Magnetic resonance in patients with cardiovascular devices. SEC-GT CRMTC/SEC-Heart Rhythm Association/SERAM/SEICAT consensus document.

Magnetic resonance has become a first-line imaging modality in various clinical scenarios. The number of patients with different cardiovascular devices, including cardiac implantable electronic devices, has increased exponentially. Although there have been reports of risks associated with exposure to magnetic resonance in these patients, the clinical evidence now supports the safety of performing these studies under specific conditions and following recommendations to minimize possible risks. This document was written by the Working Group on Cardiac Magnetic Resonance Imaging and Cardiac Computed Tomography of the Spanish Society of Cardiology (SEC-GT CRMTC), the Heart Rhythm Association of the Spanish Society of Cardiology (SEC-Heart Rhythm Association), the Spanish Society of Medical Radiology (SERAM), and the Spanish Society of Cardiothoracic Imaging (SEICAT). The document reviews the clinical evidence available in this field and establishes a series of recommendations so that patients with cardiovascular devices can safely access this diagnostic tool.

Learning Curve for Flow Diversion of Posterior Circulation Aneurysms: A Long-Term International Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Flow diversion has gradually become a standard treatment for intracranial aneurysms of the anterior circulation. Recently, the off-label use of the flow diverters to treat posterior circulation aneurysms has also increased despite initial concerns of rupture and the suboptimal results. This study aimed to explore the change in complication rates and treatment outcomes across time for posterior circulation aneurysms treated using flow diversion and to further evaluate the mechanisms and variables that could potentially explain the change and outcomes. MATERIALS AND METHODS: A retrospective review using a standardized data set at multiple international academic institutions was performed to identify patients with ruptured and unruptured posterior circulation aneurysms treated with flow diversion during a decade spanning January 2011 to January 2020. This period was then categorized into 4 intervals. RESULTS: A total of 378 procedures were performed during the study period. Across time, there was an increasing tendency to treat more vertebral artery and fewer large vertebrobasilar aneurysms (P = .05). Moreover, interventionalists have been increasingly using fewer overlapping flow diverters per aneurysm (P = .07). There was a trend toward a decrease in the rate of thromboembolic complications from 15.8% in 2011-13 to 8.9% in 2018-19 (P = .34). CONCLUSIONS: This multicenter experience revealed a trend toward treating fewer basilar aneurysms, smaller aneurysms, and increased usage of a single flow diverter, leading to a decrease in the rate of thromboembolic and hemorrhagic complications.

Quantitative analysis of tegmen bone mineral density in obese and non-obese patients.

BACKGROUND: Certain factors have been linked to lateral skull base demineralisation or erosion, which may predispose to spontaneous cerebrospinal fluid leak. There are relatively few quantitative reports of skull base changes in patient populations. METHOD: A novel refined measurement algorithm for quantification of tegmen bone mineral density was developed, and bone mineral density between obese and non-obese patient groups was compared. Computed tomography scans were analysed by three blinded reviewers, and tegmen bone mineral densities were compared. RESULTS: There were 23 patients in the obese group and 27 matched controls in the non-obese group. Inter-rater reliability was 'strong' to 'near complete' (κ = 0.75-0.86). No differences in tegmen bone mineral density were found between the groups (p = 0.64). The number of active blood pressure medications correlated positively with lateral skull base bone mineral density. CONCLUSION: A novel, refined, quantitative measurement algorithm for the assessment of tegmen bone mineral density was developed and validated. Obesity was not found to significantly affect tegmen bone mineral density.

Cellular blue nevus tumor presenting as a submandibular lymph node in a 16-year-old.

