MRI vs CT for Baseline Imaging Evaluation in Acute Large Artery Ischemic Stroke: A Subanalysis of the SWIFT-DIRECT Trial

BACKGROUND AND OBJECTIVES: Whether MRI or CT is preferable for the evaluation of patients with suspected stroke remains a matter of debate, given that the imaging modality acquired at baseline may be a relevant determinant of workflow delays and outcomes with it, in patients with stroke undergoing acute reperfusion therapies. METHODS: In this post hoc analysis of the SWIFT-DIRECT trial that investigated noninferiority of thrombectomy alone vs IV thrombolysis (IVT) + thrombectomy in patients with an acute ischemic anterior circulation large vessel occlusive stroke eligible to receive IVT within 4.5 hours after last seen well, we tested for a potential interaction between baseline imaging modality (MRI/MR-angiography [MRA] vs CT/CT-angiography [CTA]) and the effect of acute treatment (thrombectomy vs IVT + thrombectomy) on clinical and safety outcomes and procedural metrics (primary analysis). Moreover, we examined the association between baseline imaging modality and these outcomes using regression models adjusted for age, sex, baseline NIH Stroke Scale (NIHSS), occlusion location, and Alberta Stroke Program Early CT Score (ASPECTS) (secondary analysis). Endpoints included workflow times, the modified Rankin scale (mRS) score at 90 days, the rate of successful reperfusion, the odds for early neurologic deterioration within 24 hours, and the risk of symptomatic intracranial hemorrhage. The imaging modality acquired was chosen at the discretion of the treating physicians and commonly reflects center-specific standard procedures. RESULTS: Four hundred five of 408 patients enrolled in the SWIFT-DIRECT trial were included in this substudy. Two hundred (49.4%) patients underwent MRI/MRA, and 205 (50.6%) underwent CT/CTA. Patients with MRI/MRA had lower NIHSS scores (16 [interquartile range (IQR) 12-20] vs 18 [IQR 14-20], p = 0.012) and lower ASPECTS (8 [IQR 6-9] vs 8 [IQR 7-9], p = 0.021) compared with those with CT/CTA. In terms of the primary analysis, we found no evidence for an interaction between baseline imaging modality and the effect of IVT + thrombectomy vs thrombectomy alone. Regarding the secondary analysis, MRI/MRA acquisition was associated with workflow delays of approximately 20 minutes, higher odds of functional independence at 90 days (adjusted odds ratio [aOR] 1.65, 95% CI 1.07-2.56), and similar mortality rates (aOR 0.73, 95% CI 0.36-1.47) compared with CT/CTA. DISCUSSION: This post hoc analysis does not suggest treatment effect heterogeneity of IVT + thrombectomy vs thrombectomy alone in large artery stroke patients with different imaging modalities. There was no evidence that functional outcome at 90 days was less favorable following MRI/MRA at baseline compared with CT/CTA, despite significant workflow delays. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT03192332.

Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial.

BACKGROUND: Recent evidence suggests a beneficial effect of endovascular thrombectomy in acute ischaemic stroke with large infarct; however, previous trials have relied on multimodal brain imaging, whereas non-contrast CT is mostly used in clinical practice. METHODS: In a prospective multicentre, open-label, randomised trial, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and a large established infarct indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 were randomly assigned using a central, web-based system (using a 1:1 ratio) to receive either endovascular thrombectomy with medical treatment or medical treatment (ie, standard of care) alone up to 12 h from stroke onset. The study was conducted in 40 hospitals in Europe and one site in Canada. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days, assessed by investigators masked to treatment assignment. The primary analysis was done in the intention-to-treat population. Safety endpoints included mortality and rates of symptomatic intracranial haemorrhage and were analysed in the safety population, which included all patients based on the treatment they received. This trial is registered with ClinicalTrials.gov, NCT03094715. FINDINGS: From July 17, 2018, to Feb 21, 2023, 253 patients were randomly assigned, with 125 patients assigned to endovascular thrombectomy and 128 to medical treatment alone. The trial was stopped early for efficacy after the first pre-planned interim analysis. At 90 days, endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better outcome (adjusted common OR 2·58 [95% CI 1·60-4·15]; p=0·0001) and with lower mortality (hazard ratio 0·67 [95% CI 0·46-0·98]; p=0·038). Symptomatic intracranial haemorrhage occurred in seven (6%) patients with thrombectomy and in six (5%) with medical treatment alone. INTERPRETATION: Endovascular thrombectomy was associated with improved functional outcome and lower mortality in patients with acute ischaemic stroke from large vessel occlusion with established large infarct in a setting using non-contrast CT as the predominant imaging modality for patient selection. FUNDING: EU Horizon 2020.

