Complications of Percutaneous Radiofrequency Ablation for Hepatocellular Carcinoma.

Radiofrequency ablation (RFA) is a potentially curative treatment option for early Hepatocellular carcinoma. The RFA is considered safe with a relatively low incidence of complications ranging from 2%-7.9%. Though most of the complications are self-limiting, sometimes they can be life-threatening. The occurrence of the particular complication depends on various factors like tumour location and morphology, underlying disease and ablation technique. A detailed understanding of potential complications along with the associated risk factors will help to employ strategies to prevent them, identify them early and manage them when they occur. This article demonstrates various radiofrequency ablation-related complications and discusses the risk factors and technical strategies to minimise them and achieve complete ablation of the tumour.

Diagnosis and Management of Persistent Pulmonary Arterio-venous Malformations following Embolotherapy.

Embolotherapy is the primary treatment for pulmonary arterio-venous malformations (PAVMs). Approximately, 2-25% of PAVMs demonstrate persistence following embolization. Early identification and treatment of persistent PAVMs are critical to mitigating life threatening complications. The presence of prior embolic devices and complex angioarchitecture of persistent PAVMs pose technical challenges during repeat embolotherapy. In this article, we review patterns of persistence, factors affecting the persistence, endovascular treatment techniques, and outcomes.

Magnetic Resonance Imaging in Otosyphilis: A Rare Manifestation of Neurosyphilis.

We report magnetic resonance imaging (MRI) in a case with otosyphilis, which is a rare manifestation of neurosyphilis. A 50-year-old male presented with progressive hearing loss on the left side and recent-onset palsy of the left 7th and 12th cranial nerves. Computed tomography imaging showed destructive bone lesions involving the petrous temporal bone, middle ear, and mastoid region with a pathognomonic pattern of bone destruction depicted in the volume rendering technique images. MRI showed features of destructive bone lesions (gummatous lesion), meningoneuritis, and labyrinthitis. Pathological examination and treponemal antibody absorption test favored the diagnosis. Otosyphilis should be considered as a differential diagnosis in an adult patient with destructive lesions of the petrous temporal bone. To the best of our knowledge, MRI in otosyphilis has not been reported.

Does Contrast Dose Based in Lean body Weight Allow Lesser Volumes on High BMI Patients for CT Angiography?

OBJECTIVES: The objective was to evaluate whether contrast dose based on lean body weight (LBW) protocol has the potential to reduce contrast volume in patients with high basal metabolic index (BMI) compared to total body weight (TBW)-based protocols. MATERIAL AND METHODS: The Institutional Review Board approval was obtained for this prospective study. Initially, a pilot study with a sample size of 150 patients was conducted to estimate the average fat fraction in our population. Then, CT angiography (CTA) for the thoracic and abdominal aorta was performed using a 256-multidetector computed tomography scanner in 117 patients who were undergoing screening for aortic aneurysm and vascular assessment of prospective transplant donors. The patients were divided into two groups: A TBW group (n = 60) and LBW group (n = 57). Lean body weight (LBW) was estimated from the patient weight, height, and gender using Hume's equation. The TBW group received 1.2 ml/kg contrast dose and the LBW group received 1.6 ml/kg contrast dose to achieve approximately equal iodine dose in both groups. Differences in the degree of aortic enhancement between the estimated LBW and TBW group were evaluated. In higher BMI patients (>25), the mean aortic enhancement (MAEnh) and the contrast volume delivered between the LBW and TBW group were compared. RESULTS: Mean aortic enhancement (MAEnh) 422.45 (±74.5) Hounsfield unit (HU) in the TBW group and 432.67 (±69.4) HU in the LBW group showed no statistical difference (P = 0.439). In population with BMI >25, the contrast delivered in LBW protocol patients was significantly less (P = 0.00) compared to TBW protocol patients, with no significant difference in the MAEnh between the groups (P = 0.479). CONCLUSION: CTA using a LBW protocol helps to significantly reduce the volume of contrast delivered, especially in patients with BMI >25 compared to TBW protocol, without compromising the aortic enhancement.

