Radiological Resolution Research Articles

Giant cell arteritis presenting as a stroke in the internal carotid artery territory: a case-based review.

Giant cell arteritis (GCA) is a large-vessel vasculitis, typically affecting the aorta and its branches. The involvement of vertebral and internal carotid arteries occurs in a limited number of cases, and stroke as a presenting symptom of GCA is extremely unusual: this subset of the disease has a poor prognosis and rarely responds to immunosuppression.We report the case of a 70-year-old woman, who presented to the Emergency Department for ischemic stroke, which appeared to be the first and only symptom of GCA. The prompt administration of steroids and tocilizumab (TCZ) led to clinical and radiological resolution, with no residual disability at 6-month follow-up.Our case-based review, highlighting the rarity of a large vessel vasculitis presenting only with a cerebrovascular accident, provides new evidence for the efficacy of TCZ even in more unusual varieties of GCA: in these cases, TCZ should be immediately prescribed, in order to prevent mortality and severe long-term morbidity.

Modelling the impact of plasma therapy and immunotherapy for recovery of COVID-19 infected individuals.

Since the first case of COVID-19 was detected in Wuhan, China in December 2019, COVID-19 has become a pandemic causing a global economic and public health emergency. There is no known treatment or vaccine available for COVID-19 during the initial period of the outbreak. Immunotherapy and plasma therapy has been used with satisfactory efficacy over the past two decades in many viral infections like SARS (Systemic Acute Respiratory Syndrome), MERS (Middle East Respiratory Syndrome) and H1N1. Limited data from China show clinical benefit, radiological resolution, reduction in viral loads and improved survival. We aim to create a mathematical model for COVID-19 transmission and then apply various control parameters to see their effects on recovery from COVID-19 disease. We have formulated a system of non-linear ordinary differential equations, calculated basic reproduction R_{0} and applied five different controls (self-isolation, quarantine, herd immunity, immunotherapy, plasma therapy) to test the effectiveness of plasma therapy. Control optimality was checked by Lagrangian functions. Numerical simulations and bifurcation analysis were carried out. The study concludes that the COVID-19 outbreak can be controlled up to a significant level in three weeks after applying all the control strategies together. These strategies lead to reduction in hospitalization and a rise in recovery from infection. Immunotherapy is highly effective initially in hospitalized infected individuals however better results were seen in the long term with plasma therapy.

Optimal drainage of anastomosis stricture after living donor liver transplantation.

Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). Patients with biliary ASs after an LDLT (mean age: 57.3years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3-4months. Patients were followed-up for at least 1-year post-stent removal. Of the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59). EBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.

Acute Fulminant Cerebellitis in Children with COVID-19 Infection: A Rare But Treatable Complication

Acute Fulminant Cerebellitis in Children with COVID-19 Infection: A Rare But Treatable Complication

Neurocysticercosis (NCC) in Children: A Review

Neurocysticercosis (NCC) is the commonest parasitic infestation of the brain caused by Taenia solium larvae and a preventable cause of epilepsy worldwide. NCC may be parenchymal or extraparenchymal, and its clinical presentation may vary based on the location, number, and host immuneresponse to the cysts. Seizures are more frequently seen in children, and single colloidal parenchymal cyst is the common radiologic finding in pediatric NCC. The diagnosis is generally by neuroimaging, a scolex within the cyst being pathognomic; however, serology may help when the neuroimaging is inconclusive. Initial treatment generally focuses on symptomatic management by antiepileptics and corticosteroids. Albendazole is the cysticidal drug of choice in most cases; praziquental is added for multiple lesions. The outcome depends on the type, location, number of lesions, seizure recurrences and radiologic resolution of the lesions. Single lesions have a better prognosis. In endemic areas, NCC should be a differential in any child presenting with recentonset seizures, headache, vomiting, or focal motor deficits, in the absence of another known neurological condition. Due to the potentially eradicable nature of cysticercosis, preventive measures need to be encouraged.

