Postprocedural CT Research Articles

Pathological effects of lung radiofrequency ablation that contribute to pneumothorax, using a porcine model

Objectives: The incidence of pneumothorax is 7 times higher after lung radiofrequency ablation (RFA) than after lung biopsy. The reasons for such a difference have never been objectified. The histopathologic changes in lung tissue are well-studied and established for RF in the ablation zone. However, it has not been previously described what the nature of thermal injury might be along the shaft of the RF electrode as it traverses through normal lung tissue to reach the ablation zone. The purpose of this study was to determine the changes occurring around the RF needle along the pathway between the ablated zone and the pleura.Material and methods: In 3 anaesthetised and ventilated swine, 6 RFA procedures (right and left lungs) were performed using a 14-gauge unipolar multi-tined retractable 3 cm radiofrequency LeVeen probe with a coaxial introducer positioned under CT fluoroscopic guidance. In compliance with literature guidelines, we implemented a gradually increasing thermo-ablation protocol using a RF generator. Helical CT images were acquired pre- and post-RFA procedure to detect and evaluate pneumothorax. Four percutaneous 19-gauge lung biopsies were also performed on the fourth swine under CT guidance. Swine were sacrificed for lung ex vivo examinations, scanning electron microscopy (SEM) and pathological analysis.Results: Three severe (over 50 ml) pneumothorax were detected after RFA. In each one of them, pathological examination revealed a fistulous tract between ablation zone and pleura. No fistulous tract was observed after biopsies.In the 3 cases of severe pneumothorax, the tract was wide open and clearly visible on post procedure CT images and SEM examinations. The RFA tract differed from the needle biopsy tract. The histological changes that are usually found in the ablated zone were observed in the RFA tract’s wall and were related to thermal lesions. These modifications caused the creation of a coagulated pulmonary parenchyma rim between the thermo-ablation zone and the pleural space. The structural properties of the damage can explain why the RFA tract is remains patent after needle withdrawal.Conclusion: Our study demonstrates for the first time that the changes around the RF needle are the same as in the ablated zone. The damage could create fistulous tracts along the needle path between thermo-ablation zone and pleural space. These fistulas could certainly be responsible for severe pneumothorax that occurs in many patients treated with lung RFA.

Value of Nonrigid Registration of Pre-Procedure MR with Post-Procedure CT After Radiofrequency Ablation for Hepatocellular Carcinoma.

To evaluate the value of pre-radiofrequency ablation (RFA) MR and post-RFA CT registration for the assessment of the therapeutic response of hepatocellular carcinoma (HCC). A total of 178 patients with single HCC who received RFA as an initial treatment and had available pre-RFA MR and post-RFA CT images were included in this retrospective study. Two independent readers (one experienced radiologist, one inexperienced radiologist) scored the ablative margin (AM) of treated tumors on a four-point scale (1, residual tumor; 2, incomplete AM; 3, borderline AM; 4, sufficient AM), in two separate sessions: (1) visual comparison between pre-and post-RFA images; (2) with addition of nonrigid registration for pre- and post-RFA images. Local tumor progression (LTP) rates between low-risk (response score, 3-4) and high-risk groups (1-2) were analyzed using the Kaplan-Meier method at each interpretation session. The patients' reassignments after using the registered images were statistically significant for inexperienced reader (p<0.001). In the inexperienced reader, LTP rates of low- and high-risk groups were significantly different with addition of registered images (session 2) (p<0.001), but not significantly different in session 1 (p=0.101). However, in the experienced reader, LTP rates of low- and high-risk groups were significantly different in both interpretation sessions (p<0.001). Using the registered images, the cumulative incidence of LTP at 2 years was 3.0-6.6%, for the low-risk group, and 18.6-27.8% for the high-risk group. Registration between pre-RFA MR and post-RFA CT images may allow better assessment of the therapeutic response of HCC after RFA, especially for inexperienced radiologists, helping in the risk stratification for LTP.

Hemorrhagic Complications Associated with Ventriculostomy in Patients Undergoing Endovascular Treatment for Intracranial Aneurysms: A Single-Center Experience.

