Stent placement in patients with acute subarachnoid haemorrhage: when is it justified?

Abstract

Purpose

Endovascular stents are widely used for the elective treatment of cerebral aneurysms. Acute stenting is performed in the management of dissections, pseudo-aneurysms, broad-based aneurysms or as a 'bail out' measure after coil migration. The purpose of this study is to review the safety of using stents in acute subarachnoid haemorrhage.

Methods

The stent registry of our institution was reviewed for procedures in patients with acute subarachnoid haemorrhage. Imaging studies were reviewed on the hospital's PACS system and the patients' notes were retrieved to assess complications and clinical outcomes. Procedures were analysed according to the type of stent, treatment indication, antiplatelet regime, complications and outcomes.

Results

Between 2008 and 2016, 51 stents were placed during 50 stenting procedures in 49 patients with acute subarachnoid haemorrhage. This included 24 patients with saccular aneurysms, 10 with blister aneurysms, 10 dissections and five fusiform aneurysms. Stents were deployed in 'bail out' situations on eight occasions. In six cases, flow-diverting stents were used. Eighteen patients (37%) in the cohort suffered a stroke. Nine patients (18%) suffered persistent clinical deficits as a result of the stenting procedure, all but one of which occurred within 24 h. Two patients had a transient ischaemic episode, and there was evidence of asymptomatic ischaemia on imaging in four cases (8%). Five patients died, three (6%) as a result of procedural complications. Twelve patients (25%) required a further embolisation procedure.

Conclusion

The use of stents in acute subarachnoid haemorrhage incurs a considerable complication risk and should be reserved for exceptional circumstances.

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A Failure to Communicate?

Publication date: Available online 11 April 2018
Source:Academic Radiology
Author(s): Travis B. Wassermann, Christopher M. Straus
Rationale and ObjectivesComplete clinical information improves the diagnostic capacity of medical imaging, and the radiology requisition is the radiologist's primary means of receiving clinical information. This study aimed to characterize trends in the quality of clinical information in radiology requisitions at an academic medical center between 2011 and 2016.Materials and MethodsThis institution's requisition form includes two questions: "Signs and Symptoms:" and "Clinical Question to be answered…:" Requisitions for three studies (CT UPPER ABDOMEN & PELVIS W, CT HEAD WO, and XR PORT CHEST, 1 VIEW) from three selected months were individually rated in four categories of clinical information. Additionally, requisitions for 13 study types were evaluated for character count and for the proportion of requisitions with identical answers to the two questions. A total of 3250 requisitions were individually rated.ResultsThere was a decline in the quality of clinical questions in computed tomography requisitions (P = 0.016) and a decline in the quality of medical history in chest x-ray requisitions (P < .001). Of the 13 study types, nine had more than 1000 total requisitions (total n = 260,617). Of those nine studies, six showed trends of increasing character length (P < .001 for each). Four showed an increasing proportion of identical answers to the two questions (P < .001), and one showed a decreasing proportion of identical answers (P < .001).ConclusionsThis decline in the quality of clinical information is concerning. Whether it is due to increasing time pressures, a shift in the attitudes of ordering providers, or any other cause, this study demonstrates a declining trend in the quality of communication via the radiology requisition.



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Treatment choice, satisfaction and quality of life in patients with Graves' disease.

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Treatment choice, satisfaction and quality of life in patients with Graves' disease.

Clin Endocrinol (Oxf). 2018 Apr 06;:

