Lumbar stenosis is characterized by a narrowing of the spinal canal in association with progressive degenerative changes in the lumbar spine and surrounding structures, including hypertrophy of the ligamentum flavum (LF). Objectives: The aim of this study was to examine the usefulness of endoscope-assisted interlaminar lumbar decompression (EILD) for patients with lumbar stenosis and hypertrophy of the LF. Study Design: Retrospective study. Setting: Department of Anesthesiology and Pain Medicine, Neurosurgery at Wooridul Spine Hospital. Methods: A total of 51 patients were enrolled in this study. Outcomes were evaluated at baseline and at 2 weeks and 6 months postprocedure via the Numeric Rating Scale, Oswestry Disability Index (ODI), and Zurich Claudication Questionnaire (ZCQ). Results: Mean posttreatment pain scores at 2 weeks and 6 months were significantly lower, and ODI scores were significantly decreased compared with baseline. ZCQ scores were also significantly decreased compared with pretreatment surveys. Two patients required reoperation within one month. At postprocedure 6 months, a ≥ 50% reduction in pain score was recorded in 26 (80%) of 51 patients, and there was ≥ 40% reduction in ODI score in 82% of patients. No serious complications including epidural bleeding, dural or neural injuries, or infection were recorded. Limitations: This study lacked secondary outcome substantiation. In addition, the follow-up period was short (&lt; 6 months), and no patients had postprocedure magnetic resonance imaging. The number of patients was also small. Conclusions: EILD provided good outcomes and may be a reasonable treatment option for carefully selected patients with hypertrophy of the LF.

The Dark Side of Gadolinium: A Study of Arthrographic Contrast at Extreme Concentrations.

Magnetic resonance arthrography is used to optimally image the detailed intraarticular anatomy of the joint space. A common iatrogenic complication of arthrography is the extra-articular injection of the gadolinium solution in the periarticular tissues; however, a less common complication involves the abnormal concentration of gadolinium within the prepared injectate. The following describes the inadvertent injection of a hyper-concentrated intraarticular solution of gadolinium and the subsequent appearance that resulted in the post-procedure magnetic resonance imaging examination. In addition, an in-vitro experiment was performed to determine the exact etiology of the abnormal magnetic resonance imaging findings that resulted in this case. The subsequent discussion revisits the signal intensity of gadolinium at extreme concentration ranges and proposes modifications of procedure protocol to mitigate the chance of a repeat event.

Addition of Iodinated Contrast to Rectal Hydrogel Spacer to Facilitate MRI-Independent Target Delineation and Treatment Planning for Prostate Cancer

PurposeHydrogel spacers reduce rectal dose toxicity during prostate cancer radiation therapy. Current products require magnetic resonance imaging (MRI) for visualization during treatment planning, but MRI incompatibility and cost have prompted alternatives using computed tomography (CT). This case series evaluates the addition of iodinated contrast to hydrogel as such an alternative. Methods and materialsThree patients underwent rectal hydrogel spacer placement with iodinated contrast modification. CT was performed within 1 hour of injection and again 1 week later. MRI was obtained at the time of the second CT. Hydrogel delineation was compared between CT and MRI and between paired CT scans. ResultsSpacer enhancement was visible on CT immediately after hydrogel placement (mean Hounsfield units, 122; range, 52-193) but not at the second CT 1 week later (mean Hounsfield units, 8; range, −8 to 29). Delineated spacer volume did not significantly differ between immediate postprocedure CT and MRI ≥1 week later in 2 patients (patient 1: 16.6 vs 15.5 cm3; patient 2: 12.6 vs 14.7 cm3; paired t-test, P = .81). ConclusionsCT visualization of rectal hydrogel admixed with contrast is feasible and allows delineation of interface with rectum/prostate.

Silent cerebral lesions and cognitive function after pulmonary vein isolation with an irrigated gold-tip catheter: REDUCE-TE Pilot study.