Comparison of Knowledge-based Iterative Model Reconstruction (IMR) with Hybrid Iterative Reconstruction (iDose4) Techniques for Evaluation of Hepatocellular Carcinomas Using Computed Tomography.

RATIONALE AND OBJECTIVES: To compare tumor conspicuity of small hepatocellular carcinomas (HCCs) and image quality on knowledge-based iterative model reconstruction low-dose computed tomography (IMR-LDCT) with hybrid iterative reconstruction standard-dose CT (iDose4-SDCT). METHODS: Thirty-two patients (mean age 61.9 ± 9.7 years; male:female 27:5; mean body mass index 25.6 ± 3.8 kg/m2) with cirrhosis and 40 HCCs in IMR-LDCT group and 33 patients (mean age 60.1 ± 7.4 years; male:female 28:5; body mass index 26.7 ± 3.2 kg/m2) with cirrhosis and 40 HCCs in iDose4-SDCT group were included in this retrospective study. Objective analysis of reconstructed iDose4 and IMR images was done for contrast-to-noise ratio of HCCs (CNRHCC), image noise, signal-to-noise ratio of portal vein (SNRPV), and inferior vena cava (SNRIVC). Subjective analysis of tumor conspicuity and image quality was done by two independent reviewers in a blinded manner. Mean volume CT dose index, dose length product, and effective dose for both groups were compared. RESULTS: The CNRHCC was significantly higher in IMR-LDCT compared to iDose4-SDCT in both arterial phase (AP), p < 0.0001, and delayed phase (DP), p < 0.0001. Image noise was significantly lower in IMR-LDCT compared to iDose4-SDCT in AP, portal venous phase, and DP with p < 0.0001. IMR-LDCT showed significantly higher SNRPV (p < 0.0001) and SNRIVC (p < 0.0001) compared to iDose4-SDCT. On subjective analysis, IMR-LDCT images showed better image quality in AP, portal venous phase, and DP and better tumor conspicuity in AP and DP. IMR-LDCT (21.4 ± 4.6 mSv) achieved 36.9% reduction in the effective dose compared to iDose4-SDCT (33.9 ± 6.2 mSv). CONCLUSION: IMR algorithm provides better image quality and tumor conspicuity with considerable decrease in image noise compared to iDose4 reconstruction technique even on LDCT.

Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients.

AIM: To retrospectively analyze the percutaneous transhepatic techniques and their outcome in the management of biliary strictures in living donor liver transplant (LDLT) recipients. MATERIALS AND METHODS: We retrieved the hospital records of 400 LDLT recipients between 2007 and 2015 and identified 45 patients with biliary strictures. Among them, 17 patients (37.8%) (Male: female = 13:4; mean age, 36.1 ± 17.5 years) treated by various percutaneous transhepatic biliary techniques alone or in combination with endoscopic retrograde cholangiopancreatography (ERCP) were included in the study. The technical and clinical success of the percutaneous management was analyzed. RESULTS: Anastomotic strictures associated with leak were found in 12/17 patients (70.6%). Ten out of 12 (83.3%) patients associated with leak had more than one duct-duct anastomoses (range, 2-3). The average duration of onset of stricture in patients with biliary leak was 3.97 ± 2.68 months and in patients with only strictures it was 14.03 ± 13.9 months. In 6 patients, endoscopic-guided plastic stents were placed using rendezvous technique, plastic stent was placed from a percutaneous approach in 1 patient, metallic stents were used in 2 patients, cholangioplasty was performed in 1 patient, N-butyl- 2-cyanoacrylate embolization was done in 1 child with biliary-pleural fistula, internal-external drain was placed in 1 patient, and only external drain was placed in 5 patients. Technical success was achieved in 12/17 (70.6%) and clinical success was achieved in 13/17 (76.5%) of the patients. Posttreatment mean time of follow-up was 19.4 ± 13.7 months. Five patients (29.4%) died (two acute rejections, one metabolic acidosis, and two sepsis). CONCLUSIONS: Percutaneous biliary techniques are effective treatment options with good outcome in LDLT patients with biliary complications.