Currently, a complete understanding of post-ventriculostomy hemorrhagic complications in subarachnoid hemorrhage due to ruptured aneurysms remains unknown. The present study evaluates the impact of periprocedural risk factors on rates of external ventricular drain (EVD)-associated hemorrhage in the setting of endovascular treatment of intracranial aneurysms. A retrospective chart review of 107 patients who underwent EVD placement within 24h of endovascular coiling was performed. CT of head without contrast was obtained after drain placement and before endovascular treatment. Post-procedural CT was also obtained within 48h of embolization and was reviewed for new/worsened track hemorrhages. Chi-squared test was used in evaluation. Ninety-three of the 107 patients reviewed met the inclusion criteria. Four (25%) of the 16 patients on antiplatelet medications at presentation experienced post-EVD hemorrhage compared to 11 (14.3%) of 77 that were not (p=0.29). Of the 13 patients given intraprocedural antiplatelets, 3 (23.1%) demonstrated hemorrhage compared to 12 (15%) of 80 not administered these medications (p=0.46). Further, of 36 patients with intraprocedural anticoagulation, 6 (16.7%) exhibited hemorrhage compared to 9 (15.8%) of 57 in those without (p=0.91). In 17 patients who received DVT prophylaxis, 2 (11.8%) exhibited hemorrhage compared to 13 (17.1%) of 76 who did not (p=0.59). No post-EVD hemorrhage had attributable neurologic morbidity. Our results, demonstrating no significant risk factor related to EVD-associated hemorrhage rates, support the safety of EVD placement in the peri-endovascular treatment period.

CT-Guided, Ethanol Sympatholysis for Primary Axillary-Palmar Hyperhidrosis.

Primary hyperhidrosis is an excessive sweating due to an overactive sympathetic system. Our objective was to test the feasibility and provide early data on the safety/efficacy of CT-guided sympatholysis, for primary hyperhidrosis. Nine consecutive patients with axillary-palmar hyperhidrosis were treated between 2013 and 2015. CT-guided sympathetic block was performed in the outpatients at T-2, T-3, and T-4, bilaterally using alcohol under local anesthesia. Immediate postprocedure CT was obtained to assess the complications as per Common Terminology Criteria for Adverse Events, version 4. Technical success and clinical success were recorded. Primary and secondary efficacy were assessed by phone and clinical visits; mean follow-up was 12months (6-26months). Descriptive statistics was used to report the outcomes. One procedure was aborted due to eyelid ptosis after lidocaine injection. All other eight patients (5:3, F:M) (median age 32) had immediate cessation of sweating. Two major complications (pneumothorax, one requiring a chest tube) occurred. Two patients recurred with unilateral and one with bilateral symptoms. One of the unilateral recurrence and the bilateral recurrence patients was retreated successfully. Median follow-up was 1year. No cases of Horner's or compensatory hyperhidrosis were observed. CT-guided EtOH sympatholysis for axillary/palmar primary hyperhidrosis is feasible. Technical failure rate was 11%. Primary and secondary efficacy are 75 and 94%, respectively, to a median follow-up of 1 year. Risk profile appears favorable. Despite a small sample size, results confirm feasibility and encourage a larger study.

Use of 3D CT-based navigation in minimally invasive lateral lumbar interbody fusion.