Authors: Conaglen HM, Tamatea JAU, Conaglen JV, Elston MS

Abstract
Thyrotoxicosis, most often caused by Graves' disease (GD), when treated inadequately may result in premature mortality. There is little consensus as to which of the three treatment options available - antithyroid drugs (ATD), radioactive iodine (RAI) and surgery, is better.
AIMS: 1. To assess factors involved in treatment choice and treatment satisfaction in patients treated for Graves' disease. 2. To assess quality of life (QoL) following treatment of Graves' disease.
METHOD: Participants were selected from a prospective study cohort assessing thyrotoxicosis incidence and severity. Of the 172 eligible patients with Graves' disease, 123 treated patients participated (64% had received ATD only, 11% RAI and 25% total thyroidectomy, the latter two usually after a period of ATD), along with 18 untreated patients with newly diagnosed Graves' disease (overall participation rate 73%). Consented patients completed a questionnaire detailing factors involved in treatment choice, QoL and satisfaction with treatment.
RESULTS: Participants reported that the most important factors in choosing a treatment were: effects on activities of daily living, concern about use of radioiodine, possibility of depression or anxiety, and doctor's recommendations. Satisfaction levels were high across all three treatment types. QoL one year following treatment was higher than in untreated patients, and comparable to other international studies.
CONCLUSIONS: Patient satisfaction with therapy and QoL does not differ by treatment type. Therefore, clinical and social factors, in combination with patient choice and resource availability, should determine which treatment modality patients with Graves' disease should receive. This article is protected by copyright. All rights reserved.

PMID: 29633307 [PubMed - as supplied by publisher]

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Pilot Study of a Web-based Decision Tool on Post-operative Use of Radioactive Iodine.

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Pilot Study of a Web-based Decision Tool on Post-operative Use of Radioactive Iodine.

Eur Endocrinol. 2017 Apr;13(1):26-29

Authors: Baxi SS, Kurtzman R, Eaton A, Dewey E, Bickford C, Fish S, Wartofsky L, Michael Tuttle R

Abstract
Background: The Thyroid Cancer Care Collaborative developed a web-based clinical decision-making module (CDMM) to inform risk-adjusted decisions on post-thyroidectomy radioactive iodine (RAI) use in papillary thyroid cancer (PTC). Methods: In a pilot study, we evaluated the CDMM in 19 PTC cases representing low- (five), intermediate- (seven) and high-risk (seven) disease. Two PTC experts and 10 PTC physicians reviewed cases and assigned risk level and RAI recommendation. The experts used a standard approach while the others used the CDMM. We assessed agreement between responses using a weighted Kappa. Results: Between experts, risk-assignment was concordant in 100%, 57% and 86% of low-, intermediate- and high-risk cases, respectively. Between CDMM users, risk-assignment was concordant in 100%, 29% and 14% in low-, intermediate- and high-risk cases, respectively (p=0.01). CDMM-assigned risk agreed with the expert-assigned risk in 100%, 25% and 0% of low-, intermediate- and high-risk cases, respectively (Kappa=0.69). For RAI use, the experts agreed in 15 cases while CDMM users agreed in eight. On further analysis, interpretation of extrathyroidal extension and lymph node staging led to discrepancies with the CDMM. Conclusions: For a web-based CDMM to accurately inform appropriate use of RAI in PTC, standard pathological and surgical reports are necessary.

PMID: 29632603 [PubMed]

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Renal Allograft Dysfunction: Evaluation with Shear-wave Sonoelastography.

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Renal Allograft Dysfunction: Evaluation with Shear-wave Sonoelastography.