The cellular blue nevus tumor is a type of dendritic melanocytic nevus that is typically benign and exceedingly rare. The incidence of all blue nevi is about 1%, usually affecting the adult population and appearing on the extremities, sacrococcygeal or gluteal regions. There have only been a handful of case reports cited in the literature where cellular blue nevi present in the head and neck region, usually affecting the scalp and young adult population (7, 8). As such, it is exceedingly rare to encounter a cellular blue nevus tumor in the neck or infiltrating into neck lymph nodes. Here we report a rare case of a cellular blue nevus tumor presenting as a right neck mass in a pediatric 16-year-old patient, shown to invade into the submandibular lymph node and surrounding soft tissue. It is important to be aware of the cellular blue nevus tumor as a differential diagnosis in pediatric neck masses. Histological evaluation is necessary to determine tumor aggression and malignant potential which can guide further treatment in pediatric patients.

Expanding the use of flow diverters beyond their initial indication: treatment of small unruptured aneurysms.

BACKGROUND: Experience with the endovascular treatment of unruptured small intracranial aneurysms by flow diverter devices is still limited. OBJECTIVE: To assess the safety and efficacy of the SILK flow diverter (SFD) in the treatment of small unruptured cerebral aneurysms (<10 mm). METHODS: We performed a retrospective review of a prospectively maintained database of patients treated with a SFD between July 2008 and December 2013 at 4 institutions in Spain to identify all patients with small unruptured aneurysms (<10 mm). Data for patient demographics, aneurysm characteristics, and technical procedures were analyzed. Angiographic and clinical findings were recorded during the procedure and at 6- and 12-month follow-ups. RESULTS: A total of 109 small aneurysms were treated with a SFD in 104 patients (78 women; 26 men; mean, median, and range of age: 55.2, 57.1, and 19-80 years, respectively). A total of 60 patients were asymptomatic (57.7%). All except 7 aneurysms (6.4%) arose from the anterior circulation. The mean size of the aneurysms was 4.7±1.9 mm. At 6 months, the neuromorbidity and neuromortality rates were 2.9% and 0.9%, respectively. Imaging at the 12-month follow-up showed complete occlusion, neck remnants, and residual aneurysm in 88.5% (69/78), 7.7% (6/78), and 3.3% (3/78) of cases, respectively. No delayed hemorrhage occurred. CONCLUSIONS: The findings suggest that the indications for SFD can be safely extended to small intracranial aneurysms.

Cardiac computed tomography for valve disease.

Heart valve disease and coronary heart disease are very prevalent in the general population and often coincide in the same patient. Cardiac computed tomography (CT) makes it possible to noninvasively rule out coronary disease before valve surgery and to potentially avoid invasive heart catheterization in 66% to 75% of patients. The same imaging test provides abundant anatomic and functional information that complements the information from echocardiography, making it possible to characterize the etiology of the valve disease and its repercussions on the heart and aorta, as well as to quantify the severity of disease affecting the valves of the left side of the heart. In this article, we describe the anatomy of the heart valves and the technical requisites of cardiac CT for the study of the valves. We go on to explore the usefulness of CT in the preoperative study of the coronary arteries and in the morphological and functional characterization of valve disease, with special emphasis on the valves of the left side of the heart.

Predictive value of small ulcers in the evolution of acute type B intramural hematoma.

OBJECTIVE: To assess the long-term evolution and predictive factors of type B intramural hematoma (IMH). MATERIAL AND METHODS: 34 patients (33 men), mean age: 67 years (47-87) diagnosed with type B IMH by computed tomography (CT) and followed up clinically and by CT yearly. Mean follow-up was 5.9 years (2-13 years). Two evolution patterns were considered: (a) regression and (b) progression. Clinical and imaging variables were analyzed for assessing their predictor values. RESULTS: Evolution at one year was to regression in 56% and to progression in 44% of cases. There were no association among age, sex, other aortic abnormalities, presence of atherosclerotic disease or blood pressure, initial maximum aortic diameter, indexed maximum aortic diameter, IMH thickness or length, presence or absence of mediastinal hematoma and the evolution of type B IMH. Ten patients had small aortic ulcers in the acute phase. The presence of ulcers was related with progression of IMH. No differences were observed in evolution between the control at first year and the last control. CONCLUSIONS: The presence of small ulcers is a strong predictor of evolution in acute type B IMH. In addition, the regression group remains completely stable after the first year of evolution.

