Assessment of post-thrombectomy brain hemorrhage in acute ischemic stroke with dual-energy CT: how reliable is it in clinical practice?

PURPOSE: Acute ischemic stroke is currently among the main causes of mortality in Western countries. The current guidelines suggest different flowcharts of diagnostic work-up and treatment modalities, including endovascular thrombectomy. Immediately after intra-arterial recanalization, a brain CT scan is usually performed to assess for the presence of peri-procedural complications; in this setting, it is very hard, if possible, to differentiate blood from iodinated contrast material, which is normally present in ischemic tissue because of BBB disruption. Dual-energy CT may be used for this purpose, exploiting its ability to discriminate different materials. MATERIALS AND METHODS: We retrospectively studied 44 patients with acute ischemic stroke who were treated with endovascular recanalization at San Giovanni Bosco Hospital in Turin and were then scanned with DECT technology. Subsequent scan was used as standard, since iodine from contrast staining is usually reabsorbed in 24 h and blood persists longer. A χ2 test of independence was performed to examine the relationship between blood detected by DECT scan after the endovascular procedure and the presence of blood in the same areas on the following scans, with a significant result: χ2 (1, N = 37) = 10.7086, p = 0.0010. RESULTS: Patients with blood detected on DECT scans had a double chance of having hemorrhagic infarction in follow-up scans, (RR 2.02). The sensitivity and specificity of DECT were respectively 70% and 90%, with an overall diagnostic accuracy of 76% and a positive and negative predictive value, respectively, of 95% and 53%. CONCLUSION: Dual-energy CT scan after endovascular recanalization in ischemic stroke identifies early hemorrhagic infarction with excellent specificity and good overall diagnostic accuracy, representing a reliable diagnostic tool in everyday clinical practice.

Perfusion-computed tomography for simultaneous bilateral middle cerebral artery occlusion.

Bilateral simultaneous middle cerebral artery occlusion is a rare condition that may lead to severe neurological disability or death, thus requiring rapid intervention in order to restore vessels patency and brain perfusion. Perfusion-computed tomography is demonstrated to be a fundamental tool for selecting stroke patients candidate to mechanical thrombectomy, but its role for guiding the optimal strategy of endovascular treatment in concomitant multivessel cerebral occlusion has never been reported. We describe a case of bilateral middle cerebral artery occlusion in which perfusion-computed tomography was crucial both for addressing to endovascular procedure and planning the sequence treatment of mechanical thrombectomies.

The Italian Registry of Endovascular Treatment in Acute Stroke: rationale, design and baseline features of patients.

Endovascular treatment (ET) showed to be safe in acute stroke, but its superiority over intravenous thrombolysis is debated. As ET is rapidly evolving, it is not clear which role it may deserve in the future of stoke treatments. Based on an observational design, a treatment registry allows to study a broad range of patients, turning into a powerful tool for patients' selection. We report the methodology and a descriptive analysis of patients from a national registry of ET for stroke. The Italian Registry of Endovascular Treatment in Acute Stroke is a multicenter, observational registry running in Italy from 2010. All patients treated with ET in the participating centers were consecutively recorded. Safety measures were symptomatic intracranial hemorrhage, procedural adverse events and death rate. Efficacy measures were arterial recanalization and 3-month good functional outcome. From 2008 to 2012, 960 patients were treated in 25 centers. Median age was 67 years, male gender 57 %. Median baseline NIHSS was 17. The most frequent occlusion site was Middle cerebral artery (46.9 %). Intra-arterial thrombolytics were used in 165 (17.9 %) patients, in 531 (57.5 %) thrombectomy was employed, and 228 (24.7 %) patients received both treatments. Baseline features of this cohort are in line with data from large clinical series and recent trials. This registry allows to collect data from a real practice scenario and to highlight time trends in treatment modalities. It can address unsolved safety and efficacy issues on ET of stroke, providing a useful tool for the planning of new trials.

Neural network-derived perfusion maps: A model-free approach to computed tomography perfusion in patients with acute ischemic stroke.