Spontaneous Thrombosis of Varicocele: a Diagnostic Conundrum for an Acute Scrotum

Spontaneous thrombosis of varicocele is an extremely rare cause of acute scrotal swelling. Herein, we report a case of same in a young adult serving soldier ofIndian army who presented to the emergency department with a history of sudden onset left scrotal swelling of 2 days duration. There was no history of trauma. All his haematological and biochemical parameters were normal except elevated hepatic enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). The diagnosis was clinched on colourdoppler flow imaging (CDFI) and ultrasonography (USG) of the testis and scrotum. He was managed conservatively with complete clinical and radiological resolution within 2 weeks.

Striatal Atrophy and Hypometabolism in Drug-Resistant Non-Ketotic Hyperglycemic Chorea-Ballism.

Non-ketotic hyperglycemic chorea-ballism (NKHCB) is a rare movement disorder associated with poorly controlled type-2 diabetes,1 in the majority of cases characterized by: unilateral hemicorea-hemiballism, contralateral striatum hyperintensity on T1-weighted magnetic resonance imaging (MRI), and clinical and radiological improvement after blood glucose correction.2 Herein, we present a case of NKHCB with following evidence of striatal atrophy. A 56-year-old woman presented to the emergency department of another hospital because of sudden onset of involuntary movements of the left limbs attenuated during rest. She had a recent history of type-2 diabetes mellitus treated with poor glycemic control. A computed tomography scan showed striatal hyperdensity. Routine laboratory findings were normal, despite a fasting blood glucose level of 167 mg/dL and glycate hemoglobin level of 130 mmol/mol (14%). MRI scan showed striatal T1-weighted hyperintensity with a corresponding hyperintensity in T2-weighted (Fig. 1A and B) and fluid attenuated inversion recovery (FLAIR) scans. The patient was diagnosed with NKHCB. Glucose control was optimized and anti-choreic therapy was started with haloperidol 5 mg/day and tetrabenazine 25 mg/day with a slight clinical benefit. The patient arrived at our attention 4 months after symptom onset for diagnostic re-evaluation. The motor impairment persisted and involuntary movements worsened insidiously. The neurological examination showed choreoatetosic and ballic movements of the left body side. Involuntary movements increased with distraction maneuvers and resolved during rest at bed. Blood fasting glucose was 126 mg/dL and glycated hemoglobin was 62 mmol/mol (7.8%). MRI scan showed the resolution of the striatal alteration, but highlighted atrophic evolution (Fig. 1C and D). A fluorodeoxyglucose positron emission tomography scan showed an intense hypometabolism consistent with morphological MRI atrophy findings (Fig. 1E and F). Haloperidol was discontinued and clinical improvement was obtained with tetrabenazine 25 mg thrice/day, piracetam 3 g/day and topiramate 25 mg twice/day. The comparison of MRI volumes at the two timepoints showed, on the right side, a decrease in caudate head and putamen volumes and an increase in the lateral ventricle volume. The two main pathophysiological mechanisms proposed for NKHCB are related to metabolic dysfunction and to microvascular damage.3, 4 Our findings may be explained by irreversible metabolic or vascular damage. The microvascular hypothesis might explain the prevalent unilateral clinical onset. The prognostic implication of our observation is related to the high variability in outcomes.1 Extended lesions at MRI were associated with prolonged involuntary movements.5 Our findings of focal atrophy strengthen these results, suggesting a role of the pathological disease severity, in-vivo assessed by MRI, to determine the persistence of the disorder. We hypothesize that a mild disorder, solved with anti-chorea treatment, might be associated with a lower degree of atrophy, unrecognized without a volumetric analysis. In conclusion, our case of NKHCB showed focal striatal atrophy and hypometabolism after radiological resolution in a 4-month follow-up, associated with poor response to glucose-control and anti-chorea treatment. To date, for the first time we documented nuclear volume changes with a quantitative approach demonstrating irreversible pathological changes in NKHCB, explaining drug-resistant cases. (1) Research project: A. Conception, B. Organization, C. Execution. (2) Statistical Analysis: A. Design, B. Execution, C: Review and Critique. (3) Manuscript: A. Writing of the first draft, B. Review and Critique. P.G.S.: 1A, 1B, 1C, 2A, 2B, 3A F.A.: 1A, 1B, 2C, 3B N.A.: 1C, 3B M.A.V.: 1A, 1B, 1C, 2C, 3B M.F.: 1A, 1B, 2C, 3B This study has been approved by the Ethics Committee of IRCCS San Raffaele Hospital and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The patient provided written informed consent to be anonymously included in this report. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. No funding was received for this work and the authors have no conflicts of interest to report. P.G. Scamarcia, N. Anzalone, and M.A. Volontè have nothing to disclose. F. Agosta is Section Editor of NeuroImage: Clinical; has received speaker honoraria from Philips, Novartis and Biogen Idec; and receives or has received research supports from the Italian Ministry of Health, AriSLA (Fondazione Italiana di Ricerca per la SLA), and the European Research Council. M. Filippi is Editor-in-Chief of the Journal of Neurology; received compensation for consulting services and/or speaking activities from Bayer, Biogen Idec, Merck-Serono, Novartis, Roche, Sanofi Genzyme, Takeda, and Teva Pharmaceutical Industries; and receives research support from Biogen Idec, Merck-Serono, Novartis, Roche, Teva Pharmaceutical Industries, Italian Ministry of Health, Fondazione Italiana Sclerosi Multipla, and ARiSLA (Fondazione Italiana di Ricerca per la SLA).