OBJECTIVE Lateral lumbar interbody fusion (LLIF) is an increasingly popular technique used to treat degenerative lumbar disease. The technique of using an intraoperative cone-beam CT (iCBCT) and an image-guided navigation system (IGNS) for LLIF cage placement has been previously described. However, other than a small feasibility study, there has been no clinical study evaluating its accuracy or safety. Therefore, the purpose of this study was to evaluate the accuracy and safety of image-guided spinal navigation in LLIF. METHODS An analysis of a prospectively acquired database was performed. Thirty-one consecutive patients were identified. Accuracy was initially determined by comparison of the planned trajectory of the IGNS with post-cage placement intraoperative fluoroscopy. Accuracy was subsequently confirmed by postprocedural CT and/or radiography. Cage placement was graded based on a previously described system separating the disc space into quarters. RESULTS The mean patient age was 63.9 years. A total of 66 spinal levels were treated, with a mean of 2.1 levels (range 1-4) treated per patient. Cage placement was noted to be accurate using IGNS in each case, as confirmed with intraoperative fluoroscopy and postoperative imaging. Sixty-four (97%) cages were placed within Quarters 1 to 2 or 2 to 3, indicating placement of the cage in the anterior or middle portions of the disc space. There were no instances of misguidance by IGNS. There was 1 significant approach-related complication (psoas muscle abscess) that required intervention, and 8 patients with transient, mild thigh paresthesias or weakness. CONCLUSIONS LLIF can be safely and accurately performed utilizing iCBCT and IGNS. Accuracy is acceptable for multilevel procedures.

Is the rapid needle-out patient-rollover approach after CT-guided lung biopsy really effective for pneumothorax prevention?

Percutaneous CT-guided lung biopsy (PCLB) is a frequently performed procedure for sampling lung lesions. Pneumothorax is the most common complication of PCLB (range, 4-60%), requiring chest tube insertion in 0.2-8% procedures (1). Insertion of chest tube not only increases the procedure related morbidity, but also increases the hospital stay. Pneumothorax rates vary widely in different series depending on the technique, equipment used, size of lesions targeted and whether pneumothorax was defined on a chest X-ray or post procedure CT. High detection rate of pneumothorax on immediate post procedure CT scans are due to the high sensitivity of CT for detecting even very little pleural air.

Detection of Intraparenchymal Hemorrhage After Endovascular Therapy in Patients with Acute Ischemic Stroke Using Immediate Postprocedural Flat-Panel Computed Tomography Scan.

To assess the diagnostic value of parenchymal hyperdense lesions visualized on the flat-panel CT scan in detecting/excluding intraparenchymal hemorrhage (IPH) after the endovascular treatment of acute stroke patients. Two separate cohorts of acute ischemic stroke patients who underwent endovascular treatment were evaluated. In the first group, patients were evaluated for hyperdense parenchymal lesions immediately after the treatment with flat-panel CT scan; whereas, in the second group, patients underwent multidetector CT scan post procedure. IPH was defined as hyperdensity that persisted for >24 hours on follow up CT scan. A total of 30 patients were evaluated with flat panel, and 135 with multidetector CT scan immediately after the endovascular treatment. Hyperdense lesions were visualized on 7/30 (23%) of those evaluated with flat-panel CT versus 74/135 (55%) of those evaluated with multidetector CT scan. Based on 24-hour follow up imaging, hyperdense parenchymal lesions on immediate postprocedural flat-panel or multidetector CT studies had 100% sensitivity and negative predictive value for IPH; whereas, the specificity, and positive predictive value of such lesions were 88% and, 57% on the flat panel; and 53% and, 27% on the multidetector CT study, respectively. The absence of hyperdense lesions on immediate postprocedural flat-panel CT scan of ischemic stroke patients can exclude IPH with a high sensitivity and negative predictive value. The hyperdense parenchymal lesions visualized on flat-panel versus multidetector CT studies may have comparable sensitivity and negative predictive value for the detection of IPH.

A novel minimally invasive technique for lumbar decompression, realignment, and navigated interbody fusion

