Acute Combined Revascularization in Acute Ischemic Stroke with Intracranial Arterial Occlusion: Self-expanding Solitaire Stent during Intravenous Thrombolysis

PurposeTo investigate the safety and efficacy of the self-expanding Solitaire stent used during intravenous thrombolysis (IVT) for intracranial arterial occlusion (IAO) in acute ischemic stroke (AIS).Materials and MethodsConsecutive nonselected patients with AIS with IAO documented on computed tomographic angiography or magnetic resonance angiography and treated with IVT were included in this prospective study. Stent intervention was initiated and performed during administration of IVT without waiting for any clinical or radiologic signs of potential recanalization. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS), and 90-day clinical outcome was assessed by modified Rankin scale (mRS), with a good outcome defined as an mRS score of 0–2. Recanalization was rated by thrombolysis in cerebral infarction (TICI) scale.ResultsFifty patients (mean age, 66.8 y ± 14.6) had a baseline median NIHSS score of 18.0. Overall recanalization was achieved in 94% of patients, and complete recanalization (ie, TICI 3 flow) was achieved in 72% of patients. The mean time from stroke onset to maximal recanalization was 244.2 minutes ± 87.9, with a median of 232.5 minutes. The average number of device passes was 1.5, with a mean procedure time to maximal recanalization of 49.5 minutes ± 13.0. Symptomatic intracerebral hemorrhage occurred in 6% of patients. The median mRS score at 90 days was 1, and 60% of patients had a good outcome (ie, mRS score 0–2). The overall 3-month mortality rate was 14%.ConclusionsCombined revascularization with the Solitaire stent during IVT appears to be safe and effective in the treatment of acute IAO.     

Relationship of Thrombus Length to Number of Stent Retrievals,Revascularization, and Outcomes in Acute Ischemic Stroke

PurposeTo study the relationship between intracranial thrombus length and number of stent retrievals, revascularization rates, and functional outcomes in stroke.Materials and MethodsRetrospective data were collected from consecutive cases of stroke treated with endovascular procedures at a single institution from April 2012–September 2013. Thrombus length was measured in the anterior cerebral circulation. Demographic and clinical details; involved vessels; and procedural details, including the number of devices used and number of retrievals used for each device, were recorded. Revascularization rates and 90-day functional outcomes were recorded.ResultsData regarding the length of thrombus in the anterior cerebral circulation were available for 28 patients. There was no significant association between thrombus length and number of stent retrievals (P = .3780), final thrombolysis in cerebral infarction (TICI) score (P = .4835), or 90-day modified Rankin Scale score (P = .4146). There was a significant difference (P = .0280) between number of retrievals and final TICI score, with lower number of retrieval passes corresponding to higher final TICI scores.ConclusionsThe data suggest no relationship between thrombus length and number of stent retrievals, final TICI score, or functional neurologic outcomes at 90 days in stent retrieval thrombectomy for acute ischemic stroke. These results do not support a predictive value for thrombus length quantification in the evaluation of stroke.     

Endovascular Procedures versus Intravenous Thrombolysis in Stroke with Tandem Occlusion of the Anterior Circulation

PurposeStroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenous (IV) thrombolysis than stroke with single occlusion. The present study describes the impact of endovascular procedures (EPs) compared with IV thrombolysis alone on recanalization and clinical outcome.Materials and MethodsThirty patients with symptom onset less than 4.5 hours and tandem occlusion within the anterior circulation were analyzed retrospectively. Recanalization was assessed per Thrombolysis In Cerebral Infarction (TICI) classification on computed tomography, magnetic resonance imaging, or digital subtraction angiography within 24 hours. Infarct size was detected on follow-up imaging as a dichotomized variable, ie, more than one third of the territory of the middle cerebral artery. Clinical outcomes were major neurologic improvement, independent outcome (90-d modified Rankin Scale [mRS] score), symptomatic intracerebral hemorrhage (sICH; per European Cooperative Acute Stroke Study criteria), and death within 7 days.ResultsPatients treated with EPs (n = 14) were significantly younger and had a history of arterial hypertension more frequently than patients treated with IV thrombolysis alone (n = 16). Recanalization (ie, TICI score 2b/3; EP, 64%; IV, 19%; P = .01), major neurologic improvement (EP, 64%; IV, 19%; P = .01), and independent outcome (mRS score ≤ 2; EP, 54% IV, 13%; P = .02) occurred more often in the EP group, whereas infarct sizes greater than one third of the MCA territory (EP, 43%; IV, 81%; P = .03) were observed less often. Rates of sICH (P = .12) and death within 7 days (P = .74) did not differ significantly.ConclusionsHigher recanalization rate, smaller infarct volume, and better clinical outcome in the EP group should encourage researchers to include this subgroup of patients in prospective randomized trials comparing IV thrombolysis versus EP in stroke.     

