Radiological Predictors Research Articles

Facial Nerve Adherence in Vestibular Schwannomas: Classification and Radiological Predictors.

Background Facial nerve palsy is one of the most frequent complications after resection of vestibular schwannomas (VS). Several mechanisms have been implicated in the poor postoperative facial nerve outcome. Adherence between the facial nerve and tumor capsule is one of the most relevant factors. There is no clear preoperative parameter permitting identification of these adhesions. Objective The aim of this study was to identify the correlation between the grade of adherence of the facial nerve to the tumor capsule and its functional outcome after VS resection. Methods A total of 26 patients with sporadic VS (tumor sized T3, T4A, and T4B according to Hannover classification) were evaluated. Grade of adherence of the facial nerve to the tumor capsule was checked during surgery and graduated according to a proposed scale into 1 to 3 different grades. Facial nerve function was assessed postoperatively and after 1-year follow-up. Size of tumor according to Hannover classification, presence of cystic components, "cerebrospinal fluid (CSF) cleft sign," and the contour of tumor capsule were tested as radiological predictors of grade of adherence to the facial nerve. Results and Conclusion Only Grade 2 (11 cases) and 3 (15 cases) of adherence were seen in large VS. Lower grade of adherence was associated with good facial nerve outcome after 1-year follow-up ( p = 0.029). Presence of the "CSF cleft sign" and regular contour of tumor capsule were independent predictors of adherence. When both factors were associated, sensitivity and specificity of this method were 83 and 80%, respectively.

Identifying predictors for bacterial and fungal coinfection on chest computed tomography in patients with Pneumocystis pneumonia.

Pneumocystis pneumonia (PCP) is a common opportunistic infection with high mortality in individuals with decreased immunity. Pulmonary coinfections with PCP are associated with poor prognosis. The study aims to identify radiological predictors for pulmonary coinfections in patients with PCP and risk factors for mortality. This is a retrospective, five-year study was conducted in a medical center, enrolling patients diagnosed with PCP, who received a chest computed tomography (CT) scan. The radiological findings and medical records of all participants were reviewed carefully by 2 independent doctors. Univariable and multivariable analysis was performed to identify radiological predictors for pulmonary coinfection and clinical risk factors for poor prognosis. A total of 101 participants were included, of which 39 were HIV-infected and 62 were non-HIV-infected. In multivariable analysis, radiologic predictors on chest CT for coinfection with bacteria pneumonia included lack of ground glass opacity (adjusted odds ratio [aOR], 6.33; 95% confidence interval [CI], 2.03-19.77; p=0.001) and presence of pleural effusion (aOR, 3.74; 95% CI, 1.27-10.99; p=0.017). Predictors for fungal pneumonia included diffuse consolidation (adjusted OR, 6.27; 95% CI, 1.72-22.86; p=0.005) and presence of pleural effusion (adjusted OR, 5.26; 95% CI, 1.44-19.17; p=0.012). A significantly higher in-hospital mortality was associated with older age, recent corticosteroid exposure, cytomegalovirus coinfection, and acute respiratory failure. Early identification of pulmonary coinfections in PCP using radiological features on the CT scans, will enable appropriate treatment which is crucial to improve the prognosis.

Predictors of severe head injury in tertiary centre

Introduction: Severe head injury (SHI) is associated with a high mortality and morbidity rate and is one of the leading causes of death in intensive care units. The aim of this study was to identify predictors of hospital outcome and mortality in ICU admitted SHI patients and to estimate their impact.
 Methods: A retrospective analysis was carried on patients (n=321) with a severe head injury, defined as Glasgow Coma Scale (GCS) ? 8 who were admitted to the ICU neurosurgical department of National Trauma Center from 2017 to 2018. Both clinical and radiological predictors of hospitalized patients were identified.
 Results: Total mortality rate was 5.9%. 243 (75.7%) of the patients were male and 78 (24.3%) were female. 55 % of cases were due to traffic accidents. Patients Middle Ages group was 60%. Coexisting injuries, found in 25% of the patients aggravated the prognosis. Blood grouping pattern in SHI were B+, A+ and O+ 36.1, 28 and 24.3% respectively.45% of the patients had Tattoo which was aggravating factors. The outcome is highly correlated with GCS’ values. CT scan findings revealed that patients with subdural hygroma after few days of admission CT scan which was very important prognostic factors in SHI.
 Conclusions: SHI has high mortality and morbidity in today world as it has a high negative impact on young people, especially men with blood group B+. The age of the patient, presence of Tattoo, GCS at admission, the CT scanning at admission and CT scanning after a week of admission were significant predictors of outcome.

