In vivo MRI assessment of placental and foetal oxygenation changes in a rat model of growth restriction using blood oxygen level-dependent (BOLD) magnetic resonance imaging

Objectives

To evaluate whether changes in BOLD signal intensities following hyperoxygenation are related to intrauterine growth restriction (IUGR) in a rat model.

Methods

IUGR was induced in pregnant rats by ligating the left vascular uterine pedicle at day 16 of gestation. BOLD MR imaging using a balanced steady-state free-precession (balanced-SSFP) sequence on a 1.5-T system was performed on day 19. Signal intensities (SI) before and after maternal hyperoxygenation were compared in the maternal liver and in control and growth-restricted foetoplacental units (FPUs).

Results

Maternal hyperoxygenation resulted in a significant increase in SI in all regions of interest (P?<?0.05) in the 18 rats. In the control group, the SI (mean ± SD) increased by 21 %?±?15 in placentas (n?=?74) and 13 %?±?8.5 in foetuses (n?=?53). In the IUGR group, the increase was significantly lower: 6.5 %?±?4 in placentas (n?=?36) and 7 %?±?5.5 in foetuses (n?=?34) (P?<?0.05).

Conclusion

BOLD MRI allows non-invasive assessment of the foetoplacental response to maternal hyperoxygenation in the rat and demonstrates its alteration in an IUGR model. This imaging method may provide a useful adjunct for the early diagnosis, evaluation, and management of human IUGR.

Key Points

? Intra-uterine growth restriction is an important cause of perinatal morbidity and mortality. ? Blood oxygen level-dependent MRI non-invasively assesses foetoplacental response to maternal hyperoxygenation. ? In the rat, foetoplacental response to maternal hyperoxygenation is altered in IUGR. ? Functional MRI may help to assess human IUGR.     

Fetal liver iron overload: the role of MR imaging

Objective

To assess the potential role of MR imaging in the diagnosis of fetal liver iron overload.

Methods

We reviewed seven cases of abnormal liver signal in fetuses referred to MR imaging in a context of suspected congenital infection (n?=?2), digestive tract anomalies (n?=?3) and hydrops fetalis (n?=?2). The average GA of the fetuses was 31?weeks. The antenatal diagnoses were compared with histological data (n?=?6) and postnatal work-up (n?=?1).

Results

Magnetic resonance imaging demonstrated unexpected abnormal fetal liver signal suggestive of iron overload in all cases. The iron overload was confirmed on postnatal biopsy (n?=?2) and fetopathology (n?=?4). The final diagnosis was hepatic hemosiderosis (haemolytic anaemia (n?=?2) and syndromal anomalies (n?=?2)) and congenital haemochromatosis (n?=?3). In all cases, the liver appeared normal on US.

Conclusions

Magnetic resonance is the only imaging technique able to demonstrate liver iron overload in utero. Yet, the study outlines the fundamental role of MR imaging in cases of congenital haemochromatosis. The antenatal diagnosis of such a condition may prompt ante??(in the case of recurrence) or neonatal treatment, which might improve the prognosis.     

Basilar artery fenestration detected with CT angiography

Objectives

To analyse the characteristics of basilar artery (BA) fenestrations and their coexistence with aneurysms and other anomalies in a massive cases by computed tomographic angiography (CTA).

Methods

A total of 5,657 sequential cerebral CTA images performed from January 2006 to February 2012 were reviewed. CTA images were obtained from the raw datasets by using volume rendering and maximal intensity projection reconstruction.

Results

One hundred and thirty-two (2.33 %) BA fenestrations were detected with CTA, and most common at the proximal segment (n?=?124). BA fenestration-associated aneurysms were found in 34 cases and 7 located at the posterior circulation, and the frequency of posterior circulation aneurysms was significantly different in patients with and without BA fenestrations (P?=?0.025). Other associated anomalies included arteriovenous malformation (n?=?7) and moyamoya disease (n?=?6). BA fenestrations were classified into Type I (74 cases), Type II (15 cases), Type III (41 cases) and Type IV (2 cases). A significant difference was observed between Types II + III associated with convex-lens-like and slit-like fenestrations (P?=?0.008).

Conclusions

BA fenestrations were found in 2.33 % with CTA. They were significantly more often associated with posterior circulation aneurysms than those without BA fenestration. The anterior inferior cerebral artery (AICA) tends to originate more often from convex-lens-like fenestration than slit-like.