Feasibility of Percutaneous Cementoplasty Combined with Interventional Internal Fixation for Impending Pathologic Fracture of the Proximal Femur

PurposeTo evaluate the feasibility of percutaneous cementoplasty and interventional internal fixation for stabilization of impending pathologic fracture of the proximal femur.Materials and MethodsFrom May 2012 to August 2013, six consecutive patients (three men and three women; median age, 58.33 y ± 21.45; age range, 18–78 y) who underwent percutaneous cementoplasty plus interventional internal fixation for the treatment of metastases to the proximal femur were retrospectively analyzed. The Karnofsky performance status (KPS) and visual analog scale (VAS) score for pain were assessed before and 1 week after the procedure; moreover, the procedure duration, length of hospital stay, risk of fracture at the procedural site, and complications were assessed.ResultsThe KPS increased from 66.67 ± 12.11 (range, 60–90) before the procedure to 76.67 ± 13.66 (range, 60–100) 1 week after the procedure. For symptomatic patients (n = 5), the VAS score decreased from 6.80 ± 2.39 (range, 3–9) before the procedure to 1.80 ± 0.84 (range, 1–3) at 1 week after the procedure. The mean procedure duration was 90.00 minutes ± 10.56 (range, 72–102 min). The average length of hospital stay was 7 days ± 2 (range, 4–10 d). The only complication noted consisted of thrombophlebitis in one patient, on the operative side, at 15 days after the procedure. No cases of procedural site fracture during follow-up were noted (median, 192 d; range, 30–365 d).ConclusionsPercutaneous cementoplasty plus interventional internal fixation is a feasible technique for stabilization of impending pathologic fracture of the femur.     

Comparison of Simulation-based Treatment Planning with Imaging and Pathology Outcomes for Percutaneous CT-guided Irreversible Electroporation of the Porcine Pancreas: A Pilot Study

PurposeTo investigate the reliability of simulations for planning pancreatic irreversible electroporation (IRE) ablations compared with computed tomography (CT) and pathology outcomes in an animal model.Materials and MethodsSimulations were performed varying treatment parameters, including field strength (1.5–2.5 kV/cm), pulse number (70–90 pulses), and pulse length (70–100 µs). Pancreatic IRE was performed in six pigs under CT guidance. Two animals each were sacrificed for histology after 1 day, 14 days, and 28 days. Follow-up CT scans were performed on day 0, day 1, day 14, and day 28. Biochemical markers were collected before the procedure, 1 day after the procedure, and 14 days after the procedure.ResultsAll ablation zones could be visualized on CT scan immediately after the procedure and on day 1 follow-up CT scan, and all animals survived until the designated endpoints. Histopathology revealed necrosis and edema on day 1 and fibrosis and glandular atrophy after 28 days. Blood vessels close to the ablation zone appeared normal. Laboratory analysis indicated mild to moderate amylasemia and lipasemia with normalization after 14 days. The ablation size on CT scan measured a mean (± SD) 146% ± 18 (day 0, P < .126) and 168% ± 18 (day 1, P < .026) of the simulation and on pathology measured 119% ± 10 (day 1, not significant) of the simulation.ConclusionsResults from simulations for planning IRE ablations, CT, and pathology may differ from each other. Ablation zones on CT and pathology appear larger than simulated, suggesting that clinically used treatment planning may underestimate the ablation size in the pancreas.     