CT evaluation of caudal versus lumbar access to the intradural space.

BACKGROUND: Percutaneous intraspinal navigation is a new procedure that enables visualization of the central nervous system using a lumbar puncture technique. Past research shows promising potential, but is limited by damage to expensive fiberscopes due to the sharp angle of manipulation at L3-L4. Our objective in this study is to analyse the feasibility of a novel access through the sacral hiatus to eliminate this problem. METHODS: We retrospectively reviewed computed tomography images of the sacrum of 132 subjects, of which nine were excluded either secondary to incomplete imaging of the sacrum or variant anatomy that precluded any possible measurements. Of the remaining 123 patients, we measured kyphotic and lordotic curvature of the sacral canal in comparison to the angle of lumbar puncture. We also measured the anteroposterior diameters of the sacral canal at the distal, middle, and proximal portions. RESULTS: There were no significant differences according to sex or age. The kyphotic angle was a wide angle with a mean value of 167·89±11·71°. The lordotic angle had a mean value of 133·35±7·84°, making it 25·52° more obtuse than the average angle for lumbar puncture. The smallest diameter of the sacral canal was at the sacral hiatus and had a mean value of 4·49±1·66 mm. CONCLUSION: The size and anatomy of the sacral canal is feasible for PIN procedure and appears more favorable as compared to entry via lumbar puncture. The canal opening is wide enough to accommodate most small-diameter fiberscopes without difficulty, and the angles are obtuse enough to limit damage to the expensive fiberscopes.

Direct percutaneous venous puncture and embolization of giant perimedullary arteriovenous fistulas.

PMAVFs are rare entities that are formed by a direct communication between an artery that feeds the spinal cord and a vein. The goal of treatment is to occlude the shunt; this is done endovascularly either from an arterial or a venous approach. When these approaches are not possible, direct percutaneous puncture of the draining veins may be attempted to embolize the arteriovenous shunt directly.

Percutaneous treatment of cervical disk hernias using gelified ethanol.

This study investigates the efficacy of chemonucleolysis using RGE in the treatment of cervical disk hernias in a small sample of patients who had cervical diskogenic or radicular pain secondary to disk herniations. Results were satisfactory in 89.5% patients, with no adverse events recorded during the procedure or after. The use of RGE shows promising results and might be a feasible and safe alternative in the treatment of cervical disk hernias.

Neuroimaging studies in Alzheimer's disease. A review.

Alzheimer's Disease (AD) is a progressive neurodegenerative disease associated with memory loss and gradual behavioral, functional and cognitive impairment. Conventional imaging studies, such as magnetic resonance or computed tomography have played a secondary role in AD diagnosis: While other causes of memory loss and cognitive deficit can be evaluated by these imaging methods, AD structural changes are not detected until very late in the course of the disease. Recent and more precise techniques have been developed to detect subtle changes not visualized with those imaging methods. This article presents a review of the neuroimaging techniques used as a diagnostic aid for AD.

[Differential diagnosis of multiple hereditary exostosis: presentation of a clinical case with secondary chondrosarcoma and literature review]. / Encondromatosis múltiple familiar, diagnóstico diferencial: presentación de un caso clínico con condrosarcoma y revisión de la literatura.

Enchondromatoses include a heterogeneous group of congenital syndromes characterized by the presence of multiple enchondromas associated with musculo-skeletal malformations secondary to limb shortening, scoliosis, pathological fractures and pseudoarthrosis. The main complication of enchondromas is their malignant transformation to secondary chondrosarcomas, which may occur in up to 25% of cases. The multiple enchondromatosis syndromes have many clinical similarities and the differential diagnosis is therefore difficult to make. We present the clinical case of a 38-year-old patient with a diagnosis of multiple familial enchondromatosis who developed a pelvic chondrosarcoma that was treated with external hemipelvectomy. We reviewed the literature concerning the specific aspects of Mafucci, Oilier and multiple familial enchondromatosis syndromes.

