Tomography Venography Research Articles

Clinical and Angiographic Imaging Features of Isolated Cortical Venous Thrombosis

Background Cerebral venous thrombosis usually presents as dural sinus thrombosis. More rarely, it occurs in an isolated form (isolated cortical vein thrombosis; ICoVT). ICoVT is poorly recognized and underdiagnosed, and noninvasive imaging remains nebulous. The digital subtraction angiographic (DSA) patterns of ICoVT are neither well known nor documented. We present clinical and imaging details of the largest series of ICoVT, with all cases demonstrating both noninvasive imaging findings, along with angiographic confirmation. We propose a preliminary compilation of the DSA patterns of ICoVT. Methods We identified all patients with cerebral venous thrombosis at our institution between January 2013 and June 2019. Only patients in whom ICoVT was diagnosed and/or suspected with computed tomographic venography and/or magnetic resonance imaging/MR venogram with subsequent DSA confirmation were included. DSA imaging was reviewed for direct and indirect signs. Clinical data, outcomes, and follow‐up imaging were analyzed. Results We identified 109 patients with cerebral venous thrombosis; in 21 patients ICoVT was suspected on noninvasive imaging and eventually had DSA confirmation. Headache and focal neurological deficit were the most common presentations (each 67%). Ten patients (47%) presented with parenchymal changes due to ICoVT and 15 patients (71%) presented with subarachnoid hemorrhage. We identified 5 DSA patterns of ICoVT (3 direct; 2 indirect). Filling defects in cortical veins and the regional absence of cortical veins and decreased subcortical opacification were the most common patterns (52% and 90%, respectively). Sixteen patients (76%) were anticoagulated. Eighteen patients were discharged without disability or minor disability (84%). No deaths occurred. Conclusions Catheter angiography/venography may be important in diagnosing ICoVT, especially when magnetic resonance imaging/MR venogram is unclear. The angiographic patterns of ICoVT are presented.

Extracranial prevertebral venous network of the craniocervical junction: CT-digital subtraction venography analysis

Although the craniocervical junction has a complex anatomical structure associated with clinical diseases, its ventral venous network has not been well studied. This study aimed to clarify the extracranial ventral venous structure at the craniocervical junction. Head computed tomography digital subtraction venography (CT-DSV) images of 273 patients (age 6months to 93years) taken at our department were retrospectively analyzed. We analyzed the frequency and anatomical features of the venous channels, as well as their upstream and downstream connections with the surrounding channels at the ventral craniocervical junction, from the level of the hypoglossal canal to the second cervical vertebra. In 54% of the cases, the vein descended from the anterior condylar confluence, running medially along the basioccipital and fusing with its counterpart in the midline at the level of the atlanto-occipital membrane. Furthermore, 24% of this vein was connected caudally to the anterior external vertebral venous plexus. We also identified venous channels, either as a sole vein or venous plexus, on the tip of the odontoid process (10%), which has not been well described previously. The vein around the odontoid process was connected to several veins, including the aforementioned vein anterior to the condyle and the anterior internal vertebral venous plexus. CT-DSV analysis revealed a detailed venous architecture ventral to the craniocervical junction. Venous structures identified in this study may be involved in diseases in this area.

Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study.