Hepatic Blood Volume Imaging with the Use of Flat-Detector CT Perfusion in the Angiography Suite: Comparison with Results of Conventional Multislice CT Perfusion

PurposeTo prospectively determine the feasibility of flat-detector (FD) computed tomography (CT) perfusion to measure hepatic blood volume (BV) in the angiography suite in patients with hepatocellular carcinoma (HCC).Materials and MethodsTwenty patients with HCC were investigated with conventional multislice and FD CT perfusion. CT perfusion was carried out on a multislice CT scanner, and FD CT perfusion was performed on a C-arm angiographic system, before transarterial chemoembolization procedures. BV values of conventional and FD CT perfusion were measured within tumors and liver parenchyma. The arterial perfusion portion of CT perfusion BV was extracted from CT perfusion BV by multiplying it by a hepatic perfusion index. Relative values (RVs) for CT perfusion arterial BV and FD CT perfusion BV (FD BV) were defined by dividing BV of tumor by BV of parenchyma. Relationships between BV and RV values of these two techniques were analyzed.ResultsIn all patients, both perfusion procedures were technically successful, and all 33 HCCs larger than 10 mm were identified with both imaging methods. There were strong correlations between the absolute values of FD BV and CT perfusion arterial BV (tumor, r = 0.903; parenchyma, r = 0.920; both P < .001). Bland–Altman analysis showed a mean difference of −0.15 ± 0.24 between RVs for CT perfusion arterial BV and FD BV.ConclusionsThe feasibility of FD CT perfusion to assess BV values of liver tumor and surrounding parenchyma in the angiographic suite was demonstrated.     

Transcatheter CT Arterial Portography and CT Hepatic Arteriography for Liver Tumor Visualization during Percutaneous Ablation

PurposeTo evaluate the feasibility of combining transcatheter computed tomography (CT) arterial portography or transcatheter CT hepatic arteriography with percutaneous liver ablation for optimized and repeated tumor exposure.Materials and MethodsStudy participants were 20 patients (13 men and 7 women; mean age, 59.4 y; range, 40–76 y) with unresectable liver-only malignancies—14 with colorectal liver metastases (29 lesions), 5 with hepatocellular carcinoma (7 lesions), and 1 with intrahepatic cholangiocarcinoma (2 lesions)—that were obscure on nonenhanced CT. A catheter was placed within the superior mesenteric artery (CT arterial portography) or in the hepatic artery (CT hepatic arteriography). CT arterial portography or CT hepatic arteriography was repeatedly performed after injecting 30–60 mL 1:2 diluted contrast material to plan, guide, and evaluate ablation. The operator confidence levels and the liver-to-lesion attenuation differences were assessed as well as needle-to-target mismatch distance, technical success, and technique effectiveness after 3 months.ResultsTechnical success rate was 100%; there were no major complications. Compared with conventional unenhanced CT, operator confidence increased significantly for CT arterial portography or CT hepatic arteriography cases (P < .001). The liver-to-lesion attenuation differences between unenhanced CT, contrast-enhanced CT, and CT arterial portography or CT hepatic arteriography were statistically significant (mean attenuation difference, 5 HU vs 28 HU vs 70 HU; P < .001). Mean needle-to-target mismatch distance was 2.4 mm ± 1.2 (range, 0–12.0 mm). Primary technique effectiveness at 3 months was 87% (33 of 38 lesions).ConclusionsIn patients with technically unresectable liver-only malignancies, single-session CT arterial portography–guided or CT hepatic arteriography–guided percutaneous tumor ablation enables repeated contrast-enhanced imaging and real-time contrast-enhanced CT fluoroscopy and improves lesion conspicuity.     

Breast Cryoablation in Patients with Bone Metastatic Breast Cancer

PurposeTo assess retrospectively the safety and feasibility of palliative breast cryoablation to treat primary breast tumors in patients with stage IV breast cancer.Materials and MethodsIn 17 female patients (mean age ± SD, 59 y ± 13; range, 37–81 y) with 22 bone metastatic ductal invasive breast lesions (2.5 cm × 1.6 cm ± 1.4 × 1.1; range, 1.0 cm × 0.5 cm to 6.7 cm × 5.5 cm), 19 computed tomography (CT)–guided percutaneous cryoablation sessions were performed for treatment of primary breast tumors. All patients had radiologic evidence (contrast-enhanced CT or magnetic resonance imaging) of persistence or progression of the primary breast cancer despite systemic therapy. The radiologic outcome was evaluated with a mean follow-up period of 13 months (range, 3–31 mo). Treatment of skeletal metastases was unnecessary during the follow-up period.ResultsAll of the cryoablation sessions were completed and well tolerated. Complete regression of the disease was achieved in 15 (88%) patients 2 months after the cryoablation. Two (12%) patients underwent a second cryoablation treatment because of a minimal persistence of viable tumor (residual disease). No relapse of primary tumors was observed on breast imaging during the follow-up period. One patient (6%) developed a new lesion localized to the contralateral breast.ConclusionsThese data suggest that palliative cryoablation of primary advanced breast cancer is a well-tolerated, feasible, and effective treatment option. Given the palliative effects of breast cryoablation demonstrated in this series, larger studies replicating these results are warranted.     

