Use Of Computed Tomography Angiography Research Articles

The Identification of Aortoiliac and Femoral Arterial Disease: Use of CT Angiography With Advanced Image Processing Versus Conventional Angiography in Treatment Decision Making

Objectives: This study evaluated long-term outcomes after elective open surgical repair (OSR) for abdominal aortic aneurysms (AAAs). Methods: Data of all consecutive patients treated with OSR between 2000 and 2014 were retrospectively collected. Overall survival, reintervention rate, graft complications-free survival, and freedom from graft complications were analyzed. Results: A total of 490 patients (93.3%men), mean age of 71.3 years, were reviewed. Median follow-up was 53 months (range, 1-14 years) and median surveillance time was 13.2 years. Overall survival at 30 days, and 1, 5, and 13 years was 97.3% 6 0.01%, 95.9% 6 0.01%, 84.6% 6 0.02%, and 52.2% 6 0.06%, respectively. Long-term mortality was influenced by age (HR, 1.08; confidence interval [CI], 1.05-1.11; P< .001), chronic obstructive pulmonary disease (HR, 1.50; CI, 0.96-2.23; P1⁄4 .06), and chronic renal failure (HR, 1.87; CI, 1.11-3.16; P 1⁄4 .02). Thirty-five (9.6%) late graft-related complications were observed. There were no aortoenteric fistulas, but a ruptured femoral pseudoaneurysm (0.2%) resulted in one death. The 30-day, and 1-, 5-, and 13year rates of freedom from graft complications were 100%, 100%, 96%, 69% and graft complications-free survival was 97%, 96%, 81%, and 39%, respectively. Preoperative aneurysm diameter and surgical graft caliber were related to late proximal pseudoaneurysms (HR, 1.98; CI, 1.37-2.93; P < .001; and RR, 2.08; CI, 1.53-2.79; P < .001 respectively), intraoperative graft thrombosis and postoperative pseudoaneurysm to graft limb occlusion (HR, 3.09; CI, 1.11-7.64; P 1⁄4 .03; HR, 3.09, CI, 1.11-7.64; P 1⁄4 .03, respectively). Conclusions: OSR of AAA showed satisfactory 14year follow-up rates in overall survival and in freedom from graft-related complications and could be considered the procedure of choice. Preoperative aneurysm diameter and graft caliber are most important risk factors for development of pseudoaneurysms and intraoperative graft thrombosis for late limb occlusion.

Traumatic intracranial aneurysm in blunt trauma

Introduction: Computed Tomography Angiography (CTA) is being used to identify traumatic intracranial aneurysms (TICA) in patients with findings such as skull fracture and intracranial haemorrhage on initial Computed Tomography (CT) scans after blunt traumatic brain injury (TBI). However, the incidence of TICA in patients with blunt TBI is unknown. The aim of this study is to report the incidence of TICA in patients with blunt TBI and to assess the utility of CTA in detecting these lesions.Methods: A 10-year retrospective study (2003–2012) was performed at a Level 1 trauma centre. All patients with blunt TBI who had an initial non-contrasted head CT scan and a follow-up head CTA were included. Head CTAs were then reviewed by a single investigator and TICAs were identified. The primary outcome measure was incidence of TICA in blunt TBI.Results: A total of 10 257 patients with blunt TBI were identified, out of which 459 patients were included in the analysis. Mean age was 47.3 ± 22.5, the majority were male (65.1%) and median ISS was 16 [9–25]. Thirty-six patients (7.8%) had intracranial aneurysm, of which three patients (0.65%) had TICAs.Conclusion: The incidence of traumatic intracranial aneurysm was exceedingly low (0.65%) over 10-years. This study adds to the growing literature questioning the empiric use of CTA for detecting vascular injuries in patients with blunt TBI.

Emerging role of cardiovascular CT and MRI in the evaluation of stroke.

OBJECTIVE. The purposes of this article are to explore the potential for use of CT angiography and MRI and to highlight data suggestive of their usefulness in specific cardiovascular abnormalities. CONCLUSION. The evaluation of stroke requires comprehensive assessment of potential stroke mechanisms, including cardiac sources. Despite an exhaustive search for secondary causes, the precise cause of many strokes remains unknown (cryptogenic). It is well recognized, however, that some of these potential causes occur as a result of embolism from the heart or great vessels. Thus, echocardiography, in particular transesophageal echocardiography, is instrumental in a careful assessment of cardiac causes in selected individuals. Unfortunately, transesophageal echocardiography is invasive, and some patients may have relative or absolute contraindications. Cardiovascular CT angiography and MRI have growing potential compared with conventional cardiovascular echography.

