Small Clots Research Articles

Epidemiology of clinically unsuspected venous thromboembolism in children with cancer: A population-based study from Maritimes, Canada.

Inconsistencies in the definition of clinically unsuspected venous thromboembolism (VTE) in pediatric patients recently led to the recommendation of standardizing this terminology. Clinically unsuspected VTE (cuVTE) is defined as the presence of VTE on diagnostic imaging performed for indications unrelated to VTE in a patient without symptoms or clinical history of VTE. The prevalence of cuVTE in pediatric cancer patients is unclear. Therefore, the main objective of our study was to determine the prevalence of cuVTE in pediatric cancer patients. All patients 0-18years old, treated at the IWK in Halifax, Nova Scotia, from August 2005 through December 2019 with a known cancer diagnosis and at least one imaging study were eligible (n=743). All radiology reports available for these patients were reviewed (n=18,120). The VTE event was labeled a priori as cuVTE event for radiology reports that included descriptive texts indicating a diagnosis of thrombosis including thrombus, central venous catheter-related, thrombosed aneurysm, tumor thrombosis, non-occlusive thrombus, intraluminal filling defect, or small fragment clot for patients without documentation of clinical history and or signs of VTE. A total of 18,120 radiology reports were included in the review. The prevalence of cuVTE was 5.5% (41/743). Echocardiography and computed tomography had the highest rate of cuVTE detection, and the most common terminologies used to diagnose cuVTE were thrombus and non-occlusive thrombus. The diagnosis of cuVTE was not associated with age, sex, and type of cancer. Future efforts should focus on streamlining radiology reports to characterize thrombi. The clinical significance of these cuVTE findings and their application to management, post-thrombotic syndrome, and survival compared to cases with symptomatic VTE and patients without VTE should be further studied.

Successive Development and Rupture of Blister-Like Anterior Communicating Artery Aneurysms at Mirror Locations.

This is the first report of the successive development and rupture of blister-like anterior communicating artery (ACoA) aneurysms at mirror locations with a short interval. A 49-year-old man presented with an angiogram-negative subarachnoid hemorrhage with significant basal frontal interhemispheric blood. Surgical exploration revealed a blister-like aneurysm on the left side of the superior wall of the ACoA, which was treated using a microsuturing technique. On the 18th day after the initial subarachnoid hemorrhage, the second operation due to another angiogram-negative hemorrhage revealed a de novo blister-like aneurysm with a small blood clot on the posterosuperior wall of the ACoA close to the right A1/A2 junction. The rupture point and ACoA on the right side were occluded using an aneurysm clip. Follow-up digital subtraction angiogram (DSA) at 4 years and computed tomography angiogram (CTA) at 14 years after the surgery showed no recurrence or associated abnormality.

Gastrointestinal Tract and Kidney Injury Pathogenesis in Post-COVID-19 Syndrome.

COVID-19 is a global health emergency that requires worldwide collaboration to control its spread. The scientific community is working to understand the different aspects of the post-COVID-19 syndrome and potential treatment strategies. Interestingly, there have been reports of gastrointestinal tract (GIT) involvement in the post-COVID-19 syndrome, suggesting the presence of both severe and mild GIT disorders. The development of the post-COVID-19- GIT syndrome involves various factors, such as impaired GIT mucosa cells, disruptions in the feeling of satiety, reduced blood supply due to the formation of small blood clots, and increased prostaglandin secretion caused by an excessive immune response. GIT symptoms have been observed in around 16% of COVID-19 patients. Other complications include kidney damage and prolonged impairment in the filtration and excretion functions of the glomeruli and tubules. The pathogenesis of post-COVID-19 renal syndrome involves factors, like an overactive immune response, reduced lung perfusion and oxygenation, viral infection in kidney tissues, endothelial dysfunction, and decreased blood volume. Roughly 20% of hospitalized patients experience renal manifestations after recovering from COVID-19.