Key Points

? Basilar artery fenestrations were found in 2.33?% of patients undergoing CT angiography. ? Fenestrations were seen more often in the lower third with slit-like configurations. ? No obvious relationship exists between basilar artery fenestration and aneurysm formation. ? Basilar artery fenestrations perhaps predispose a patient to posterior circulation aneurysm formation. ? The AICA tends to originate more often from convex-lens-like than slit-like fenestrations.     

Frequency and predictors of endoleaks and long-term patency after covered stent placement for the treatment of intracranial aneurysms: a prospective, non-randomised multicentre experience

Objective

We investigated immediate/late endoleaks and long-term patency following stent-graft placement for treatment of intracranial aneurysms located within the distal internal carotid artery (ICA) or vertebral artery (VA).

Methods

Forty-five aneurysms in 41 patients receiving covered stents in three centres were followed. Outcome measures included aneurysm occlusion rate, endoleaks, late in-stent stenosis rate, clinical improvement, neurological deficiencies and death.

Results

Total aneurysm exclusion was achieved in 69.2% (n?=?27), with 30.8% (n?=?12) experiencing immediate residual endoleaks. Angiographic follow-up (mean 43.5?±?14.3 months) revealed that 87.2% (n?=?34) were completely occluded with only 12.8% (n?=?5) showing residual endoleaks. Predictors of immediate endoleaks in our patient group were stent number (P?=?0.023) and stent diameter (P?=?0.022), while predictors of late endoleaks in our patient group were stent diameter (P?=?0.035) and stent angulation (P?=?0.021). Late in-stent stenosis rates were 18.0?±?13.3 and 29.0?±?18.5% compared with the period immediately following implantation at 2- and 6-year follow-ups respectively. Smoking (P?=?0.017) and stent angulation (P?=?0.020) were predictors of late in-stent stenosis.

Conclusion

Treating intracranial aneurysms with Willis stent-grafts has an acceptable immediate and late occlusion rate and long-term stented artery patency rate.

Key Points

? Covered stents can be a treatment option for intracranial aneurysms. ? Technical success for treating distal ICA and VA aneurysms can reach 97.6%. ? However immediate and late endoleaks occur in 30.8 and 12.8% respectively. ? The number, diameter and angulation of stents are possible predictors of endoleaks. ? Smoking and stent angulation seem to predict late in-stent stenosis.     

Uterine Artery Embolization versus Myomectomy: Impact on Quality of Life—Results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial

Purpose

This study was designed to compare quality of life (QoL) outcomes after uterine artery embolization (UAE) or myomectomy.

Methods

Women with symptomatic fibroids diagnosed by ultrasound who wished to preserve their uterus were randomized to myomectomy (n?=?81) or UAE (n?=?82). Endpoints at 1?year were QoL measured by a validated questionnaire, hospital stay, rates of complications, and need for reintervention.

Results

UAE patients had shorter hospitalization (2 vs. 6?days, p?significant and equal improvements in QoL scores had occurred in both groups (myomectomy n?=?59; UAE n?=?61). There had been two (2.9%) major complications among UAE versus 6 (8%) among myomectomy patients (not significant). By 2?years, among UAE patients (n?=?57) there were eight (14.0%) reinterventions for inadequate symptom control compared with one (2.7%) among myomectomy patients (n?=?37). Half of the women who required hysterectomy had concomitant adenomyosis missed by US.

Conclusions

UAE and myomectomy both result in significant and equal improvements in QoL. UAE allows a shorter hospital stay and fewer major complications but with a higher rate of reintervention.     

Chemoembolization for Hepatocellular Carcinoma Supplied Exclusively by the Hepatic Falciform Artery

Purpose

The purpose of this study was to describe imaging appearances of hepatocellular carcinoma (HCC) supplied exclusively by the hepatic falciform artery (HFA) and safety of chemoembolization via the HFA.

Methods

During the past 6?years, we have performed chemoembolization for the treatment of 12 patients with HCCs supplied exclusively by the HFA. Computed tomography (CT) scans, digital subtraction angiograms, and medical records were retrospectively reviewed by consensus.