New and evolving concepts in CT for abdominal vascular imaging.

Computed tomographic (CT) angiography has become the standard of care, supplanting invasive angiography for comprehensive initial evaluation of acute and chronic conditions affecting the vascular system in the abdomen and elsewhere. Over the past decade, the capabilities of CT have improved substantially; simultaneously, the expectations of the referring physician and vascular surgeons have also evolved. Increasingly, CT angiography is used as an imaging biomarker for treatment selection and assessment of effectiveness. However, the growing use of CT angiography has also introduced some challenges, as potential radiation-associated and contrast media-induced risks need to be addressed. These concerns can be partly confronted by modifying scanning parameters (applying a low tube voltage) with or without using software-based solutions. Most recently, multienergy technology has endowed CT with new capabilities offering improved CT angiographic image quality and novel plaque characterization while decreasing radiation and iodine dose. In this article, we discuss current and new approaches using both conventional and multienergy CT for studying vascular disease in the abdomen. We propose various approaches to overcoming commonly encountered image quality challenges in CT angiography. In addition, we describe supplemental strategies for improving patient safety that leverage the available technology.

Utility of CT angiography in cervical spine trauma: analysis of radiation and cost

Purpose: Vertebral artery injuries (VAIs) can be seen in cervical injuries. This investigation was conducted to assess the impact of head and neck computed tomography (CT) angiography (CTA) on planning treatment of vertebral artery injuries, if these tests were ordered appropriately, and to estimate cost and associated exposure to radiation and contrast material. Methods : This retrospective review included all patients who underwent CT of the cervical spine and CTA of the head and neck from March 2011 to October 2012 at a single institution. Patients were divided into two groups, those with and those without cervical spine fracture appreciated on CT of the cervical spine. The frequency of vascular injury on CTA in those with a cervical fracture was assessed. The frequency of vascular injury treatment and modifications owed to a positive CTA of head and neck were also assessed. A study was considered appropriate if it was ordered in accordance with the modified Denver Screening criteria. Effective radiation dose (mSv) was calculated by multiplying dose length product (DLP) from the scanner with the standard conversion coefficient (k) (k = 0.0021 mSv/mGy x cm). Results: In the 387 CTAs of head and neck, a cervical injury was recorded in 128 patients. Twenty CTA scans were correctly ordered for non-spinal indications, and 19 were ordered off protocol. CTA was found positive in 1 patient for whom the imaging was off protocol and 1 for whom the clinical indication was non-cervical. There were 19 positive CTA cases of head and neck, none of which underwent surgical intervention. CTA was positive in 13 of 48 patients who had suffered a C2 fracture; this accounted for 13 of the 19 positive CTA studies (p < 0.01). Estimated fee for CTA was $3783, and radiation exposure was 4 mSv with a standard deviation (±1.3). Conclusion : CTA of head and neck ordered off an institutional imaging protocol has a low probability of being positive. Adherence to protocols for CTA of head and neck can reduce costs and decrease unnecessary exposure to radiation and contrast medium. --------------------------------------- Cite this article as: Shuaib W, Khan AA, Mehta AS, Vijayasarathi A, Hidalgo J. Utility of CT angiography in cervical spine trauma: analysis of radiation and cost. Int J Cancer Ther Oncol 2014; 2 (4):02043. DOI : 10.14319/ijcto.0204.3

Cardiac imaging and functional assessment in pregnancy

There are multiple imaging modalities available for the assessment of pregnant women with known or suspected cardiac disease. Because of its safety and general availability, echocardiography is the preferred study of choice for the evaluation of ventricular function, valvular heart disease, congenital heart disease, evaluation of the aorta, and the estimation of cardiac hemodynamics in a pregnant patient. Cardiac MRI can be performed, especially for diseases of the aorta and complex congenital heart disease. Radiation exposure for the fetus and the mother will be discussed in the use of CT angiography, nuclear imaging, and left-heart catheterization including coronary angiography for specific indications in the pregnant woman. The use of exercise testing during pregnancy for functional assessment will be presented.

Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: Frequency, predictive factors, and safety

IntroductionDemonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. MethodsWe retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and December 2011. ResultsWe included 157 patients (mean age, 74±11; mean NIHSS score, 5 [2–13]). Of the total, 56.7% of the patients were admitted to hospital during the first 8hours. CT-angiography was performed in 71 cases (45.2%), arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P<.001) and atrial fibrillation (64% vs 32%, P=.006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming these associations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2±24.5minutes in patients who underwent CT-angiography, and 53.5±34.3minutes in those who did not (P=.495). ConclusionsArterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor.

The use of CT angiography in the evaluation of living donors for kidney transplantation

ObjectiveTo study the prevalence of renal vascular and other abnormalities by CT angiography in kidney donors at our center. Material and methodsA hundred potential kidney donors underwent CT angiogram as a part of their preoperative workup between December 2009 and May 2013. We retrospectively studied the CT angiogram and compared the findings with the surgical findings. ResultsWe studied 100 patients with mean age of 46.8 years. The incidence of renal accessory artery in our patients was 27%. Also, renal accessory vein was detected in 17% of subjects. Early branching of renal artery was identified in 7% of cases. Amongst, the abnormalities of renal parenchyma, most common were simple renal cysts which were seen in 9% of the subjects. In addition, 4% of donors had nephrolithiasis, 3% had duplication of renal system and 1 donor had horseshoe kidney. CT angiographic findings were concordant with intra-operative findings in 93% of the cases, missing small renal vein in 2 cases, 2 small veins in 1 case and 1 accessory artery. Two cases of early branching were reported as accessory artery. ConclusionIn the majority of cases, there was good correlation between preoperative CT renal angiography and operative findings. CT angiography is one of the most important exams in the preoperative evaluation of renal donor candidates.

Computed tomography (CT) angiography for confirmation of the clinical diagnosis of brain death

The diagnosis of death using neurological criteria (brain death) has profound social, legal and ethical implications. The diagnosis can be made using standard clinical tests examining for brain function, but in some patient populations and in some countries additional tests may be required. Computed tomography (CT) angiography, which is currently in wide clinical use, has been identified as one such test. To assess from the current literature the sensitivity of CT cerebral angiography as an additional confirmatory test for diagnosing death using neurological criteria, following satisfaction of clinical neurological criteria for brain death. We performed comprehensive literature searches to identify studies that would assess the diagnostic accuracy of CT angiography (the index test) in cohorts of adult patients, using the diagnosis of brain death according to neurological criteria as the target condition. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5) and the following databases from January 1992 to August 2012: MEDLINE; EMBASE; BNI; CINAHL; ISI Web of Science; BioMed Central. We also conducted searches in regional electronic bibliographic databases and subject-specific databases (MEDION; IndMed; African Index Medicus). A search was also conducted in Google Scholar where we reviewed the first 100 results only. We handsearched reference lists and conference proceedings to identify primary studies and review articles. Abstracts were identified by two authors. Methodological assessment of studies using the QUADAS-2 tool and further data extraction for re-analysis were performed by three authors. We included in this review all large case series and cohort studies that compared the results of CT angiography with the diagnosis of brain death according to neurological criteria. Uniquely, the reference standard was the same as the target condition in this review. We reviewed all included studies for methodological quality according to the QUADAS-2 criteria.We encountered significant heterogeneity in methods used to interpret CT angiography studies and therefore, where possible, we re-analysed the published data to conform to a standard radiological interpretation model. The majority of studies (with one exception) were not designed to include patients who were not brain dead, and therefore overall specificity was not estimable as part of a meta-analysis. Sensitivity, confidence and prediction intervals were calculated for both as-published data and as re-analysed to a standardized interpretation model. Ten studies were found including 366 patients in total. We included eight studies in the as-published data analysis, comprising 337 patients .The methodological quality of the studies was overall satisfactory, however there was potential for introduction of significant bias in several specific areas relating to performance of the index test and to the timing of index versus reference tests.Results demonstrated a sensitivity estimate of 0.84 (95% confidence interval (CI) 0.69 to 0.93). The 95% approximate prediction interval was very wide (0.34 to 0.98). Data in three studies were available as a four-vessel interpretation model and the data could be re-analysed to a four-vessel interpretation model in a further five studies, comprising 314 patient events. Results demonstrated a similar sensitivity estimate of 0.85 (95% CI 0.77 to 0.91) but with an improved 95% approximate prediction interval (0.56 to 0.96). The available evidence cannot support the use of CT angiography as a mandatory test, or as a complete replacement for neurological testing, in the management pathway of patients who are suspected to be clinically brain dead.CT angiography may be useful as a confirmatory or add-on test following a clinical diagnosis of death, assuming that clinicians are aware of the relatively low overall sensitivity. Consensus on a standard radiological interpretation protocol for future published studies would facilitate further meta-analysis.