Follow-Up Study of the Chest CT Characteristics of COVID-19 Survivors Seven Months After Recovery.

Background: It has remained a concern whether any long-term pulmonary sequelae exist for COVID-19 survivors.Methods: Forty-one patients (22 men and 19 women, 50 ± 14 years) confirmed with COVID-19 performed follow-up chest CT and cardiopulmonary exercise testing at 7 months after discharge. Patients were divided into fibrosis group and non-fibrosis group according to the evidence of fibrosis on follow-up CT. The clinical data and the CT findings were recorded and analyzed.Results: The predominant CT patterns of abnormalities observed at 7 months after discharge were parenchymal band (41%), interlobular septal thickening (32%), and traction bronchiectasis (29%). Sixty-one percent of the patients achieved complete radiological resolution, and 29% of patients developed pulmonary fibrosis. Compared with the patients in the non-fibrosis group, the patients in the fibrosis group were older, with a longer hospital stay, a higher rate of steroid and mechanical ventilation therapy, lower levels of lymphocyte and T cell count, higher levels of D-dimer and lactic dehydrogenase, and higher quantitative CT parameters (opacity score, volume of opacity, and percentage of opacity) at discharge. Besides, oxygen consumption and metabolic equations were decreased and ventilatory equivalent for carbon dioxide was increased in patients in the fibrosis group. Logistic regression analyses revealed that age, steroid therapy, presence of traction bronchiectasis on chest CT at discharge, and opacity score at discharge, were independent risk factors for developing pulmonary fibrosis at 7 months after discharge. Receiver operating characteristic analysis revealed that the combined clinical-radiological model was better than the clinical-only model in the prediction of pulmonary fibrosis.Conclusions: The chest CT lesions could be absorbed without any sequelae for most patients with COVID-19, whereas older patients with severe conditions are more prone to develop fibrosis, which may further lead to cardiopulmonary insufficiency. The combined clinical-radiological model may predict the formation of pulmonary fibrosis early.

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series.

In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality. To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children. We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6years, median weight 7.2kg. Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3mL/kg in the first 24h, and 13.4mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21days (range 4-57days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease. Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.

Six-month Follow-up Chest CT Findings after Severe COVID-19 Pneumonia.