Clinical and radiological risk factors of autograft cranioplasty resorption after decompressive craniectomy for traumatic brain injury

ObjectiveThe repositioning of an autologous bone flap after decompressive craniectomy (DC) for traumatic intracranial hypertension remains the first-line treatment for cranial reconstruction. Aseptic autologous bone flap resorption (BFR) is the most frequent complication. The identification of possible predictive parameters for BFR would help to improve the management of these patients. Patients and methodsThree hundred and nine patients undergoing autologous bone flap repositioning after previous DC for TBI between September 2003 and September 2017 were included in the study. ResultsBFR was identified in 76 (24,59 %) of the 309 patients undergoing autologous CP. Age of ≤ 45 years and CP bone fragmentation were seen to be significant independent risk factors for BFR (p = 0.001 and p = 0.018, respectively) using multivariate logistic regression analysis. Of the radiologic predictors, CP size and the gap between CP and the skull defect were independently associated with BFR (p = 0.034 and p = 0.0003, respectively).The Youden index and ROC curve analysis were used to estimate the cut-off values for the continuous parameters and determine the sensitivity and specificity of the radiologic risk factors. The cut-off value for these two factors was found to be 114,98 cm2 and ≥ 578,5 mm2, respectively. The area under the ROC curve was 0.627 for bone flap size and 0.758 for the DC–CP gap. The DC–CP gap had greater sensitivity and specificity as a predictor of BFR, compared to bone flap size (p = 0.079 and p = ≤ 0.001, respectively). ConclusionsIn this large cohort of patients with autologous cranioplasty, younger age, fragmented autologous bone flap and a wide gap between CP and cranial defect were predictive of bone flap resorption.

Prediction of Outcome Using Quantified Blood Volume in Aneurysmal SAH.

In patients with SAH, the amount of blood is strongly associated with clinical outcome. However, it is commonly estimated with a coarse grading scale, potentially limiting its predictive value. Therefore, we aimed to develop and externally validate prediction models for clinical outcome, including quantified blood volumes, as candidate predictors. Clinical and radiologic candidate predictors were included in a logistic regression model. Unfavorable outcome was defined as a modified Rankin Scale score of 4-6. An automatic hemorrhage-quantification algorithm calculated the total blood volume. Blood was manually classified as cisternal, intraventricular, or intraparenchymal. The model was selected with bootstrapped backward selection and validated with the R 2, C-statistic, and calibration plots. If total blood volume remained in the final model, its performance was compared with models including location-specific blood volumes or the modified Fisher scale. The total blood volume, neurologic condition, age, aneurysm size, and history of cardiovascular disease remained in the final models after selection. The externally validated predictive accuracy and discriminative power were high (R 2 = 56% ± 1.8%; mean C-statistic = 0.89 ± 0.01). The location-specific volume models showed a similar performance (R 2 = 56% ± 1%, P = .8; mean C-statistic = 0.89 ± 0.00, P = .4). The modified Fisher models were significantly less accurate (R 2 = 45% ± 3%, P < .001; mean C-statistic = 0.85 ± 0.01, P = .03). The total blood volume-based prediction model for clinical outcome in patients with SAH showed a high predictive accuracy, higher than a prediction model including the commonly used modified Fisher scale.

Machine learning volumetry of ischemic brain lesions on CT after thrombectomy-prospective diagnostic accuracy study in ischemic stroke patients.

Ischemic lesion volume (ILV) is an important radiological predictor of functional outcome in patients with anterior circulation stroke. Our aim was to assess the agreement between automated ILV measurements on NCCT using the Brainomix software and manual ILV measurements on diffusion-weighted imaging (DWI). This was a prospective single-center observational study of patients with CT angiography (CTA) proven anterior circulation occlusion treated with endovascular thrombectomy (May 2018 to May 2019). NCCT ILV was measured automatically by the Brainomix software. DWI ILV was measured manually. The McNemar's test was used to test sensitivity and specificity. The Somer's delta was used to test the differences between concordant and discordant ASPECTS regions. The Bland-Altman plot was calculated to compare the differences between Brainomix and DWI ILVs. Forty-five patients were included. Median Brainomix ILV was 23ml (interquartile range [IQR], 15-39ml), and median DWI ILV was 11.5ml (IQR, 7-32ml) in the TICI 2b-3 group. In the TICI 0-2a, the NCCT ILV was 39ml (IQR, 18-62ml) and DWI ILV was 30 (IQR, 11-105ml). The DWI ILVs in patients with good clinical outcome (mRS 0-2) was significantly lower compared with patients with mRS ≥ 3 (10mL vs 59mL, p = 0.002). Similar trend was observed for Brainomix ILV measurements (21mL vs 39mL, p = 0.012). There was a high correlation and accuracy in the detection of follow-up ischemic changes in particular ASPECTS regions. NCCT ILV measured automatically by the Brainomix software might be considered a valuable radiological outcome measure.

Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically.

Background and Purpose- It is unclear which factors predict acute neurological deterioration in patients with large vessel occlusion and mild symptoms. We aim to evaluate the frequency, timing, and potential predictors of acute neurological deterioration ≥4 National Institutes of Health Stroke Scale (NIHSS) points in medically managed patients with large vessel occlusion and mild presentation. Methods- Single-center retrospective study of patients with consecutive minor stroke (defined as NIHSS score of ≤5 on presentation) and large vessel occlusion from January 2014 to December 2017. Primary outcome was acute neurological deterioration ≥4 NIHSS points during the hospitalization. Secondary outcomes included ΔNIHSS (defined as discharge minus admission NIHSS score). Results- Among 1133 patients with acute minor strokes, 122 (10.6%) had visible occlusions on computed tomography angiography/magnetic resonance angiography. Twenty-four (19.7%) patients had ≥4 points deterioration on NIHSS at a median of 3.6 (1-16) hours from arrival. No clinical or radiological predictors of acute neurological deterioration ≥4 NIHSS points were observed on multivariable analysis. Rescue endovascular thrombectomy was performed more often in the ones with acute neurological deterioration ≥4 NIHSS points compared with patients with no deterioration (54% versus 0%; P<0.001). Acute neurological deterioration ≥4 NIHSS points was associated with ΔNIHSS ≥4 points (33% versus 4.9%; P<0.01) and a trend toward lower independence rates at discharge (50% versus 70%; P=0.06) compared with the group with no deterioration. In patients with any degree of neurological worsening, patients who underwent rescue thrombectomy were more likely to be independent at discharge (73% versus 38%; P=0.02) and to have a favorable ΔNIHSS (-2 [-3 to 0] versus 0 [-1 to 6]; P=0.05) compared with the ones not offered rescue thrombectomy. Conclusions- Acute neurological deterioration ≥4 NIHSS points was observed in a fifth of patients with large vessel occlusion and mild symptoms, occurred very early in the hospital course, impacted functional outcomes, and could not be predicted by any of the studied clinical and radiological variables. Rescue thrombectomy was associated with improved clinical outcomes at discharge in patients with neurological deterioration.

Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores: Subanalysis of the RESCUE-Japan Registry 2.

Background and Purpose- The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion. Methods- Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0-2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy. Results- We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30-4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59-5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32-6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22-4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71-3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P<0.05). Conclusions- Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.

Radiological and clinical associations with scoliosis outcomes after posterior fossa decompression in patients with Chiari malformation and syrinx from the Park-Reeves Syringomyelia Research Consortium.

In patients with Chiari malformation type I (CM-I) and a syrinx who also have scoliosis, clinical and radiological predictors of curve regression after posterior fossa decompression are not well known. Prior reports indicate that age younger than 10 years and a curve magnitude < 35° are favorable predictors of curve regression following surgery. The aim of this study was to determine baseline radiological factors, including craniocervical junction alignment, that might predict curve stability or improvement after posterior fossa decompression. A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and a syrinx (≥ 3 mm in width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°) in patients who underwent posterior fossa decompression and who also had follow-up imaging. Of 825 patients with CM-I and a syrinx, 251 (30.4%) were noted to have scoliosis present at the time of diagnosis. Forty-one (16.3%) of these patients underwent posterior fossa decompression and had follow-up imaging to assess for scoliosis. Twenty-three patients (56%) were female, the mean age at time of CM-I decompression was 10.0 years, and the mean follow-up duration was 1.3 years. Nine patients (22%) had stable curves, 16 (39%) showed improvement (> 5°), and 16 (39%) displayed curve progression (> 5°) during the follow-up period. Younger age at the time of decompression was associated with improvement in curve magnitude; for those with curves of ≤ 35°, 17% of patients younger than 10 years of age had curve progression compared with 64% of those 10 years of age or older (p = 0.008). There was no difference by age for those with curves > 35°. Tonsil position, baseline syrinx dimensions, and change in syrinx size were not associated with the change in curve magnitude. There was no difference in progression after surgery in patients who were also treated with a brace compared to those who were not treated with a brace for scoliosis. In this cohort of patients with CM-I, a syrinx, and scoliosis, younger age at the time of decompression was associated with improvement in curve magnitude following surgery, especially in patients younger than 10 years of age with curves of ≤ 35°. Baseline tonsil position, syrinx dimensions, frontooccipital horn ratio, and craniocervical junction morphology were not associated with changes in curve magnitude after surgery.