Abstract W P109: CT Angiography of Symptomatic Intracranial Atherosclerosis: Anatomical Predictors of Fractional Flow

Background: Current use of CT angiography (CTA) for intracranial atherosclerosis (ICAD) focuses solely on measurement of maximal degree in isolated stenosis, a parameter that poorly predicts subsequent stroke. Noninvasive modeling with computational fluid dynamics (CFD) measures hemodynamic impact of stenoses based on fractional flow. We tested a novel method to compare anatomy- and CFD-based hemodynamics. Methods: A geometric mesh of ICAD lesions was derived from CTA. Semi-automated seed placement and centerline calculation across stenotic segments was used to automatically identify luminal stenoses, tandem lesions, plaque length and associated volumes. Fractional flow, the pressure drop across lesions, was calculated and compared to CFD-derived values using Ansys CFX and CFD-post, with boundary conditions for laminar flow. Results: CTA of 73 patients (mean age 72.7 ± 10.2 years; 58% men) with recently symptomatic ICAD were analyzed by semi-automated anatomical measures and CFD. Lesions included 45 M1, 14 ICA, 11 Bas and 3 VA intracranial lesions with median stenosis of 62.0% (40-93). Median plaque length was 12.2 (2.9-29.9) mm. Total plaque volumes measured median 75.1 (19.2-325.3) mm 3 with focal stenoses accounting for 40.0 (6.3-168.5) mm 3 . Pressure drop across the lesion calculated anatomically based on maximal stenosis averaged 34.7% (IQR 18.1-76.9) and 12.7% (IQR 5.0-40.2), the latter accounting for plaque length. These correlated moderately with fractional flow measured by CFD (ρ=0.545 and ρ=0.561, respectively). Plaque volumes of the entire lesion or the focal stenosis, the presence of tandem lesions or irregular surface morphology did not correlate with CFD-derived fractional flow. Conclusions: Detailed anatomy of intracranial atherosclerotic lesions can be extracted by semi-automated techniques, revealing extensive heterogeneity. Clinical studies are needed to discern whether CTA anatomy or CFD-derived fractional flow measures predict recurrence of stroke in the territory.

Pretreatment Advanced Imaging in Patients with Stroke Treated with IV Thrombolysis: Evaluation of a Multihospital Data Base

CT angiography, CT perfusion, and MR imaging have all been advocated as potentially useful in treatment planning for patients with acute ischemic stroke. We evaluated a large multihospital data base to determine how the use of advanced imaging is evolving in patients treated with intravenous thrombolysis. Patients with acute ischemic stroke receiving IV thrombolytic therapy from 2008 to 2011 were identified by using the Premier Perspective data base. Mortality and discharge to long-term care rates were compared following multivariate logistic regression between patients who received head CT only versus those who received CTA without CT perfusion, CT perfusion, or MR imaging. Of 12,429 included patients, 7305 (59%) were in the CT group, 2359 (19%) were in the CTA group, 848 (7%) were in the CTP group, and 1917 (15%) were in the MR group. From 2008 to 2011, the percentage of patients receiving head CT only decreased from 64% to 55%, while the percentage who received cerebral CT perfusion increased from 3% to 8%. The use of CT angiography and MR imaging marginally increased (1%-2%). Outcomes were similar between CT only and advanced imaging patients, except discharge to long-term care was slightly more frequent in the CTP group (OR = 1.17 [95% CI, 0.96-1.43]; P = .0412) and MR group (OR = 1.14 [95% CI, 1.01-1.28]; P = .0177) and mortality was lower in the MR group (OR = 0.64 [95% CI, 0.52-0.79]; P < .0001). Use of advanced imaging is increasing in patients treated with IV thrombolysis. While there were differences in outcomes among imaging groups, the clinical effect of advanced imaging remains unclear.

Oclusión arterial de gran vaso diagnosticada por angiografía por tomografía computarizada en el ictus isquémico agudo: frecuencia, factores predictores y seguridad

IntroductionDemonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. MethodsWe retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011. ResultsWe included 157 patients (mean age, 74±11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P<.001) and atrial fibrillation (64% vs 32%, P=.006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming these associations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2±24.5minutes in patients who underwent CT-angiography, and 53.5±34.3minutes in those who did not (P=.495). ConclusionsArterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor.