Time to treatment with bridging intravenous alteplase before endovascular treatment:subanalysis of the randomized controlled SWIFT-DIRECT trial.

BACKGROUND: We hypothesized that treatment delays might be an effect modifier regarding risks and benefits of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT). METHODS: We used the dataset of the SWIFT-DIRECT trial, which randomized 408 patients to IVT+MT or MT alone. Potential interactions between assignment to IVT+MT and expected time from onset-to-needle (OTN) as well as expected time from door-to-needle (DTN) were included in regression models. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes included mRS shift, mortality, recanalization rates, and (symptomatic) intracranial hemorrhage at 24 hours. RESULTS: We included 408 patients (IVT+MT 207, MT 201, median age 72 years (IQR 64-81), 209 (51.2%) female). The expected median OTN and DTN were 142 min and 54 min in the IVT+MT group and 129 min and 51 min in the MT alone group. Overall, there was no significant interaction between OTN and bridging IVT assignment regarding either the functional (adjusted OR (aOR) 0.76, 95% CI 0.45 to 1.30) and safety outcomes or the recanalization rates. Analysis of in-hospital delays showed no significant interaction between DTN and bridging IVT assignment regarding the dichotomized functional outcome (aOR 0.48, 95% CI 0.14 to 1.62), but the shift and mortality analyses suggested a greater benefit of IVT when in-hospital delays were short. CONCLUSIONS: We found no evidence that the effect of bridging IVT on functional independence is modified by overall or in-hospital treatment delays. Considering its low power, this subgroup analysis could have missed a clinically important effect, and exploratory analysis of secondary clinical outcomes indicated a potentially favorable effect of IVT with shorter in-hospital delays. Heterogeneity of the IVT effect size before MT should be further analyzed in individual patient meta-analysis of comparable trials. TRIAL REGISTRATION NUMBER: URL: https://www. CLINICALTRIALS: gov ; Unique identifier: NCT03192332.

ADC measurement relevance to predict hemorrhage transformation after mechanical thrombectomy.

BACKGROUND: ADC (apparent coefficient diffusion) value has been known to predict hemorrhage transformation (HT) after thrombolysis and recently, after mechanical thrombectomy (MT). We aimed to evaluate that utility separately in basal ganglia and superficial territory. We used HT occurrence with or without NIHSS change as primary outcome measures. METHODS: This single-center retrospective study included consecutive stroke patients receiving MT for internal carotid artery (ICA) or middle cerebral artery (M1 or M2) occlusion. In patient with or without HT, using the Heidelberg Bleeding Classification, on follow-up CT scan at 24-48 h, we assessed the ADC value separately in basal ganglia and superficial territory on MRI before MT to search for the correlation. Multivariable analysis was performed using variables with significant differences between the HT group and non-HT group. RESULTS: One hundred seventeen patients were included in the final analysis. HT distribution was as follows: 9 patients (7.69%) HI1 or 2; 14 patients (11.97%) PH1; 21 patients (17.95%) PH2; 29 patients (24.79%) subarachnoid hemorrhage; and 21 patients (17.95%) symptomatic intracranial hemorrhage (sICH). Mean ADC minimal value in basal ganglia in the HT group was significantly lower than in the non-HT group (377.6 × 10-6 mm2/s [± 52.4] vs 413.3 × 10-6 mm2/s [± 72.5]; p = 0.0229) with an area under the curve (AUC) of 0.6622 (95% CI: 0.5-0.8; p = 0.014). MRI-MT time was significantly longer in the HT group (p = 0.0002), but there was no association between ADC value and onset-MRI or MRI-MT times (Spearman's coefficients <0.7, p > 0.05). Glycemia at admission (>1.5 g/L) (OR = 4.2; 95% CI [1.611; 10.961]) and carotid occlusion (OR = 2.835; 95% CI [1.134; 7.091]) were independently associated with HT. CONCLUSIONS: ADC value in basal ganglia, unlike brain superficial territory, are correlated to HT risk after MT.

Celiac Trunk Mycotic Aneurysm: Diagnosis and Treatment of a Post-infective Endocarditis Complication.

