Anterior ischemic stroke: Analysis of the multivariable CT-based models for prediction of clinical outcome.

OBJECTIVE: To determine the predictive value of multiple CT-based measurements, individually and collectively, including arterial collateral filling (AC), tissue perfusion parameters, as well as cortical venous (CV) and medullary venous (MV) outflow, in patients with acute ischemic stroke (AIS). METHODS: We retrospectively reviewed a database of patients with AIS in the middle cerebral artery distribution, who underwent evaluation by multiphase CT-angiography and perfusion. AC pial filling was evaluated using a multiphase CTA imaging. The CV status was scored using the adopted PRECISE system based on contrast opacification of the main cortical veins. The MV status was defined by the degree of contrast opacification of medullary veins in one cerebral hemisphere as compared to the contralateral hemisphere. The perfusion parameters were calculated using FDA-approved automated software. A good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days. RESULTS: A total of 64 patients were included. Each of the CT-based measurements could predict clinical outcomes independently (P<0.05). AC pial filling and perfusion core based models did slightly better compared to each of the other models (AUC = 0.66). Among models with two variables, the perfusion core combined with MV status had the highest AUC=0.73 followed by a combination of MV status and AC (AUC=0.72). Multivariable modeling with all four variables resulted in the highest predictive value (AUC=0.77). CONCLUSION: The combination of arterial collateral flow, tissue perfusion, and venous outflow provides a more accurate prediction of clinical outcome in AIS than each variable alone. This additive effect of these techniques suggests that the information collected by each of these methods only partially overlaps.

Appearance of medullary and cortical veins on multiphase CT-angiography in patients with acute ischemic stroke.

OBJECTIVE: We sought to determine if interhemispheric asymmetry of cortical and medullary veins evaluated on CT angiography can provide a more accurate prediction of outcome in patients with acute ischemic stroke when compared to hemispheric asymmetry of cortical or medullary vein drainage alone. METHODS: We retrospectively reviewed a database of patients with anterior circulation distribution acute ischemic stroke, who were evaluated by multiphase CTA. Cortical veins were evaluated using the adopted Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) system. Medullary veins were evaluated by the presence of asymmetry determined by 5 or more medullary veins visualized in one hemisphere as compared to the contralateral. Good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days. RESULTS: 64 patients were included. The adopted PRECISE score was associated with a good clinical outcome in patients with AIS (OR=3.29; 95 % CI: 1.16 - 9.30; p = 0.023) and had a stronger association with clinical outcome (AUC=0.644) as compared to the asymmetry of MV (AUC=0.609). In a multivariable logistic regression model, combined medullary and cortical vein asymmetry were independently associated with clinical outcomes (AUC=0.721). CONCLUSION: Combined cortical and medullary vein interhemispheric asymmetry is a stronger predictor of clinical outcome in acute ischemic stroke compared to cortical or medullary vein asymmetry alone.

Neonatal sacrococcygeal teratoma with acute renal failure.

Teratomas are germ cell tumours composed of multiple types of cells derived from more than a single germ cell layer. The most common site of an extragonadal teratoma is the sacrococcygeal region. We report a case of a 16-day-old female child with a large swelling in the sacrococcygeal region extending laterally into the buttocks with severely deranged renal functions. Ultrasonography and CT helped in making the diagnosis and, more importantly, to delineate the extent of the tumour and the involvement of adjacent organs and tissues: in our case, lower bilateral ureters. Imaging findings and clinical presentation led to the diagnosis of sacrococcygeal teratoma with renal failure.

Wunderlich's syndrome (spontaneous renal haemorrhage).

Wunderlich's syndrome is a rare condition characterised by spontaneous non-traumatic renal haemorrhage into the subcapsular and perirenal space. The commonest cause of Wunderlich's syndrome is renal neoplasms, with angiomyolipoma and renal cell carcinoma being the most common benign and malignant lesions, respectively. We report a case of Wunderlich's syndrome in a 46-year-old woman. She presented in the emergency department with the chief complaints of sudden onset of abdominal pain with no significant medical history. Imaging findings and clinical history led to the diagnosis of Wunderlich's syndrome. The patient underwent left partial nephrectomy and recovered without any complications. She is presently doing well.