Research Progress in Regulatory Mechanism of Valproic Acid on Inflammatory Responses to Burns and Trauma

Inflammation plays an important role in the defense of the human body. The inflammatory response can suppress the spread of pathogens, accelerate the removal of necrotic cells, and repair the damaged tissues and organs. However, an excessive inflammatory response can be fatal as it may lead to cellular apoptosis, necrosis of tissues and organs, and systemic dysfunction. An inflammatory response occurs when the skin is burned or injured, causing more severe and extensive pathological damage to the injured area. For example, inflammation can damage the coagulation system in the capillaries, resulting in the formation of small blood clots in the affected areas. In severe cases, inflammation can lead to necrosis of the injured area and may even affect other uninjured areas, causing hypoxia and inadequate blood supply. The role of valproic acid (VPA), a histone deacetylase inhibitor, has been increasingly recognized in recent years. Evidence suggests that VPA can effectively alleviate tissue and organ injuries secondary to ischemia and hypoxia, and improve the body’s tolerance to ischemia-hypoxia and inflammatory insults, thus increasing the survival rates of the patients. This article reviews the latest research progress made in the mechanisms by which VPA regulates inflammatory response to burns.

Abstract WP189: TIGER Study: Effectiveness and Safety of Tigertriever Are Maintained When Treating Large Clot Size

Introduction: Larger volume thrombi are associated with a lower probability of functional independence defined as a modified Rankin Score (mRS) ≤2 and a higher number of retrieval attempts. A subanalysis of the TIGER study data was performed in order to assess the effectiveness and safety of Tigertriever in small and large clot sizes. Methods: The TIGER study was a single arm, prospective, multi-center trial assessing the efficacy and safety of the Tigertriever, a radially-adjustable stent retriever, for LVO-related stroke. The trial enrolled 160 subjects, of which 150 had successful mTICI 2b-3 revascularization (94%) at end of all procedures. The interventionalists evaluated the clot length angiographically prior to the treatment, and analysis was performed to compare the Tigertriever performance in short clots with long clots. Results: Data is available from 135 (78 males) out of the 160 subjects enrolled in the study.The median clot length was 9mm with a range of 1-50mm. Subjects were divided into two subgroups: Group A; subjects with small clot length, ≤9mm (n=69) and group B, subjects with large clot length, >9mm (n=66). Baseline NIHSS was significantly smaller in group A compared to group B (16.9 vs.19, respectively, P=0.02). Median clot size in group A was 6.1mm and 16.5mm in group B. The mean number of passes with Tigertriever to achieve successful revascularization (mTICI 2b-3) was slightly higher in group B, but not statistically different (1.7 in group A vs. 2 in group B, P=0.07). First pass effect (63% vs. 50% NS), good clinical outcome (62% vs. 53% NS), sICH (1.4% vs. 3% NS) and ENT (Embolization to new territory 2.9% vs. 1.5% NS) were comparable in group A and group B, respectively. Conclusions: Despite the impaired neurological functioning as indicated by significantly higher baseline NIHSS in subjects admitted with larger clot length, Tigertriever efficacy and safety were maintained when treating these large clots compared to small clots.

Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden.

The optimal primary recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) remains controversial. We aimed to explore the safety and efficacy of balloon angioplasty as the first-choice recanalization strategy for ICAS-ELVO with small clot burden. Consecutive ICAS-ELVO patients presenting with microcatheter "first-pass effect" during endovascular treatment (EVT) were retrospectively analyzed. Patients were divided into preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT) groups based on the first-choice recanalization strategy. The reperfusion and clinical outcomes between the two groups were compared. Seventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in the PMT group, those in the PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p = .010) and complete reperfusion (expanded thrombolysis in cerebral ischemia ≥ 2c; 76.0% vs. 53.8%, p = .049), (ii) shorter puncture-to-recanalization time (49.5min vs. 89.0min, p < .001), (iii) lower operation costs (¥48,499.5 vs. ¥ 99,086.0, p < .001), and (iv) better 90-day functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p = .032). Logistic regression analysis revealed that balloon angioplasty as the first-choice recanalization strategy was an independent predictor of 90-day excellent functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" (adjusted odds ratio = 6.01, 95% confidence interval: 1.15-31.51, p = .034). Direct balloon angioplasty potentially improves 90-day functional outcomes for ICAS-ELVO patients with small clot burden, and may be a more appropriate first-choice recanalization strategy than mechanical thrombectomy for these patients.