Pseudoaneurysms could be the dynamic evolution of an infectious break in the arterial wall; in the post-antibiotic era they are uncommon complication following infective endocarditis (IE) and are associated with high rates of morbidity and mortality especially for patients in whom a prompt diagnosis and therapeutic strategy are not performed. In this report, we describe a case of pseudoaneurysm of the celiac trunk developed as a complication of IE. Endovascular treatment is our first-line approach.

Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial.

BACKGROUND: Whether thrombectomy alone is equally as effective as intravenous alteplase plus thrombectomy remains controversial. We aimed to determine whether thrombectomy alone would be non-inferior to intravenous alteplase plus thrombectomy in patients presenting with acute ischaemic stroke. METHODS: In this multicentre, randomised, open-label, blinded-outcome trial in Europe and Canada, we recruited patients with stroke due to large vessel occlusion confirmed with CT or magnetic resonance angiography admitted to endovascular centres. Patients were randomly assigned (1:1) via a centralised web server using a deterministic minimisation method to receive stent-retriever thrombectomy alone or intravenous alteplase plus stent-retriever thrombectomy. In both groups, thrombectomy was initiated as fast as possible with any commercially available Solitaire stent-retriever revascularisation device (Medtronic, Irvine, CA, USA). In the combined treatment group, intravenous alteplase (0·9 mg/kg bodyweight, maximum dose 90 mg per patient) was administered as early as possible after randomisation for 60 min with 10% of the calculated dose given as an initial bolus. Personnel assessing the primary outcome were masked to group allocation; patients and treating physicians were not. The primary binary outcome was a score of 2 or less on the modified Rankin scale at 90 days. We assessed the non-inferiority of thrombectomy alone versus intravenous alteplase plus thrombectomy in all randomly assigned and consenting patients using the one-sided lower 95% confidence limit of the Mantel-Haenszel risk difference, with a prespecified non-inferiority margin of 12%. The main safety endpoint was symptomatic intracranial haemorrhage assessed in all randomly assigned and consenting participants. This trial is registered with ClinicalTrials.gov, NCT03192332, and is closed to new participants. FINDINGS: Between Nov 29, 2017, and May 7, 2021, 5215 patients were screened and 423 were randomly assigned, of whom 408 (201 thrombectomy alone, 207 intravenous alteplase plus thrombectomy) were included in the primary efficacy analysis. A modified Rankin scale score of 0-2 at 90 days was reached by 114 (57%) of 201 patients assigned to thrombectomy alone and 135 (65%) of 207 patients assigned to intravenous alteplase plus thrombectomy (adjusted risk difference -7·3%, 95% CI -16·6 to 2·1, lower limit of one-sided 95% CI -15·1%, crossing the non-inferiority margin of -12%). Symptomatic intracranial haemorrhage occurred in five (2%) of 201 patients undergoing thrombectomy alone and seven (3%) of 202 patients receiving intravenous alteplase plus thrombectomy (risk difference -1·0%, 95% CI -4·8 to 2·7). Successful reperfusion was less common in patients assigned to thrombectomy alone (182 [91%] of 201 vs 199 [96%] of 207, risk difference -5·1%, 95% CI -10·2 to 0·0, p=0·047). INTERPRETATION: Thrombectomy alone was not shown to be non-inferior to intravenous alteplase plus thrombectomy and resulted in decreased reperfusion rates. These results do not support omitting intravenous alteplase before thrombectomy in eligible patients. FUNDING: Medtronic and University Hospital Bern.

Deployment of low-profile flow-diverter through a double lumen balloon catheter (remo-diversion technique) to treat recurrent middle cerebral artery bifurcation aneurysm: A technical note.

Wide neck intracranial aneurysms are often difficult to treat with coiling alone, and sophisticated techniques such as balloon-assisted coiling, stent-assisted coiling, flow-diversion, or intrasaccular flow-disruption are sometimes required.This technical note reports the endovascular treatment of a recurrent middle cerebral bifurcation aneurysm by remodeling technique followed by flow-diverter (Silk Vista Baby) deployment through a remodeling balloon (double lumen balloon Eclipse 2L).

Stealth Luminescent Organic Nanoparticles Made from Quadrupolar Dyes for Two-Photon Bioimaging: Effect of End-Groups and Core.