Results

Tumors were located in Couinaud segments IV (n?=?7) and III (n?=?5) and in subcapsular areas around the falciform ligaments. Tumor size ranged from 1.0 to 1.8?cm (mean, 1.3?cm; median, 1.3?cm). HFAs originated from A4 (n?=?7), A3 (n?=?4), and the left hepatic artery near the umbilical point (n?=?1). All tumors were supplied exclusively by the HFA. Prophylactic embolization of the distal HFA before chemoembolization was performed using gelatin sponge particles in only one patient, and selective chemoembolization via the HFA was achieved in all patients. One patient suffered from a skin rash after chemoembolization and recovered after conservative management. Individual responses of tumors supplied exclusively by the HFA were complete response (n?=?8), partial response (n?=?1), and stable disease (n?=?2) at the first follow-up enhanced CT scan.

Conclusions

The HFA can supply HCC located in subcapsular areas around the falciform ligament, and the tumors can be safely chemoembolized without significant complications.     

Diagnostic accuracy of dual-source CT coronary angiography with prospective ECG-triggering on different heart rate patients

Objective

To evaluate the diagnostic accuracy of dual-source CT (DSCT) prospective ECG-triggering coronary angiography in patients with different heart rate (HR).

Methods

103 patients with suspected coronary artery disease underwent DSCT prospective ECG-triggered coronary angiography and invasive coronary angiography (ICA). The patients were grouped by HR during CT scans: low HR (??60?bpm, n?=?34); medium HR (60?n?=?36) and high HR (>70?bpm, n?=?33). The sensitivity and specificity of DSCT in detecting ??50% stenosis were compared among subgroups where ICA was the gold standard. Image quality was scored using a 4-point scale.

Results

A total of 1,580 (95.9%) coronary artery segments were evaluable. Sensitivity and specificity were 82.8% and 98.4%, 88.3% and 98.7%, and 80.3% and 98.6% for different subgroups (all p?>?0.05). The overall area under the curve of the receiver-operating characteristic analysis was 0.94. The image quality scores were 3.1?±?0.3, 3.1?±?0.3 and 3.0?±?0.4 for subgroups (p?>?0.05). The overall average effective radiation dose was 3.60?±?1.60?mSv.

Conclusion

DSCT coronary angiography with prospective ECG-triggering could be just as accurate in patients with medium to high HR compared to those with low HR.     

Uterine Artery Embolization Versus Laparoscopic Uterine Artery Occlusion: The Outcomes of a Prospective, Nonrandomized Clinical Trial

Purpose

To compare outcomes of two different types of occlusive therapy of uterine fibroids.

Methods

Women with fibroid(s) unsuitable for laparoscopic myomectomy (LM) were treated with uterine artery embolization (UAE) or laparoscopic uterine artery occlusion (LUAO).

Results

Before the procedure, patients treated with UAE (n?=?100) had a dominant fibroid greater in size (68 vs. 48?mm) and a mean age lower (33.1 vs. 34.9?years) than surgically treated patients (n?=?100). After 6?months, mean shrinkage of fibroid volume was 53?% after UAE and 39?% after LUAO (p?=?0.063); 82?% of women after UAE, but only 23?% after LUAO, had complete myoma infarction (p?=?0.001). Women treated with UAE had more complications (31 vs. 11 cases, p?=?0.006) and greater incidence of hysteroscopically verified intrauterine necrosis (31 vs. 3?%, p?=?0.001). Both groups were comparable in markers of ovarian functions and number of nonelective reinterventions. The groups did not differ in pregnancy (69?% after UAE vs. 67?% after LUAO), delivery (50 vs. 46?%), or abortion (34 vs. 33?%) rates. The mean birth weight of neonates was greater (3270 vs. 2768?g, p?=?0.013) and the incidence of intrauterine growth restriction lower (13 vs. 38?%, p?=?0.046) in post-UAE patients.

Conclusion

Both methods are effective in the treatment of women with future reproductive plans and fibroids not suitable for LM. UAE is more effective in causing complete ischemia of fibroids, but it is associated with greater risk of intrauterine necrosis. Both methods have low rate of serious complications (except for a high abortion rate).     

Factors affecting long-term restenosis after carotid stenting for carotid atherosclerotic disease

Introduction

The most significant factors leading to restenosis are yet to be described in the literature. The purpose of our study was to identify the incidence of restenosis in our patients with carotid artery stenting (CAS) for carotid atherosclerotic disease and to identify risk factors that are significantly responsible or related to the restenosis.