IntroductionStroke is one of the most feared complications during catheter ablation of atrial fibrillation (AF). While symptomatic thromboembolic events are rare, magnetic resonance imaging (MRI) may identify asymptomatic (ie, silent) cerebral lesions (SCLs) following pulmonary vein isolation (PVI) procedures.Methods and ResultsThe REDUCE‐TE Pilot was a prospective multicenter, single‐arm observational study investigating the incidence of SCL in patients with symptomatic paroxysmal AF undergoing PVI with a novel gold‐tip, externally irrigated ablation catheter. After ablation, cerebral diffusion‐weighted MRI and a postablation follow‐up were performed at 1 to 3 days after the ablation procedure. A neurocognitive test was done before and after ablation. The primary study endpoint was the occurrence of one or more new SCLs. Secondary study endpoints included neurocognitive status, procedural success rate, and periprocedural complications including symptomatic thromboembolic events. A total of 104 patients were enrolled (69% male, mean age: 61.5 ± 9.7 years, mean CHA2DS 2‐VASc score: 1.7 ± 1.2). Postprocedural MRI examination was performed in 97 patients, and in nine of them (9.3%; 95% CI: 4.3‐16.9%) a total of 11 SCLs were detected. Univariate analyses did not reveal any significant predictor for new SCLs. Nonsignificant trends were observed for low activated clotting time during ablation and for international normalized ratio value outside the range of 2 to 3 at ablation. There was no evidence of significant deterioration of neurocognitive function after PVI. In four patients, a pericardial tamponade was noted but all patients fully recovered during follow‐up.ConclusionsAblation of AF using a novel gold‐tip, externally irrigated ablation catheter, resulted in SCLs in approximately one out of 10 patients without a measurable effect on neurocognitive function.

Leptomeningeal Enhancement Is Associated with Transient Neurologic Deficits after Flow Diversion of Intracranial Aneurysms

To evaluate the relationship between blood-brain barrier disruption and transient neurologic deficits (TNDs) after neuroendovascular interventions (NEIs) using postcontrast T2/FLAIR (pcFLAIR) imaging. This is a prospective study of 41 consecutive patients undergoing flow diversion therapy for unruptured aneurysm treatment. Patients underwent postprocedural magnetic resonance imaging within 24 hours of the procedure, including diffusion-weighted imaging (DWI) and pcFLAIR sequences. Regression analyses were performed to identify risk factors for developing TNDs. In total, 13 patients (31.7%) developed neurologic complications ranging from visual field defects to dense hemiplegia. All deficits were transient, resolving spontaneously within 72 hours. Five of 13 patients (38.5%) with TNDs had presence of lesions on DWI whereas the remaining 8 patients (61.5%) did not. In contrast, all patients who developed TNDs had leptomeningeal enhancement on pcFLAIR imaging, and no patient with normal pcFLAIR imaging developed TNDs. Regression analysis revealed the extent of pcFLAIR enhancement is associated with development of postprocedure neurologic deficits (P < 0.0001). Video electroencephalography monitoring was performed in 4 symptomatic patients manifesting severe deficits. In all instances electroencephalography demonstrated ipsilateral hemispheric slowing and eventual resolution corresponding to ensuing clinical improvement. Only 1 of these 4 patients presented with a lesion on DWI. This study challenges conventional dogma that TNDs are ischemic in etiology and suggests blood-brain barrier impairment may be a potential alternative mechanism. These findings are applicable to stroke and other reversible neurologic diseases.

Abstract No. 671 Uterine artery embolization for pedunculated subserosal leiomyomas: is it still contraindicated?

To evaluate the safety and efficacy of uterine artery embolization (UAE) for pedunculated subserosal leiomyomas (PSLs). Of 1069 patients who underwent UAE for symptomatic leiomyomas or adenomyosis from 2007 to 2016, 55 patients (mean age, 40.3 ± 4.8 years) with 66 PSLs (mean diameter, 6.61 ± 2.04 cm) were enrolled in this study. Each PSL was categorized into either of two groups: high-risk PSL (stalk diameter <25% of the diameter of leiomyoma) and low-risk PSL (stalk diameter 25–50% of the diameter of leiomyoma). Postprocedural magnetic resonance imaging was performed 3 months after UAE. The rates of infarction and volume reduction were compared between PSLs and non-PSL dominant leiomyomas and between high-risk and low-risk PSLs. Complications related to PSLs were assessed. At a median follow-up of 96 days (range, 36–348 days) after UAE, none of the patients (0%) had complications related to PSLs, even among high-risk cases. Mean volume reductions of 38.2% and 38.4% were achieved for PSLs and non-PSL dominant leiomyomas, respectively (P = 0.953). There were three (5.5%) minor adverse events but none were related to PSL. There was no significant difference in volume reduction and infarction rates between low-risk and high-risk PSLs UAE is safe and effective in patients with PSLs even for high-risk cases (stalk diameter <25% of the diameter of leiomyoma). PSL should not be considered a contraindication for UAE.