Use Of Advanced Imaging Research Articles

Evaluation and Resuscitation of the Pregnant Orthopaedic Trauma Patient: Considerations for Maternal and Fetal Outcomes.

» Orthopaedic injuries warranting trauma activation in pregnant patients are associated with increased risks of preterm birth, placental abruption, and infant and maternal death.» Physiological changes associated with pregnancy can mask the severity of orthopaedic injury sustained during trauma. Providers must perform all appropriate imaging studies associated with the mechanism of injury and perform a careful clinical examination in order to avoid missing injuries.» Pregnancy is a hypercoagulable state, and adequate prophylaxis for blood clots includes low-dose heparin as well as mechanical prophylaxis. Additionally, patients who have sustained orthopaedic trauma must be assessed frequently for thrombophlebitis.» Fetal outcomes are dependent on maternal resuscitation. In addition to the normal steps of trauma resuscitation, additional measures (including Rhesus typing, obtaining a coagulation profile, placing the patient in the left lateral decubitus position, early use of supplemental oxygen to maintain SaO2 [oxygen saturation] at >95%, having a low threshold for intubation, and placing a nasogastric tube to prevent aspiration) should also be performed. Fetal assessment should be completed after appropriate maternal resuscitation.» Factors related to the definitive treatment of orthopaedic injuries, including the type of surgical fixation, use of advanced imaging, and methods of surgical anesthesia, should prioritize maternal outcome. Thorough work-up of maternal injuries and comprehensive maternal resuscitation lead to the greatest benefit in terms of fetal outcomes.

National Trends in Imaging Rates for Eye-Related Emergency Department Visits in the United States

To identify nationwide trends and factors associated with advanced imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) use for eye-related emergency department (ED) visits. Retrospective, trend study. Setting: National Hospital Ambulatory Medical Care Survey 2007-2015. Eye-related ED patients who underwent CT or MRI. Population-based CT/MR imaging rates and independent factors associated with imaging. An estimated 7 million eye-related ED visits occurred between 2007 and 2015. Adjusted for annual eye-related ED visits, the rate of imaging use rose 94%, from 121.7 per 1,000 eye-related ED visits in 2007 to 236.0 per 1,000 eye-related ED visits in 2015. Visual disturbances, contusion of the eye and/or adnexa, open globes and open wounds of ocular adnexa, diplopia, superficial corneal and/or conjunctival injuries, and orbital fractures accounted for 73.2% of all visits where imaging was performed. On multivariable analysis, older patients (odds ratio [OR]= 1.02, 95% confidence interval [CI] 1.01-1.03) and females (OR=2.07, 95% CI 1.18-3.63) were more likely to undergo imaging than younger patients and males. Imaging was also more likely to be performed for Medicare beneficiaries (OR=2.12, 95% CI 1.08-4.15) than for privately insured patients. Patients who were admitted to the hospital were 6 times more likely (OR=6.39, 95% CI 2.04-20.0) to undergo imaging than those who were not admitted. Advanced imaging for eye-related ED visits has escalated at a higher rate than ED visits for eye complaints. Future studies to develop evidence-based algorithms for use of CT/MR imaging for eye complaints that can help balance benefits against financial costs and health risk are warranted.

190 Advanced Imaging Use and Trends in Hospitalizations from the Emergency Department

Hospital costs constitute nearly one-third of health care expenditures. In the context of increasing pressure to reduce hospital care spending, hospitalizations after emergency department (ED) visits have declined over the past decade. Some have hypothesized that the concurrent increase in ED advanced imaging use may have contributed to the decline in ED hospitalizations. In this study, we examined the trends in ED hospitalization rates among ED patients who received advanced imaging compared to ED patients who did not.

Cardiac papillary fibroelastoma, a cause of acute embolic stroke: Report of two cases