This study evaluated major vascular injury risk in distal femoral osteotomy (DFO) via the subvastus approach and examined the relationship between the posterior border of the vastus medialis (VM) and the superficial femoral artery (SFA) and vein (SFV). Eighty limbs from 80 patients were evaluated using lower extremity computed tomographic venography. The positional relationship between the VM, SFA, and SFV was evaluated by measuring the angle between each structure and the horizontal reference point (VMA: VM angle, FAA (femoral arterial angle), FVA (femoral venous angle) and the distance between VM and the SFA and SFV (VMAD: VM-arterial distance, VMVD: VM-venous distance) in each axial slice (0/10/20/30/40mm) proximal to the level of the superior patellar margin. The proximity of the posterior border of the VM and the SFA/SFV as a vertical distance, measured between the slice of the superior border of the patella and the slice where the posterior border of the VM contacted the SFA was evaluated. Single and multiple regression analyses were performed using the vertical distance as the objective variable. As the slice shifted proximally, the VMA significantly increased (24.9 ± 8.5, 36.3 ± 8.8, 47.4 ± 11.8, 59.9 ± 14, 70.3 ± 13.7 degrees, respectively, p < 0.001 between all slices) and moved posteromedially from a medial direction. FAA (94.2 ± 7, 86.9 ± 9.2, 78.4 ± 9.7, 71.4 ± 9.8, 66.6 ± 10.5 degree, respectively, p < 0.001 between all slices) and FVA (100.6 ± 4.9, 98.3 ± 5.9, 93.7 ± 7.5, 88 ± 9.2, 81.1 ± 10.5 degrees, respectively, p < 0.001 between all slices) decreased and moved from a posterolateral to a posteromedial direction, while VMAD (35.4 ± 7.8, 24.1 ± 7.3, 14.3 ± 6, 8.4 ± 7, 6.2 ± 6.3mm, respectively, p < 0.001 between all slices) and VMVD significantly decreased (42.7 ± 7.3, 32 ± 7.4, 22.4 ± 6.8, 14.5 ± 10.6, 8.7 ± 7.1mm, respectively, p < 0.001 between all slices). The average vertical distance was 36 ± 9.3mm (range 18.6-61.5mm). The body height and the patellar length significantly affected the vertical distance. The posterior border of the VM shifted posteromedially from distal to proximal and contacted the SFA at an average of 36mm from the suprapatellar border. Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy. Case series, Level IV.

The Role of Intra-Operative Duplex Ultrasonography Following Translabyrinthine Approach for Vestibular Schwannoma.

ObjectiveSigmoid sinus (SS) stenosis is a complication of translabyrinthine approach. Velocity changes in the SS measured by intra-operative doppler ultrasound may help in identifying patients at risk for sinus occlusion.PatientsSS velocity was measured using doppler ultrasound prior to opening dura and again prior to placement of the abdominal fat graft.InterventionData collected included: patient age, surgical side, sinus dominance, tumor volume, intra-operative doppler ultrasound measurements, post-operative venous sinus imaging, anticoagulation, and morbidities and mortalities.Main Outcome MeasureSS patency and velocity.ResultsEight patients were included in the analysis (22 to 69 years). Four had left-sided and four had right-sided craniotomies. Sigmoid sinuses were either right-side dominant or co-dominant. The mean velocity ± standard deviation (SD) prior to dura opening and abdominal fat packing was 23.2 ± 11.3 and 25.5 ± 13.9 cm/s, respectively, p = 0.575. Post-operative Magnetic Resonance Venography (MRV) imaging showed four sigmoid sinus occlusions; seven patients showed sigmoid sinus stenosis, and one internal jugular vein occlusion. One patient had post-operative Computed Tomography Venography (CTV) only. Of the four patients with MRV occlusions, CTVs were performed with three showing occlusion and all four-showing stenosis. One patient with internal jugular vein occlusion on MRV received warfarin anticoagulation. There was one cerebrospinal fluid leak requiring ear closure, one small cerebellar infarct, and one with facial nerve palsy (House-Brackman Grade 3).ConclusionSS velocity changes before and after tumor resection were not predictive of sinus occlusion. We hypothesize that sinus occlusion may be caused by related factors other than thrombosis, such as external compression of the sinus secondary to abdominal fat grafting.

Cerebral Venous Thrombosis (CVT)

Altered mental status, which affects four to ten percent of emergency hospital patients, is a common symptom. Without a lot of information from the lab, radiography, and physical exam, determining the aetiology could be challenging. The provider's clinical judgement is used to guide the diagnosis procedure based on the available history. As a result, if a reasonable suspicion is not present when examining alternative reasons, less common diagnosis may be overlooked or delayed. CVST (cerebral venous sinus thrombosis) is an uncommon and poorly understood condition with a high rate of morbidity and mortality. Summary: CVST is a rare yet life-threatening condition that strikes teenagers and young adults. Its natural manifestations might range from mild to spectacular and deep. However, if detected early enough, adequate therapy can often lead to total recovery. Magnetic Resonance Imaging Venography (MRV) is the current gold standard for diagnosing CVST, while Computed Tomography Venography (CTV) has been demonstrated to be almost as good in detecting CVST. When MRV is not easily available, this is critical because it speeds up the virus's disposition and the initiation of anticoagulant medication.

Current Best Practice in the Management of Varicose Veins.