CT Fluoroscopy–Guided Percutaneous Fiducial Marker Placement for CyberKnife Stereotactic Radiosurgery: Technical Results and Complications in 222 Consecutive Procedures

PurposeTo evaluate technical outcome and safety of computed tomographic (CT) fluoroscopy–guided percutaneous fiducial marker placement before CyberKnife stereotactic radiosurgery.Materials and MethodsRetrospective analysis was performed of 196 patients (106 men) undergoing CT fluoroscopy–guided fiducial marker placement in 222 consecutive procedures under local anesthesia from March 2006 to February 2012. Technical success was defined as fiducial marker location in the tumor or vicinity suitable for CyberKnife radiosurgery evaluated on postinterventional planning CT. Complications were classified per Society of Interventional Radiology (SIR).ResultsOne hundred ninety-six patients (age, 61.5 y ± 13.1) underwent percutaneous placement of 321 fiducial markers (mean per tumor, 1.2 ± 0.5; range, 1–4) in 37 primary tumors and 227 metastases in the thorax (n = 121), abdomen (n = 122), and bone (n = 21). Fiducial marker placement was technically successful in all procedures: intratumoral localization in 193 (60.1%), at tumor margin in 50 (15.6%), and outside of tumor in 78 cases (24.3%; mean distance to marker, 0.4 cm ± 0.6; range, 0–2.9 cm). Complications were observed in 63 placement procedures (28.4%), including minor self-limiting pneumothorax (n = 21; SIR class B) and self-limiting pulmonary hemorrhage (n = 35; SIR class A), and major pneumothorax requiring thoracostomy/drainage insertion (n = 14; SIR class D) and systemic toxicity of local anesthetic drug (n = 1; SIR class D).ConclusionsCT fluoroscopy–guided percutaneous fiducial marker placement can be performed with high technical success under local anesthesia in various anatomic regions. Although self-limiting in most cases, pneumothorax and pulmonary hemorrhage are frequently observed during fiducial marker implantation into lung tumors.     

Utility of Cone-Beam CT Imaging in Prostatic Artery Embolization

PurposeTo evaluate the utility of cone-beam computed tomography (CT) in patients undergoing prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia.Materials and MethodsFrom January 2012 to January 2013, 15 patients (age range, 59–81 y; mean, 68 y) with moderate- or severe-grade lower urinary tract symptoms, in whom medical management had failed were enrolled in a prospective United States trial to evaluate PAE. During pelvic angiography, 15 cone-beam CT acquisitions were performed in 11 patients, and digital subtraction angiography was performed in all patients. Cone-beam CT images were reviewed to assess for sites of potential nontarget embolization that impacted therapy, a pattern of enhancement on cone-beam CT suggesting additional PAs, confirmation of prostatic parenchymal perfusion before embolization, and contralateral prostatic parenchymal enhancement.ResultsCone-beam CT was successful in 14 of 15 acquisitions, and PAE was successful in 14 of 15 patients (92%). Cone-beam CT provided information that impacted treatment in five of 11 patients (46%) by allowing for identification of sites of potential nontarget embolization. Duplicated prostatic arterial supply and contralateral perfusion were each identified in 21% of patients (three of 11). Prostatic perfusion was confirmed before embolization in 50% of acquisitions (seven of 14).ConclusionsCone-beam CT is a useful technique that can potentially mitigate the risk of nontarget embolization. During treatment, it can allow for the interventionalist to identify duplicated prostatic arterial supply or contralateral perfusion, which may be useful when evaluating a treatment failure.     