Radiology. 2018 Apr 10;:170577

Authors: Ghonge NP, Mohan M, Kashyap V, Jasuja S

Abstract
Purpose To evaluate whether shear-wave sonoelastography can help differentiate stable renal allograft from acute allograft dysfunction and chronic allograft dysfunction and to correlate shear-wave sonoelastography measurements with resistive index (RI), serum creatinine level, estimated glomerular filtration rate (eGFR) obtained with the Nankivell equation, and biopsy findings. Materials and Methods A prospective study of 60 patients who had undergone renal transplantation was conducted between October 2014 and March 2016. Patients were classified as having stable allograft, acute allograft dysfunction, or chronic allograft dysfunction on the basis of clinical parameters. Mean parenchymal stiffness was compared. The Banff score was used wherever applicable. Receiver operating characteristic curves were drawn to evaluate the feasibility of differentiation. Results Thirty patients had graft dysfunction (acute in 19 patients and chronic in 11). Mean parenchymal stiffness values in stable allograft, acute allograft dysfunction, and chronic allograft dysfunction were 8.51 kPa ± 2.44, 11.06 kPa ± 2.91, and 24.50 kPa ± 4.49, respectively (stable vs acute dysfunction, P = .010; stable vs chronic dysfunction, P < .001; acute sysfunction vs chronic dysfunction, P < .001). The allograft parenchymal stiffness values for patients with Banff grade I (mild interstitial fibrosis and tubular atrophy) differed significantly from those with Banff grade II (moderate interstitial fibrosis and tubular atrophy) (P = .02). Parenchymal stiffness showed a negative correlation with eGFR (r = -0.725; P < .001) and a positive correlation with RI (r = 0.562; P < .001) and serum creatinine level (r = 0.714; P < .001). The sensitivity was 73.68% and specificity was 80% in the differentiation of stable graft from acute graft dysfunction (threshold value, 10.11 kPa). Conclusion Shear-wave sonoelastographic evaluation of renal parenchymal stiffness may help differentiate stable allograft from acute and chronic allograft dysfunction. The inverse correlation of parenchymal stiffness with eGFR and positive correlation with RI and serum creatinine level show that shear-wave sonoelastography may reflect functional status of the renal allograft.

PMID: 29634441 [PubMed - as supplied by publisher]

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Breast Cancer Screening: Two (or Three) Heads Are Better than One?

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Breast Cancer Screening: Two (or Three) Heads Are Better than One?

Radiology. 2018 Apr 10;:180207

Authors: Rosenberg RD, Seidenwurm D

PMID: 29634440 [PubMed - as supplied by publisher]

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Double Reading in Breast Cancer Screening: Cohort Evaluation in the CO-OPS Trial.

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Double Reading in Breast Cancer Screening: Cohort Evaluation in the CO-OPS Trial.

Radiology. 2018 Apr 10;:171010

Authors: Taylor-Phillips S, Jenkinson D, Stinton C, Wallis MG, Dunn J, Clarke A

Abstract
Purpose To investigate the effect of double readings by a second radiologist on recall rates, cancer detection, and characteristics of cancers detected in the National Health Service Breast Screening Program in England. Materials and Methods In this retrospective analysis, 805 206 women were evaluated through screening and diagnostic test results by extracting 1 year of routine data from 33 English breast screening centers. Centers used double reading of digital mammograms, with arbitration if there were discrepant interpretations. Information on reader decisions, with results of follow-up tests, were used to explore the effect of the second reader. The statistical tests used were the test for equality of proportions, the χ2 test for independence, and the t test. Results The first reader recalled 4.76% of women (38 295 of 805 206 women; 95% confidence interval [CI]: 4.71%, 4.80%). Two readers recalled 6.19% of women in total (49 857 of 805 206 women; 95% CI: 6.14%, 6.24%), but arbitration of discordant readings reduced the recall rate to 4.08% (32 863 of 805 206 women; 95% CI: 4.04%, 4.12%; P < .001). A total of 7055 cancers were detected, of which 627 (8.89%; 95% CI: 8.22%, 9.55%; P < .001) were detected by the second reader only. These additional cancers were more likely to be ductal carcinoma in situ (30.5% [183 of 600] vs 22.0% [1344 of 6114]; P < .001), and additional invasive cancers were smaller (mean size, 14.2 vs 16.7 mm; P < .001), had fewer involved nodes, and were likely to be lower grade. Conclusion Double reading with arbitration reduces recall and increases cancer detection compared with single reading. Cancers detected only by the second reader were smaller, of lower grade, and had less nodal involvement. © RSNA, 2018.

PMID: 29634439 [PubMed - as supplied by publisher]

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Coronary CT Angiography-derived Fractional Flow Reserve: Machine Learning Algorithm versus Computational Fluid Dynamics Modeling.

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Coronary CT Angiography-derived Fractional Flow Reserve: Machine Learning Algorithm versus Computational Fluid Dynamics Modeling.