Temporary balloon occlusion test of the left vertebral artery using parenchymography as tolerance predictor. A case report.

Temporary balloon occlusion is used as tolerance predictor in patients undergoing vascular occlusion with the aid of clinical assessment during a 30-40 minute temporary occlusion. Several other techniques have been used to help predict each patient's tolerance. Digital cerebral parenchymography (DCP) was originally described to improve our analysis of brain perfusion during ischemic events. We report a case using DCP as tolerance predictor in a patient undergoing sacrifice of the left vertebral artery.

Clinical and radiological features of posterior communicating artery aneurysms.

SUMMARY: Treatment of unruptured intracranial aneurysms based on critical size and predictive risk factors is generally accepted, but several factors contribute to the clinical outcome in a patient with subarachnoid hemorrhage (SAH) secondary to a ruptured aneurysm. We decided to evaluate other parameters that might contribute to the clinical outcome of patients with a ruptured posterior communicating artery aneurysm. A retrospective review of the medical records of patients diagnosed and/or treated of cerebral aneurysms at our institution was carried out. We selected patients with Pcom aneurysms that presented with SAH and reviewed conventional and tridimensional angiographic images to determine its anatomical orientation and correlated the data with amount of SAH and clinical presentation and outcome. A total of 112 Pcom aneurysms presented with SAH and were included in this study. 92 patients were women and 20 were men, with a mean age of 57 years (range 25-81). According to anatomical orientation, 43 were inferolateral, 30 lateral, 13 superolateral, three inferomedial, two in medial location, two superomedial, 11 inferoposterior, five posterior and three superoposterior. Aneurysms in superolateral location are to be watched carefully, it is likely that this location joins several conditions for these aneurysms to grow faster or have a higher hemodynamic stress which makes them more at risk of rupture and contribute to a worse clinical outcome.

Imaging of isolated cerebral mucormycosis. A report of three cases.

Mucormycosis is a rare infection in immunosupressed patients caused by fungi from the family Mucoraceae. Three types of disease spread have been described: rhinocerebral, systemic and isolated. Isolated spread is the most uncommon form, usually resulting in death. It has been described in diabetics, immunosupressed patients and intravenous drug abusers. Neuroimaging can aid the diagnosis of this entity, but biopsy remains the only reliable method. Imaging findings of Mucormycosis include abscesses and hemorrhagic or ischemic infarcts, usually in the basal ganglia and frontal lobes. Single or multiple lesions have been described as well as meningoencephalitis. Understanding these findings can help to detect the infection in an early stage. We describe three cases of isolated cerebral mucormycosis; all of them were intravenous drug abusers with one patient also being HIV positive.

Management of spinal dural arteriovenous fistulae with emphasis on an endovascular approach.

Spinal arteriovenous shunts are rare and present at a rate of approximately 1:10 with cerebral arteriovenous shunts. Spinal dural arteriovenous fistulas (SDAVF) are the most common type of spinal vascular malformation in the adult and account for about 60% of all, with a marked male predominance (5:1). Endovascular treatment has gained force as the treatment of choice in recent years. We reviewed the patients sent to our service at Clinica del Rosario in Madrid and Hospital General de Cataluña in Barcelona between January 1991 and December 2005 with a diagnosis of SDAVF made clinically or by imaging for possible endovascular treatment. Location, presenting symptoms, and clinical outcome according to treatment were analyzed. A total of 104 patients were diagnosed and treated for a SDAVF, 85 were men and 19 women aged between 23 and 79 years (average 58). Seventy-six were treated with embolization alone (73%), 21 with a combination of endovascular therapy and surgery (20.1%) and seven patients had surgery alone (6.7%). Of the embolization group, 62 patients were cured (81.5%), 11 improved (14.4%) and three (3.9%) worsened. Of the group with combined therapy, 13 (61.9%) were cured, five (23.8%) improved and three (14.2%) worsened. Among the surgery group, four (57.2%) were cured and three (42.8%) worsened. Endovascular approach with liquid adhesive is gaining more acceptance as the treatment of choice for SDAVF if the conditions allow a super selective catheterization of the shunt. These patients benefit most when diagnosis is made early in the course of the pathology and have a better chance of a complete remission of symptoms.