Focused endoscopic endonasal craniocervical junction approach for resection of retro-odontoid lesions: surgical techniques and nuances.

Lesions posterior to the odontoid process pose a surgical challenge. Posterolateral approaches to this region are considerably risky for the spinal cord. Transoral approaches are limited in terms of exposure and can also carry morbidity. We describe a focused endoscopic endonasal approach (EEA) for removing an osteochondroma located dorsal to the odontoid process. The surgical pearls and pitfalls using stepwise image-guided EEA cadaveric dissections are highlighted defining the importance of various craniocervical junction (CCJ) lines on imaging. EEA to CCJ can be offered, with lower morbidity than other approaches, even for lesions that extend posterior and caudal to the odontoid process. Radiologic predictors of exposure and intraoperative techniques to enhance endoscopic visualization are discussed.

Predicting Recovery and Outcome after Pediatric Stroke: Results from the International Pediatric Stroke Study.

To characterize predictors of recovery and outcome following pediatric arterial ischemic stroke, hypothesizing that age influences recovery after stroke. We studied children enrolled in the International Pediatric Stroke Study between January 1, 2003 and July 31, 2014 with 2-year follow-up after arterial ischemic stroke. Outcomes were defined at discharge by clinician grading and at 2 years by the Pediatric Stroke Outcome Measure. Demographic, clinical, and radiologic outcome predictors were examined. We defined changes in outcome from discharge to 2 years as recovery (improved outcome), emerging deficit (worse outcome), or no change. Our population consisted of 587 patients, including 174 with neonatal stroke and 413 with childhood stroke, with recurrent stroke in 8.2% of childhood patients. Moderate to severe neurological impairment was present in 9.4% of neonates versus 48.8% of children at discharge compared to 8.0% versus 24.7% after 2 years. Predictors of poor outcome included age between 28 days and 1 year (compared to neonates, odds ratio [OR] = 3.58, p < 0.05), underlying chronic disorder (OR = 2.23, p < 0.05), and involvement of both small and large vascular territories (OR = 2.84, p < 0.05). Recovery patterns differed, with emerging deficits more common in children <1 year of age (p < 0.05). Outcomes after pediatric stroke are generally favorable, but moderate to severe neurological impairments are still common. Age between 28 days and 1 year appears to be a particularly vulnerable period. Understanding the timing and predictors of recovery will allow us to better counsel families and target therapies to improve outcomes after pediatric stroke. ANN NEUROL 2020;87:840-852.

Pelvic injury patterns in blast: Morbidity and mortality.

Pelvic trauma has emerged as one of the most severe injuries to be sustained by the victim of a blast insult. The incidence and mortality due to blast-related pelvic trauma is not known, and no data exist to assess the relative risk of clinical or radiological indicators of mortality. The UK Joint Theater Trauma Registry was interrogated to identify those sustaining blast-mediated pelvic fractures during the conflicts in Iraq and Afghanistan, from 2003 to 2014, with subsequent computed tomography image analysis. Casualties that sustained more severe injuries remote to the pelvis were excluded. One hundred fifty-nine casualties with a 36% overall mortality rate were identified. Pelvic vascular injury, unstable pelvic fracture patterns, traumatic amputation, and perineal injury were higher in the dismounted fatality group (p < 0.05). All fatalities sustained a pelvic vascular injury. Pelvic vascular injury had the highest relative risk of death for any individual injury and an associated mortality of 56%. Dismounted casualties that sustained unstable pelvic fracture patterns, traumatic amputation, and perineal injury were at three times greater risk (relative risk, 3.00; 95% confidence interval, 1.27-7.09) to have sustained a pelvic vascular injury than those that did not sustain these associated injuries. Opening of the pubic symphysis and at least one sacroiliac joint was significantly associated with pelvic vascular injury (p < 0.001), and the lateral displacement of the sacroiliac joints was identified as a fair predictor of pelvic vascular injury (area under the receiver operating characteristic curve, 0.73). Dismounted blast casualties with pelvic fracture are at significant risk of a noncompressible pelvic vascular injury. Initial management of these patients should focus upon controlling noncompressible pelvic bleeding. Clinical and radiological predictors of vascular injury and mortality suggest that mitigation strategies aiming to attenuate lateral displacement of the pelvis following blast are likely to result in fewer fatalities and a reduced injury burden. Prognostic, level III.