Superselective Yttrium-90 Radioembolization for Hepatocellular Carcinoma Yields High Response Rates with Minimal Toxicity

PurposeTo assess the safety and efficacy of yttrium-90 (⁹⁰Y) radioembolization when performed in a superselective fashion for patients with unresectable hepatocellular carcinoma (HCC).Materials and MethodsThis retrospective study included 20 patients with unresectable HCC. Median Model for End-Stage Liver Disease score was 10.5 (range, 6–25), with 8 of 20 patients (40%) classified Child-Pugh class B and 1 of 20 patients (5%) classified class C cirrhosis. Segmental tumor-associated portal vein thrombus was present in 12 patients (60%), and a transjugular intrahepatic portosystemic shunt was present in 4 patients (20%). Median tumor diameter was 3.9 cm (range, 2.5–7.1 cm). All patients underwent superselective ⁹⁰Y radioembolization targeted to a single liver segment using glass microspheres.ResultsMedian dose to the treated segment was 254 Gy, and median dose to the tumor was 536 Gy. No grade 3–4 hepatotoxicity occurred. The most common clinical toxicities were fatigue (30%), abdominal pain (10%), and postembolization syndrome (10%). Follow-up imaging demonstrated complete European Association for the Study of the Liver response of the index tumor in 19 of 20 patients (95%) and stable disease in 1 of 20 patients (5%). In patients with complete response, local tumor recurrence rate was 5.3% (1 of 19 patients). Median time to progression was 319 days. Overall survival was 90% (18 of 20 patients) with a median follow-up period of 275 days (range, 32–677 d).ConclusionsWhen performed in a segmental fashion, ⁹⁰Y radioembolization demonstrates high response rates and low local tumor recurrence rates. Complete imaging response can be achieved in patients with locally aggressive disease. This study demonstrates no clinically significant hepatotoxicity, despite moderate liver dysfunction in many patients.     

Early Treatment Response Evaluation after Yttrium-90 Radioembolization of Liver Malignancy with CT Perfusion

PurposeTo evaluate computed tomography (CT) perfusion for assessment of early treatment response after transarterial radioembolization of patients with liver malignancy.Materials and MethodsDynamic contrast-enhanced CT liver perfusion was performed before and 4 weeks after transarterial radioembolization in 40 patients (25 men and 15 women; mean age, 64 y ± 11; range, 35–80 y) with liver metastases (n = 27) or hepatocellular carcinoma (HCC) (n = 13). Arterial perfusion (AP) of tumors derived from CT perfusion and tumor diameters were measured on CT perfusion before and after transarterial radioembolization. Success of transarterial radioembolization was evaluated on morphologic follow-up imaging (median follow-up time, 4 mo) based on Response Evaluation Criteria in Solid Tumors (Version 1.1). CT perfusion parameters before and after transarterial radioembolization for different response groups were compared. Kaplan-Meier curves were plotted to illustrate overall 1-year survival rates.ResultsLiver metastases showed significant differences in AP before and after transarterial radioembolization in responders (P < .05) but not in nonresponders (P = .164). In HCC, AP values before and after transarterial radioembolization were not significantly different in responders and nonresponders (P = .180 and P = .052). Tumor diameters were not significantly different on CT perfusion before and after transarterial radioembolization in responders and nonresponders with liver metastases and HCC (P = .654, P = .968, P = .148, P = .164). In patients with significant decrease of AP in liver metastases after transarterial radioembolization, 1-year overall survival was significantly higher than in patients showing no reduction of AP.ConclusionsCT perfusion showed early reduction of AP in liver metastases responding to transarterial radioembolization; tumor diameter remained unchanged early after treatment. No significant early treatment response to transarterial radioembolization was found in patients with HCC. In patients with liver metastases, a decrease of AP after transarterial radioembolization was associated with a higher 1-year overall survival rate.     

Dynamic Volumetric CT Angiography for the Detection and Classification of Endoleaks: Application of Cine Imaging Using a 320-Row CT Scanner with 16-cm Detectors

PurposeTo assess the feasibility and diagnostic performance of dynamic volumetric computed tomography (CT) angiography with large-area detectors in the detection and classification of endoleaks after endovascular aneurysm repair (EVAR).Materials and MethodsLow-dose dynamic volumetric CT angiography performed with the patient in Fowler position was used to scan the entire stent graft with a 16-cm-area detector during the first follow-up examination after EVAR. There were 39 consecutive patients (36 men and 3 women; mean age, 74 y ± 8.7) examined with approximately 14–20 intermittent scans (temporal resolution, 2 s; scan range, 160 mm). The effective radiation dose, image quality, interobserver and intraobserver agreement for endoleak detection, and time delay between peak enhancement of the aorta and endoleaks were evaluated.ResultsAll examinations with the patient in Fowler position enabled the entire stent graft to be scanned and were rated as diagnostic. The mean effective radiation dose was 13.1 mSv. Endoleaks were detected in eight patients (type Ia, n = 1; type II, n = 6; type III, n = 1). Interobserver agreement (κ = 0.794) and intraobserver agreement (κ = 1.00) for detection of endoleaks were excellent. The mean time delay between peak enhancement of the aorta and the endoleaks was significantly less for type I/III endoleaks (2.0 s ± 0) compared with type II endoleaks (5.3 s ± 1.0; P < .001).ConclusionsLow-dose dynamic volumetric CT angiography performed with the patient in Fowler position is feasible after EVAR. Dynamic information, including cine imaging, the timing of peak enhancement, and the Hounsfield units index, is useful in detecting and classifying endoleaks.     