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Establishing a jugular-femoral venous route for recanalization of complicated inferior vena cava in Budd\u2013Chiari Syndrome after transfemoral access failure

Recanalization of inferior vena cava (IVC) with complete obstruction, old thrombosis or long segmental stenosis/obstruction (complicated IVC) via transfemoral access may fail in patients with Budd-Chiari syndrome (BCS). In this study, 34 consecutive patients with BCS underwent recanalization of complicated IVC occlusion via jugular-femoral venous (JFV) route establishment. BCS with complicated IVC was detected by reviewing preoperative color Doppler ultrasonography or computed tomography (CT) venography, and confirmed by intraoperative venography. Clinical data on technical success, complications, and follow-up outcomes were analyzed. Except for one patient received surgical repair of rupture IVC after recanalization, technical success of IVC recanalization was achieved in remaining 33 (97.1%) patients. No perioperative deaths was found. Three complications were observed during recanalization, for a complication rate of 8.8%. Bleeding of the femoral vein was observed in one patient, and two patients showed bleeding of IVC. The IVC lesion diameter and blood flow of the distal IVC increased significantly after the procedure. Twenty-four patients (77.4%) were clinically cured, and four patients (12.9%) showed clinical improvement. The 1-year, 3-year, 5-year primary patency rates were 85.9%, 76.4% and 70.0%, respectively. The 5-year secondary patency rate was 96.8%. There were three deaths during follow up, and the 5-year survival rate was 90.0%. In conclusion, JFV route establishment and angioplasty for complicated IVC is safe and effective for patients with BCS after transfemoral access failure.

Effects of Different Degrees of Extraluminal Compression on Hemodynamics in a Prominent Transverse-Sigmoid Sinus Junction.

ObjectivesTo simulate hemodynamic changes after extraluminal compression in pulsatile tinnitus (PT) patients with a prominent transverse-sigmoid sinus junction (PTSJ).MethodsOne patient-specific case was reconstructed based on computed tomography venography (CTV) images of a PT patient. The compression degree served as a new index in this study. Cases with 10, 20, 30, 40, 50, 60, 70, 80, and 90% of the compression degree of the control subject were constructed. Steady-state computational fluid dynamics (CFD) were assessed. The wall pressure distribution, wall maximum pressure (Pmax) and flow pattern (velocity streamlines and velocity vector) of the PTSJ were calculated to evaluate hemodynamic differences among all cases.ResultsWith increasing compression, the wall pressure at the compression point and downstream of the PTSJ decreased but increased upstream. When the compression degree exceeded 70%, the upstream pressure increased significantly. Above 50% compression, the blood flow pattern downstream of the sigmoid sinus tended to spiral, especially after 80% compression. Beyond 60% compression, the blood flow pattern under the compression axis became more medial.ConclusionMechanical compression of PTSJ changes wall pressure and blood flow patterns. The degree of compression should be carefully observed to avoid possible complications or reoccurrence.

Sex-related differences regarding cephalic vein lead access for CIEDs implantation

BackgroundMinimally invasive and safe central venous access is imperative for lead insertion of cardiac implantable electronic devices (CIEDs). The purpose of this trial was to explore and compare the usability of the cephalic vein (CV) between both sexes.Methods and resultsThis single-center prospective study included 102 consecutive patients in a period of six months. Pre-procedural contrast-enhanced venographic images of the upper arm were performed in all included patients. Our attention was focused on comparing several morpho-anatomical CV characteristics such as venous diameter, presence of valves and angle of entrance of the CV into the subclavian vein (SV). Study results concerning the CV morpho-anatomical differences were more favorable regarding the female patient group, with significant differences in CV diameter (p-0.030). There was also a difference in favor of the female group regarding the favorable CV angle of entrance into the SV, found in the 61.7% versus 54.4% in the male patient group. The comparison of usability of the CV and CVC technique was explored by comparing the number of leads inserted through the CV in both sexes. Two leads were implanted in 11.7% in the female group versus 5.8% in the male group, and 0 leads through the CV in 38.2% of the female patients versus 50% of male group.ConclusionFemale patients have more favorable cephalic vein morpho-anatomical futures and better usability for lead placement than male patients.