BackgroundLittle is known about the long-term lung radiographic changes in convalescent COVID-19 patients, especially the severe cases.PurposeTo prospectively assess pulmonary sequelae and explore the risk factors for lung fibrotic-like changes on six-month follow-up chest CT of survivors of severe COVID-19 pneumonia.Materials and Methods114 patients (80[70%] men; mean age, 54±12 years) were studied prospectively. Initial and follow-up CT scans were obtained on 17±11 days and 175±20 days respectively after symptom onset. Lung changes (opacification, consolidation, reticulation, and fibrotic-like changes) and CT extent scores (score per lobe, 0-5; maximum score, 25) were recorded. Patients were divided into two groups: group#1 presence and group#2 absence of CT evidence of fibrotic-like changes (traction bronchiectasis, parenchymal bands, and/or honeycombing) based on their six-month follow-up CT. Between-group differences were assessed by Fisher’s exact test, two-sample t-test or Mann-Whitney U test. Multiple logistic regression analyses were performed to identify the independent predictive factors of fibrotic-like changes.ResultsOn follow-up CT, evidence of fibrotic-like changes was observed in 40/114 (35%) of patients (group#1), while the remaining 74/114 (65%) patients (group#2) showed either complete radiological resolution (43/114, 38%) or residual ground-glass opacification or interstitial thickening (31/114, 27%). Multivariable analysis identified age >50 years (odds ratio [OR]:8.5, 95%CI:1.9-38, p=.01), heart rate >100bpm at admission (OR:5.6, 95%CI:1.1-29, p=.04), duration of in-hospital stay ≥17 days (OR:5.5, 95%CI:1.5-21, p=.01), and acute respiratory distress syndrome (OR:13, 95%CI:3.3-55, p<.001), non-invasive mechanical ventilation (OR:6.3, 95%CI:1.3-30, p=.02) and total CT score ≥18 (OR:4.2, 95%CI:1.2-14, p=.02) on initial CT as independent predictors for lung fibrotic-like changes at 6 months.ConclusionsSix-month follow-up CT showed lung fibrotic-like changes in more than one-third of patients who survived severe COVID-19 pneumonia. These changes were associated with an older age, acute respiratory distress syndrome, longer in-hospital stays, tachycardia, non-invasive mechanical ventilation and higher initial chest CT score.See also the editorial by Wells, Devaraj, and Desai.

The Use of Mucolytic Agent in Percutaneous Drainage of Liver Abscess: A Case-Series Analysis.

Background: Liver abscess is a scarce but potentially fatal suppurative process. There is a general tendency for minimally invasive treatment, such as broad-spectrum antibiotherapy and percutaneous drainage. Multiloculated, multiple or incompletely liquefied abscesses often limit the efficacy of percutaneous drainage. This study aims to assess the effectiveness of percutaneous drainage and intracavitary instillation of a mucolytic agent for liver abscesses. Material and method: From our department database, we have identified patients with liver abscess admitted during the period 2015 - 2020, treated by ultrasound-guided percutaneous drainage and intracavitary instillation of mucolytic agent. Data regarding imaging appearance, drainage technique, inflammatory markers and clinical course were assessed. Results: Twenty-one patients with multiloculated liver abscesses, sized 8 to 17 cm, were percutaneously drained, with local anaesthesia, under ultrasound guidance. The bacteriological exam of the aspirate showed bacterial infection in 19 cases, mostly Klebsiella pneumoniae, and 2 fungal infections. Acetylcysteine in dilution 1: 1 with saline was instilled daily on the 12F or 14 F drainage catheter. Clinical and radiological resolution was achieved within 14 to 29 days. Two cases required supplementary drainage of a non-communicating residual cavity. There were no complications, periprocedural deaths or relapse at 3 months follow-up. Conclusions: Percutaneous drainage is effective even in the management of multiloculated liver abscesses, facilitated by the use of intracavitary mucolytic agent.