Abstract TP59: Atherosclerosis and Unsuccessful Recanalization in Acute Stroke Patients

Unsuccessful recanalization rates in acute ischemic stroke patients range between 8-18%. Currently, there are no models to predict thrombectomy reperfusion success with current thrombectomy techniques. We aimed to describe the clinical and radiological features of patients with unsuccessful thrombectomy (UT) and its association with intracranial atherosclerosis (ICAD). A cohort of 413 consecutive, adult, thrombectomy patients admitted to two comprehensive stroke centers were reviewed from 2014 to 2017. Patients with anterior circulation large vessel occlusions (LVOs) and a thrombolysis in cerebral infarction (TICI) score of ≤2a were selected. Demographics, clinical and imaging data were obtained from electronic medical records. Head CT, CT angiography and digital subtraction angiography (DSA) images were reviewed by one independent investigator to evaluate ASPECTS score, vessel calcifications, clot burden score and CTA and DSA collateral score. Proposed causes of UT were categorized based on angiography evaluation by two independent neurointerventionalists. Analysis was performed using descriptive frequency analysis and univariate logistic regression models. A total of 87 low TICI score (≤2a) patients from 413 procedures were included. The median age was 74 years (IQR 58.5-84) and 58% were female. The most common comorbidity was hypertension (73.5%), followed by hyperlipidemia (46%). TICI score of 0 was found in 23% (N=20), 1 in 9.2% (N=8), and 2a in 67.8% (N=59). The inpatient mortality rate was 19.5% (17/87). Out of the remaining 70 patients, 78.5% (N=55) had a 3-month follow up modified Rankin Scale (mRS) of 3-6. The most common proposed cause of poor revascularization in our study was presence of ICAD [29.9% (n=32) of patients]. In our cohort of UT patients with ICAD, 68.8% (N=22) had TICI 2a score with majority (96.8%) having a 3 months mRS of 3-6. Patients with ICAD had 7.3% increased odds of having angiographic collateral score of 5 (p=0.035) and 15.2% increased odds of having an absence of hyperdense MCA in noncontrast CT scan (p=0.003). ICAD is frequently found in patients that undergo UT. Identification of radiological predictors of ICAD may be helpful to consider alternative revascularization strategies for LVOs.

Poor intensive stroke care is associated with short-term death after spontaneous intracerebral hemorrhage

ObjectivesThe case fatality from spontaneous ICH (SICH) remains high. The quality and intensity of early treatment is one of the determinants of the outcome. We aimed to study the association of early intensive care, using the Intracerebral Hemorrhage–Specific Intensity of Care Quality Metrics (IHSICQM) with the 30-day in-hospital mortality in Algarve, Portugal. Patients and Methodsanalysis of prospective collected data of 157 consecutive SICH patients (2014–2016). Logistic regression was performed to assess the role of IHSICQM on the 30-day in-hospital mortality controlling for the most common clinical and radiological predictors of death. Receiver operating characteristic (ROC) curve was developed to evaluate the prediction accuracy of the IHSICQM score (C-statistics). Resultsforty-five (29 %) patients died. The group of deceased patients had lower intensity of care (lower IHSICQM score) and higher proportion of poor prognosis associated factors (pre-ICH functional dependency, intraventricular dissection/glycaemia). On the multivariate analysis, higher IHSICQM was associated with reduction of the odds of death, 0.27 (0.14-0.50) per each increasing point. The ROC curve showed a high discriminating ability of isolated IHSICQM in predicting the 30-day mortality (AUC = 0,95; 95 % CI = [0,86; 0,95]). Conclusionthe early intensity of quality of care independently predicts the 30-day in-hospital mortality. Quantification of the intensity of SICH is a valid tool to persuade improvement of SICH care, as well to help comparison of performances within and between hospitals.