Microwave Thermal Ablation of Spinal Metastatic Bone Tumors

PurposeTo assess feasibility, safety, and efficacy of microwave ablation of spinal metastatic bone tumors.Materials and MethodsRetrospective study of 17 patients with 20 spinal metastatic tumors treated with microwave ablation under computed tomographic guidance between March 2011 and August 2013 was performed. Ablations were performed under local anesthesia and nitrous oxide ventilation. Lesions were lumbar (n = 10), sacral (n = 7), and thoracic (n = 3) in location. Primary neoplastic sites were lung (n = 9), prostate (n = 4), kidney (n = 6), and uterus (n = 1). Adjunct cementoplasty was performed in nine cases, and a temperature-monitoring device was used in four cases. Procedure effectiveness was evaluated by visual analog scale (VAS) during a 6-month follow-up. Patient medical records were reviewed, and demographic and clinical data, tumor characteristics, and information on pain were assessed.ResultsMean ablation time was 4.4 minutes ± 2.7 (range, 1–8 min), with an average of 3.8 cycles per ablation at 60 W (range, 30–70 W). The preprocedure mean VAS score was 7.4 ± 1.2 (range, 6–9). Pain relief was achieved in all but one patient. Follow-up VAS scores were as follows: day 0, 1.3 ± 1.8 (P < .001); day 7, 1.6 ± 1.7 (P < .001); month 1, 1.9 ± 1.6 (P < .001); month 3, 2.2 ± 1.5 (P < .001); and month 6, 2.3 ± 1.4 (P < .01). No complications were noted.ConclusionsMicrowave ablation appears to be feasible, safe, and an effective treatment of painful refractory spinal metastases and may be considered as a potential alternative percutaneous technique in the management of spinal metastases.     

Prevalence and impact of scan-related anxiety during coronary CT angiography: A prospective cohort study of 366 patients

BackgroundScanxiety, the anxiety/stress associated with an imaging test, has never been evaluated in relation to coronary CT angiography (Coronary CTA). As it could impact heart rate and thereby affect image quality of Coronary CTA, we aimed to evaluate the prevalence, severity, and impact of scanxiety on quality and interpretability of Coronary CTA.Methods366 consecutive patients were prospectively presented with a clinical questionnaire comprising two tests to evaluate their scan-related anxiety: the Impact of Event IES-6 (6 questions, final score 0–24) and a visual stress-scale (1 question, score 1–10). Patient demographics, heart rate and final image quality scored by two readers were recorded. Potential independent correlations were sought between IES-6 scanxiety level and image quality, heart rate variability and demographics, using an ordinal logistic regression model.Results344 patients (59.9% men, 57.6 ± 10.7yo) completed the questionnaire. 74.1% (255 patients) reported some scan-related distress, with a mean IES-6 score of 4.1 ± 4.3 (range 0–18). There was no significant difference in terms of age, sex or indications for Coronary CTA between the non-anxious (IES-6 = 0) and the anxious (IES-6>0) patients. There was no significant independent correlation between image quality and IES-6 score (OR = 0.98, p = 0.62), nor between IES-6 score and heart rate variability (effect = −0.005, p = 0.97).ConclusionThe prevalence of scan-related anxiety – aka scanxiety – in Coronary CTA patients is high (74.1%) but does not appear to impact image quality and interpretability.     