Radiology. 2018 Apr 10;:171291

Authors: Tesche C, De Cecco CN, Baumann S, Renker M, McLaurin TW, Duguay TM, Bayer RR, Steinberg DH, Grant KL, Canstein C, Schwemmer C, Schoebinger M, Itu LM, Rapaka S, Sharma P, Schoepf UJ

Abstract
Purpose To compare two technical approaches for determination of coronary computed tomography (CT) angiography-derived fractional flow reserve (FFR)-FFR derived from coronary CT angiography based on computational fluid dynamics (hereafter, FFRCFD) and FFR derived from coronary CT angiography based on machine learning algorithm (hereafter, FFRML)-against coronary CT angiography and quantitative coronary angiography (QCA). Materials and Methods A total of 85 patients (mean age, 62 years ± 11 [standard deviation]; 62% men) who had undergone coronary CT angiography followed by invasive FFR were included in this single-center retrospective study. FFR values were derived on-site from coronary CT angiography data sets by using both FFRCFD and FFRML. The performance of both techniques for detecting lesion-specific ischemia was compared against visual stenosis grading at coronary CT angiography, QCA, and invasive FFR as the reference standard. Results On a per-lesion and per-patient level, FFRML showed a sensitivity of 79% and 90% and a specificity of 94% and 95%, respectively, for detecting lesion-specific ischemia. Meanwhile, FFRCFD resulted in a sensitivity of 79% and 89% and a specificity of 93% and 93%, respectively, on a per-lesion and per-patient basis (P = .86 and P = .92). On a per-lesion level, the area under the receiver operating characteristics curve (AUC) of 0.89 for FFRML and 0.89 for FFRCFD showed significantly higher discriminatory power for detecting lesion-specific ischemia compared with that of coronary CT angiography (AUC, 0.61) and QCA (AUC, 0.69) (all P < .0001). Also, on a per-patient level, FFRML (AUC, 0.91) and FFRCFD (AUC, 0.91) performed significantly better than did coronary CT angiography (AUC, 0.65) and QCA (AUC, 0.68) (all P < .0001). Processing time for FFRML was significantly shorter compared with that of FFRCFD (40.5 minutes ± 6.3 vs 43.4 minutes ± 7.1; P = .042). Conclusion The FFRML algorithm performs equally in detecting lesion-specific ischemia when compared with the FFRCFD approach. Both methods outperform accuracy of coronary CT angiography and QCA in the detection of flow-limiting stenosis.

PMID: 29634438 [PubMed - as supplied by publisher]

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Risk Estimation for Biliary Atresia in Patients with Neonatal Cholestasis: Development and Validation of a Risk Score.

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Risk Estimation for Biliary Atresia in Patients with Neonatal Cholestasis: Development and Validation of a Risk Score.

Radiology. 2018 Apr 10;:172390

Authors: Kim JR, Hwang JY, Yoon HM, Jung AY, Lee JS, Kim JS, Namgoong JM, Kim DY, Oh SH, Kim KM, Cho YA

Abstract
Purpose To develop and validate a scoring system based on clinical and imaging features to predict the risk for biliary atresia in patients with neonatal cholestasis. Materials and Methods Patients with neonatal cholestasis who underwent both ultrasonography (US) and hepatobiliary scintigraphy (n = 480) were retrospectively identified from two tertiary referral hospitals from January 2000 to February 2017. Patients from one hospital were classified as the derivation cohort (n = 371), and those from the other hospital were classified as the validation cohort (n = 109). Clinical and imaging features associated with biliary atresia were assessed. Histopathologic or intraoperative cholangiographic findings served as the reference standard for biliary atresia. A prediction model was developed by using logistic regression and was then transformed into a scoring system. The scoring system was internally and externally validated. Results Among the 371 patients in the derivation cohort, 97 (26.15%) had biliary atresia. A scoring system was constructed with the following variables: full-term birth, presence of the triangular cord sign at US, abnormal gallbladder morphology at US, and failure of radioisotope excretion to the small bowel at hepatobiliary scintigraphy. The maximum possible score with this system is 7 points. This system enabled differentiation of biliary atresia in the derivation cohort (C statistic, 0.981; 95% confidence interval [CI]: 0.970, 0.992) and the validation cohort (C statistic, 0.995; 95% CI: 0.987, 1.000). The risk score also showed good calibration in both the derivation and the validation cohorts (P = .328 and P = .281, respectively). Conclusion A simple scoring system combining clinical and imaging features can help accurately estimate the risk for biliary atresia in patients with neonatal cholestasis.