Prevalence and Risk Factors of Posterior Reversible Encephalopathy Syndrome in Isfahan, Iran.

Background:Posterior reversible encephalopathy syndrome (PRES) is a rare clinical-radiological syndrome characterized by such symptoms as headaches, altered consciousness, blurred vision, seizure, and focal neurological deficits. We herein present well-documented PRES cases and discuss the risk factors and characteristic imaging patterns of this syndrome.Materials and Methods:We prospectively examined 31 patients with PRES in Alzahra Hospital, Isfahan, Iran, and compared the underlying diseases of PRES in terms of their clinical features and cranial magnetic resonance imaging (MRI) findings.Results:The most common underlying disease was hypertension (90.3%), followed by systemic lupus erythematosus (32.3%), preeclampsia (25.8%), chronic renal failure (22.6%), and rheumatoid arthritis (22.6%). Interestingly, we also reported heroin abuse as a possible risk factor for PRES (9.7%). The most frequent clinical signs were headaches (54.8%), seizure (54.8%), and blurred vision (35.5%). The most frequent lesions on cranial MRI were in the parieto-occipital area (87.1%), followed by the cerebellum (19.4%) and the frontal lobe (12.9%). Other abnormalities on MRI were less common. In addition, 16.1% of the study population had vasospasm on magnetic resonance arteriography (MRA). Clinical recovery was followed by radiological resolution in all the patients.Conclusions:The clinical presentation is nonspecific, most patients present with a combination of symptoms, particularly headaches and seizure. MRI is crucial for the diagnosis of PRES, and MRA is useful in that it can identify associated vasospasm. Timely diagnosis and treatment are required to avoid a devastating outcome.

Mild encephalopathy with reversible extensive white matter lesions in a child with acute adenoviral infection and a literature review

Mild encephalopathy with a reversible splenial lesion (MERS) is a known clinical-radiological description. However, MERS with extensive lesions (MERS type-2) is rarely associated with adenovirus. There are only three published cases of MERS type-2 associated with adenovirus infection. We present a 10-year-old previously healthy girl who presented with speech difficulty and mild encephalopathy after three days of prodromal illness. The magnetic resonance imaging (MRI) revealed bilateral diffusion restriction in the parietal white matter, splenium and genu of the corpus callosum without mass effect and slight thickening at the splenium of corpus callosum with no contrast enhancement. With empirical and support treatment, her neurological examination was completely normal by the 18th hour. The nasopharyngeal respiratory adenoviral PCR resulted positive. She was discharged with total clinical and radiological resolution on the 10th day of admission. The case was diagnosed with MERS type-2 which is rarely associated with adenoviral infection. This report is the first case of adenovirus related MERS type-2 in a Turkish child. Pediatricians, child neurologists, child infection specialists and radiologists should recognize this condition to ensure appropriate diagnosis.

Syringomyelia Resolution Following Chiari Surgery: A Novel Scale for Communication and Research.

The pathophysiological connection between Chiari malformation and syringomyelia is accepted. Debate remains, however, how can we best define changes in syringomyelia following surgery. To introduce a grading system focusing on syrinx reduction based on routinely and reproducible radiological information, and provide a suggestion of the application of this scale for prediction of patient's prognoses. Data from 48 patients with Chiari malformation and syringomyelia were compiled. We calculated syrinx cross-sectional area by approximating an ellipse in the largest axial plane. We compared the percentage of reduction or enlargement following surgery. The percentage change was grouped into four grades: Grade 0=Increasing size, grade I≤50% reduction, grade II=50% to 90% reduction, grade III≥90% reduction. A total of 89.6% of patients had syrinx improvement after surgery. A total of 5 patients were grade 0, 14 were grade I, 20 patients were grade II, and 9 patients met criteria for grade III. The mean postoperative syrinx area was 24.1mm2 (0-169mm2) with a mean syrinx reduction of 62.7%. Radiological improvement of syringomyelia can be mathematically defined and standardized to assist in communication in outcome-based trials. Radiological resolution is expected most patients.