We present a novel, minimally invasive, navigation-guided approach for surgical treatment of degenerative spondylolisthesis (DS) that is a hybrid of the two most common techniques, posterior interbody fusion (PLIF) and transforaminal interbody fusion (TLIF). DS is an acquired condition with intersegmental instability of one or more lumbar motion segments. Seven patients with single level lumbar DS underwent lumbar arthrodesis utilizing the hybrid technique (HLIF) in our center. Using a standard unilateral midline approach a decompression and partial facetectomy on one side was performed, allowing for implantation of a specially designed interbody cage. Pedicle screws were placed using neuronavigation in a vertical vector on the side of the partial facetectomy and dorsolaterally (percutaneous) on the contralateral side. Patient and operative data, numeric rating scale (NRS) pain scores, core outcome measures index (COMI) and Oswestry disability index (ODI) were recorded preoperatively as well as 6 weeks, 3months, 6months and 1year after surgery. All patients completed the 1year follow-up. There was significant postoperative improvement of NRS, COMI and ODI scores at all postoperative follow-up time points (p<0.05). The radiological assessments of realignment showed a reduction of listhesis from an average of 21.04% (standard deviation [SD] 5.1) preoperatively to 9.14% (SD 4.0) postoperatively (p<0.001). The average blood loss was 492ml. Post-procedure CT scans demonstrated correct implant placement in all but one patient who required a revision of a single pedicle screw. HLIF allows thorough decompression as well as realignment and interbody fusion for patients with DS and may help reduce tissue trauma in comparison to other minimally invasive lumbar fusion techniques.

Endovascular management of coarctation of the aorta in adult patients

BackgroundCoarctation is a congenital heart defect with an incidence of 5–8%, more frequent in boys; however, the overwhelming majority of patients undergo surgery earlier as pediatric patients. Currently, the treatment of choice in adolescents and adults is endovascular management. MethodWe used all three common catheter-based techniques: simple balloon dilatation, stent placement, and stent-graft placement. All treated patients underwent pre- and post-procedural CT angiography. Group of patientsBetween 2004 and 2014, we treated a total of 10 patients with coarctation. They included seven men and three women, with a mean age of 41.1 (21–59) years. Eight patients were treated for native coarctation, and two for re-coarctation. Dominant features included hypertension (eight patients) and left-sided heart failure (four patients); some patients presented with multiple conditions at a time. Simple dilatation was performed in two patients while four had both stent and stent-graft placement. ResultsAll procedures were technically successful, with a long-term beneficial effect seen in all patients. All patients with hypertension showed improvement, with medication either reduced or completely discontinued in four cases.

Cross-sectional imaging of common and unusual complications after endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is currently a primarily therapeutic procedure that is extensively employed to treat several biliopancreatic disorders. Although widely considered a safe procedure, ERCP is associated with a non-negligible morbidity and occasional mortality. Due to the number and complexity of operative ERCPs performed, radiologists are increasingly faced with urgent requests for investigation of suspected post-procedural complications, which often have similar clinical and laboratory manifestations. This pictorial essay reviews the usual post-procedural CT findings, the clinical features and imaging appearances of common and unusual post-ERCP occurrences including interstitial oedematous and necrotising acute pancreatitis, haemorrhages, retroperitoneal and intraperitoneal duodenal perforations, infections and stent-related complications. Emphasis is placed on the pivotal role of multidetector CT, which is warranted after complex or prolonged ERCP procedures as it represents the most effective modality to detect and grade ERCP-related complications and to monitor nonsurgically treated patients. Timely diagnosis and optimal management require a combination of clinical and laboratory data with imaging appearances; therefore, this article aims to provide an increased familiarity with interpretation of early post-ERCP studies, particularly to triage those occurrences that require interventional or surgical treatment. In selected patients MRI allows imaging pancreatitis and abnormal collections without the use of ionising radiation. Teaching Points • Endoscopic retrograde cholangiopancreatography (ERCP) allows treating many biliopancreatic disorders.• Due to the number and complexity of procedures, post-ERCP complications are increasingly encountered.• Main complications include acute pancreatitis, haemorrhages, duodenal perforation and infections.• Diagnosis and management of complications rely on combined clinical, laboratory and imaging data.• Multidetector CT is most effective to diagnose, categorise and monitor post-ERCP complications.

Middle Cerebral Artery Residual Contrast Stagnation on Noncontrast CT Scan Following Endovascular Treatment in Acute Ischemic Stroke Patients.