Molecular-based Fluorescent Organic Nanoparticles (FONs) are versatile light-emitting nano-tools whose properties can be rationally addressed by bottom-up molecular engineering. A challenging property to gain control over is the interaction of the FONs' surface with biological systems. Indeed, most types of nanoparticles tend to interact with biological membranes. To address this limitation, we recently reported on two-photon (2P) absorbing, red to near infrared (NIR) emitting quadrupolar extended dyes built from a benzothiadiazole core and diphenylamino endgroups that yield spontaneously stealth FONs. In this paper, we expand our understanding of the structure-property relationship between the dye structure and the FONs 2P absorption response, fluorescence and stealthiness by characterizing a dye-related series of FONs. We observe that increasing the strength of the donor end-groups or of the core acceptor in the quadrupolar (D-π-A-π-D) dye structure allows for the tuning of optical properties, notably red-shifting both the emission (from red to NIR) and 2P absorption spectra while inducing a decrease in their fluorescence quantum yield. Thanks to their strong 1P and 2P absorption, all FONs whose median size varies between 11 and 28 nm exhibit giant 1P (106 M-1.cm-1) and 2P (104 GM) brightness values. Interestingly, all FONs were found to be non-toxic, exhibit stealth behaviour, and show vanishing non-specific interactions with cell membranes. We postulate that the strong hydrophobic character and the rigidity of the FONs building blocks are crucial to controlling the stealth nano-bio interface.

Scalable OneM2M IoT Open-Source Platform Evaluated in an SDN Optical Network Controller Scenario.

Software Defined Networking represents a mature technology for the control of optical networks, though all open controller implementations present in the literature still lack the adequate level of maturity and completeness to be considered for (pre)-production network deployments. This work aims at experimenting on, assessing and discussing the use of the OneM2M open-source platform in the context of optical networks. Network elements and devices are implemented as IoT devices, and the control application is built on top of an OneM2M-compliant server. The work concretely addresses the scalability and flexibility performances of the proposed solution, accounting for the expected growth of optical networks. The two experiment scenarios show promising results and confirm that the OneM2M platform can be adopted in such a context, paving the way to other researches and studies.

Intracranial aneurysm treatment with intrasaccular flow disruption: comparison of WEB-21 and WEB-17 systems.

BACKGROUND: New generations of Woven EndoBridge (WEB) devices (WEB-21 and WEB-17) are available to treat aneurysms with a width <6.5 mm. Limited comparisons between both systems exist in the literature, but mid-term efficacy has not been compared. Our study aimed to compare the indications, feasibility, and safety of both systems and to evaluate their efficacy at mid-term follow-up (12 months). METHODS: Aneurysms treated with WEB-21 and WEB-17 were extracted from a prospective database. Patient and aneurysm characteristics, complications, and anatomical results were analyzed by an interventional neuroradiologist, independent of the procedures. RESULTS: From June 2015 to November 2019, 87 patients with 92 aneurysms were treated with WEB-21 (38/92, 41.3%) and WEB-17 (54/92, 58.7%). WEB-21 and WEB-17 had high treatment feasibility (97.4% and 94.4%, respectively). A higher percentage of ruptured aneurysms were treated with WEB-17 (9.3%) than with WEB-21 (2.6%; p=0.03). Morbidity and mortality at 1 month were similar in both groups (no morbidity in either group, and mortality 2.7% in the WEB-21 group and 2.0% in the WEB-17 group). The rate of complete and adequate aneurysm occlusion was not significantly higher with the WEB-17 system (59.2% and 95.9%, respectively) compared with the WEB-21 (52.9% and 85.3%, respectively). CONCLUSIONS: This study showed the high feasibility of aneurysm treatment with both the WEB-21 and WEB-17 systems. Indications were relatively similar with both devices except for ruptured aneurysms, which were more frequently treated with the WEB-17 device. Efficacy at 12 months (complete and adequate occlusions) was slightly, but not significantly, better with the WEB-17 device.

Understanding the Origins of Problem Geomagnetic Storms Associated with "Stealth" Coronal Mass Ejections.