An Uncommon Cause of Hematemesis in a Patient With End-stage Renal Disease

Question: A 45-year-old man presented with an acute onset of large volume hematemesis associated with worsening facial and neck swelling for the past 6 months. He has a significant past medical history of end-stage renal disease secondary to congenital dysplastic kidneys and has been on hemodialysis for the past 30 years. He has no history of chronic liver disease. Clinical examination revealed diffuse facial and neck edema. Dilated superficial veins were also seen on his upper anterior chest wall. A pulsatile left brachiocephalic arteriovenous fistula was present. The patient was intubated and urgent esophagogastroduodenoscopy was performed. The following bleeding lesion was visualized 25 cm from the incisors (Figure A). What is the diagnosis? Look on page 405 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The patient was suspected to have downhill esophageal varices. The bleeding varix located 25 cm from the incisors was band ligated with successful hemostasis (Figure B). A computed tomographic venography of the thorax was performed, which revealed an occluded right brachiocephalic to superior vena cava stent (white arrow) and a prominent azygos vein (red arrow) (Figure C). The patient underwent a percutaneous central venogram and balloon angioplasty of the occluded right brachiocephalic and superior vena cava stent (Figure D). After the procedure, the patient’s facial and neck swelling diminished rapidly and there were no further episodes of bleeding. Downhill varices, or otherwise known as proximal esophageal varices are most commonly due to superior vena cava obstruction secondary to various etiologies such as malignancy, mediastinal fibrosis, and central venous catheter placement.1Ostler P.J. Clarke D.P. Watkinson A.F. Gaze M.N. Superior vena cava obstruction: a modern management strategy.Clin Oncol (R Coll Radiol). 1997; 9: 83-89Abstract Full Text PDF PubMed Google Scholar Although malignancy is the most common etiology of superior vena cava obstruction, bleeding downhill varices tend to occur more in patients with benign etiologies, such as central venous catheter placement.2Loudin M. Anderson S. Schlansky B. Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction: case report and literature review.BMC Gastroenterol. 2016 24; 16: 134Crossref PubMed Scopus (13) Google Scholar This phenomenon may be due to increased venous return and pressure secondary to the underlying arteriovenous access for hemodialysis. The underlying superior vena cava obstruction leads to diversion of venous return through the azygos vein, which in turns causes engorgement of the veins draining the proximal to middle aspect of the esophagus, and causing the development of downhill varices.3Marini T.J. Chughtai K. Nuffer Z. et al.Blood finds a way: pictorial review of thoracic collateral vessels.Insights Imaging. 2019; 10: 63Crossref PubMed Scopus (3) Google Scholar During acute bleeding, endoscopic therapies such as variceal band ligation can be used for hemostasis. However, the mainstay of treatment is to treat and relieve the underlying superior vena cava obstruction. Clinicians should have a high index of suspicion for downhill varices if a patient with end-stage renal disease on hemodialysis presents with upper gastrointestinal bleeding, especially if the patient has a history of central venous catheter placement.

Simultaneous antegrade urography of the upper urinary tract and retrograde cystography combined with computed tomography imaging in the management of ureteral complications after renal transplantation.

BackgroundTo investigate the significance of simultaneous urography of the upper and lower urinary tract of transplanted kidneys combined with computed tomography urography (CTU), computed tomography arteriography (CTA), and computed tomography venography imaging in the planning of open surgery performed to treat any ureteral complications of a transplanted kidney.MethodsIn all, 24 patients with ureteral complications after renal transplantation were admitted, 12 of whom had renal graft ostomy during open surgery. Simultaneous antegrade urography of the upper urinary tract and retrograde cystography of the transplanted kidneys were performed on the patients. With the use of computed tomography imaging results, surgical planning was carried out.ResultsAll surgeries were successfully completed according to preoperative planning. Three patients underwent end-to-end anastomosis of the ureter and bladder muscle flap, 8 patients underwent ureterocystostomy, and 1 patient underwent an end-to-end ureteral anastomosis. After the follow-up up to now, all the patients had stable renal function, and no complications such as ureteral stenosis or urine leakage have thus far reoccurred in the transplanted kidneys.ConclusionsWhen open surgery is required to treat any ureteral complications following renal transplantation, preoperative multiangle imaging can be used to better understand the condition of the transplanted urinary tract and thus aid considerably in surgical planning.