We evaluated the relationship between middle cerebral artery (MCA) residual contrast stagnation on immediate postprocedural noncontrast CT scan and intraparenchymal hemorrhage (IPH) after endovascular treatment in acute ischemic stroke patients. The clinical and imaging data from patients with acute unilateral MCA M1 occlusion who underwent endovascular treatment over a 3.5-year period were reviewed. Bilateral M1 segments were selected on the first postangiography CT scan, and average attenuation was determined in Hounsfield units (HU); the difference between average HU values was calculated. Postprocedural CT scans were also evaluated for presence of IPH, defined as hyperdensity persisting on follow-up CT scans obtained >24-hours postprocedure. Of 80 patients included in our series; 10/80 developed IPH on immediate postprocedural CT scan. Patients with IPH had a higher (ipsilateral-contralateral) M1 residual attenuation difference (P < .001). An average ipsilateral M1 attenuation which was ≥5 HU greater than contralateral artery had a 3.8 times increase in relative risk of IPH (95% confidence interval: 2-7.1). On immediate postprocedural noncontrast CT scan of stroke patients with acute MCA M1 occlusion after endovascular treatment, higher residual contrast stagnation in the affected MCA, compared to contralateral artery, is associated with an increased risk of IPH.

Abstract T P25: Angiographic Predictors Of Hemorrhagic Transformation In Acute Endovascular Treatment Of Ischemic Stroke: A Retrospective Review

Background: Hemorrhagic transformation can follow endovascular recanalization in the setting of acute ischemic stroke (AIS). There are several case series and reports that have looked at CT based predictors of hemorrhage, none exist for conventional angiography. Herein, we present preliminary data on conventional digital subtraction angiography (DSA) predictors of hemorrhagic transformation. Objectives: To identify DSA predictors of hemorrhagic transformation in AIS patients undergoing endovascular treatment. Methods: We retrospectively identified 27 consecutive AIS patients who underwent endovascular treatment at two large tertiary urban hospitals. DSA images from endovascular intervention and post-procedure CTs were reviewed in these patients. DSA images were screened for time to recanalization, as well as presence of early venous shunting (VS) and early and persistent parenchymal contrast staining (CS). Results: There were 14 males and 13 females with a mean age of 59.5 ± 17.1 years and an average NIH stroke scale of 16 ± 6.1. Fourteen patients also received IV tPA prior to DSA. Average time from symptom onset to recanalization was 346 ± 250 minutes, 6/27 patients did not have known time of onset. New hemorrhage on post-procedure CT was seen in 13/27 (48%) patients. In these 13 patients DSA showed early VS in 11 (84%) and CS in 9 (69%) , both VS and CS were present in 8 (61.5%). Neither VS nor CS was noted in the 14 patients who did not have hemorrhagic transformation following endovascular intervention. Conclusion: Our findings suggest that the presence of early VS and/or CS in DSA images of AIS patients may predict subsequent hemorrhagic transformation. The presence of such findings should alert the interventionalist to cease further attempts at endovascular revascularization.

Abstract W MP3: Endovascular Therapy in Large Vessel Occlusion Strokes with ASPECTS of 5-7 May Result in Reduced Infarct Volumes and Better Functional Outcomes

Introduction: Intra-arterial therapy (IAT) for large vessel occlusions strokes (LVOS) has been increasingly utilized. The benefit of endovascular reperfusion in patients with mid-range ASPECTS remains to be established. Materials and methods: Retrospective analysis of LVOS patients with ASPECTS 5-7 treated with IAT (n=86) or medical therapy alone (±IV t-PA; n=15) at two academic centers from 2009-2012. Definitions employed: Symptomatic ICH: any parenchymal hematoma; Successful reperfusion: modified TICI≥2B; Good and acceptable clinical outcomes: 90-day mRS 0-2 and 0-3, respectively. Final infarct volumes were calculated based on 24-hour post-procedure CT or MRI scans. Results: Mean age (67±14 vs. 67±19 years) and baseline NIHSS (20±5 vs. 20±6) were similar in the IAT and medical treatment groups. Successful reperfusion was achieved in 58 (67%) IAT patients. Symptomatic and asymptomatic ICH occurred in 9 (10%) and 31 (36%) IAT patients, respectively. The IAT rates of 90-day good and acceptable outcomes were 20% (17/86) and 33% (28/86), respectively. Successful reperfusion in IAT patients was associated with smaller FIV (p=0.015) and higher rates of good (p=0.02) and acceptable (p=0.03) outcomes. The median final infarct volume was significant lower with IAT vs. medical therapy (80ml [IQR, 38-122] vs. 190ml [121-267], p=0.015). There was a strong trend towards a higher hemicraniectomy requirement in medically vs. endovascularly treated patients (20% versus 6%, p=0.06) despite similar in-hospital mortality (20% versus 26.7 %, p=0.75). Conclusions: Despite a low probability of achieving functional independence, IAT in LVOS patients with ASPECTS 5-7 appears to result in smaller final infarct volumes leading to a reduction in the need for hemicraniectomy and decreasing the degree of overall disability. Therefore, it may be a reasonable option for patients and families who favor a shift from severe to moderate disability. Prospective studies utilizing shift in outcome measures are warranted to confirm these results.