Methods

In this retrospective analysis of patients who underwent CAS for atherosclerotic disease between years 2002 and 2006, we studied various demographic, clinical, and medical factors, plaque characteristics, and technical aspects of CAS. All patients were followed up with carotid Doppler ultrasound at baseline (after 2 to 4?weeks of CAS) and then with Doppler ultrasound and clinically for various intervals of time. The restenosis was classified based on carotid Doppler ultrasound results. Clinically, restenosis was classified as symptomatic or asymptomatic. Pearson correlation coefficient was used to assess the statistical correlation of the different factors with the incidence of restenosis.

Results

We had a total of 105 patients, with a total of 204.6 patient-year follow-up (mean, 1.95?years; range, 0?C7.3?years). The overall incidence of restenosis was 26.7?% (n?=?28): mild, 7.6?% (n?=?8); moderate, 10.5?% (asymptomatic, 11; symptomatic, 0); and severe, 8.6?% (asymptomatic, 5; symptomatic, 4). Overall, 14.3?% (n?=?4) patients with restenosis were symptomatic and 7.1?% (n?=?2) underwent retreatment. Post-stenting residual stenosis greater than either 30?% (p?=?0.016) or 50?% (p?=?0.05) were significant for long-term restenosis. Plaques longer than 20?mm were significantly related to restenosis (p?<?0.001).

Conclusion

The most important factor to explain restenosis was the immediate post-CAS residual stenosis and length of the plaque.     

Coronary artery assessment by multidetector computed tomography in patients with prosthetic heart valves

Objectives

Patients with prosthetic heart valves may require assessment for coronary artery disease. We assessed whether valve artefacts hamper coronary artery assessment by multidetector CT.

Methods

ECG-gated or -triggered CT angiograms were selected from our PACS archive based on the presence of prosthetic heart valves. The best systolic and diastolic axial reconstructions were selected for coronary assessment. Each present coronary segment was scored for the presence of valve-related artefacts prohibiting coronary artery assessment. Scoring was performed in consensus by two observers.

Results

Eighty-two CT angiograms were performed on a 64-slice (n?=?27) or 256-slice (n?=?55) multidetector CT. Eighty-nine valves and five annuloplasty rings were present. Forty-three out of 1160 (3.7%) present coronary artery segments were non-diagnostic due to valve artefacts (14/82 patients). Valve artefacts were located in right coronary artery (15/43; 35%), left anterior descending artery (2/43; 5%), circumflex artery (14/43; 32%) and marginal obtuse (12/43; 28%) segments. All cobalt-chrome containing valves caused artefacts prohibiting coronary assessment. Biological and titanium-containing valves did not cause artefacts except for three specific valve types.

Conclusions

Most commonly implanted prosthetic heart valves do not hamper coronary assessment on multidetector CT. Cobalt-chrome containing prosthetic heart valves preclude complete coronary artery assessment because of severe valve artefacts.

Key Points

? Most commonly implanted prosthetic heart valves do not hamper coronary artery assessment ? Prosthetic heart valve composition determines the occurrence of prosthetic heart valve-related artefacts ? Bj?rk–Shiley and Sorin tilting disc valves preclude diagnostic coronary artery segment assessment     

Endovascular treatment for superior cerebellar artery aneurysms: morphological features,technique, and outcome

Introduction

Superior cerebellar artery (SCA) aneurysms have distinctive morphologic configurations and vascular origins. Herein, we have analyzed the angioarchitectural characteristics of SCA aneurysms and outcomes achieved through endovascular treatment.

Methods

Data accruing prospectively from January, 2002 to September, 2013 yielded 53 SCA aneurysms in 53 patients. Each lesion was classified as either basilar artery (BA), BA–SCA, or SCA type, according to the nature of incorporated vasculature. Clinical and morphologic outcomes were assessed, with emphasis on technical aspects of treatment.

Results

Angles formed by SCA and posterior cerebral artery were obtuse (124.8?±?29.1°) on sides ipsilateral to aneurysms, differing significantly from contralateral counterparts (44.8?±?22.0°) (p?n?=?19, 67.9 %) facilitated aneurysm selection for approach via contralateral vertebral artery (n?=?28), whereas pre-shaped 45/90/J microcatheters (n?=?21, 84.0 %) primarily were used for ipsilateral vertebral artery approach (n?=?25). Single-microcatheter technique (52.8 %) was most often applied, followed by double-microcatheter (34.0 %), stent-assisted (9.4 %), and microcatheter-protection techniques (3.8 %). Aneurysmal occlusion was satisfactorily achieved in 45 lesions (82.1 %), with no procedure-related morbidity and mortality. In follow-up monitoring of 46 patients for a mean period of 25.8?±?24.4 months, only a single instance of major recanalization (2.2 %) occurred.