Cardiac Papillary Fibroelastoma (PFE) is a rare benign cardiac tumor mainly clinically asymptomatic that unexpectedly can cause a wide variety of embolic manifestations in heart and brain. Our first case was a 27 years old Indian man, with no previous cardiac or cerebral diseases history, presented in emergency department (ED) with sudden onset of acute nausea, vomiting, vertigo and imbalance. The neurological exam (NE) showed cerebellar ataxia. Brain imaging showed acute right cerebellar infarct. The transesophageal echocardiogram (TEE) showed a cardiac mass of the mitral valve that was subsequently defined as PFE by the cardiac MRI. The second case was a 50 years old Arabic male with no previous cardiac or cerebral diseases history, presented at our ED with acute onset of aphasia and right sided weakness. NE confirmed the aphasia and right hemiparesis. Brain imaging showed patchy left middle cerebral artery infarction. TEE showed mobile echo density noted attached to the aortic valve which was consistent with the PFE. Evidence of large vessels occlusion and post infective vegetation were excluded in both cases. We have presented two cases of PFEs associated with cerebral embolic stroke. These clinical cases strengthen the notion that cardiac tumors carried a high risk of cerebral embolic presentation and emphasize the need to suspect their presence at every age in the event of an embolic stroke. Advanced imaging use is important for a correct diagnosis and management.

2804 Outcomes in Intra-Ductal Papillary Mucinous Neoplasms in the New York Harbor Veteran Population: An Update

INTRODUCTION: Over the last few years there has been an increase in the frequency of findings of intra-ductal papillary mucinous neoplasms (IPMNs). This is likely due to the increased use of advanced abdominal imaging as well as in increase in the quality of these images. In most cases, decisions are based on consensus rather than evidence based as to how to proceed with regard to follow up imaging, biopsy, or even surgical resection. At ACG 2017, we presented the outcomes of and natural history of patients with IPMNs in the Brooklyn VA. Since that presentation, we have an update regarding further data points as well as in increase in the number of patients we analyzed. METHODS: Retrospective chart review was performed on patients with diagnosis, based on coding) of pancreatic cyst, pancreatic lesion, and intra-ductal pancreatic mucinous neoplasm from the New York Harbor Veterans Affairs Hospital from 2000 to 2015. 767 patients were initially flagged, and based on either radiology reports or clinic notes 104 were determined to actually have an IPMN. We looked at basic demographics, risk factors and survival data. RESULTS: Baseline characteristics are outlined in Table 1 of the 104 patients formally diagnosed with an IPMN. In summary, 101 are male. The average age at the time of initial diagnosis was 71.5 years old, the median age was 72 years old. The average Body Mass index was 27.3. The subjects in this study were overwhelmingly African American (40.6%) and White (42.6%). There was a small Hispanic component (14.6%). There were no Asian patients in the study. Nine patients underwent surgical resection. 33 patients died and the median time to survival was not able to be calculated at this time. The average age at the time of death was 78.9 years old. In the 33 patients that died only 6 Patients (5.7% of total patients diagnosed) died from pancreatic causes. CONCLUSION: The management of IPMNs presents a clinical challenge for gastroenterologists today. To date, the levels of evidence in which the current guidelines are based on is poor. Our study is limited by factors such as advanced age, gender and multiple comorbidities preventing further invasive interventions. It is due to these factors, that our study is not applicable to the general population. Therefore, we recommend further larger multicenter trials with a diverse cohort to establish the risk of IPMN’s and their effect on mortality from pancreatic cancer.

Evaluation and Management of Chronic Venous Disease Using the Foundation of CEAP.

Venous disease is common. Depending on the population studied, the prevalence may be as high as 80%. Significant chronic venous disease with venous ulcers or trophic skin changes is reported to affect 1-10% of the population. A systematic assessment of the clinical findings associated with chronic venous disease will facilitate appropriate imaging. Based on imaging and assessment, patients with reflux or obstruction can be recommended proper medical and endovascular or surgical management. Many types of endovascular management are available to treat reflux and eliminate varicose veins and tributaries. More recently adopted non-thermal non-tumescent techniques have been shown to be comparable with more widely performed laser or radiofrequency ablation techniques. A thorough clinical assessment, appropriate duplex ultrasound imaging, and use of advanced imaging when needed will allow clinicians to optimize therapy for patients with chronic venous disease based on the etiology, anatomy involved, and the pathophysiology.

Patterns of Surveillance Advanced Imaging and Serum Tumor Biomarker Testing Following Launch of the Choosing Wisely Initiative.