Synergistic effect of innovative bentonite and poly aluminum chloride (PAC) combination for excess and digested sludge thickening and dewatering

Urban wastewater sludge dewatering is one of the challenging issues that wastewater treatment plants face today and needs sustainable solutions. This study aimed to evaluate the effectiveness of the bentonite and poly aluminum chloride (PAC) combination as physical and chemical conditioners for sludge conditioning. This research has shown that the optimal dose for conditioning untreated excess and anaerobically digested sludge is a 0.3% PAC-to-bentonite ratio (1.8 g/g PAC + 6 g/g bentonite for anaerobically digested sludge and 0.324 g/g PAC + 1.08 g/g bentonite for biological excess sludge). Additional tests on extracellular polymeric substances proved that this method can significantly affect parameters such as total organic carbon, protein, and polysaccharides in sludge samples. It was found that time to filtration and specific resistance to filtration parameters were also reduced by 78% and 72% in anaerobically digested sludge and by 90% and 66% in untreated excess sludge respectively when this combination was used. Significant changes in other parameters such as sludge particle size, zeta potential, and others demonstrate the effect of PAC and bentonite combination on sludge types. In addition, the cost for preparing the solutions of both polymers at the considered optimal concentrations was calculated. For each ton of conditioned sludge, the cost ranges between 77$ and 94$. It has been demonstrated that the combination of bentonite and PAC, along with other conventional materials such as acidic modified bentonite, facilitates the dewatering process effectively despite the smaller clots in the sludge after conditioning, which reduces the porosity of the sludge and prevents dewatering.

Investigation of the Effects of an Inferior Vena Cava Filter and Captured Clot Size on the Hemodynamic Parameters in Non-Newtonian Turbulent Pulsatile Blood Flow

In this computational fluid dynamics (CFD)-based study, the effects of inferior vena cava (IVC) filter implantation on the risk of IVC thrombosis have been investigated using different hemodynamic parameters, including time-averaged wall shear stress (TAWSS), the oscillating shear index (OSI), and the relative residence time (RRT). The boundary conditions in this study have been based on physiological pulses. Additionally, the k–ω model and the Carreau model have been chosen to represent the turbulent flow regime and non-Newtonian blood, respectively. For this purpose, three blood clots with the largest cross-sectional diameters of 30%, 50%, and 70% of the filter diameter have been used. Capturing a small clot in the filter has the minimum effect on the hemodynamic parameters, while by increasing the size of the captured clot, OSI and RRT parameters increase in areas downstream of the filter on the wall. The presence of a filter and clot increases the risk of thrombosis. In the case of capturing large clots, there is the possibility of damage to endothelial cells or platelet activation. Captured clots lead to the formation of plaque and thrombus on the IVC wall. However, the possibility of thrombus growth on its surface is not negligible, particularly if larger clots are trapped in the filter.

C3 (Clinical Case) Late Presentation of Radial Nerve Palsy Secondary to Extravasation of Peripherally Inserted Catheter in a Neonate: What Paediatricians Need to Know