Conclusion

Coil embolization of SCA aneurysms is a safe and effective treatment modality, enabling individualized procedural strategies to accommodate distinctive angio-anatomic configurations.     

MRI findings of treated bacterial septic arthritis

Introduction

The purpose of this study was to report the MRI findings that can be encountered in successfully treated bacterial septic arthritis.

Materials and methods

The study included 12 patients (8 male and 4 female; mean age 38?years, range 9–85) with 13 proven cases of bacterial septic arthritis. The joints involved were hip (n?=?3), knee (n?=?3), shoulder (n?=?2), sacroiliac (n?=?2), ankle (n?=?1), wrist (n?=?1), and elbow (n?=?1). MRI examinations following surgical debridement and at initiation of antibiotic therapy and after successful treatment were compared for changes in effusion, synovium, bone, and periarticular soft tissues. Imaging findings were correlated with microbiological and clinical findings.

Results

Joint effusions were present in all joints at baseline and regressed significantly at follow-up MRI (p?=?0.001). Abscesses were present in 5 cases (38?%), and their sizes decreased significantly at follow-up (p?=?0.001). Synovial enhancement and thickening were observed in all joints at both baseline and follow-up MRI. Myositis/cellulitis was present in 10 cases (77?%) at baseline and in 8 cases (62?%) at follow-up MRI. Bone marrow edema was present in 10 joints (77?%) at baseline and persisted in 8 joints (62?%). Bone erosions were found in 8 joints (62?%) and persisted at follow-up MRI in all cases.

Conclusion

The sizes of joint effusions and abscesses appear to be the factors with the most potential for monitoring therapy for septic arthritis, since both decreased significantly following successful treatment. Synovial thickening and enhancement, periarticular myositis/cellulitis, and bone marrow edema can persist even after resolution of the infection.     

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

Objectives

To retrospectively investigate the prevalence and characteristics of intracranial vascular lesions in patients with acute severe headache with the use of CT angiography (CTA).

Methods

We systematically searched for neurologically intact patients with acute severe headache and normal unenhanced head CT. The study group consisted of 512 patients; 251 male; mean age 46.2?±?12.4 years. All patients underwent CTA between 1 day and 2 months after the headache attack. CTA images were interpreted by two experienced neuroradiologists for the presence of vascular lesions.

Results

Thirty-four (6.6 %) of the 512 patients had intracranial vascular lesions on CTA, including 33 aneurysms (2 patients had 2 aneurysms each), 2 moyamoya disease and 1 arterial dissection. No gender- or age-related differences were found. Aneurysms arose most commonly on the internal carotid artery (n?=?12), followed by the anterior communicating artery (n?=?7), and the middle cerebral artery (n?=?7). Maximal diameters ranged from 2.0 to 13.1 mm (mean, 3.9?±?2.6 mm).

Conclusions

CTA is a feasible tool for diagnosing intracranial vascular lesions in patients with acute severe headache. The prevalence of vascular lesions in our series was 6.6 %, which is higher than that predicted in the general population.

Key Points

? Unruptured cerebral aneurysms may be a cause of acute severe headache ? CTA assesses intracranial vascular lesions in patients with acute severe headache ? The prevalence of vascular lesions in our series of patients was 6.6 %     

Gadoxetic acid enhanced MRI for differentiation of FNH and HCA: a single centre experience

Objectives

Evaluation of enhancement characteristics of histopathologically confirmed focal nodular hyperplasias (FNHs) and hepatocellular adenomas (HCAs) with gadoxetic acid-enhanced MRI.

Methods

Sixty-eight patients with 115 histopathologically proven lesions (FNHs, n?=?44; HCAs, n?=?71) examined with gadoxetic acid-enhanced MRI were retrospectively enrolled (standard of reference: surgical resection, n?=?53 patients (lesions: FNHs, n?=?37; HCAs, n?=?53); biopsy, n?=?15 (lesions: FNHs, n?=?7; HCAs, n?=?18)). Two radiologists evaluated all MR images regarding morphological features as well as the vascular and hepatocyte-specific enhancement in consensus.

