Carotid artery stenting in unfavorable vascular anatomy: Effect of embolic protection filter use on periprocedural complications.

OBJECTIVE: To investigate the effect of embolic protection device (EPD) use on periprocedural complications in patients with carotid artery stenosis with anatomical variations. METHOD: The study retrospectively evaluated 185 patients who consecutively underwent carotid artery stenting between November 2020 and December 2023. Forty-four patients with difficult anatomical structures, anatomical variations in the common carotid artery (CCA) and internal carotid artery (ICA) (tortuosity, kinking, or coiling), and a CCA-ICA angle of >60 degrees were included in the sample. The patients were divided into two groups according to the use of EPD filters during the procedure and compared in terms of periprocedural events. RESULTS: Of the 44 patients included in the study, 24 (54.5 %) were male, and the mean age of all patients was 68.7 ± 8.7 years. Comorbidities were present in 93.2 % (n = 41) of the patients. The most common comorbidity was hypertension (n = 32, 72.8 %). The CCA-ICA angle was ≥60 degrees in 45.4 % (n = 20) of all patients. ICA tortuosity was detected in 27.2 % (n = 12) of the patients, ICA kinking in 13.6 % (n = 6), ICA coiling in 6.8 % (n = 3), and CCA tortuosity in 6.8 % (n = 3). Procedure-related periprocedural events developed in 38.6 % (n = 17) of the patients. Postprocedural mortality occurred in two patients, secondary to myocardial infarction in one and COVID-19 pneumonia in the other. There was no significant difference between the filter and non-filter groups in relation to periprocedural events (p = 0.638). Major stroke did not occur in either group. Minor neurological events occurred in 15 % (n = 3/20) of the patients in the filter group and 16.7 % (n = 4/24) of those in the non-filter group. The incidence of vasospasm was statistically higher in patients using filters compared to those without filters (30 % vs. 0 %; P = 0.005, respectively). CONCLUSION: Evaluation of vascular anatomy before carotid artery stenting is important to decide on the technical procedure to be applied in the procedure. The use of EPD in unfavorable anatomy does not reduce periprocedural neurological events. Instead, it results in technical difficulties, prolongs the duration of procedure, and leads to arterial vasospasm. Considering the high periprocedural events in this study, carotid endarterectomy may be a better alternative to endovascular treatment in patients with unfavorable carotid artery anatomy.

Endovascular Pipeline Shield Treatment of Iatrogenic Internal Carotid Artery Pseudoaneurysm and Carotid-Cavernous Fistula.

Pseudoaneurysm (PA) and carotid cavernous fistula (CCF) of the internal carotid artery (ICA) is an uncommon complication of endoscopic endonasal surgery that occurs in 1% of cases. We report on the successful placement of flow-diverting stents (FDS) to ICA pseudoaneurysm and caroticocavernous fistula caused by iatrogenic ICA injury for a pituitary adenoma in a 37-year-old female. After placement of the pipeline shield given a certain time, dual antiplatelet agents (DAPT) and follow-up angiogram verified complete aneurysm obliteration and effective endoluminal reconstruction of the injured vessel. In managing ICA pseudoaneurysms, the placement of flow-diverting stents is a viable vessel-sparing technique.

Split Bolus Method in Computerized Tomography.

The split-bolus method in computed tomography (CT) is the method used in the evaluation of renal dynamic enhancement stages and in the detection of pathologies. When designing the CT urography technique, there are several important options such as single-bolus and split bolus techniques. The single-bolus method consists of three separate post-contrast phases: arterial, nephrographic, and excretory (pyelogram), as a result raising the total radiation dose imparted to patients. On the other hand, in the split-bolus technique, the contrast dose is divided into several separate administrations to obtain the nephrographic and excretory phases simultaneously. With the split-bolus technique, by reducing the radiation dose and the number of phases that the patient will be exposed to, urinary system evaluation and the whole abdomen pathological evaluations can be performed. The device to be used in imaging must be a tomography device with at least 16 Multidetector CT sections. The bolus tracking method is one of the most accurate contrast delivery methods for renal dynamics and the split-bolus technique. Automatic dose calibration is used.

Predictive role of magnetic resonance imaging in the distinction of isocitrate dehydrogenase (IDH) mutant grade 4 astrocytomas versus glioblastomas.

BACKGROUND: Isocitrate dehydrogenase (IDH) mutation status is a crucial prognostic factor in high-grade glial tumors. PURPOSE: To investigate whether magnetic resonance imaging (MRI) features can display a diagnostic performance in the determination of IDH mutation in high-grade gliomas. MATERIAL AND METHODS: A total of 170 patients including 24 IDH mutant grade 4 astrocytomas and 146 glioblastomas (GBM) were retrospectively examined via contrast-enhanced (CE) MRI before surgery. Immunohistochemistry and genomic sequence analyses were performed on specimen materials for the determination of IDH mutational status. Certain morphological and diffusion-weighted imaging (DWI) parameters were utilized to see if they could play a role to be non-invasive potential imaging predictors in the discrimination of IDH mutant versus wild-type (WT) high-grade gliomas. RESULTS: On histopathological examination, IDH mutation was detected in 24 patients with high-grade glioma and 146 of the patients were found to be WT. Certain morphological criteria of tumor location and involvement, tumor margins, visual detection of diffusion restriction on DWI, and quantitative apparent diffusion coefficient (ADC) parameters consisting of ADCmean, ADCmin, and ADCr could be used as imaging predictors in the discrimination of high-grade IDH mutant versus WT tumors. CONCLUSION: Certain MRI morphologic features and visual detection of diffusion restriction on DWI and quantitative ADC parameters consisting of ADCmean, ADCmin, and ADCr can be considered non-invasive, significant independent imaging predictors in the discrimination and can obviate invasive procedures for histopathological diagnosis.

CT and MR Imaging Findings in Methanol Intoxication Manifesting with BI Lateral Severe Basal Ganglia and Cerebral Involvement.

Our case report describes a 54-year-old man who was admitted to our hospital complaining of visual impairment with gastrointestinal and neurological symptoms. Initial computed tomography examination showed bilateral symmetric putaminal and cerebral white matter hypodensities. Evaluation of the following magnetic resonance imaging, restricted diffusion in these corresponding areas were found to be compatible with cytotoxic edema. Teaching Point: Diffusion-weighted imaging (DWI) plays a crucial role in the diagnosis of acute methanol intoxication.

CT-guided Percutaneous Radiofrequency Ablation of Osteoid Osteoma with Double Nidi in One Session.

Osteoid osteoma with multiple nidi is a rare condition. The aim of this report is to share a case of an osteoid osteoma with two separate nidi, which underwent radio-frequency ablation (RFA) treatment under CT-guidance for each of the nidi in the same session. A 15-year girl with osteoid osteoma in left tibia was referred to our clinic for percutaneous RFA. She had pain that worsened at nights. The patient was diagnosed as osteoidosteoma, according to radiologic findings and the clinical symptoms. After CT-guided percutaneous RFA of each nidi in the same procedure, pain was relieved in 24 hours. Each of the RFA-treatments was successful in pain control without any complications and no recurrence occurred during eight months of follow-up period. To our knowledge, this case is one of the very few cases with double nidi, which was treated with RFA in one session. RFA is safe in treatment of osteoid osteomas; even two close and separate nidi can safely be treated in the same session. Key Words: Osteoid osteoma, Nidi, Treatment, Radiofrequency ablation.