PMID: 29634437 [PubMed - as supplied by publisher]

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Radiation Dose Reduction by Using CT with Iterative Model Reconstruction in Patients with Pulmonary Invasive Fungal Infection.

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Radiation Dose Reduction by Using CT with Iterative Model Reconstruction in Patients with Pulmonary Invasive Fungal Infection.

Radiology. 2018 Apr 10;:172107

Authors: Yan C, Xu J, Liang C, Wei Q, Wu Y, Xiong W, Zheng H, Xu Y

Abstract
Purpose To compare the diagnostic quality of reduced radiation dose computed tomography (CT) with iterative model reconstruction (IMR) versus that of conventional low-dose CT in patients with pulmonary invasive fungal infection. Materials and Methods This prospective observational study included 48 patients (mean age ± standard deviation, 39.9 years ± 11.3) known to have or suspected of having pulmonary invasive fungal infection between October 2016 and July 2017. Patients underwent CT with IMR (at 80 kV with 20 mA) immediately after low-dose CT (at 80 kV with automatic exposure control). Images were reconstructed by using a hybrid iterative reconstruction (HIR) algorithm and IMR. Two radiologists independently assessed subjective image quality, noise, and visibility of normal and abnormal findings by using a five-point scale. Objective measurements, including image noise, contrast-to-noise ratio (CNR), and corresponding figure of merit (FOM), were compared by using repeated-measures analysis of variance with Bonferroni post hoc tests for multiple comparisons. Results The mean effective dose was 0.3 mSv ± 0.3 for CT with IMR and 0.7 mSv ± 0.2 for low-dose CT (P < .01). When the image noise and CNR were normalized to the effective dose, CT images obtained with IMR had significantly higher FOM than did other image series (P < .0001). Subjectively, visibility of CT features of invasive fungal infection on CT scans reconstructed with IMR was rated as noninferior to that on low-dose CT scans reconstructed with HIR, except for the halo sign. Conclusion CT with IMR had approximately 60% dose reduction compared with conventional low-dose CT, with reduced noise and improved depiction of abnormal findings, in patients with pulmonary invasive fungal infection.

PMID: 29634436 [PubMed - as supplied by publisher]

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LI-RADS for MR Imaging Diagnosis of Hepatocellular Carcinoma: Performance of Major and Ancillary Features.

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LI-RADS for MR Imaging Diagnosis of Hepatocellular Carcinoma: Performance of Major and Ancillary Features.

Radiology. 2018 Apr 10;:171678

Authors: Cerny M, Bergeron C, Billiard JS, Murphy-Lavallée J, Olivié D, Bérubé J, Fan B, Castel H, Turcotte S, Perreault P, Chagnon M, Tang A

Abstract
Purpose To evaluate the performance of major features, ancillary features, and categories of Liver Imaging Reporting and Data System (LI-RADS) version 2014 at magnetic resonance (MR) imaging for the diagnosis of hepatocellular carcinoma (HCC). Materials and Methods This retrospective institutional review board-approved study included patients with liver MR imaging and at least one pathologically proved lesion. Between 2004 and 2016, 102 patients (275 observations including 113 HCCs) met inclusion criteria. Two radiologists independently assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS category. Per-lesion estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed by using generalized estimating equation models. Results Major features (arterial phase hyperenhancement, washout, capsule, and threshold growth) had a sensitivity of 88.5%, 60.6%, 32.9%, and 41.6%, and a specificity of 18.6%, 84.8%, 98.8%, and 83.2% for HCC, respectively. Ancillary features (mild-moderate T2 hyperintensity, restricted diffusion, mosaic architecture, intralesional fat, lesional fat sparing, blood products, and subthreshold growth) had a sensitivity of 62.2%, 54.8%, 9.9%, 30.9%, 23.1%, 2.8%, and 48.3%, and a specificity of 79.4%, 90.6%, 99.4%, 94.2%, 83.1%, 99.3%, and 91.4% for HCC, respectively. The LR-5 or LR-5 V categories had a per-lesion sensitivity of 50.8% and a specificity of 95.8% for HCC, respectively. The LR-4, LR-5, or LR-5 V categories (determined by using major features only vs combination of major and ancillary features) had a per-lesion sensitivity of 75.9% and 87.9% and a per-lesion specificity of 87.5% and 86.2%, respectively. Conclusion The use of ancillary features in combination with major features increases the sensitivity while preserving a high specificity for the diagnosis of HCC.