Results

For the hepatobiliary phase, relative enhancement of the lesions and lesion to liver enhancement were significantly lower for HCAs (mean, 48.7 (±48.4) % and 49.4 (±33.9) %) compared to FNHs (159.3 (±92.5) %; and 151.7 (±79) %; accuracy of 89 % and 90 %, respectively; P?<?0.001). Visual strong uptake of FNHs vs. hypointensity of HCAs in the hepatobiliary phase resulted in an accuracy of 92 %. This parameter was superior to all other morphological and dynamic vascular criteria alone and in combination (accuracy, 54–85 %).

Conclusions

For differentiation of FNHs and HCAs by means of MRI, gadoxetic acid uptake in the hepatobiliary phase was found to be superior to all other criteria alone and in combination.

Key Points

? EOB-MRI is well suited to differentiate FNHs and hepatocellular adenomas. ? For this purpose hepatobiliary phase is superior to unenhanced and dynamic imaging. ? Hepatobiliary phase (peripheral) hyper- or isointensity is typical for FNH. ? Hepatobiliary phase hypointensity is typical for hepatocellular adenomas. ? EOB-MRI helps to avoid misinterpretations of benign hepatocellular lesions.     

Diagnostic value of combined 18F-FDG PET/MRI for staging and restaging in paediatric oncology

Purpose

The present study compares the diagnostic value of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and MRI to combined/registered ¹⁸F-FDG PET/MRI for staging and restaging in paediatric oncology.

Methods

Over 8?years and 2?months, 270 ¹⁸F-FDG PET and 270 MRI examinations (mean interval 5?days) were performed in 132 patients with proven (n?=?117) or suspected (n?=?15) malignant disease: solid tumours (n?=?64), systemic malignancy (n?=?53) and benign disease (n?=?15). A total of 259 suspected tumour lesions were analysed retrospectively during primary diagnosis and 554 lesions during follow-up. Image analysis was performed separately on each modality, followed by analysis of combined and registered ¹⁸F-FDG PET/MRI imaging.

Results

A total of 813 lesions were evaluated and confirmed by histopathology (n?=?158) and/or imaging follow-up (n?=?655) after 6?months. In the separate analysis of ¹⁸F-FDG PET and MRI, sensitivity was 86?%/94?% and specificity 85?%/38?%. Combined/registered ¹⁸F-FDG PET/MRI led to a sensitivity of 97?%/97?% and specificity of 81?%/82?%. False-positive results (¹⁸F-FDG PET n?=?69, MRI n?=?281, combined ¹⁸F-FDG PET/MRI n?=?85, registered ¹⁸F-FDG PET/MRI n?=?80) were due to physiological uptake or post-therapeutic changes. False-negative results (¹⁸F-FDG PET n?=?50, MRI n?=?20, combined ¹⁸F-FDG PET/MRI n?=?11, registered ¹⁸F-FDG PET/MRI n?=?11) were based on low uptake or minimal morphological changes. Examination-based evaluation during follow-up showed a sensitivity/specificity of 91?%/81?% for ¹⁸F-FDG PET, 93?%/30?% for MRI and 96?%/72?% for combined ¹⁸F-FDG PET/MRI.

Conclusion

For the detection of single tumour lesions, registered ¹⁸F-FDG PET/MRI proved to be the methodology of choice for adequate tumour staging. In the examination-based evaluation, MRI alone performed better than ¹⁸F-FDG PET and combined/registered imaging during primary diagnosis. At follow-up, however, the examination-based evaluation demonstrated a superiority of ¹⁸F-FDG PET alone.     

Detection and treatment of spinal CSF leaks in idiopathic intracranial hypotension

Introduction

This study aimed to evaluate the diagnostic imaging findings and treatment results of patients with idiopathic intracranial hypotension (IIH) due to cerebrospinal fluid (CSF) leaks.