Geomagnetic storms are an important aspect of space weather and can result in significant impacts on space- and ground-based assets. The majority of strong storms are associated with the passage of interplanetary coronal mass ejections (ICMEs) in the near-Earth environment. In many cases, these ICMEs can be traced back unambiguously to a specific coronal mass ejection (CME) and solar activity on the frontside of the Sun. Hence, predicting the arrival of ICMEs at Earth from routine observations of CMEs and solar activity currently makes a major contribution to the forecasting of geomagnetic storms. However, it is clear that some ICMEs, which may also cause enhanced geomagnetic activity, cannot be traced back to an observed CME, or, if the CME is identified, its origin may be elusive or ambiguous in coronal images. Such CMEs have been termed "stealth CMEs". In this review, we focus on these "problem" geomagnetic storms in the sense that the solar/CME precursors are enigmatic and stealthy. We start by reviewing evidence for stealth CMEs discussed in past studies. We then identify several moderate to strong geomagnetic storms (minimum Dst < - 50  nT) in solar cycle 24 for which the related solar sources and/or CMEs are unclear and apparently stealthy. We discuss the solar and in situ circumstances of these events and identify several scenarios that may account for their elusive solar signatures. These range from observational limitations (e.g., a coronagraph near Earth may not detect an incoming CME if it is diffuse and not wide enough) to the possibility that there is a class of mass ejections from the Sun that have only weak or hard-to-observe coronal signatures. In particular, some of these sources are only clearly revealed by considering the evolution of coronal structures over longer time intervals than is usually considered. We also review a variety of numerical modelling approaches that attempt to advance our understanding of the origins and consequences of stealthy solar eruptions with geoeffective potential. Specifically, we discuss magnetofrictional modelling of the energisation of stealth CME source regions and magnetohydrodynamic modelling of the physical processes that generate stealth CME or CME-like eruptions, typically from higher altitudes in the solar corona than CMEs from active regions or extended filament channels.

A Bottom-Up Approach to Red-Emitting Molecular-Based Nanoparticles with Natural Stealth Properties and their Use for Single-Particle Tracking Deep in Brain Tissue.

Fluorescent nanoparticles dedicated to bioimaging applications should possess specific properties that have to be maintained in the aqueous, reactive, and crowded biological environment. These include chemical and photostability, small size (on the scale of subcellular structures), biocompatibility, high brightness, and good solubility. The latter is a major challenge for inorganic nanoparticles, which require surface coating to be made water soluble. Molecular-based fluorescent organic nanoparticles (FONs) may prove a promising, spontaneously water-soluble alternative, whose bottom-up design allows for the fine-tuning of individual properties. Here, the critical challenge of controlling the interaction of nanoparticles with cellular membranes is addressed. This is a report on bright, size-tunable, red-emitting, naturally stealthy FONs that do not require the use of antifouling agents to impede interactions with cellular membranes. As a proof of concept, single FONs diffusing up to 150 µm deep in brain tissue are imaged and tracked.

An ICT Prototyping Framework for the "Port of the Future".

Seaports are genuine, intermodal hubs connecting seaways to inland transport links, such as roads and railways. Seaports are located at the focal point of institutional, industrial, and control activities in a jungle of interconnected information systems. System integration is setting considerable challenges when a group of independent providers are asked to implement complementary software functionalities. For this reason, seaports are the ideal playground where software is highly composite and tailored to a large variety of final users (from the so-called port communities). Although the target would be that of shaping the Port Authorities to be providers of (digital) innovation services, the state-of-the-art is still that of considering them as final users, or proxies of them. For this reason, we show how a canonical cloud, virtualizing a distributed architecture, can be structured to host different, possibly overlapped, tenants, slicing the information system at the infrastructure, platform, and software layers. Resources at the infrastructure and platform layers are shared so that a variety of independent applications can make use of the local calculus and access the data stored in a Data Lake. Such a cloud is adopted by the Port of Livorno as a rapid prototyping framework for the development and deployment of ICT innovation services. In order to demonstrate the versatility of this framework, three case studies relating to as many prototype ICT services (Navigation Safety, e-Freight, and Logistics) released within three industrial tenants are here presented and discussed.

Role of percutaneous cholecystostomy in all-comers with acute cholecystitis according to current guidelines in a general surgical unit.