Abstract Introduction/Background Peripherally inserted central catheters (PICC) are an essential and common procedure in neonatal intensive care units (NICUs). Peripheral nerve injuries secondary to PICC extravasation are a rare occurrence in neonates, who commonly recover with no sequalae. Rarely, extravasation results in compression and ischemia involving adjacent nerves, muscles or joints. Peripheral nerve injury may be induced by compression from tissue infiltration or irritation by the infiltrate. Timely diagnosis and treatment are essential to avoid complex or irreversible nerve damage, such as compartment syndrome, requiring extensive interventions. Isolated radial nerve injury in infants and neonates is limited to a few cases reported in the literature, which have been commonly related to in-utero compression or birth injury due to peripheral positioning. We report a late presentation of an isolated radial nerve injury secondary to PICC extravasation in a preterm infant, leading to neuropraxia and long-term impairment of hand function. Case Description An extreme preterm female infant (245/7 weeks’ gestation, 640 grams) was admitted to the NICU with a complex neonatal course. At 6 days after birth, a right antecubital PICC was inserted for vascular access and to provide parenteral nutrition. It was removed after 18 days following extravasation. Two months later, she developed a right wrist drop, flexed fingers, and edema of the right hand. Her right wrist flexion, elbow flexion, shoulder joint range of motion, and sensation remained intact. A Doppler study showed a small non-occlusive clot in the right brachial vein, attributed to the previous PICC. She was unable to voluntarily open her right hand or extend her metacarpophalangeal (MCP) or interphalangeal (IP) joints (see Figure A, below). Clinical diagnosis of radial nerve palsy was made, and she was referred to physiotherapy (PT) and occupational therapy (OT). Splinting, passive exercise and left-hand constraint resulted in some improvement of the right hand’s strength. At 12 months of age, she had left hand preference with limited active extension of right MCPs and IPs (Figure B). She received a Botox injection to the right-hand flexors to allow strengthening of the extensor muscles. Follow-up at 18 months showed full extension of the index and middle finger MCPs and IPs, but residual lag in ring and small finger IPs. Discussion To our knowledge, this is the first case report of isolated radial nerve injury in an infant following PICC extravasation and soft tissue infiltration. Interestingly, the clinical signs of radial nerve injury in this case presented almost two months after PICC extravasation. Additionally, the left-hand preference and limitation of the active extension of the fingers of the right hand remained at one year of corrected age. Given that this has exceeded the expected recovery time of radial nerve palsy, Botox injection was performed with good response and near age-appropriate development of fine motor skills at 18 months of corrected age. Paediatricians should be aware that the manifestation of potential nerve injury in neonates may have a delayed presentation. Neurology consultation to confirm the diagnosis and rule out other causes of muscle weakness, and referral to PT/OT, are crucial for managing infants and neonates with peripheral nerve injury because treatment is largely focused on splinting and passive motion exercise. Generally, radial nerve palsy carries a relatively good prognosis, with complete functional recovery within 1-6 months. The fact that this case developed long-term complications with impaired right-hand function, despite nerve recovery, raises concerns about the prognosis. Conclusion Peripherally inserted central venous catheters are an everyday procedure in the NICU. Radial nerve palsy secondary to venous catheter extravasation is rare in infants and neonates. Clinicians should be aware of the clinical signs of radial nerve palsy and initiate consultation and referral to physiotherapy and occupational therapy early. Families can be reassured of the good prognosis and functional recovery.

Neurological complications as the hallmark symptoms of thrombotic thrombocytopenic purpura in sickle cell disease

Thrombotic thrombocytopenic purpura (TTP) is a type of microangiopathy, which is characterized by the formation of small blood clots in the vessels, leading to organ damage and low platelet count. In sickle cell disease (SCD), TTP can occur due to the activation of the coagulation system and damage to the endothelial cells lining the blood vessels. The importance of TTP in SCD lies in its potential to cause severe and life-threatening complications, including stroke, renal and heart failure. Early recognition and treatment of TTP in SCD are crucial to prevent these complications and improve outcomes. In this letter, we highlighted the significance of neurological complications in the diagnosis of TTP in SCD.

Hemostatic Complications During Neonatal Extracorporeal Membrane Oxygenation: Roller Pump and Centrifugal Pump Driven Circuits.