Image-Guided Ovarian Mass Biopsy: Efficacy and Safety

PurposeImage-guided needle biopsy represents a minimally invasive method for pathologic diagnosis of a mass. This study evaluates the diagnostic yield, accuracy, and safety of ovarian mass biopsy with combined core and fine-needle technique.Materials and MethodsMedical records of all women at least 18 years of age, referred from gynecologic oncology, who underwent image-guided ovarian mass biopsy from 2001 through 2011 were reviewed. Among 27 patients, ultrasound guidance was used in 13 (48%), six transabdominal and seven transvaginal; computed tomography guidance was used in 14 (52%), nine transabdominal and five transgluteal. Biopsy indications were suspected metastasis (n = 15; 56%), suspected ovarian cancer to be treated with neoadjuvant chemotherapy (n = 10; 37%), and relative contraindication to surgery (n = 2; 7%). Mean maximum lesion dimension was 9.9 cm (range, 2–23 cm), with solid composition in nine (33%), cystic in six (22%), and mixed in 12 (44%). Biopsy pathologic findings were compared versus those of the surgical specimen or, for masses that were not resected, versus the stability of benign masses and response to chemotherapy of malignant masses on follow-up.ResultsAll biopsies yielded a diagnosis. No biopsy-related complications were noted. Eleven patients (41%) did not undergo lesion resection and were followed for an average of 28.8 months (range, 0.3–118.4 mo). In no patient did malignancy develop during clinical follow-up after a benign biopsy diagnosis. Sensitivity and specificity for diagnosis of malignancy were 100% ± 0 (19 of 19) and 88% ± 26 (seven of eight), respectively, for cancer detection. In nine patients (33%) with final pathologic diagnosis of epithelial ovarian cancer, tumor seeding was not observed during a mean follow-up of 44.6 months (range, 1.3–110.2 mo).ConclusionsImage-guided ovarian mass core needle biopsy results in a pathologic diagnosis of benign and malignant masses with high yield, accuracy, and safety.     

Quantitative Assessment of Lipiodol Deposition after Chemoembolization: Comparison between Cone-Beam CT and Multidetector CT

PurposeTo evaluate the ability of cone-beam computed tomography (CBCT) performed directly after transarterial chemoembolization to assess ethiodized oil (Lipiodol) deposition in hepatocellular carcinoma (HCC) and compare it with unenhanced multidetector computed tomography (CT).Materials and MethodsConventional transarterial chemoembolization was used to treat 15 patients with HCC, and CBCT was performed to assess Lipiodol deposition directly after transarterial chemoembolization. Unenhanced multidetector CT was performed 24 hours after transarterial chemoembolization. Four patients were excluded because the margin of tumor or area of Lipiodol deposition was unclear. The image enhancement density of the entire tumor and liver parenchyma was measured by ImageJ software, and tumor-to-liver contrast (TLC) was calculated. In addition, volumetric measurement of tumor and Lipiodol was performed by semiautomatic three-dimensional volume segmentation and compared using linear regression to evaluate consistency between the two imaging modalities.ResultsThe mean value of TLC on CBCT was not significantly different from TLC on multidetector CT (337.7 HU ± 233.5 vs 283.0 HU ± 152.1, P = .103).The average volume of the whole tumor and of only the regions with Lipiodol deposition and the calculated average percentage of Lipiodol retention on CBCT were not significantly different compared with multidetector CT (tumor volume, 9.6 cm³ ± 11.8 vs 10.8 cm³ ± 14.2, P = .142; Lipiodol volume, 6.3 cm³ ± 7.7 vs 7.0 cm³ ± 8.1, P = .214; percentage of Lipiodol retention, 68.9% ± 24.0% vs 72.2% ± 23.1%, P = .578). Additionally, there was a high correlation in the volume of tumor and Lipiodol between CBCT and multidetector CT (R² = 0.919 and 0.903).ConclusionsThe quantitative image enhancement and volume analyses demonstrate that CBCT is similar to multidetector CT in assessing Lipiodol deposition in HCC after transarterial chemoembolization.     