Sinistral Portal Hypertension and Anastamotic Varices Secondary to Splenic Vein Thrombosis After a Whipple Procedure

Introduction: A 70-year-old Pakistani woman with a past medical history of coronary artery disease status post recent bare metal stent x 3 (on aspirin and clopidogrel), with a remote history (1989) of a pancreaticoduodenectomy for a benign pancreatic mass that was complicated by splenic vein thrombosis, was admitted to the hospital for worsening anemia. On admission, she was noted to have a hemoglobin of 5 g per dL (9.7 grams per dL 1 month prior). Symptoms included increased fatigue and weakness, and she reported dark stools unchanged while taking oral iron. Of note she had a history of overt, obscure upper gastrointestinal bleeding with several admissions and extensive evaluations from 2001-2012, which were unsuccessful in identifying a source of bleeding. Her most recent endoscopic studies included a normal colonoscopy and an upper endoscopy that revealed post-Whipple anatomy with a widely patent gastrojejunostomy (GJ) and small type 2 gastro-esophageal varices (GOV2) without stigmata of recent bleeding. Push-enteroscopy was performed, which identified small, nonbleeding GOV2s along the fundus. The GJ anastomosis was characterized by friable mucosa and extensive vascular ectasia. The efferent jejunal limb was normal. During the procedure, active bleeding was induced by scope trauma to the GJ anastomosis requiring patient intubation and intra-procedural transfusions. A post-procedure CT angiogram revealed prominent submucosal vasculature localized to the GJ anastomosis diagnostic of anastomotic varices with additional short gastric varices between the spleen and stomach. Moreover, the spleen was enlarged (13 cm) and the splenic vein was not visualized secondary to chronic splenic vein thrombosis. There was no evidence of cirrhosis, suggesting isolated left-sided portal hypertension. Our patient was treated with splenectomy, and has not experienced recurrent bleeding during approximately 2 years of clinical follow-up. Sinistral portal hypertension, also known as left-sided portal hypertension, is hypertension confined to the gastrosplenic side of the portal venous system. To our knowledge, this is the first case of sinistral portal hypertension leading to varices at a GJ anastomosis. Sinistral portal hypertension accounts for less than 5% of all portal hypertension, and is most commonly caused by splenic vein occlusion related to pancreatic disorders. As most patients are asymptomatic, the exact incidence is unknown, but bleeding (variceal or nonvariceal) is the most common manifestation. Splenectomy decreases venous flow through collateral vessels and decompresses associated varices. Rebleeding is rare after splenectomy in various case series.

Vertebral augmentation for neoplastic lesions with posterior wall erosion and epidural mass.