Recently three different neonatal extracorporeal membrane oxygenation (ECMO) circuits have been employed in our clinic. These circuits were compared for clotting and bleeding complications. Initially, we used an ECMO circuit containing a roller pump and venous bladder without severe complications. Manufacturing of circuit components was discontinued, necessitating the replacement of this circuit by a circuit with a centrifugal pump with 3/8 inch inlet and outlet. Acute increase of oxygenator resistance requiring emergency changeout became unexpectedly a regularly occurring complication. The increase in resistance was suspected to be caused by oxygenator clotting, although oxygenator function was preserved. To prevent this complication, we changed to a levitating centrifugal pump with 1/4 inch inlet and outlet, after which no oxygenator malfunction has been observed. Macroscopic and electron microscopic analysis demonstrates that small clots are formed within the circuit, presumably in or near the centrifugal pump, which are transported to the oxygenator and clog up the hollow fiber layer at the inlet side, barely penetrating the oxygenator beyond this first layer. Our results suggest that low blood velocities accompanied with recirculation of blood within or near the centrifugal pump and/or heat generation within the pump could contribute to the formation of these clots.

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

An Uncommon Cause of Recurrent Upper Gastrointestinal Bleeding

Question: A 28-year-old man was admitted to the emergency department with sudden hematemesis and melena. He reported 2 episodes of upper gastrointestinal bleeding in the last 2 years. In the first one, an erosive bulbitis was diagnosed and, 2 years later, a Dieulafoy lesion was identified adjacent to the cardia in the gastric lesser curvature that was treated with epinephrine injection, polidocanol, and application of 1 through-the-scope clip. On admission he was hypotensive and tachycardic with a hemoglobin level of 11 g/dL. Upper digestive endoscopy showed a vascular stump with a small adherent clot at the fundus/body transition of the gastric greater curvature, without active bleeding (Figure A), and endoscopic therapy with epinephrine injection and through-the-scope clip application was performed. Concomitantly, involving the described lesion and throughout the gastric fundus, exuberant protrusions suspicious of vascular origin were observed (Figures B and C). What might be the diagnosis and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Due to the exuberant vascular protrusions in the gastric fundus, an abdominal computed tomography angiography was performed that identified numerous intraparietal vascular structures in the gastric fundus, with opacification in the arterial phase, suggestive of arteriovenous malformation (AVM) emerging from the splenic and left gastric arteries (Figure D). On the second day after the procedure, he presented recurrent bleeding, with hematemesis, hemodynamic instability, and a decrease of 2 g of hemoglobin. An upper digestive endoscopy was performed, identifying previously placed clips with a vascular stump visible in the middle and endoscopic therapy was repeated with over-the-scope clip application (Figure E). After the procedure the patient remained under therapy with proton pump inhibitors, without recurrence of bleeding. After multidisciplinary decision, angiography was performed with selective catheterization of the splenic artery and embolization of 2 short engorged branches vascularizing the AVM with multiple microcoils (Figure F). It was not possible to selectively catheterize one of the branches of the splenic artery as well as one of the branches of the left gastric artery. A second procedure was scheduled, but the patient refused another intervention and was lost to follow-up. AVMs are congenital lesions with persistent connections between their arterial and venous components, which result from a failure of the embryonic vascular plexus to fully differentiate and develop a mature capillary bed.1Schimmel K. Ali M.K. Tan S.Y. et al.Arteriovenous malformations-current understanding of the pathogenesis with implications for treatment.Int J Mol Sci. 2021; 22: 9037Crossref PubMed Scopus (10) Google Scholar Gastric AVMs are a rare cause of upper gastrointestinal bleeding, with few cases described in the literature, and the best therapeutic strategy remains to be defined.2Hirayama Y. Takai C. Korekawa K. et al.Gastric arteriovenous malformation with characteristic endoscopic findings.Intern Med. 2018; 57: 2341-2345Crossref PubMed Scopus (2) Google Scholar,3Latar N.H. Phang K.S. Yaakub J.A. Muhammad R. Arteriovenous malformation of the stomach: a rare cause of upper gastrointestinal bleeding.Med J Malaysia. 2011; 66: 142-143PubMed Google Scholar This case demonstrates the complexity of its diagnosis and treatment and illustrates the potential complementary role of endoscopy and selective angiography in the management of this pathology.