Adding steroids in severe community-acquired pneumonia treatment

Background Community-acquired pneumonia (CAP) is the most serious respiratory infection and the leading cause of death from infectious disease around the world. Objective The aim of this study was to evaluate the impact of adjuvant systemic steroids on mortality, complications, and duration of hospitalization in severe CAP. Patients and methods In a cross-sectional, randomized, controlled clinical trial conducted in the Chest Department at the Respiratory Intensive Care Unit during the period between September 2017 and September 2018. Patients were diagnosed as having severe CAP rapidly assessed by infectious disease society of America/American thoracic society (IDSA/ATS) 2007 were included in this study. Results A total of 50 patients were included in this study. These patients were randomly divided into two groups: Group I (steroid group), and group II (control group). The mean age was 55±16.01 and 58.8±20.92 years, respectively. The use of steroids in the treatment of severe CAP is associated with significant improvement in renal, liver, and erythrocyte sedimentation rate parameters with more rapid clinical, radiological, and ultrasonographic resolution. There was a significant reduction in time to clinical stability in group I compared with group II (4.35±1.24 vs 6.54±1.99 days; P=0.02). However, steroid therapy do not affect the duration of ICU stay, need of noninvasive or invasive mechanical ventilation, and duration of hospitalization. Conclusion Adding steroids in severe CAP treatment significantly decreases both complications and mortality.

Experience managing distal ureteral strictures with Boari flap-psoas hitch and comparison of open and laparoscopic procedures

BackgroundTo summarize our experience with the Boari flap-psoas hitch and compare the indications, perioperative data and outcomes between open and laparoscopic procedures.MethodsThis study retrospectively reviewed 35 patients with complex distal ureteral stricture between January 2015 and April 2019. All patients were treated with Boari flap-psoas hitch by either an open or a laparoscopic procedure. Selection criteria were based on the etiology, comorbidities, medical history, and patient preference.ResultsAll surgeries were performed successfully. The median operation time was 201 min (range, 120 to 300 min), and the median estimated blood loss was 50 mL (range, 20 to 400 mL). The median postoperative hospitalization was 9 days (range, 3 to 46 days). Nineteen patients were treated by the open procedure, and 16 were treated by the transperitoneal laparoscopic procedure. The surgical indication of open surgery was broader than that for laparoscopic surgery. For patients experiencing iatrogenic injury and ureterovesical reimplantation failure, no significant differences in sex, laterality, operative time, ASA score or postoperative hospitalization stay were observed between the two groups. The median estimated blood loss was lower in the laparoscopic group than in the open group (P=0.047). Patients in the open group had more surgical complications than patients in the laparoscopic group (P=0.049). The postoperative follow-up showed the radiological resolution of hydronephrosis in 33 patients.ConclusionsWith the appropriate surgical considerations, Boari flap-psoas hitch is a valid method to bridge distal ureteral defects. For select patients, laparoscopic surgery had advantages being a minimal invasive surgery with less estimated blood loss and fewer surgical complications.

Epilepsy Outcomes and Hippocampal Volumes in Children with Multiple Parenchymal Neurocysticercoses.