PMID: 29634435 [PubMed - as supplied by publisher]

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A morphometric analysis of the suitability of the transverse cervical artery as a recipient artery in head and neck free flap microvascular reconstruction.

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A morphometric analysis of the suitability of the transverse cervical artery as a recipient artery in head and neck free flap microvascular reconstruction.

Surg Radiol Anat. 2018 Apr 09;:

Authors: Reissis M, Reissis D, Bottini GB, Messiha A, Davies DC

Abstract
PURPOSE: Gold standard recipient arteries in head and neck free flap microvascular reconstruction are currently branches of the external carotid. However, these arteries can be compromised by neck dissection or radiotherapy, resulting in 'vessel-depleted neck' and 'frozen neck' respectively. In such cases, the transverse cervical artery (TCA) may be a suitable recipient artery.
METHODS: The origin, course and diameter of the TCA were determined in 46 sides of neck from 23 cadavers. The distances from the origin of the TCA to the angle of the mandible, floor of the mouth and mandibular symphysis were measured to determine the pedicle length required for free flap anastomosis.
RESULTS: The TCA was present bilaterally in all subjects investigated and its course across the posterior triangle of the neck was constant between individuals. The mean distances from the origin of the TCA to the angle of mandible, floor of mouth and mandibular symphysis were 10.0, 9.2 and 12.6 cm, respectively. There were no significant differences in these distances between the left and right sides of the neck (p > 0.05 for all comparisons). The distances from the TCA origin to the angle of the mandible and floor of the mouth were significantly longer in males than in females (p = 0.004) and correlated directly with the greater height of males compared to females (p = 0.0004). The mean diameter of the TCA measured 2 cm from its origin was 2.2 mm.
CONCLUSION: The TCA is a suitable and reliable recipient artery for free flap microvascular reconstruction, when branches of the external carotid artery are unavailable.

PMID: 29632965 [PubMed - as supplied by publisher]

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Monte Carlo method for gamma spectrometry based on GEANT4 toolkit: Efficiency calibration of BE6530 detector

Publication date: September 2018
Source:Journal of Environmental Radioactivity, Volume 189
Author(s): Guembou Shouop Cebastien Joel, Ndontchueng Moyo Maurice, Nguelem Mekongtso Eric Jilbert, Motapon Ousmanou, Strivay David
The combination of gamma-ray spectrometry, the development of related Monte Carlo method and the GEANT4 (GEometry ANd Tracking) toolkit have been developed for gamma spectrometry simulation. The main objective was to validate simulation models of broad energy germanium (BEGe) detector geometry built in our laboratory (BE6530 model). Monte Carlo simulation of the geometry of BE6530 detector for efficiency calibration was carried out with GEANT4 toolkit. The simulated efficiencies curves using MC were compared with experimental results. Measurement uncertainties for both simulation and experimental estimations of the efficiency were assessed in order to see whether the consequences of the realistic measurement fall inside adequate cut-off points. The validation of the simulation was carried out by experimentally estimating the activity concentration in a reference sample and the comparison showed good correlation between experimental and simulation. Therefore, from the outcomes of this study, it can be concluded that Monte-Carlo simulation is a helpful, reasonable option that additionally gives more prominent adaptability, greater flexibility, precision and accuracy, and gained time when determining the detector response and efficiency in routine of environmental radioactivity monitoring.

Graphical abstract

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