Acute Hepatic and Renal Toxicity Assessment of Euphorbia huanchahana (Klotzsch &amp; Garcke) Boissier (Huachangana) in Holtzman Rats

Background: Euphorbia huachahana (Klotzch &amp; Garcke) Boissier (Huachangana) (EhKGBh) has been used for over a century for medicinal purposes in the Peruvian population; however, its safety and possible toxic effects of use have not been reported. The purpose of this study was to determine the acute hepatic and renal toxicity of EhKGBh in Holtzman rats. Methods: Analytical and experimental study. The population consisted of 52 rats of both sexes weighing between 300 and 350 g divided into four groups: G1 and G2 EhKGBh groups (26 rats each) and two control groups (10 rats each). The experimental group was administered EhKGBh at a single dose of 2000 mg/kg P.O. to demonstrate toxicity during the 14-day follow-up. A daily assessment of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total bilirubin (TBIL), and conjugated bilirubin (CBIL) was performed. Results: Evaluation of the liver tissue showed mild changes in inflammation, predominantly vascular, with small clots. Kidney tissue did not show inflammatory or necrotic changes. However, we showed differences in the weight of the rats between both groups (p &lt; 0.004) and significant increases in TBIL (0.98–1.07 mg/dL), CBIL (0.43–0.45 mg/dL), AST (126.4–141.8 U/L), and ALP (254–298 U/L) but not ALT (39.7–41.1 U/L) (p &lt; 0.05). Conclusion: The single dose of EhKGBh extract at 2000 mg/kg has no toxicity, and there is no change in tissue toxicity during the 14-day follow-up.

Improvement of Umbilical Cord Blood Gas Analysis with Implementation of Clot Catchers.

Umbilical cord blood gas testing is a key component of objective pre- and perinatal evaluation of fetal acid base status to determine presence of intrapartum asphyxia and risk of neonatal encephalopathy. Heparinized cord blood is more likely to form small clots than other blood sources, which can interfere with, or preclude, sample analysis. Cord blood samples are irreplaceable and cannot be recollected, thereby compromising clinical decision-making when analysis is not possible. We evaluated processes to prevent excessive rates of cord blood clotting and quantified their impact on successful testing of blood gas specimens. Verified result and cancellation data were obtained retrospectively from the laboratory information system. Clot catchers were evaluated using noncord remnant specimens. Collection syringes were compared via collection from remnant cord sections. Prior to implementation of any interventions, retrospective analysis indicated a cancellation rate of 18.6% for umbilical cord blood gas specimens (arterial and venous) and 0.7% for noncord blood arterial and venous samples. Clot catchers were validated for clinical use, with a bias of <±4% for all analytes. After clot catchers were implemented for all cord specimens, cancellation rate decreased approximately 5-fold in the first month and remained <5% a year after implementation. A limited comparison of two heparin syringe types revealed a small difference in the overall rate of specimen clotting. Implementation of clot catchers was acceptable for analysis of cord blood samples, and when implemented resulted in a sustained 5-fold decrease in the rate of cord blood gas order cancellation.

Automated cerebral microbleed detection using selective 3D gradient co-occurance matrix and convolutional neural network