A novel approach to the selection of an appropriate pacing position for optimal cardiac resynchronization therapy using CT coronary venography and myocardial perfusion imaging: FIVE STaR method (fusion image using CT coronary venography and perfusion SPECT applied for cardiac resynchronization therapy)

BackgroundNearly one-third of patients with advanced heart failure (HF) do not benefit from cardiac resynchronization therapy (CRT). We developed a novel approach for optimizing CRT via a simultaneous assessment of the myocardial viability and an appropriate lead position using a fusion technique with CT coronary venography and myocardial perfusion imaging. Methods and ResultsThe myocardial viability and coronary venous anatomy were evaluated by resting Tc-99m-tetrofosmin myocardial perfusion imaging (MPI) and contrast CT venography, respectively. Using fusion images reconstructed by MPI and CT coronary venography, the pacing site and lead length were determined for appropriate CRT device implantations in 4 HF patients. The efficacy of this method was estimated by the symptomatic and echocardiographic functional parameters. In all patients, fusion images using MPI and CT coronary venograms were successfully reconstructed without any misregistration and contributed to an effective CRT. Before the surgery, this method enabled the operators to precisely identify the optimal indwelling site, which exhibited myocardial viability and had a lead length necessary for an appropriate device implantation. ConclusionsThe fusion image technique using myocardial perfusion imaging and CT coronary venography is clinically feasible and promising for CRT optimization and enhancing the patient safety in patients with advanced HF.

High-Resolution Magnetic Resonance Black Blood Thrombus Imaging and Serum D-Dimer in the Confirmation of Acute Cortical Vein Thrombosis.

Cerebral cortical vein thrombosis (CCVT) is often misdiagnosed because of its non-specific diagnostic symptoms. Here, we analyzed a cohort of patients with CCVT in hopes of improving understandings and treatments of the disease. A total of 23 patients with CCVT (confirmed with high-resolution imaging), who had been diagnosed between 2017 and 2019, were enrolled in this cohort study. Baseline demographics, clinical manifestations, laboratory data, radiological findings, treatment, and outcomes were collected and analyzed. Fourteen females and nine males were enrolled (mean age: 32.7 ± 11.9 years), presenting in the acute (within 7 days, n = 9), subacute (8–30 days, n = 7), and chronic (over 1 month, n = 7) stages. Headaches (65.2%) and seizures (39.1%) were the most common symptoms. Abnormally elevated plasma D-dimers were observed in the majority of acute stage patients (87.5%). The diagnostic accuracy of contrast-enhanced magnetic resonance venography (CE-MRV) and high-resolution magnetic resonance black-blood thrombus imaging (HR-MRBTI) in detecting CCVT were 57.1 and 100.0%, respectively. All patients had good functional outcomes after 6-month of standard anticoagulation (mRS 0–1) treatment. However, four CCVT patients that had cases involving multiple veins showed symptom relief after batroxobin therapy (p = 0.030). HR-MRBTI may be a fast and accurate tool for non-invasive CCVT diagnosis. HR-MRBTI combined with D-dimer can also precisely identify the pathological stage of CCVT. Batroxobin may safely accelerate cortical venous recanalization in combination with anticoagulation. Follow-up studies with larger sample sizes are suggested to evaluate the safety and efficacy of batroxobin for treating CCVT.

Updates in Magnetic Resonance Venous Imaging.

For years, magnetic resonance angiography (MRA) has been a leading imaging modality in the assessment of venous disease involving the pelvis and lower extremities. Current advancement in noncontrast MRA techniques enables imaging of a larger subset of patients previously excluded due to allergy or renal insufficiency, allowing for preintervention assessment and planning. In this article, the current status of MR venography, with a focus on current advancements, will be presented. Protocols and parameters for MR venographic imaging of the pelvis and lower extremities, including contrast and noncontrast enhanced techniques, will be reviewed based on a recent literature review of applied MR venographic techniques. Finally, several disease-specific entities, including pelvic congestion and compression syndromes, will be discussed with a focus on imaging parameters that may best characterize these disease processes and optimize anatomical planning prior to intervention.

Atypical iliac vein compression in patients with symptomatic May-Thurner syndrome.