Traumatic hepatic arteriohepatic venous fistula managed with selective coil embolization: a case report.

Hepatic arterioportal fistulae are frequent vascular complications due to neoplasm, trauma and iatrogenic injury. On the other hand, fistulae between the hepatic arteries and hepatic veins (arteriohepatic venous fistula) are rare. We report the case of a 45-year-old male who suffered from a blunt abdominal trauma with abdominal distension. Initial cross-sectional imaging revealed laceration of the right lobe of liver with an arteriovenous fistula and hemoperitoneum. The diagnosis of arteriohepatic venous fistulae was confirmed on digital subtraction angiography (DSA) and treated angiographically with superselective coil embolization. Post-embolization angiogram showed complete occlusion of arteriovenous fistulae. We emphasis on the management part of the fistulae and endovascular treatment.

In vitro acetylcholinesterase inhibition by psoralen using molecular docking and enzymatic studies.

INTRODUCTION: Alzheimer's disease (AD) has increased at an alarming rate and is now a worldwide health problem. Inhibitors of acetylcholinesterase (AChE) leading to inhibition of acetylcholine breakdown constitute the main therapeutic strategy for AD. Psoralen was investigated as inhibitor of AChE enzyme in an attempt to explore its potential for the management of AD. MATERIALS AND METHODS: Psoralen was isolated from powdered Psoralea corylifolia fruits. AChE enzyme inhibitory activity of different concentrations of psoralen was investigated by use of in vitro enzymatic and molecular docking studies. Further, the enzyme kinetics were studied using Lineweaver-Burk plot. RESULTS: Psoralen was found to inhibit AChE enzyme activity in a concentration-dependent manner. Kinetic studies showed psoralen inhibits AChE in a competitive manner. Molecular docking study revealed that psoralen binds well within the binding site of the enzyme showing interactions such as π-π stacking and hydrogen bonding with residues present therein. CONCLUSION: The result of AChE enzyme inhibitory activity of the psoralen in this study is promising. It could be further explored as a potential candidate for further development of new drugs against AD.

Utility of C-arm CT in overcoming challenges in patients undergoing Transarterial chemoembolization for hepatocellular carcinoma.

Transarterial chemoembolization (TACE) is the well-known treatment for hepatocellular carcinoma. Multiple digital subtraction angiography (DSA) acquisitions in different projections are required to identify difficult arterial feeders. Moreover, the tell-tale tumor blush can be obscured by proximity to lung base, small size of lesion, and breathing artifacts. C-arm CT is a revolutionary advancement in the intervention radiology suite that allows acquisition of data which can be reformatted in multiple planes and volume rendered incorporating both soft tissue and vascular information like multidetector computed tomography (MDCT). These images acquired during the TACE procedure can provide critical inputs for achieving a safe and effective therapy. This case series aims to illustrate the utility of C-arm CT in solving specific problems encountered while performing TACE.

Imaging findings in a distinct lethal inherited arteriopathy syndrome associated with a novel mutation in the FBLN4 gene.

OBJECTIVES: We present the imaging findings of a newly identified lethal arteriopathy associated with a novel mutation in the gene encoding fibulin-4, occurring in a distinct community from southern India. MATERIAL AND METHODS: A total of 31 children from a distinct population subgroup who presented with characteristic arterial dilatation and tortuosity were studied. All children except one belonged to unrelated families from an ethno-religious group (Muslim) from the northern coastal belt of southern India. CT angiography was performed in 30 children and contrast MRA in one. RESULTS: Impressive dilatation and elongation of ascending aorta, arch, descending aorta and main pulmonary arteries with characteristic narrowing of aortic isthmus were seen in all patients. Stenosis of arch branches, abdominal visceral branches and pulmonary artery branches was observed in 21 (68%), 23 (62.5%) and 20 (65%) patients respectively. Genetic studies revealed an identical mutation in exon 7 of the FBLN4 gene. On follow-up, 27 of them had died before the age of 3 years and only two children were alive after the age of 4 years. CONCLUSIONS: FBLN4-associated vasculopathy is a highly lethal disease characterized by severe aneurysmal dilatation of thoracic aorta, its branches and pulmonary arteries with stenoses at typical locations. KEY POINTS: • Homozygous mutations in exon 7 of the FBLN4 gene can produce lethal vasculopathy. • Fibulin-4 is a critical determinant in human elastogenesis. • Imaging findings can give a clue to underlying connective tissue disorders.