Methods

Between February 2009 and April 2012, 26 IIH patients (15 men, median age 49?years) presenting with orthostatic headache (n?=?20) and/or with spontaneous subdural effusions or subarachnoid hemorrhage (n?=?19) were enrolled. Twenty-three patients underwent a whole spine CT and MRI myelography, starting 45?min after the intrathecal injection of 9?cc of iomeprol (Imeron 300 M) and 1?cc of gadobutrolum (Gadovist). Three patients only underwent MR myelography after intrathecal gadobutrolum injection. Adjacent to the level(s) of the detected CSF leak(s) along the nerve roots, 20?cc of fresh venous blood with 0.5?cc Gadovist was injected epidurally (blood patch, BP). The distribution of the BP was visualized by MRI the following day. Treatment results were evaluated clinically and by myelography 2?weeks after the application of the BP. Retreatment was offered to patients with persistent symptoms and continued CSF leakage.

Results

CSF leaks were detected at the cervical (n?=?12), thoracic (n?=?25), or lumbar (n?=?21) spine. In 23 patients, more than one spinal segment was affected. One patient refused treatment. BP were applied in one (n?=?9) or several (n?=?16) levels. Clinical and/or radiological improvement was achieved after one (n?=?16), two (n?=?5), three (n?=?3), or five (n?=?1) BPs.

Conclusion

CT and MRI myelography allow the reliable detection of spinal CSF leaks. The targeted and eventually repeated epidural BP procedure is a safe and efficacious treatment.     

Postpartum haemorrhage from ruptured pseudoaneurysm: efficacy of transcatheter arterial embolisation using N-butyl-2-cyanoacrylate

Objectives

To evaluate the efficacy of transcatheter arterial embolisation (TAE) using N-butyl-2-cyanoacrylate (NBCA) in the treatment of postpartum haemorrhage (PPH) due to ruptured pseudoaneurysm.

Methods

From March 2004 to December 2010, 33 patients underwent TAE using NBCA for massive PPH. Twenty-one patients (63.6 %) were in coagulopathic condition. Angiograms and medical records were retrospectively reviewed to determine technical/clinical success, complications and recurrent haemorrhage after TAE. Telephone interviews were conducted to obtain fertility-related data.

Results

Emergent angiograms revealed ruptured pseudoaneurysms at the uterine (n?=?17), vaginal (n?=?14), internal pudendal (n?=?3) and obturator (n?=?1) arteries, which were successfully embolised with NBCA. Four patients required additional embolisation of the uterine (n?=?3) or ovarian artery (n?=?1) with an absorbable gelatine sponge. Adequate haemostasis was achieved in 31 patients (93.9 %) after TAE. Two patients experienced persistent (n?=?1) or recurrent (n?=?1) haemorrhage, which required hysterectomy. There were no major embolisation-related complications. All 29 patients who were interviewed reported regaining of their regular menstruation. Nine patients had normal pregnancies and delivered healthy babies at full term.

Conclusions

TAE using NBCA is an effective treatment of PPH from ruptured pseudoaneurysms. In particular, NBCA is a potent embolic material in patients with coagulopathy. It does not seem to adversely affect future fertility.

Key Points

? Transcatheter arterial embolisation is a safe and effective treatment for postpartum haemorrhage. ? NBCA is potent embolic material to treat bleeding patients with severe coagulopathy. ? NBCA does not seem to adversely affect future fertility.     

Ten Years of Experience with the GORE EXCLUDER? Stent-Graft for the Treatment of Aortic and Iliac Aneurysms: Outcomes from a Single Center Study

Purpose

This study was designed to assess the long-term outcome of selected patients with aortic, aortoiliac, and isolated common iliac aneurysms treated with the GORE EXCLUDER^? stent-graft.

Methods

Between December 1998 and June 2010, 121 nonconsecutive patients underwent insertion of a GORE EXCLUDER^? stent-graft to treat an aortic (n?=?80; 66%), aortoiliac (n?=?25; 21%), or isolated common iliac (n?=?16; 13%) aneurysm. Procedural and follow-up data were collected prospectively. Primary endpoints are overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary endpoints are device- and procedure-related complications, including all types of endoleaks or endotension, and reintervention.

Results

The mean follow-up is 4.98?years (standard deviation, 3.18; median follow-up, 4.05?years). The estimated percentage overall survival (with 95% confidence interval) after respectively 5 and 10?years of follow-up is 74.5% (65.8; 81.3) and 57.8% (47.7; 66.7). The estimated intervention-free survival after respectively 5 and 10?years is 90% (84.3; 96.1) and 77.7% (67; 88.4). There was no aneurysm rupture during follow-up. Early postoperative complications occurred in 16 patients (13%); none were fatal. Late reinterventions were performed in 18?patients (15%). Finally, throughout the follow-up period, endoleaks were identified: type I (n?=?4; 3%); type II (n?=?39; 32%); type?III (n?=?0; 0%); endotension was seen in 11 patients (9%).