Cerebral Microbleeds (CMBs) are small blood clots that form in the brains of many elderly and stroke victims. This promotes dementia as well as other physiological challenges in their daily activities. Early detection of CMBs is critical for limiting the long-term impacts that lead to confusing behavior. Because CMBs in the brain are so minute, manual identification by neurologists might be difficult at times, leading to misinterpretations. In this paper, we propound a newfangled feature extraction technique for the detection of CMB, by Selective 3D Gradient Co-occurance Matrix (S3DGCM). Our proposed framework efficiently detects the cerebral microbleeds (CMB) from magnetic resonance images by incorporating the Scharr Gradient operator with the concepts of the Co-occurance Matrix. The selected ROI was classified as CMB or non-CMB using a Convolutional Neural Network (CNN) classifier with Long Short Term Memory (LSTM) based on the extracted features from the S3DGCM. When compared with the previous methods, our method can extract more useful features which increase the accuracy rate in the detection process. The proposed work has been verified on two datasets containing MRI images with CMBs and Non-CMBs. The experimental results specify that our proposed scheme yields a promising result with the best sensitivity of 98.76%, specificity of 97.21%, an accuracy of 98.24%, and an F1-score of 98.76%.

Dual-energy spectral CT imaging of pulmonary embolism with Mycoplasma pneumoniae pneumonia in children.

Pulmonary embolism (PE) associated with Mycoplasma pneumoniae pneumonia (MPP) in children has already attracted more attention. CT pulmonary angiography (CTPA) has been the preferred method for diagnosing PE, but it has some limitations, especially for children. Dual-energy spectral CT has been used in diagnosing PE in adults. To evaluate the application of dual-energy spectral CT in diagnosing PE in children with MPP. Eighty-three children with MPP and highly suspected PE, underwent CTPA with spectral imaging mode, 25 children were diagnosis with PE. Noise, clot-to-artery contrast-to-noise ratio, image quality and diagnosis confidence were calculated and assessed on nine monochromatic image sets (40 to 80keV). CTPA images were observed for the presence, localization and embolic degrees of PE. Clots were divided into intra- and extra-consolidation clots. For extra-consolidation clots, iodine concentration (IC) of perfusion defects and normal lung, perfusion defects of four children before and after the treatment were measured and compared. For intra-consolidation clots, IC of consolidation areas with clots and consolidation areas without clot were measured and compared. The optimal energy level for detecting PE in children was 55keV. 116 clots (29 extra-consolidations) were found, IC of defect regions was 0.69 ± 0.28mg/mL (extra-consolidations) and 0.90 ± 0.23mg/mL (intra-consolidations), both significantly lower than the 2.76 ± 0.45mg/mL in normal lungs and 10.25 ± 1.76mg/mL in consolidations without clots (P < 0.001). Significant difference was found in the presence or absence of perfusion defects between occlusive clots and nonocclusive clots (P < 0.001). IC of the perfusion defects significantly increased after treatment (P < 0.001). In dual-energy spectral CTPA, 55keV images optimize PE detection for children, and MD images quantify pulmonary blood flow of PE, and may help to detect small clots and quantify embolic degrees.

Real-Time MRI-Guided Stereotactic Aspiration of Spontaneous Intracerebral Hematoma: A Preclinical Feasibility Study.

Minimally invasive surgical techniques have reinvigorated the role of surgical options for spontaneous intracranial hematomas; however, they are limited by the lack of real-time feedback on the extent of hematoma evacuation. To describe the development of a MRI-guided catheter-based aspiration system, the ClearPoint Pursuit Neuroaspiration Device (ClearPoint Neuro) and validation in phantom models. In this preclinical experimental trial, 8 phantom brains with skull models were created to simulate an intracranial hematoma with 2 clot sizes, 30 cc (small clot) and 60 cc (large clot). After registration, the aspiration catheter (Pursuit device) was aligned to the desired planned trajectory. The aspiration of the clot was performed under real-time MRI scan in 3 orthogonal views. The primary end point was reduction of the clot volume to less than 15 cc or 70% of the original clot volume. Successful completion of clot evacuation was achieved in all models. The average postaspiration clot volume was 9.5 cc (8.7 cc for small clots and 10.2 cc for large clots). The average percentage reduction of clot volume was 76.3% (range 58.7%-85.2%). The average total procedure time (from frame registration to final postaspiration clot assessment) was 50 min. The average aspiration time was 6.9 min. This preclinical trial confirms the feasibility and efficacy of MRI-guided aspiration under real-time image guidance in simulation models for intracranial hematoma. Clinical use of the system in patients would further validate its efficacy and safety.