Objective: In this study, we investigate whether a Convolutional Neural Network (CNN) can generate informative parametric maps from the pre-processed CT perfusion data in patients with acute ischemic stroke in a clinical setting. Methods: The CNN training was performed on a subset of 100 pre-processed perfusion CT dataset, while 15 samples were kept for testing. All the data used for the training/testing of the network and for generating ground truth (GT) maps, using a state-of-the-art deconvolution algorithm, were previously pre-processed using a pipeline for motion correction and filtering. Threefold cross validation had been used to estimate the performance of the model on unseen data, reporting Mean Squared Error (MSE). Maps accuracy had been checked through manual segmentation of infarct core and total hypo-perfused regions on both CNN-derived and GT maps. Concordance among segmented lesions was assessed using the Dice Similarity Coefficient (DSC). Correlation and agreement among different perfusion analysis methods were evaluated using mean absolute volume differences, Pearson correlation coefficients, Bland-Altman analysis, and coefficient of repeatability across lesion volumes. Results: The MSE was very low for two out of three maps, and low in the remaining map, showing good generalizability. Mean Dice scores from two different raters and the GT maps ranged from 0.80 to 0.87. Inter-rater concordance was high, and a strong correlation was found between lesion volumes of CNN maps and GT maps (0.99, 0.98, respectively). Conclusion: The agreement between our CNN-based perfusion maps and the state-of-the-art deconvolution-algorithm perfusion analysis maps, highlights the potential of machine learning methods applied to perfusion analysis. CNN approaches can reduce the volume of data required by deconvolution algorithms to estimate the ischemic core, and thus might allow the development of novel perfusion protocols with lower radiation dose deployed to the patient.

Treatment of Acute Necrotising Pancreatitis and Its Complications: The Surgeon's Perspective.

Acute necrotising pancreatitis (ANP) is associated with high complication and mortality rates. It is still difficult for the surgeon to choose and schedule the most appropriate treatment. Compared to the past, the current minimally invasive "step-up" approach enables better outcomes in terms of morbidity/mortality, notwithstanding long periods of hospitalisation, and above all ensures better levels of residual pancreatic function. We hereby report the case of a patient hospitalised in our division for approximately 4 months with a diagnosis of ANP complicated by infection and late bleeding, handled with a sequential approach.

Cardiac Computed Tomography Angiography Follow-Up of Resorbable Magnesium Scaffolds.

INTRODUCTION: An ancillary advantage of bioresorbable scaffolds is the possibility of non-invasive imaging assessment of the treated coronary segment. Cardiac computed tomography angiography (CCTA) studies of resorbable magnesium scaffolds (RMS) are scarce. METHODS: In this collaborative, international study, nine patients who had an RMS implanted underwent CCTA as part of follow-up assessment. Core-lab blinded quantitative and qualitative assessment was performed by an independent CCTA investigator. RESULTS: Eight studies were amenable for quantitative analysis, and the blinded CT investigator successfully located and evaluated patency of RMS in all cases. The CCTA follow-up in-scaffold percentage diameter stenosis and area stenosis was 22.2% (12.4-30) and 39.1% (0.23-0.50), in keeping with mild in-scaffold late loss and underlying plaque growth. Moreover, a detailed coronary plaque characterization at treated segments was feasible (fibrous plaque in 69.9%, fibrofatty in 17.13%, necrotic in 4.78% and calcium in 5.72%). As in 6 out of 8 cases, the presentation was an acute coronary syndrome, these preliminary results could suggest plaque stabilization and a good coronary vessel healing with RMS. CONCLUSION: Non-invasive, follow-up assessment of RMS with CCTA is feasible. Further CCTA studies for either clinical or research purposes with the present and upcoming generation of resorbable magnesium scaffolds are warranted.

Infundibulum of Accessory Anterior Cerebral Artery: Rare, Likely Benign Malformation of Anterior Communicating Artery Complex to Keep in Mind.

BACKGROUND: Infundibular dilations (IDs) are funnel-shaped enlargements located at the origin of cerebral arteries. Neuroradiologists and neurosurgeons are familiar with IDs of the posterior communicating artery, which are relatively common. Other locations, being unexpected sites of IDs, can pose diagnostic and therapeutic challenges. CASE DESCRIPTION: In this paper, we describe a case of infundibulum of the accessory anterior cerebral artery, diagnosed with 3-dimensional reconstructions of computed tomography angiography, which is to our knowledge the first report of an ID of this anatomic variant. CONCLUSIONS: Anterior communicating artery represents a rare location for infundibular dilations. Differential diagnosis between them and true aneurysms can be sometimes challenging, especially when associated with anatomic variants; thus neurosurgeons and radiologists must be aware of these pathologic entities.