CT-Guided Transthoracic Needle Aspiration Biopsy of Subsolid Lung Lesions

PurposeTo assess the diagnostic performance of computed tomography (CT)–guided transthoracic needle aspiration biopsy (TNAB) in the evaluation of persistent subsolid lung lesions.Materials and MethodsA retrospective review of all CT-guided TNABs performed at a single institution from January 2002 to November 2012 was conducted to identify patients with persistent subsolid lung lesions. The diagnostic performance of CT-guided TNAB was assessed through comparison of cytologic diagnoses with core needle biopsy, surgical resection, or imaging and clinical follow-up. The cytologic, histologic, and imaging features of each lesion were characterized, and CT-guided TNAB complications were recorded.ResultsIn 32 patients, a diagnosis of benign or malignant disease was identified through evaluation of pathologic or follow-up data. There were 18 men and 14 women, with a mean age of 67.1 years ± 9.6 (range, 52–86 y). The mean lesion diameter was 21 mm ± 11 (range, 8–62 mm). A final diagnosis of malignancy was made in 28 cases (87.5%); four benign lesions were also diagnosed. The overall sensitivity of CT-guided TNAB in the evaluation of these lesions was 89.2%, and the specificity and positive predictive value were 100%. Two pneumothoraces (6.3%) were identified.ConclusionsAmong patients with subsolid lung lesions, CT-guided TNAB is safe and shows high sensitivity. The high specificity and positive predictive value of the procedure allow for definitive treatment decisions to be made for most patients.     

Large Pulmonary Arteriovenous Malformations: Long-Term Results of Embolization with AMPLATZER Vascular Plugs

PurposeTo analyze the long-term results of endovascular treatment of large pulmonary arteriovenous malformations (PAVMs) using the AMPLATZER vascular plug (AVP; AGA Medical Corp, Golden Valley, Minnesota).Materials and MethodsBetween May 2007 and April 2011, 18 patients with 24 large PAVMs, defined as PAVMs that had a feeding artery with a diameter of ≥ 8 mm, were treated with AVP I or AVP II. A single AVP device was used for each PAVM. Aneurysmal sac diameters, sac perfusion, sac shrinkage, and complete resolution before and after the intervention were analyzed. Complete histories, laboratory values, physical examinations, and multidetector computed tomography images were reviewed. The mean occlusion time for AVP I and AVP II and the mean arterial oxygen saturation (SaO₂) before and after the intervention were compared.ResultsThe mean diameter of the feeding artery was 11.46 mm ± 2.18 (range, 8–13.3 mm). The mean occlusion time was 7.34 minutes ± 1.23 for AVP I and 6.25 minutes ± 1.12 for AVP II (P = .11). The mean SaO₂ before and after the intervention was 63.71% ± 8.10% (range, 51%–76%) and 96.28% ± 0.49% (range, 96%–97%), respectively (P = .045). No major periprocedural complications were observed. The mean follow-up duration was 36.33 months ± 10.63 (range, 28–56 mo). During the follow-up period, there were no persistent sac perfusions, migration of the AVPs, major complications, or recanalizations.ConclusionsTreatment of large PAVMs with AVPs is an effective method for obtaining excellent long-term results. Embolization of large feeding arteries can be accomplished with AVPs without major complications.     

Cryoablation of Sternal Metastases for Pain Palliation and Local Tumor Control

PurposeTo determine safety and effectiveness of cryoablation of sternal metastases for pain palliation and local tumor control.Materials and MethodsA tumor ablation database was retrospectively reviewed for sternal cryoablation procedures performed between January 2005 and June 2013, which yielded 15 procedures to treat 12 sternal metastases in 12 patients (five men). Median patient age was 57 years (range, 38–80 y). Metastases arose from five primary sites (breast, lung, kidney, ampulla, and thyroid), and median tumor size was 3.8 cm (range, 2.2–7.5 cm). Seven patients (58%) underwent cryoablation for pain palliation, and five (42%) underwent cryoablation for local tumor control of oligometastatic disease. Clinical outcomes (including complications, local tumor control, and pain response) were evaluated retrospectively.ResultsMean pain scores decreased from 7.0 ± 1.9 (median, 7; range, 4–10) at baseline to 1.8 ± 1.2 (median, 1.5; range, 0–4) following cryoablation (P = .00049). Two patients had durable pain palliation, and four had greater than 1 month of pain relief, with a median duration of 5.7 months (range, 1.5–14.7 mo). Two patients in whom recurrent pain developed underwent repeat cryoablation, with durable pain relief. Allowing for a single repeat treatment, local tumor control was achieved in four of five patients (80%) treated for this indication, with median follow-up of 8.4 months (range, 2.6–13.6 mo). In one patient (8%), an infectious complication developed that was successfully treated with antibiotics on an outpatient basis.ConclusionsCryoablation is a safe and potentially effective treatment for patients with painful sternal metastases and can achieve local tumor control in select patients.