Use of CT Angiography and Digital Subtraction Angiography in Patients with Ruptured Cerebral Aneurysm: Evaluation of a Large Multihospital Data Base

Both CT angiography and digital subtraction angiography are used to detect aneurysms in patients with subarachnoid hemorrhage. We examined a large multihospital data base to determine how practice is evolving with regard to the use of CT angiography and DSA in patients with ruptured cerebral aneurysm. The Premier Perspective data base was used to identify hospitalizations of patients treated with clipping or coiling of ruptured cerebral aneurysms from 2006-2011. Billing information was used to determine pretreatment and posttreatment use of DSA and CT angiography during hospitalization. A total of 4972 patients (1022 clipping, 3950 coiling) at 116 hospitals were identified. The percentage of patients with SAH who underwent pretreatment CT angiography significantly increased from 20% in 2006 to 44% in 2011 (P < .0001), whereas the percentage of patients who underwent DSA remained unchanged from 96-94% (P = .28). This CT angiography trend was observed in coiling patients (17-42%, P < .0001) and clipping patients (32-54%, P < .0001). There was a significant increase in the percentage of patients who underwent posttreatment imaging from 41% in 2006 to 48% in 2011 (P = .0037). This trend was observed in clipping patients (33-65%, P < .0001) but not coiling patients (43-45%, P = .62). For the pretreatment evaluation of ruptured aneurysms, the use of CT angiography increased from 2006-2011 without a corresponding decrease in the use of DSA. These results raise the question of potential redundancy without added clinical value of the second test.

Intracranial Aneurysms in Patients With Carotid Disease

Before the routine use of computed tomography (CT) angiography, decisions for carotid artery treatment were mostly based on ultrasound findings and conventional angiography. Implementation and increasing use of CT angiography provided better visualization of the carotid and vertebrobasilar arteries system leading to an unexpected more frequent detection of unruptured intracranial aneurysms (UIAs). Concomitant presence of intracranial aneurysms in patients with severe carotid stenosis is a potential cause of significant mortality and morbidity. Due to the possible higher risk of aneurysm rupture after carotid procedures and ischemic events after aneurysm repair, the simultaneous presence of both lesions creates several therapeutic dilemmas. We review the prevalence of UIAs in patients with carotid occlusive disease and management difficulties and the current treatment strategies for handling the concomitant presence of these life-threatening diseases.

Ascending Thoracic Aorta: Postoperative Imaging Evaluation

Advances in computed tomography (CT) scanners and electrocardiographic gating techniques have resulted in superior image quality of the ascending aorta and increased the use of CT angiography for evaluating the postoperative ascending aorta. Several abnormalities of the ascending aorta and aortic arch often require surgery, and various open techniques may be used to reconstruct the aorta, such as the Wheat procedure, in which both an ascending aortic graft and an aortic valve prosthesis are implanted; the Cabrol and modified Bentall procedures, in which a composite synthetic ascending aorta and aortic valve graft are placed; the Ross procedure, in which the aortic valve and aortic root are replaced with the patient's native pulmonary valve and proximal pulmonary artery; valve-sparing procedures such as the T. David-V technique, which leaves the native aortic valve intact; and more extensive arch repair procedures such as the elephant trunk and arch-first techniques, in which interposition or inclusion grafts are implanted, with or without replacement of the aortic valve. Normal postoperative imaging findings, such as hyperattenuating felt pledgets, prosthetic conduits, and reanastomosis sites, may mimic pathologic processes. Postoperative complications seen at CT angiography that require further intervention include pseudoaneurysms, anastomotic stenoses, dissections, and aneurysms. Radiologists must be familiar with these procedures and their imaging features to identify normal postoperative appearances and complications.