The purpose of this study was to assess advanced imaging (bone scan, CT, or PET/CT) and serum tumor biomarker use in asymptomatic breast cancer survivors during the surveillance period. Cancer registry records for 2,923 women diagnosed with primary breast cancer in Washington State between January 1, 2007, and December 31, 2014, were linked with claims data from 2 regional commercial insurance plans. Clinical data including demographic and tumor characteristics were collected. Evaluation and management codes from claims data were used to determine advanced imaging and serum tumor biomarker testing during the peridiagnostic and surveillance phases of care. Multivariable logistic regression models were used to identify clinical factors and patterns of peridiagnostic imaging and biomarker testing associated with surveillance advanced imaging. Of 2,923 eligible women, 16.5% (n=480) underwent surveillance advanced imaging and 31.8% (n=930) received surveillance serum tumor biomarker testing. Compared with women diagnosed before the launch of the Choosing Wisely campaign in 2012, later diagnosis was associated with lower use of surveillance advanced imaging (odds ratio [OR], 0.68; 95% CI, 0.52-0.89). Factors significantly associated with use of surveillance advanced imaging included increasing disease stage (stage III: OR, 3.65; 95% CI, 2.48-5.38), peridiagnostic advanced imaging use (OR, 1.76; 95% CI, 1.33-2.31), and peridiagnostic serum tumor biomarker testing (OR, 1.35; 95% CI, 1.01-1.80). Although use of surveillance advanced imaging in asymptomatic breast cancer survivors has declined since the launch of the Choosing Wisely campaign, frequent use of surveillance serum tumor biomarker testing remains prevalent, representing a potential target for further efforts to reduce low-value practices.

What Physicians and Health Organizations Should Know About Mandated Imaging Appropriate Use Criteria.

The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.

Diagnostic Imaging Use for the Initial Evaluation of Low Back Pain by Primary Care Providers in the United States: 2011-2016

ObjectiveHigh-value care guidelines from multiple medical societies recommend against imaging for the initial evaluation of low back pain in the absence of red flag symptoms. We aimed to determine the current temporal and geographic landscape of imaging ordering patterns for this indication among US primary care providers. MethodsUsing a national commercial insurance claims database, we identified patients between 18 and 64 years old who presented to a primary care provider for an initial evaluation of low back pain between 2011 and 2016. Patients were identified via International Classification of Diseases codes, and the use of diagnostic imaging was identified by Current Procedural Terminology codes. Geographic regions were based on the location of patient residence. ResultsOverall, 627,118 encounters met inclusion criteria. Imaging acquisitions increased over time, from 14% of encounters in 2011 to 16% in 2016 (P < .01). Radiographs represented 96% of ordered imaging, CT 2%, and MRI 3%. The likelihood of having any imaging for low back pain varied significantly by US census region and by US state (P < .01). The greatest use of imaging was in the Midwest (13.9%) and the South (18.5%), and lowest in the Northeast and West (6.2% and 13.6%). DiscussionImaging utilization for the initial evaluation of low back pain by primary care providers has increased on a national level from 2011 to 2016, largely represented by radiographs. Significant regional variation also exists. Encouragingly, the use of advanced imaging has remained at a low level in the primary care setting (<1.0%).

Dentinogenic ghost cell tumor: A case report

BACKGROUNDDentinogenic ghost cell tumor (DGCT) is an uncommon locally invasive odontogenic neoplasm. It is considered to be a solid variant of calcifying odontogenic cyst (COC). This tumor makes up for only 2%-14% of all COCs and less than 0.5% of all odontogenic tumors which owes to its rarity. The purpose of this paper was to describe a case of DGCT and the treatment adopted in our case, and to provide a review of this case in the indexed literature.CASE SUMMARYIn this article, we discussed a case of 18 year old male who reported with a chief complaint of a recurrent swelling and dull aching pain in upper left back region of the jaw. Computed tomography scan was carried out which revealed hypodense lesion with a few hyperdense flecks within it suggesting the presence of calcification. On incisional biopsy, diagnosis of COC was given. After segmental resection of the lesion, histopathogically odontogenic epithelium was noted along with calcifications, ghost cells and dentinoid material. Special staining was done with van Gieson and it showed pink areas of dentinoid material and yellow colour represented ghost cells. Hence, amalgamation of careful clinical examination, use of advanced radiographic imaging and detailed histopathological examination confirmed the diagnosis of DGCT. The patient was followed up for one year and there was no recurrence of the lesion or signs of any residual tumor.CONCLUSIONRadical treatment should be carried out along with mandatory long-term follow up in order to avoid recurrence in aggressive lesions.

Advanced diagnostic imaging utilization during emergency department visits in the United States: A predictive modeling study for emergency department triage.

BackgroundEmergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS). The addition of advanced diagnostic imaging (ADI), namely CT, ultrasound (U/S), and MRI to ED encounter work up is a predictor of longer length of stay. Earlier and improved prediction of patients’ need for advanced imaging may improve overall ED efficiency. The aim of the study was to detect the association between ADI utilization and the structured and unstructured information immediately available during ED triage, and to develop and validate models to predict utilization of ADI during an ED encounter.MethodsWe used the United States National Hospital Ambulatory Medical Care Survey data from 2009 to 2014 to examine which sociodemographic and clinical factors immediately available at ED triage were associated with the utilization of CT, U/S, MRI, and multiple ADI during a patient’s ED stay. We used natural language processing (NLP) topic modeling to incorporate free-text reason for visit data available at time of ED triage in addition to other structured patient data to predict the use of ADI using multivariable logistic regression models.ResultsAmong the 139,150 adult ED visits from a national probability sample of hospitals across the U.S, 21.9% resulted in ADI use, including 16.8% who had a CT, 3.6% who had an ultrasound, 0.4% who had an MRI, and 1.2% of the population who had multiple types of ADI. The c-statistic of the predictive models was greater than or equal to 0.78 for all imaging outcomes, and the addition of text-based reason for visit information improved the accuracy of all predictive models.ConclusionsPatient information immediately available during ED triage can accurately predict the eventual use of advanced diagnostic imaging during an ED visit. Such models have the potential to be incorporated into the ED triage workflow in order to more rapidly identify patients who may require advanced imaging during their ED stay and assist with medical decision-making.

HOW DO IMAGING PRACTICES VARY ACROSS THE UNITED STATES WHEN DIAGNOSING A MEDIAL EPICONDYLE FRACTURE?

Background: A number of controversies surround the evaluation of medial epicondyle fractures, including the use of advanced imaging at the time of diagnosis. In an era of increased focus on resource utilization, an analysis of diagnostic testing for this injury is timely. The purpose of this study is to evaluate national variation in diagnostic imaging for pediatric medial epicondyle fractures. Methods: The Pediatric Health Information System, a national database consisting of 49 children’s hospitals, was queried for all patients with a medial epicondyle fracture between 2004 and 2015. Demographic information was collected as well as data regarding diagnostic imaging at initial presentation. United States Census guidelines were used to categorize hospitals geographically into regions and divisions. Univariate analysis was followed by purposeful entry multivariate regression to control for confounders. Results: A total of 7799 patients underwent 9961 imaging procedures at initial presentation, of which 9627 were plain radiographs (1.2 x-rays per patient). Additionally, 286 patients (3.7%) obtained a computed tomography (CT) scan and 46 (0.6%) received magnetic resonance imaging (MRI). After controlling for confounders in a multivariate model, patients in cities with a pediatric population below 300,000 were 2.5 times more likely to undergo CT scan than in a city with over 1 million children (95% CI 1.7, 3.9; p&lt;0.001). Geography was also predictive, with children in the Northeast at 3.1 times higher odds of receiving a CT scan (95% CI 2.2, 4.3; p&lt;0.001). When region was further stratified into Census division, those in New England had 4.6 times higher odds of undergoing CT (95% CI 2.5, 8.7; p&lt;0.001). Patients treated at a hospital with 300 or fewer beds were 2.6 times more likely to receive MRI than in larger hospitals (95% CI 1.2, 5.4; p=0.01). Older age was associated with higher odds of receiving a CT (p&lt;0.001) while younger age was associated with higher likelihood of MRI (p=0.006). Conclusions: There is substantial variation in imaging practices across the United States when diagnosing a medial epicondyle fracture. CT scans are more likely to be ordered in smaller cities and in older children, while MRI is more likely to be obtained in smaller hospitals and in younger children. CT is ordered most frequently in the Northeast, especially in New England. Improved evidence relating to the initial evaluation of medial epicondyle fractures may help reduce the current variation in resource utilization.

Advanced Imaging in the Evaluation of Migraine Headaches.

The use of advanced imaging in routine diagnostic practice appears to provide only limited value in patients with migraine who have not experienced recent changes in headache characteristics or symptoms. However, advanced imaging may have potential for studying the biological manifestations and pathophysiology of migraine headaches. Migraine with aura appears to have characteristic spatiotemporal changes in structural anatomy, function, hemodynamics, metabolism, and biochemistry, whereas migraine without aura produces more subtle and complex changes. Large, controlled, multicenter imaging-based observational trials are needed to confirm the anecdotal evidence in the literature and test the scientific hypotheses thought to underscore migraine pathophysiology.

Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training

Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources. Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1-9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non-house staff. Generalized linear models further estimated the modifying effect of the house staff variable. Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17-0.64) and non-house staff (baseline increase, 0.58; 95% CI, 0.34-0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period. Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non-house staff.

Abstract 145: Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy: A Systematic Review and Meta-analysis

Introduction: There is clinical equipoise regarding the use of advanced imaging for selecting acute ischemic stroke (AIS) patients eligible for mechanical thrombectomy (MT) during the first 6 hours from symptom onset. However, accumulating evidence indicates that advanced neuroimaging represents an invaluable and time independent prognostic factor. Methods: We performed a systematic review and meta-analysis of available randomized clinical trials (RCTs) to evaluate the impact of patient selection with advanced neuroimaging on the 3-month: 1. functional independence (FI, mRS: 0-2), 2. favorable functional outcome [FFO, modified Rankin Scale scores (mRS): 0-1], 3. all-cause mortality and 4. functional improvement (assessed with ordinal analysis of the mRS-scores). Results: Among the 10 eligible RCTs (1979 total patients, mean age: 67 years), 5 studies reported the use of advanced imaging. Studies using advanced neuroimaging showed higher treatment effects of MT on 3-month FI (OR=3.79, 95%CI: 2.71-5.28 vs. OR=1.76, 95%CI: 1.39-2.24; p for subgroup differences&lt;0.001), FFO (OR=3.16, 95%CI: 1.94-5.14 vs. OR=1.75, 95%CI: 1.30-2.34; p for subgroup differences=0.04) and functional improvement (cOR=2.77, 95%CI: 2.04-3.76 vs. 1.60, 95%CI: 1.32-1.95; p for subgroup differences: 0.003) compared to studies using conventional neuroimaging. Including only studies in the early (0-8hrs) time window advanced imaging selection was associated with better 3-month FI rates (p for subgroup differences: 0.04) compared to conventional imaging selection. No difference in the mortality (p for subgroup differences: 0.27) and sICH rates (p for subgroup differences 0.93) was found between the two groups. No evidence of heterogeneity was documented in all the aforementioned subgroups (I 2 &lt;30%, p for Cochran Q&gt;0.17 for all analyses). Conclusions: Our findings indicate that AIS patient selection for MT based on advanced neuroimaging appears to be associated with improved clinical outcomes, including lower mortality rates. The use of advanced neuroimaging for both the selection and prediction of prognosis for MT candidates should not depend on the elapsed time from symptom onset.

Abstract WP77: Automated Accurate Determinations of Acute Infarct Core Volumes From CT Angiography Using Machine Learning

Background: Guideline-based acute ischemic stroke (AIS) evaluations require the use of advanced parenchymal imaging including CT perfusion (CTP) to determine the presence of large vessel occlusion (LVOs) and infarct core. The availability of CTP in all hospitals that receive patients with possible AIS is limited. An accurate method to evaluate possible AIS patients that does not require CTP is urgently needed. Methods: Consecutive patients from 3/2018 - 5/2018 evaluated emergently for possible AIS within 24 hours of onset at our institution were identified. Patients were included if they underwent contemporaneous non-contrast CT, CT angiogram (CTA) and CT Perfusion (CTP) with RAPID (IschemaView) post-processing. A linear Support Vector Machine (SVM) was created using CTA data alone and trained against the CTP-RAPID infarct core volume determinations, which was used as the “gold standard.” Performance parameters were calculated using 10-fold cross-validation. Results: Among 139 subjects, median age was 64 [54-73], 48% were female, 40% were white and 34% were African-American. From this population, 16 subjects (12%) were ultimately diagnosed with AIS. Median time from onset to imaging was 3.9 hours [1.7-10.1], NIHSS 16.5 [8-24], and RAPID infarct core and “at risk” volumes were 35.5 mL [13-72] and 128.5 mL [80-165]. The CTA-based SVM classified AIS versus stroke mimic with excellent discrimination (AUC 0.95 ± 0.08) and accuracy of 89% ± 3%. In patients with AIS, CTA-based SVM estimation of infarct core correlated well with the CTP-RAPID (Spearman's rho 0.82 (p&lt;0.001) and Figure ). Conclusion: Our machine learning algorithm was able to accurately discriminate AIS versus stroke-mimic, and reproduce CTP-based infarct core measurements from CTA imaging alone. A complete AIS neuroimaging evaluation, for LVO as well as infarct core, may be obtainable from CTA, an imaging modality with much broader availability than CTP.