A novel approach to inoperable or recurrent rectal cancer by chemoembolization: A new arrow in our quiver?

PURPOSE: Assess the feasibility, safety and efficacy of TACE with irinotecan loaded micro particles (debiri) for the treatment of locally advanced rectal cancer patients. RESULTS: We assessed the Edmonton Symptom Assessment System (ESAS). The tool is designed to assess nine common symptoms in cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath. The ESAS score was 7 in 10/12 (83%) patients before treatment and 6 in 2/12 (16.5%) patients. After treatment in 6/12 (50%) patients the score dropped to 3; 3/12 (33%) reported 4, 1/12 (8%) reported 2. All patients experienced local control disease with a degree of citoreduction; in 4 cases (33%) we observed outstanding responses with a dramatic reduction in the tumors size which led us to surgical radical resections. MATERIALS AND METHODS: We run a prospective mono-institutional study where we recruited, 12 non- consecutive patients with histology confirmation of rectal cancer, inoperable and not treatable due to severe comorbidities, or pelvic recurrence/progression after curative treatment, chemotherapy, radiotherapy and/or surgery. Their performance status (PS) ECOG was 2-3 . Twelve patients (10 male and 2 female) with a median age 71 (range 56-89) were recruited in the study. CONCLUSIONS: The study has met the primary endpoint and showed encouraging activity. Debiri could be a possible option for locally advanced/inoperable or recurred rectal cancer patients. Further trials are warranted to validate this methodic in early stages.

Inferior mesenteric artery chemoembolization and chemotherapy for advanced rectal cancer: report of a clinical case.

Patients with advanced and incurable colorectal cancer have a very poor prognosis. Curative-intent resection was performed in 70%-90% of cases in reported series of colorectal cancer, sometimes after neoadjuvant chemotherapy and radiotherapy. The remaining 10%-30% of patients are treated with palliative intent, where treatment is aimed at relieving disease-related symptoms and improving quality of life. The provision of palliative care for these patients is complicated and outcomes are often disappointing. Although there are many available options including a variety of surgical and nonsurgical interventions, the best management remains controversial. Transarterial chemoembolization with irinotecan-loaded drug-eluting beads (DEBIRI) is an effective, minimally invasive procedure performed by interventional radiologists that allows intra-arterial drug delivery to stop vascular feeding and exert local cytotoxic effects. We here report on a patient treated with DEBIRI followed by systemic chemotherapy with the FOLFOX regimen for locally advanced, inoperable colorectal cancer.

Acute pyelonephritis: analysis of 52 cases.

Acute pyelonephritis (APN) is a frequent disease, but diagnostic approach, evolution into abscesses, and indication to hospitalization are still open problems. We have made a retrospective analysis of APN cases observed in our hospital. We identified 58 patients (pt) and selected 52 of these who presented fever and loin pain at the onset (31 were hospitalized in Nephrology and 21 in other units). Urine culture was positive in 11/48 cases (22.9%), blood cultures in 3/26 cases (11.5%) (Escherichia coli). Renal sonography was normal in 20/48 cases (41.6%) and suggestive for APN in 23/48 cases (47.9%). CT with contrast medium was normal in 9/28 cases (32.1%) and positive in 19/28 cases (67.8%), with evidence of unique or multiple hypodense areas; abscesses were found in 8 patients (28.5%). No statistically significant differences were found between patients with positive or negative CT as regards fever, leukocytosis, ESR, CRP, CRP at 20 days, urinary leukocytes, urine culture, duration of symptoms before hospitalization. Moreover no differences were found between patients with and without abscesses. CT was performed more frequently among patients hospitalized in Nephrology than among patients hospitalized in other services (24/31-77.4%-vs. 4/21-19%-, p = 0.05). NMR was abnormal in 6/9 cases. A radiographic documentation of APN was obtained in 61.53% of patients with clinical diagnosis of APN. Of these, only 18.7% had positive urine culture. In conclusion, our data suggest that demonstration of urine infection is not necessary for APN diagnosis, when clinical and/or radiologic diagnosis of APN has been made. Evolution into abscesses is frequent and not easily susceptible on clinical ground; for this reason we think it is advisable to perform CT or NMR systematically. Differences in clinical behavior between different units suggest the need for diagnostic guidelines.