Value of CT angiography for the detection of intracranial vascular lesions in patients with acute severe headache

To retrospectively investigate the prevalence and characteristics of intracranial vascular lesions in patients with acute severe headache with the use of CT angiography (CTA). We systematically searched for neurologically intact patients with acute severe headache and normal unenhanced head CT. The study group consisted of 512 patients; 251 male; mean age 46.2 ± 12.4 years. All patients underwent CTA between 1 day and 2 months after the headache attack. CTA images were interpreted by two experienced neuroradiologists for the presence of vascular lesions. Thirty-four (6.6 %) of the 512 patients had intracranial vascular lesions on CTA, including 33 aneurysms (2 patients had 2 aneurysms each), 2 moyamoya disease and 1 arterial dissection. No gender- or age-related differences were found. Aneurysms arose most commonly on the internal carotid artery (n = 12), followed by the anterior communicating artery (n = 7), and the middle cerebral artery (n = 7). Maximal diameters ranged from 2.0 to 13.1 mm (mean, 3.9 ± 2.6 mm). CTA is a feasible tool for diagnosing intracranial vascular lesions in patients with acute severe headache. The prevalence of vascular lesions in our series was 6.6 %, which is higher than that predicted in the general population. • Unruptured cerebral aneurysms may be a cause of acute severe headache • CTA assesses intracranial vascular lesions in patients with acute severe headache • The prevalence of vascular lesions in our series of patients was 6.6 %

The Use of CT Angiography in the Diagnosis of Coronary Artery Disease

This article describes the features of computed tomography angiography (CTA) and how these features allow high temporal and spatial resolution of specific cardiac structures. In CTA, the X-ray tube rotates around the patient 3 times per second—much faster than the 1- to 3-second rotation time of conventional CT—providing high temporal resolution. The small size allows creation of high-resolution, artifact-free coronary artery and cardiac reconstructions.

Superficial temporal artery–middle cerebral artery bypass using local anesthesia and a sedative without endotracheal general anesthesia

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses have continually evolved, and new strategies have been advocated for reducing anesthetic or surgical morbidity and mortality. Further simplifying, and decreasing the invasiveness of, STA-MCA bypass by performing this operation without endotracheal general anesthesia was believed to be feasible in certain subsets of patients. The authors performed STA-MCA bypass using local anesthesia with a sedative in 10 patients with hemodynamically compromised occlusive cerebrovascular disease, as well as multiple comorbidities, between February 2010 and September 2011. The technique is based on the preoperative identification of the point at which the donor and recipient vessels are in closest proximity. Preoperative use of CT angiography allowed the authors to identify the target point precisely and use a minimally invasive procedure. All patients received dexmedetomidine as the sole sedative agent, together with scalp-blocking local anesthesia, with an unsecured airway. Successful STA-MCA bypass surgeries were achieved via a preselected minimally invasive approach in all cases. There was good hemodynamic stability throughout surgery. No airway or ventilation complications occurred, and no patients were converted to general anesthesia. Subjectively, patients tolerated the technique well with a high rate of satisfaction. There were no perioperative morbidities or deaths. Postoperative MR angiography confirmed a patent bypass in all patients. All patients remained symptom free and returned to normal daily life following the operation. This initial experience confirms the feasibility of performing STA-MCA bypass without endotracheal general anesthesia. This novel technique produced a high degree of patient satisfaction.

Use of CT Angiography and CT Perfusion Imaging in the Selection of Hyperacute Stroke Patients to Undergo Emergent Carotid Endarterectomy Versus Intra-Cranial Thrombectomy

Use of CT Angiography and CT Perfusion Imaging in the Selection of Hyperacute Stroke Patients to Undergo Emergent Carotid Endarterectomy Versus Intra-Cranial Thrombectomy

Further experience with the free soleus perforator flaps using CT-angiography as a planning tool – A preliminary study

IntroductionThe soleus perforator flap is a soft tissue flap with minimal donor site morbidity however is not frequently utilised due to the unpredictability of the perforating vessel to serve as the vascular pedicle. We have trialed the use of CT-angiography as a planning tool to predict location, length, course, and calibre of the pedicle to make this a more reliable choice. MethodsTwenty consecutive patients with intraoral squamous cell carcinomas were assessed with CT-angiography to examine the peroneal perforators before considering soleus flap raising. If a sizeable perforator could be visualised at the upper half of the lower leg, flap raising was carried out, and the result of the CT-angiography was compared with the intra-operative findings. ResultsCT-angiography allowed for visualisation of perforators measuring 1mm in diameter and could predict location, length and course of the vessel. Accordingly, eight of the 20 patients had to be excluded from flap raising due to missing, too fine or too far distally located perforators. Intra-operative findings corresponded well with the results of the CT-scans. ConclusionCT-angiography is a useful tool for planning the soleus perforator flap and allows selection of the most suitable perforator making the use of this flap more reliable.