Use of Advanced Imaging in the Emergency Department: New Obstacles or New Opportunities to Improve Patient Care?

Use of Advanced Imaging in the Emergency Department: New Obstacles or New Opportunities to Improve Patient Care?

Treatment of Advanced Prostate Cancer.

The therapeutic landscape of prostate cancer has been transformed over the last decade by new therapeutics, advanced functional imaging, next-generation sequencing, and better use of existing therapies in early-stage disease. Until 2004, progression on androgen deprivation therapy for metastatic disease was treated with the addition of secondary hormonal manipulation; in the last decade, six systemic agents have been approved for the treatment of castration-resistant prostate cancer. We review clinical trials and survival benefit for these therapies and assess how the understanding of the disease shifted as these therapies were developed. We also discuss advances in noncastrate disease states, identification of biomarkers for prognosis and treatment selection, and opportunities in locoregional therapy to delay androgen deprivation therapy.

Visceral Artery Aneurysms: Decision Making and Treatment Options in the New Era of Minimally Invasive and Endovascular Surgery.

The abdominal viscera blood supply is derived from anterior branches of the abdominal aorta. Visceral artery aneurysms (VAAs) include aneurysms of the following arteries and their branches: the celiac artery, the hepatic artery, the splenic artery, the superior mesenteric artery, the inferior mesenteric artery, the pancreaticoduodenal artery, and the gastroduodenal artery. Overall VAAs comprise < 2% of all types of arterial aneurysms. Asymptomatic VAAs are now being encountered more frequently due to the widespread use of advanced diagnostic abdominal imaging. The incidental finding of a VAA frequently leaves clinicians with a dilemma as to the best course of management. The focus of this review is on current treatment options and management guidelines for both symptomatic and asymptomatic VAAs.

Preoperative Surveillance Thoracic MRI for Thoracic Dorsal Column Stimulation: Case Series

Background: To date, there have been no guidelines, studies, or consensus statements regarding the use of advanced imaging studies as a preoperative screening tool prior to patients undergoing spinal cord stimulation (SCS). Objectives: The purpose of this case series is to highlight the importance of obtaining thoracic imaging studies as part of a thorough initial clinical assessment prior to percutaneously or surgically placing an SCS electrode. Methods: We undertook a 3-year retrospective review of patients undergoing evaluation for SCS therapy in an academic interventional pain management and neurosurgery practice. Patients with chronic neuropathic pain underwent a trial with percutaneous dorsal column stimulation, and if response to the trial was &gt; 50% reduction in pain and improvement in function, the patient was implanted using either a percutaneous approach or placement of a paddle electrode with an internal pulse generator (IPG). All patients had advanced thoracic imaging performed (magnetic resonance imaging [MRI] if possible, or computed tomography [CT] if contraindicated) prior to percutaneous trial or paddle electrode implantation. Results: In 3 years, 88 patients underwent a trial of SCS, of which 75 patients (85%) were referred for implantation of a permanent percutaneous or paddle stimulator with IPG. Two patients (1.2%) treated by trial and implant were found to have a thoracic lesion on surveillance imaging, which contraindicated SCS implantation. One patient had thoracic imaging prior to undergoing the trial and one patient had thoracic surveillance imaging after the trial, but before surgical paddle placement. Limitations: The retrospective nature and lack of a control group in this case series are limitations of this study. Conclusion: This case series outlines the importance of considering advanced thoracic imaging studies for screening/surveillance purposes prior to SCS therapy. Placement of SCS electrodes in the thoracic epidural space without prior understanding of spinal anatomy potentially puts patients at unnecessary risk. In the cases presented, had patients undergone SCS trial and subsequent implant without screening imaging, thoracic lesions would have been missed, increasing the likelihood of diagnostic and therapeutic complications. Our incidental findings of lesions on MRI prior to SCS trial or implant support the use of a screening protocol for other centers providing thoracic SCS therapies. Key words: Thoracic, dorsal column stimulation, chronic pain, surveillance MRI, patient selection