P550 Long-term effectiveness of anti-TNF agents in symptomatic stricturing Crohn’s disease

Abstract Background Approximately one half of the patients with Crohn’s disease (CD) develop intestinal strictures during their lifetime. The effectiveness of currently approved drugs in fibrosis-predominant lesions is very limited. Our aim was to determine the effectiveness of anti-TNF therapy in CD complicated by symptomatic intestinal strictures in a real-world setting. Methods We included adult patients with symptomatic stricturing CD receiving their first-line anti-TNF therapy. Strictures were defined as constant luminal narrowing with pre-stenotic dilatation. We excluded those patients with previous anti-TNF exposure, surgery or endoscopic therapy of the stenosis. The effectiveness of the anti-TNF was defined as a composite outcome combining the persistence of the treatment and without dose or frequency intensification, with no new immunomodulators, surgery or endoscopic therapy during follow-up. A multivariate Cox regression was performed and the final multivariate model was determined using a backward procedure. Results A total of 262 patients from 32 sites were included (141 received infliximab and 121 adalimumab). The median number of stenosis per patient was 1 (range 1–9). The treatment was effective in 81% and 59% of patients after 6 and 12 months, respectively, while this outcome was fulfilled by 21% after a median of 40 months (IQR, 19–85). During follow-up, anti-TNF therapy required a dose or frequency adjustment in 39% of patients, 12% required a new immunomodulator or endoscopic therapy in 4%. The proportion of subjects requiring surgery was 15% and 21% after 1 and 2 years, respectively, with an overall rate of surgery of 32%. Infliximab was associated with a higher rate of surgery as compared with adalimumab (OR 1.78; 95% CI, 1,025-3,09). A shorter time since the diagnosis of CD or the stricture and the initiation of anti-TNF therapy was associated with a greater effectiveness at 6 and 12 months (HR 0.99 95% CI 0.99–1, p = 0.045; HR 0.99 95% CI 0.99–0.99, p = 0.015; HR 0.98 95% CI 0.96–0.99, p = 0.024; HR 0.99 95% CI 0.98–1.0, p = 0.046; respectively). In the survival analysis, younger age, lower albumin levels at baseline, strictures being located in the descending colon, concomitant use of mesalamine and the presence of ulcers or lymphadenopathy at the stricture were associated with lower effectiveness. The anti-TNF agent was discontinued in 131 patients (50%), and 88 subjects (34%) required a switch to a new biologic. Conclusion Anti-TNF agents are effective in approximately 20% of patients with CD complicated with symptomatic strictures. Early introduction of anti-TNF therapy improves the effectiveness in the short term in these patients. Some clinical and radiological predictors can identify patients with a lower probability of response.

Tolosa-Hunt Syndrome: Long-Term Outcome and Role of Steroid-Sparing Agents.

Background:Tolosa-Hunt Syndrome (THS) is one of the causes of cavernous sinus syndrome causing painful ophthalmoplegia. Literature on long-term outcome of this rare condition is scarce.Aims and Objectives:The aim is to study the recurrence and role of steroid-sparing agents in THS.Methodology:All cases of THS treated at a tertiary-level teaching hospital during a 10-year period were studied. Clinical and radiological profile, response to treatment and recurrences were noted.Results:A total of 44 cases were studied. The mean age was 49.5 years, Males constituted 23/44 (52%). The first symptom was pain in 90%. Ptosis with ophthalmoplegia was the most common deficit 29/44 (66%). Lesions confined to cavernous sinus 27/44 (61%) was the most frequent magnetic resonance imaging finding. All patients received steroids as the initial treatment and 15/44 (34%) received steroid-sparing agents. Follow-up ranged from 6 to 120 months (Mean 39 months). Two patients had alternative diagnosis of leptomeningeal malignancy and hypertrophic pachymeningitis on follow-up. Recurrences occurred in 18/37 (48.6%). Time for recurrence varied from 8 months to 7 years. (Mean 18 months). No clinical or radiological predictors for recurrence were identified. Patients who received steroid-sparing agents had a significantly lower recurrence 3/15 (20%) versus 14/26 (53.8%)P < 0.034.Conclusions:Around 50% of patients with THS can have recurrence. Steroid-sparing agents appear to prevent recurrence. A prospective multicenter randomized controlled trial may help to evaluate the risk and benefits of steroid-sparing therapy and to identify any possible predictors for recurrence.