ABSTRACTBackground:We aimed to study the radiological and epilepsy outcomes of children with multiple neurocysticercosis (NCC) and the relationship with hippocampus volume.Study Design:Observational study.Materials and Methods:Children between 5 and 18 years of age with NCC lesions and completed more than 2-year follow-up were enrolled. Magnetic resonance imaging (MRI) brain with a predefined protocol was done as per clinical indication, and bilateral hippocampi volume was measured with a region of interest-based manual method. Proportion of children who had radiological resolution of lesions, proportion of children who were seizure-free for at least 3 months after antiepileptic drugs withdrawal, and mean hippocampi volume were calculated.Results:During the study period, 229 children followed up in pediatric NCC clinic were enrolled, the mean age was 10.5 ± 3 years, and 129 (56%) were boys. A total of 159 (65%) children had single-lesion NCC, and 79 (35%) had multiple lesion (> 2) NCC. Resolution of lesions was seen in 8% children with multiple NCC, significantly less as compared to the single NCC group (8% vs. 27%, P = 0.006). Multiple-lesion NCC group had a higher rate of calcification as compared to children with a single lesion (66% vs. 47%, P = 0.008). Twenty-nine (37%) children with multiple-lesion NCC were seizure free for at least 3 months after antiepileptic drug withdrawal. Mean combined hippocampal volume in children with single-lesion NCC was 2.96 (0.62) mL and multiple-lesion NCC was 2.88(0.43) mL.Conclusion:Children with multiple-lesion NCC have lower resolution, and higher calcification during follow-up in comparison to single-lesion NCC. Frequency of children who remained seizure-free 3-month post AED withdrawal was similar in single- and multiple-lesion groups.

Effects of proprotein convertase subtilisin/kexin type-9 inhibitors on fatty liver.

BACKGROUNDMany studies have investigated the progression of nonalcoholic fatty liver disease (NAFLD) and its predisposing risk factors, but the conclusions from these studies have been conflicting. More challenging is the fact that no effective treatment is currently available for NAFLD.AIMTo determine the effects of proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitors on fatty infiltration of the liver.METHODSThis retrospective, chart review-based study was conducted on patients, 18-year-old and above, who were currently on PCSK9 inhibitor drug therapy. Patients were excluded from the study according to missing pre- or post-treatment imaging or laboratory values, presence of cirrhosis or rhabdomyolysis, or development of acute liver injury during the PCSK9 inhibitor treatment period; the latter being due to false elevation of liver function markers, alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Radiographic improvement was assessed by a single radiologist, who read both the pre- and post-treatment images to minimize reading bias. Fatty infiltration of the liver was also assessed by changes in ALT and AST, with pre- and post-treatment levels compared by paired t-test (alpha criterion: 0.05).RESULTSOf the 29 patients included in the study, 8 were male (27.6%) and 21 were female (72.4%). Essential hypertension was present in 25 (86.2%) of the patients, diabetes mellitus in 18 (62.1%) and obesity in 15 (51.7%). In all, patients were on PCSK9 inhibitors for a mean duration of 23.69 ± 11.18 mo until the most recent ALT and AST measures were obtained. Of the 11 patients who received the radiologic diagnosis of hepatic steatosis, 8 (72.73%) achieved complete radiologic resolution upon use of PCSK9 inhibitors (mean duration of 17.6 mo). On average, the ALT level (IU/L) decreased from 21.83 ± 11.89 at pretreatment to 17.69 ± 8.00 at post-treatment (2-tailed P = 0.042) and AST level (IU/L) decreased from 22.48 ± 9.00 pretreatment to 20.59 ± 5.47 post-treatment (2-tailed P = 0.201).CONCLUSIONPCSK9 inhibitors can slow down or even completely resolve NAFLD.

Clinico-radiological Profile of Posterior Reversible Encephalopathy Syndrome and Its Associated Risk Factors in PICU: A Single-center Experience from a Tertiary Care Hospital in Bhubaneswar, Odisha.