Identifying and reducing errors with surgical simulation.

The major determinant of a patient's safety and outcome is the skill and judgment of the surgeon. While knowledge base and decision processing are evaluated during residency, technical skills-which are at the core of the profession-are not evaluated. Innovative state of the art simulation devices that train both surgical tasks and skills, without risk to patients, should allow for the detection and analysis of errors and "near misses". Studies have validated the use of a sophisticated endoscopic sinus surgery simulator (ES3) for training residents on a procedural basis. Assessments are proceeding as to whether the integration of a comprehensive ES3 training programme into the residency curriculum will have long term effects on surgical performance and patient outcomes. Using various otolaryngology residencies, subjects are exposed to mentored training on the ES3 as well as to minimally invasive trainers such as the MIST-VR. Technical errors are identified and quantified on the simulator and intraoperatively. Through a web based database, individual performance can be compared against a national standard. An upgraded version of the ES3 will be developed which will support patient specific anatomical models. This advance will allow study of the effects of simulated rehearsal of patient specific procedures (mission rehearsal) on patient outcomes and surgical errors during the actual procedure. The information gained from these studies will help usher in the next generation of surgical simulators that are anticipated to have significant impact on patient safety.

Mediastinitis necrotizante descendente / Descendant necrotic mediastinitis

Se presentan dos casos de mediastinitis necrotizante descendente, posteriores a absceso retrofaríngeo que fueron manejados por los autores en la Clínica Vascular Navarra y en la Clínica San Rafael. Se revisa esta patología infrecuente con el fin de que sea reconocida como una posible complicación mortal de faringoamigdalitis logrando un tratamiento temprano apropiado con el fin de evitar un desenlace fatal

Effects of aflatoxin B(1) on the liver and kidney of broiler chickens during development.

Aflatoxin B(1) (AFB(1)) negatively affects chicken (Gallus domesticus) growth. This effect is more severe during development. We studied the influence of age on the toxic effects of AFB(1) on plasma, renal and hepatic enzymes, under two protocols, in adult and in developing Arbor-Acres chickens. Protocol A: 100 male 4-week-old chickens (640 g), received AFB(1), 0.5, 1.0, or 2.0 microg/g of feed (daily p.o.), a fourth group received an aflatoxin-free diet. Five birds/group were slaughtered at 7, 14, 21 and 28 days of treatment. Body, hepatic and renal weights, succinate-dehydrogenase (SDH) and glutamate-dehydrogenase (GluDH) in plasma and liver were measured. Hepatic SDH and GluDH decreased (P<0.05). Protocol B: two groups of 24 male 1-week-old chickens (106 g) received either aflatoxin-free feed (n=24) or AFB(1) feed (2.0 microg/g). At days 7, 14, 21 and 28, the same parameters of Protocol A were measured. AFB(1) markedly reduced body weight gain (20-30%), plasma proteins, albumin, renal and hepatic protein content (P<0.05) and increased absolute and relative weights of the kidney (P<0.05). SDH and GluDH were reduced (P<0.05), while total renal gamma-glutamyltranspeptidase (GGT) increased (P<0.05). Results suggest that serum proteins, SDH and GluDH are sensitive early indicators of this toxicity that was more severe in developing chickens. Decrease in serum albumin might be used as an early and suitable indicator of the deleterious effect of this mycotoxin in developing chickens.