S3534 FOLFOX Causing Fatal Cardiac Adverse Event While Managing Colorectal Cancer

Introduction: Colorectal cancer (CRC) is the 3rd most common cancer worldwide and the 3rd leading cause of cancer death in women and the 4th in men. 5-fluorouracil (5-FU)–based regimens remain a cornerstone in managing CRC. Given the high incidence of CRC and ultimately the high rate of utilization of 5-FU, the adverse events of 5-FU must be well addressed – including the rare ones. We present a 36-year-old man with no prior cardiac history who had nearly fatal cardiac complications after receiving 5-FU. Case Description/Methods: A 36-year-old man with type 1 Diabetes Mellitus, end-stage renal disease (secondary to hemolytic uremic syndrome) status-post (s/p) transplant, and stage III mucinous adenocarcinoma of the ascending colon s/p partial colectomy presented with chest pain while receiving 5-FU bolus as part of his first FOLFOX cycle. Initial troponin I was elevated at 0.14 and kept up trending. EKG was suggestive of myopericarditis (Fig. 1A). Transthoracic echocardiogram showed reduced ejection fraction of 25-30% and global hypokinesis. 24 hours later, the patient had pulseless electrical activity and was resuscitated followed by another 2 episodes of polymorphic ventricular tachycardia (pVT) arrest. Cardiac catheterization was done subsequently and a 5 cm clot was removed from the left circumflex artery (LCX) (Fig. 1B). Post-clot removal, he suffered 3 more pVT arrests. Repeat coronary angiogram revealed small clot had embolized to the distal first obtuse marginal vessel which was not able to be retrieved. An implantable cardioverter-defibrillator was discussed for secondary prevention but ultimately the patient decided against it given his immunosuppressive state and the high likelihood of infections. He had no further cardiac events and was discharged. His upcoming oncologic management of CRC will not involve 5-FU based regimens. Discussion: We presented a young patient with no prior cardiac history who had 6 cardiac arrests, secondary to myopericarditis, within 48 hours of receiving 5-FU. It is highly unlikely that the patient had ischemic cardiomyopathy given his age and the lack of other risk factors. The clot in the LCX is mostly secondary to coronary vasospasms due to 5-FU. This case aims to highlight an extreme – yet possible – complication of 5-FU in CRC patients. More research is needed to help risk stratify patients with CRC before receiving 5-FU.Figure 1.: (A) Diffuse ST Elevations with Diffuse PR Depressions That are Most Consistent with Pericarditis (B) 5 cm Clot in Left Circumflex Artery.

Torsion of wandering spleen, splenectomy and autotransplantation of splenic slices

The aim of this research is to highlight the peculiarity of the incident, to discuss the decision for the transplant splenic slices, and to present the positive results of this approach. The case includes a 14-year-old girl who was presented with atypical abdominal pain last year. Ultrasound imaging showed an abdominal mass in the left lower abdomen. Following that, a CT was performed where the wandering spleen was imaged. Doppler control revealed relatively good blood flow, but partial spleen stems rotation while blood tests revealed thrombocytopenia. However, during the surgical procedure, the spleen appeared 2 ½ times veering the axis of the vascular pedicle. The decision to splenectomy was made due to the presence of small clots during palpation of the vasculature, the appearance of thrombocytopenia, and the technically inadequate splenopexy due to the large vascular pedicle. Partial spleen auto-transplantation on the omental was subsequently carried out. The follow up provided satisfactory results in size and function. The wandering spleen has difficulty in its clinical diagnosis. Visual inspection could document the diagnosis. The suggested treatment is splenopexy, but in the decision for splenectomy, as in this case, with evidence of viable splenic tissue, the successful autotransplantation of splenic slices reduces the risk of splenectomy complications, such as the post-splenectomy sepsis.