Endovascular treatment of aneurysm of splenic artery arising from splenomesentric trunk using stent graft.

We report a rare case of aneurysm of splenic artery arising anomalously from the superior mesenteric artery (SMA). The aneurysm was treated successfully by coil embolization of the splenic artery distal to aneurysm and then deploying a stent graft in the SMA. A combination of stent graft and coil embolization for the treatment of aberrant splenic artery aneurysm has been reported only once. We describe the imaging findings and the endovascular procedure in this patient.

Diffusion-weighted MRI in acute posterior ischemic optic neuropathy.

Blindness following surgery, especially cardiac surgery, has been reported sporadically, the most common cause being ischemic optic neuropathy. The role of MRI in the diagnosis of this condition is not well established. We present a case of postoperative posterior ischemic optic neuropathy that was diagnosed on diffusion-weighted MRI.

In the workup of patients with obscure gastrointestinal bleed, does 64-slice MDCT have a role?

PURPOSE: The purpose was to prospectively determine the sensitivity of 64-slice MDCT in detecting and diagnosing the cause of obscure gastrointestinal bleed (OGIB). MATERIALS AND METHODS: Our study included 50 patients (male 30, female 20) in the age range of 3-82 years (average age: 58.52 years) who were referred to our radiology department as part of their workup for clinically evident gastrointestinal (GI) bleed or as part of workup for anemia (with and without positive fecal occult blood test). All patients underwent conventional upper endoscopy and colonoscopy before undergoing CT scan. Following a noncontrast scan, all patients underwent triple-phase contrast CT scan using a 64-slice CT scan system. The diagnostic performance of 64-slice MDCT was compared to the results of capsule endoscopy, 99m-technetium-labeled red blood cell scintigraphy (99mTc-RBC scintigraphy), digital subtraction angiography, and surgery whenever available. RESULTS: CT scan showed positive findings in 32 of 50 patients. The sensitivity, specificity, positive predictive value, and negative predictive values of MDCT for detection of bleed were 72.2%, 42.8%, 81.2%, and 44.4%, respectively. Capsule endoscopy was done in 15 patients and was positive in 10 patients; it had a sensitivity of 71.4%. Eleven patients had undergone 99mTc-RBC scintigraphy prior to CT scan, and the result was positive in seven patients (sensitivity 70%). Digital subtraction angiography was performed in only eight patients and among them all except one patient showed findings consistent with the lesions detected on MDCT. CONCLUSION: MDCT is a sensitive and noninvasive tool that allows rapid detection and localization of OGIB. It can be used as the first-line investigation in patients with negative endoscopy and colonoscopy studies. MDCT and capsule endoscopy have complementary roles in the evaluation of OGIB.

Pituitary stalk transection syndrome: Comparison of clinico-radiological features in adults and children with review of literature.

Hypo-pituitarism results from impaired production of one or more of anterior pituitary trophic hormones. A rare cause of hypo-pituitarism is pituitary stalk transection syndrome. The MRI features of this condition in children and its association with hormonal deficiencies have been reported earlier. Reports on adults with this disorder are scarce, with only one small case series published in the recent literature. We studied the hormonal deficiency pattern and MRI findings of 12 patients with pituitary stalk transection syndrome who presented to our department between 2004 and 2011. Six patients were children and six were adults (≥18 years). This article compares the adult clinico-radiological phenotype of pituitary transection syndrome with the pediatric group of patients with same condition.