Cervicomedullary angle as an independent radiological predictor of postoperative neurological outcome in type A basilar invagination

To propose an independent radiological index to evaluate surgical outcomes of A type basilar invagination, a retrospective study was conducted to compare the clinical outcome between procedures 1 and 2 by applying intraoperative consistent traction and manual reduction. Moreover, the atlantodental interval (ADI), cervicomedullary angle (CMA), bilateral sagittal inclination of atlantoaxial joint (SIAA) were measured and compared to pre-operation. Postoperatively, only these patients undergoing procedure 2 achieved significant neurological improvement. The ADIs and the SIAAs decreased in both groups, these differences are statistically significant between pre- and post- operation. For postoperative CMAs, only these patients undergoing modified surgery gained significant improvement of angle with mean 141°. We concluded that the CMA or SIAA could be a radiological predictor to evaluate surgical outcome in BI, among which the CMA is a more independent and easily measurable predictor that is closely correlated with satisfactory neurological improvements. Moreover, procedure 2 with intraoperative resistant cranial traction and manual reduction can help us achieve a good CMA.

Sensitivity and specificity of clinical, biochemical, and radiological predictors of common bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography: a binary logistic regression analysis

Sensitivity and specificity of clinical, biochemical, and radiological predictors of common bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography: a binary logistic regression analysis

Clinical and Radiological Features Associated with Bladder Invasion and Need for Urological Intervention in Suspected Placenta Accreta

Purpose: We investigated clinical and radiological predictors of bladder invasion and need for urological intervention in pregnant women with suspected placenta accreta. Methods: We conducted a retrospective study including pregnant women with ultrasonographic (US) suspicion of placenta accreta. Surgical and clinical data were reviewed, and seven US parameters were used to classify the patients. A single and expert radiologist reviewed Magnetic Resonance Imaging (MRI) and used nine parameters for classification. Chi-square, Fisher´s exact test or Mann-Whitney and logistic regression were used to calculate the risk of bladder invasion and need of cystorrhaphy for continuous variables. Results: Twenty-seven patients fulfilled all the inclusion criteria, and the histological diagnosis of placenta accreta, increta or percreta was performed in 5, 8 and 14 patients respectively. Regarding clinical data, the risk of placenta percreta increases 35.7% for each maternal year and three times for each cesarean section. Bilateral prophylactic double J catheter was attempted in all patients, but successful in 81,48%, mostly in percreta patients. There were signs of bladder invasion in 9 patients, all with placenta percreta. The risk of bladder injury suture increases by 26.41% for each maternal year, in the same way, increase 5.7 times for each cesarean section. Conclusion: Maternal age and number of cesareans are the only direct predictors of the depth of placental invasion and risk of urological intervention. None US or MRI parameters had a predictive role in the depth of invasion or to the risk of cystorrhaphy.

Traumatic Microbleeds in the Hippocampus and Corpus Callosum Predict Duration of Posttraumatic Amnesia.

Radiologic predictors of posttraumatic amnesia (PTA) duration are lacking. We hypothesized that the number and distribution of traumatic microbleeds (TMBs) detected by gradient recalled echo (GRE) magnetic resonance imaging (MRI) predicts PTA duration. Academic, tertiary medical center. Adults with traumatic brain injury (TBI). We identified 65 TBI patients with acute GRE MRI. PTA duration was determined with the Galveston Orientation and Amnesia Test, Orientation Log, or chart review. TMBs were identified within memory regions (hippocampus, corpus callosum, fornix, thalamus, and temporal lobe) and control regions (internal capsule and global). Regression tree analysis was performed to identify radiologic predictors of PTA duration, controlling for clinical PTA predictors. TMB distribution, PTA duration. Sixteen patients (25%) had complicated mild, 4 (6%) had moderate, and 45 (69%) had severe TBI. Median PTA duration was 43 days (range, 0-240 days). In univariate analysis, PTA duration correlated with TMBs in the corpus callosum (R = 0.29, P = .02) and admission Glasgow Coma Scale (GCS) score (R = -0.34, P = .01). In multivariate regression analysis, admission GCS score was the only significant contributor to PTA duration. However, in regression tree analysis, hippocampal TMBs, callosal TMBs, age, and admission GCS score explained 26% of PTA duration variance and distinguished a subgroup with prolonged PTA. Hippocampal and callosal TMBs are potential radiologic predictors of PTA duration.