Conclusions

Aneurysm exclusion with use of the GORE EXCLUDER^? stent-graft is durable through a mean follow-up of nearly 5?years. There was no postprocedural aneurysm rupture. Complications occurred throughout the follow-up period, requiring continued clinical and radiological surveillance.     

Magnetic resonance imaging to assess the effect of exercise training on pulmonary perfusion and blood flow in patients with pulmonary hypertension

Objectives

To evaluate whether careful exercise training improves pulmonary perfusion and blood flow in patients with pulmonary hypertension (PH), as assessed by magnetic resonance imaging (MR).

Methods

Twenty patients with pulmonary arterial hypertension or inoperable chronic thromboembolic PH on stable medication were randomly assigned to control (n?=?10) or training groups (n?=?10). Training group patients received in-hospital exercise training; patients of the sedentary control group received conventional rehabilitation. Medication remained unchanged during the study period. Changes of 6-min walking distance (6MWD), MR pulmonary flow (peak velocity) and MR perfusion (pulmonary blood volume) were assessed from baseline to week 3.

Results

After 3 weeks of training, increases in mean 6MWD (P?=?0.004) and mean MR flow peak velocity (P?=?0.012) were significantly greater in the training group. Training group patients had significantly improved 6MWD (P?=?0.008), MR flow (peak velocity ?9.7?±?8.6 cm/s, P?=?0.007) and MR perfusion (pulmonary blood volume +2.2?±?2.7 mL/100 mL, P?=?0.017), whereas the control group showed no significant changes.

Conclusion

The study indicates that respiratory and physical exercise may improve pulmonary perfusion in patients with PH. Measurement of MR parameters of pulmonary perfusion might be an interesting new method to assess therapy effects in PH. The results of this initial study should be confirmed in a larger study group.

Key Points

? Quantification of magnetic resonance perfusion is feasible in patients with pulmonary hypertension. ? Quantified magnetic resonance perfusion may become useful for non-invasive monitoring of treatment. ? Quantification of lung perfusion allows new insights into lung (patho-)physiology of PH. ? Careful exercise training improves pulmonary perfusion and blood flow in patients with PH.     

Reconstructions with identical filling (RIF) of the heart: a physiological approach to image reconstruction in coronary CT angiography

Objectives

To compare image quality in coronary artery computed tomography angiography (cCTA) using reconstructions with automated phase detection and Reconstructions computed with Identical Filling of the heart (RIF).

Methods

Seventy-four patients underwent ECG-gated dual source CT (DSCT) between November 2009 and July 2010 for suspected coronary heart disease (n?=?35), planning of transcatheter aortic valve replacement (n?=?34) or evaluation of ventricular function (n?=?5). Image data sets by the RIF formula and automated phase detection were computed and evalutated with the AHA 15-segment model and a 5-grade Likert scale (1: poor, 5: excellent quality). Subgroups regarding rhythm (sinus rhythm = SR; arrhythmia = ARR) and potential premedication were evaluated by a per-segment, per-vessel and per-patient analysis.

Results

RIF significantly improved image quality in 10 of 15 coronary segments (P?<?0.05). More diagnostic segments were provided by RIF regarding the entire cohort (n?=?693 vs. 590, P?<?0.001) and all of the subgroups (e.g. ARR: n?=?143 vs. 72, P?<?0.001). In arrhythmic patients (n?=?19), more diagnostic vessels (e.g. LAD: n?=?10 vs. 3; P?<?0.014) and complete data sets (n?=?7 vs. 1; P?<?0.001) were produced.

Conclusions

RIF reconstruction is superior to automatic diastolic non-edited reconstructions, especially in arrhythmic patients. RIF theory provides a physiological approach for determining the optimal image reconstruction point in ECG-gated CT angiography.

Key Points

? Conventional CT coronary angiography suffers from numerous artefacts in patients with irregular rhythms ? Coronary computed tomography angiograms (cCTA) were reconstructed with identical cardiac filling (RIF) ? RIF reconstructions provide improved image quality compared to non-edited standard reconstructions ? RIF theory links physiology with cardiac CT.