The presence of a cortical erosion of the posterior wall or an epidural mass is commonly considered a contraindication to performing a vertebral augmentation, considering the perceived increased risk of an epidural cement leak. Our aim was to assess technical and clinical complications of vertebral augmentation procedures performed for pain palliation and/or stabilization of neoplastic lytic vertebral body lesions, with cortical erosion of the posterior wall, often associated with a soft-tissue epidural mass. In 48 patients, we performed retrospective vertebral augmentation assessment on 70 consecutive levels with cortical erosion of the posterior wall, as demonstrated by preprocedural CT/MR imaging. An epidural mass was present in 31/70 (44.3%) levels. Cavity creation was performed with Coblation Wands before cement injection in 59/70 levels. Injection of high-viscosity polymethylmethacrylate was performed under real-time continuous fluoroscopic control. Postprocedural CT of the treated levels was performed in all cases. Clinical follow-up was performed at 1 and 4 weeks postprocedurally. In 65/70 (92.8%) levels, the vertebral augmentation resulted in satisfactory polymethylmethacrylate filling of the lytic cavity and adjacent trabecular spaces in the anterior half of the vertebral body. An epidural leak of polymethylmethacrylate occurred in 10/70 (14.2%) levels, causing radicular pain in 3 patients, which spontaneously resolved within 1 week in 2 patients, while 1 patient with a T1-T2 foraminal leak developed severe weakness of the intrinsic hand muscles and a permanent motor deficit. In our series of vertebral augmentation of neoplastic lytic vertebral lesions performed for palliation of pain and/or stabilization, we observed a polymethylmethacrylate epidural leak in only 14.2% of levels, despite the presence of cortical erosion of the posterior wall and an epidural mass, with an extremely low rate of clinical complications. Our data seem to justify use of vertebral augmentation in patients with intractable pain or those at risk for vertebral collapse.

Thromboembolic complications after Zenith® Low Profile Endovascular Graft for infrarenal abdominal aneurysms.

The purpose of this study was to objectify and evaluate risk factors for thromboembolic complications after treatment with a Zenith(®) Low Profile Endovascular Graft (Zenith LP). Results were compared with those in the recent literature on endovascular aortic repair (EVAR) and with the thromboembolic complications in the patient group treated with a Zenith Flex Endovascular Graft in our institute in the period before the use of the Zenith LP. All consecutive patients who were suitable for treatment with a Zenith LP endograft between October 2010 and December 2011 were included. The preprocedural computed tomography scan (CT), procedural angiographic images, and the postprocedural CT scans were evaluated for risk factors for and signs of thromboembolic complications. All patients treated between December 2007 and November 2012 with a Zenith Flex endograft were retrospectively evaluated for thromboembolic complications. In the study period 17 patients were treated with a LP Zenith endograft. Limb occlusion occurred in 35 % of the patients. Limb occlusions occurred in 24 % of the limbs at risk (one limb occluded twice). In one patient two risk factors for limb occlusion were identified. Between December 2007 and November 2012, a total of 43 patients were treated with a Zenith Flex endograft. No limb occlusion or distal embolization occurred. Despite that this was a small retrospective study, the Zenith LP endograft seems to be associated with more frequent thromboembolic complications compared with the known limb occlusion rates in the literature and those of the patients treated with a Zenith Flex endograft in our institute.

Treatment of supratentorial spontaneous intracerebral hemorrhage using image-guided minimally invasive surgery: Initial experiences of a flat detector CT-based puncture planning and navigation system in the angiographic suite.

The intracerebral hemorrhage drainage through minimally invasive approach is emerging as an alternative for traditional craniotomy, due to its improved survival rate and reduced complication rate. In this study, we investigated the feasibility and safety of a flat detector CT-based puncture planning and navigation system for minimally invasive hematoma drainage on patients with intracerebral hemorrhage. The minimally invasive hematoma drainage was performed on 21 hypertensive patients with intracerebral hemorrhage in the angiographic suite with the guidance of a flat detector CT-based puncture planning and navigation system. This system is integrated in the angiographic machine, and was used for 1) planning the needle path based on a preprocedural flat detector CT scan, 2) advancing the catheter with real-time fluoroscopic guidance, and 3) confirming the procedure outcome based on an immediate postprocedural flat detector CT. The surgery efficiency, accuracy, and the treatment outcome were measured and compared with the published data. All procedures were successfully completed with the catheter placed 4 ± 1 mm from the planned position. The average surgery time was 40 ± 7 minutes. The volume of the hematoma was reduced to 28 ± 4% of the original volume. The Glasgow Coma Scale score was significantly improved from 10 ± 1 at the admission to 14 ± 1 at the discharge. The Extended Glasgow Coma Scale score also improved from 5 ± 1 at the discharge to 6 ± 1 at the 6-month follow-up. No major complication, rebleeding, and mortality were observed in this study. This flat detector CT-based needle guidance system provided a feasible, convenient, and safe way to perform the puncture and drainage of brain hematoma in the angiographic suite.

Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia

Peroral endoscopic myotomy (POEM) is a promising new endoscopic method for the treatment of achalasia. The aim of this study was to analyze the value of routine postoperative CT of the chest to detect POEM-associated adverse events. Single-center, retrospective study. Tertiary care center. Between August 2010 and July 2012, 428 patients underwent POEM. Three hundred postprocedure CT POEM patients were retrospectively analyzed and findings correlated with clinical outcome and management. The frequency of postoperative pathological CT scan findings after POEM and the rate of interventions required for adverse event management. The main CT findings could be divided into frequent and reversible sequelae of POEM, pneumomediastinum (48%), pneumoperitoneum (37%), and subcutaneous emphysema (28%), and into potential adverse events such as pneumothorax (17%), pleural effusion (66%), pneumonitis (52%), and focal atelectasis (21%). Only 17 of 50 patients with pneumothorax (5.6% of all patients) and 2 of 200 patients with pleural effusion (0.7% of all patients) required interventional treatment based on clinical symptoms. In 1 patient, a hematoma was observed on a CT scan before any clinical manifestation occurred. Increasing age and the use of air instead of CO2 were associated with an increased rate of pneumothorax (P = .031; 95% confidence interval, 1.002-1.049 and P < .001; 95% confidence interval, 0.012-0.157, respectively). Single-center, retrospective study. Routine chest CT scan for achalasia patients undergoing POEM is probably not warranted because of the high rate of minor and clinically irrelevant findings. The use of CO2 is obligatory to reduce related adverse events.

Impact of the ASPECT scores and distribution on outcome among patients undergoing thrombectomy for acute ischemic stroke

IntroductionThis study investigates whether the Alberta Stroke Program Early CT Score (ASPECTS) quantification is associated with outcome following mechanical thrombectomy.ObjectiveTo determine whether preintervention non-perfect ASPECT scores involving cortical or subcortical...

Thoraco-lumbar traumatic vertebral fractures augmentation by osteo-conductive and osteo-inductive bone substitute containing strontium–hydroxyapatite: our experience

The aim of our study was to evaluate the effectiveness of osteointegrable strontium-hydroxyapatite (Sr-HA) bone cement in the treatment of thoracolumbar traumatic vertebral fractures by percutaneous vertebroplasty (VTP). We treated 35 patients [29 (82.85 %) men, 6 (17.14 %) women, mean age 34.05 ± 8.36 years (range 21-54 years)] with single type A1.1 and A1.2 thoracolumbar traumatic vertebral fracture without endospecal bone fragments. Pain intensity was evaluated before and at 1 day; 1 week; and 1, 6, and 12 months after VTP by a 10-point visual analog scale (VAS) score (0 = no pain, 10 = unbearable pain). Physical status and quality of life were evaluated by Oswestry Disability Index (ODI) questionnaire before and 1, 6, and 12 months after VTP. Procedural technical success was achieved in all patients with no deaths observed during follow-up. In three patients (8.57 %), postprocedural CT showed cement leakages: one intradiscal and two in venous plexus. No adjacent vertebral body fractures nor intrasomatic recollapse was detected. The VAS and ODI scores showed a statistically significant reduction 1 week after procedure (P value <0.0001) with a progressive statistically significant reduction during follow-up (P value <0.0001). Twenty-three patients (65.71 %) assigned a value of 0 to the VAS scale at 1 year after treatment. Strontium-hydroxyapatite bone cement is an effective and safe bone filler in percutaneous vertebroplasty with low leakage rate and absence of major complications when performed by a skilled equipe. It allows an immediate and long-lasting stabilization with a significant pain reduction and quality of life improvement.