We aimed to investigate the incidence, etiology, treatment, and clinical course of atypical iliac vein compressions (AIVCs) among patients with May-Thurner syndrome (MTS). A total of 173 patients who presented with MTS were retrospectively analyzed at a single center. Computed tomographic venography (CTV) was used to diagnose MTS. An AIVC was defined as the compression of the left common iliac vein (LCIV) by structures other than the right common iliac artery (RCIA) or the compression of other venous structures in the pelvic cavity instead of the LCIV. The patients with AIVC were categorized into the LCIV compression group (category A) and non-LCIV compression group (category B). Ten patients with AIVC were identified (5.8%; male/female, 5/5), five in category A and five in category B. The median age of patients was 76 years (range, 51-94 years), and the median follow-up duration was 388 days (range, 12-4694 days). In category A, the LCIVs were compressed by the left common iliac artery (LCIA) (n=2), uterine leiomyoma (n=1), LCIA aneurysm (n=1), and RCIA aneurysm (n=1). In category B, the right common iliac veins were compressed by the RCIA (n=4) and L5 osteophyte (n=1). Endovascular treatment, including balloon angioplasty and stent placement, was performed in six patients, three from each group. Three patients underwent conservative treatment due to their advanced age and comorbidities. Endovascular aneurysm repair was performed in one patient with RCIA aneurysm. Follow-up images were available for six patients, and all of them had patent venous flow. The AIVC had an incidence of 5.8% (10/173) among symptomatic MTS patients and wide spectrum of etiologies. Pathogenesis-tailored endovascular treatments are safe and effective.

The Venous Occlusion Image Score: A Novel Quantitative Scoring Instrument for Cerebral Venous Sinus Thrombosis

PurposeThis study aims to test the validity of a new quantitative scoring instrument−the Venous Occlusion Image Score (VOIS), and assess the diagnostic and prognostic value of VOIS for cerebral venous sinus thrombosis (CVST). MethodsThe VOIS divided the major cerebral venous sinuses and internal jugular veins into nine parts of interest. CT venography and DSA source images and reconstruction were extracted from the database, then interpreted and scored independently according to VOIS by a panel of three reviewers. Inter-observer and intra-observer reliability were determined using the intraclass correlation coefficient (ICC) and the kappa coefficient (κ). The primary outcome was the 3-month functional outcome and evaluated by modified Rankin Scale (mRS). The sensitivity and specificity of VOIS for the primary outcomes were computed. Logistic regression was applied to evaluate the association between the score on VOIS and the primary outcomes. ResultsFifty-six patients with CVST were included in the study. For 16 patients underwent cerebral CTV and DSA, excellent interobserver agreement was observed for DSA (ICC=0.90, 95%CI = 0.87 − 0.92, P < 0.001), and CTV (ICC = 0.92, 95%CI = 0.84 − 0.93, P < 0.001). The κ coefficient of agreement for the two radiology measures was 0.88 (95%CI = 0.79-0.92), indicating good inter-method agreement. For 56 patients followed up by CTV, baseline VOIS value correlated inversely with the severity of stroke on the National Institutes of Health Stroke Scale (r = −0·53, P < 0·001), and modified Rankin Scale (r = −0·59, P < 0·001). Baseline CTV-VOIS value predicted functional outcome (P < 0·05). ConclusionVOIS may serve as a convenient and reliable method in the treatment guidance and outcome prediction of patients with CVST.

COMPLEX VENOUS THROMBOEMBOLISM DECISION-MAKING IN POSTPARTUM PATIENT

Background May-Thurner syndrome and pregnancy are independent risk factors for the development of deep vein thrombosis (DVT). Emerging data suggests an association for venous thromboembolism (VTE) development in COVID-19 patients. Treatments for DVT vary and include thrombolysis, mechanical thrombectomy and long-term anticoagulation. We describe a unique case of this in a postpartum female. Case A 31 year old female G3P0121 and recent cesarean section 1 month ago presented with left lower extremity swelling, severely limited ambulation and 3+ edema of the left leg extending to the hip without any right leg edema. She was COVID-19 antibody positive. Occlusive DVTs were confirmed via venous duplex ultrasound and computed tomographic venography of the abdomen and pelvis, extending from distal inferior vena cava to the left popliteal vein. Decision-making Invasive venography confirmed the non-invasive imaging findings. After administering 12-14 mg of tissue plasminogen activator (tPA), multiple aspirations were performed using a rheolytic thrombectomy catheter. However persistent dense thrombus in the iliac and femoral veins remained, thus subsequent balloon angioplasty was performed but unsuccessful. Intravascular ultrasound confirmed the presence of May-Thurner syndrome at the junction of the left common iliac vein and the inferior vena cava. Finally an infusion catheter was placed for tPA. Within 48 hours, patient developed oliguric renal failure likely due to a combination of contrast-induced and pigment nephropathy requiring intermittent hemodialysis. Repeat ultrasound showed resolution of DVT along with improving edema and renal function. Warfarin was chosen for long-term anticoagulation due to renal failure and breast-feeding. Conclusion Pregnancy is a pro thrombotic state that may lead to VTE even in the postpartum period. Decision-making and treatment in these patients may be complex and require a multidisciplinary approach.