ObjectivePosterior reversible encephalopathy syndrome (PRES) is a clinico-radiographic entity of heterogeneous etiologies having similar clinical and neuroimaging features. Pediatric data are sparse, making early diagnosis challenging, which needs a high index of suspicion. So, we conducted this study to evaluate clinico-radiological features, associated risk factors, etiology, and outcome in children.Materials and methodsThis is a retrospective case series of patients, diagnosed as having PRES and followed up at a tertiary care hospital in Eastern India between September 2016 and December 2019.ResultsAmong 16 patients with a median age of 9.5 years [interquartile range (IQR) 8–13.75] and a male preponderance (75%), common underlying diseases were post-streptococcal glomerulonephritis (56.3%) and renovascular hypertension (12.5%). Acute elevation of blood pressure was found in all patients (n = 16). The neurological symptom was seizure (87.5%), mental changes (68.75%), headache (43.8%), vomiting (31.3%), and visual disturbances (31.3%). The most common triggering factor was hypertension (100%), use of mycophenolate mofetil and prednisolone (12.5%), and hemodialysis (12.5%). Anemia was present in 15 (93.4%) patients at the time of admission. All showed abnormal neuroimaging with 55% having atypical involvement. The most common site was the parietal-occipital cortex (88%), frontal and temporal lobe (44% cases each), and the cerebellum (13%). Clinical recovery was followed by a radiological resolution in all survived except in one, who developed visual impairment.ConclusionPosterior reversible encephalopathy syndrome should be considered in the differential diagnosis of patients who present with acute neurological disturbances and underlying diseases such as renal disorders, vasculitis, malignancy, and use of immunosuppressant accompanied by hypertension. Early diagnosis and treatment of comorbid conditions are of paramount importance for the early reversal of the syndrome.How to cite this articleBehera CK, Jain MK, Mishra R, Jena PK, Dash SK, Sahoo RK. Clinico-radiological Profile of Posterior Reversible Encephalopathy Syndrome and Its Associated Risk Factors in PICU: A Single-center Experience from a Tertiary Care Hospital in Bhubaneswar, Odisha. Indian J Crit Care Med 2020;24(12):1223–1229.

Diagnostic accuracy of cardiac computed tomography and 18F-fluorodeoxyglucose with positron emission tomography/computed tomography in cardiac masses

Abstract Background Understanding the nature of cardiac masses represents a challenge for clinicians in order to select the appropriate therapeutic strategies. The diagnostic accuracy of cardiac computed tomography (CT) and 18F-fluorodeoxyglucose (18F-FDG) with positron emission tomography/CT (PET/CT) in identifying the nature of cardiac masses has not been evaluated before in a large population. Purpose To assess the diagnostic value of CT and 18F-FDG PET/CT in defining the nature of cardiac masses, integrating morphologic features and metabolic activity. Methods Out of 223 we selected a final cohort 60 patients which underwent cardiac CT scan and 18F-FDG PET/CT. All masses had histological certain, apart from thrombi, in which was defined radiologic resolution after adequate anticoagulant treatment. For each mass, eight morphologic CT signs and standardized uptake value (SUVmax, SUVmean), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) in 18F-FDG PET, were evaluated. Results Twenty patients had benign cardiac masses and 40 patients malignant cardiac masses. Irregular tumour margins, pericardial effusion, invasions, solid nature of the mass, mass diameter, TC contrast up-take and pre-contrast characteristics were strongly associated with the malignant nature of cardiac masses (p&amp;lt;0.001). Additionally, the presence of at least four CT signs was able to discriminate malignancies, withsensitivity of 95% and specificity of 95% (AUC=0.988, 95% CI 0.969–1). The mean value of SUVmax, SUVmean, MTV and TLG was significantly higher in malignant cardiac masses than in benign lesions (p&amp;lt;0.001). ROC curve for diagnostic accuracy of 18F-FDG PET/CT parameters in detecting malignant lesions showed an excellent performance of SUV (AUC=0.948, 95% CI 0.891–1), MTV (AUC=0.928, 95% CI 0.841–1) and TLG (AUC=0.961, 95% CI 0.902–1). Conclusions In patients with cardiac masses, cardiac computed tomography and 18F-FDG PET/CT findings provide independent and incremental prognostic information regarding their nature. A systematic use of CT and 18F-FDG PET/CT is therefore useful for diagnostic and therapeutic purposes. PET-CT evaluation of cardiac masses Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): S. Orsola Malpighi Hospital, University of Bologna