Role of 3D reconstructed images in primary pulmonary vein stenosis.

Primary pulmonary vein stenosis (PPVS) is a rare congenital cardiac anomaly. The surgical management of PPVS requires anatomical delineation of pulmonary venous drainage along with exact localization of the stenosis. Since echocardiography cannot visualize the whole length of pulmonary veins (PV), computed tomography (CT) pulmonary venography becomes necessary. Three-dimensional (3D) reconstruction helps in planning PV augmentation and for prognostication. Here, we present 3D reconstructed CT pulmonary venography images of a 3-month-old child who presented to us with PPVS.

Prediction of Postoperative Risk of Raised Intracranial Pressure After Spontaneous Skull Base Cerebrospinal Fluid Leak Repair.

A relationship between idiopathic intracranial hypertension and spontaneous skull base cerebrospinal fluid (CSF) leaks has been proposed, by which CSF leak decreases intracranial pressure (ICP) and masks the symptoms and signs of elevated ICP. These patients are at risk of developing papilledema, symptoms of elevated ICP, or a recurrent CSF leak after CSF leak repair. The objective of this study was to assess whether radiographic signs of raised ICP on preoperative magnetic resonance or computed venography (MRI or CTV) are predictors of postoperative papilledema, recurrence of CSF leak, or need for CSF shunt surgery. We performed a retrospective review of systematically collected demographics, fundus examination, and presurgical brain MRI and magnetic resonance venography/computed tomography venography (MRV/CTV) in patients seen at 1 institution between 2013 and 2019 with spontaneous skull base CSF leak repair. Patients were divided into 2 groups depending on whether they developed papilledema, recurrent CSF leak, or required CSF shunting (Group 1) or not (Group 2). Fifty-seven patients were included, among whom 19 were in Group 1. There was no difference in demographic characteristics or clinical features between patients in Group 1 and Group 2. Controlling for other imaging features, bilateral transverse venous sinus stenosis (TVSS) on preoperative imaging increased the odds of being in Group 1 by 4.2 times (95% confidence interval [CI], 1.04-21.2, P = 0.04), optic nerve tortuosity decreased the odds of being in Group 1 by 8.3 times (95% CI: 1.4-74.6, P = 0.02). Imaging of the intracranial venous system with MRV or CTV is warranted before repair of spontaneous CSF leak, as bilateral TVSS is an independent risk factor for postoperative papilledema, CSF leak recurrence, or need for a CSF shunting procedure.

Parameters Indicating Development of Influenza-Associated Acute Necrotizing Encephalopathy: Experiences from a Single Center.

BackgroundInfluenza-associated acute necrotizing encephalopathy (IANE) can be lethal and disabling and have a sudden onset and deteriorate rapidly but lacks early diagnostic indicators. We aimed to examine the early clinical diagnostic indicators in children with IANE.Material/MethodsAcute influenza patients were grouped according to their clinical manifestations: flu alone (FA), flu with febrile seizure (FS), influenza-associated encephalopathy (IAE), and IANE. The clinical features, biomarkers, neuroelectrophysiological results, and neuroimaging examination results were compared.ResultsA total of 31 patients were included (FA (n=4), FS (n=8), IAE (n=14), and IANE (n=5)). The IANE group, whose mean age was 3.7 years, was more likely to show rapid-onset seizure, acute disturbance of consciousness (ADOC), Babinski’s sign, and death/sequela. More patients in the IANE group required tracheal intubation mechanical ventilation and received intravenous immunoglobulins (IVIG) and glucocorticoids. The alanine aminotransferase (ALT), aspartate transaminase (AST), and lactate dehydrogenase (LDH) levels in the IANE group were significantly higher than in the FS and IAE groups. The aquaporin-4 (AQP-4) antibody and malondialdehyde (MDA) levels in the serum and cerebrospinal fluid (CSF) were notably higher in IANE patients in the acute stage compared with FS and IAE patients. All patients in the IANE group had positive neuroimaging findings.ConclusionsEarly clinical warning factors for IANE include rapid-onset seizures in patients under 4 years of age, ADOC, and pathological signs. Increased AQP-4 antibodies and MDA levels in CSF might contribute to early diagnosis. Early magnetic resonance venography (MRV) and susceptibility-weighted imaging (SWI) sequences, or thrombelastography to identify deep vein thrombosis, might indicate clinical deterioration.