Acute calculous cholecystitis (ACC) is a very common complication of gallstone-related disease. Its currently recommended management changes according to severity of disease and fitness for surgery. The aim of this observational study is to assess the short- and long-term outcomes in all-comers admitted with diagnosis of ACC, treated according to 2013 Tokyo Guidelines (TG13). A retrospective analysis was conducted on a prospectively maintained database of 125 patients with diagnosis of ACC consecutively admitted between January 2017 and September 2019, subdivided in three groups according to TG13: percutaneous cholecystostomy (PC group), cholecystectomy (CH group), and conservative medical treatment (MT group). The primary end point was a composite of morbidity and/or mortality rates; the secondary end points were ACC recurrence, readmission, need for cholecystectomy rates and overall length of hospital stay (LOS). After a median follow-up of 639 days, overall morbidity rate was 20.8% and mortality rate was 6.4%. Death was directly related to AC during the index admission in two out of eight cases. There were no significant differences in primary end point according to the treatment group. Concerning secondary end points, ACC recurrence rate was not significantly different after PC (10.0%) or MT (9.1%); the readmission rates were significantly higher (p < 0.0001) in the MT group (48.5%) and in the PC group (25.0%) than in the CH group (5.8%); need for cholecystectomy rates was significantly higher (p < 0.0001) in the MT group (42.4%) than in the PC group (20.0%); median overall LOS was significantly higher in the PC (16 days) than in the MT (9 days) and than in the CH group (5 days). PC is an effective and safe rescue procedure in high-risk patients with ACC, representing a definitive treatment in 80% of cases of this specific subgroup.

Dataset on the identification of a prognostic radio-immune signature in surgically resected Non Small Cell Lung Cancer.

The immune regulation of cancer growth and regression has been underscored by the recent success of immunotherapy. The possibility that immune microenvironmental factors may impact on clinical outcome and treatment response still requires intense investigations. Hereby, supporting data of the research article "Integrated CT Imaging and Tissue Immune Features Disclose a Radio-Immune Signature with High Prognostic Impact on Surgically Resected NSCLC" [1], are presented. With the ultimate aim to provide non-invasive prognostic scores, we report on our approach to correlate different Tumor Immune Microenvironment (TIME) profiles with CT imaging-derived qualitative (semantic, CT-SFs) and quantitative (radiomic, CT-RFs) features in a cohort of 60 surgically resected NSCLC. The renowned characterization of TIME, essentially based on the score evaluation of Programme Death Ligand-1 (PD-L1) and Tumor Infiltrating Lymphocytes (TILs), was implemented here by the assessment of effector and suppressor phenotypes including the analysis of Programme Death receptor 1 (PD-1). Thus, we defined two main TIME categories: hot inflamed (PD-L1high, CD8/CD3high and PD-1/CD8low) as opposed to cold inactive (PD-L1low, CD8/CD3lowand PD-1/CD8high). Importantly, as reported in the extended publication [1], these distinctive immune contextures identified different prognostic classes and were decoded by radiomics. To corroborate our radiomic approach, a comparative estimation of CT-RFs extracted from 60 NSCLC and 13 non neoplastic tissues was undertaken, documenting high discrimination ability. Moreover, we tested the potential association of qualitative radiologic features with clinico-pathological and TIME parameters. Taken together, our findings suggest that CT-SFs and CT-RFs may underlay specific patterns of lung cancer.

Integrated CT imaging and tissue immune features disclose a radio-immune signature with high prognostic impact on surgically resected NSCLC.

OBJECTIVES: Qualitative and quantitative CT imaging features might intercept the multifaceted tumor immune microenvironment (TIME), providing a non-invasive approach to design new prognostic models in NSCLC patients. MATERIALS AND METHODS: Our study population consisted of 100 surgically resected NSCLC patients among which 31 served as a validation cohort for quantitative image analysis. TIME was classified according to PD-L1 expression and the magnitude of Tumor Infiltrating Lymphocytes (TILs) and further defined as hot or cold by the tissue analysis of effector (CD8-to-CD3high/PD-1-to-CD8low) or inert (CD8-to-CD3low/PD-1-to-CD8high) phenotypes. CT datasets acted as source for qualitative (semantic, CT-SFs) and quantitative (radiomic, CT-RFs) features which were correlated with clinico-pathological and TIME profiles to determine their impact on survival outcome. RESULTS: Specific CT-SFs (texture [TXT], effect [EFC] and margins [MRG]) strongly correlated to PD-L1 and TILs status and showed significant impact on survival outcome (TXT, HR:3.39, 95 % CI 1.12-10-27, P < 0.05; EFC, HR:0.41, 95 % CI 0.18-0.93, P < 0.05; MRG, HR:1.93, 95 % CI 0.88-4.25, P = 0.09). Seven CT derived radiomic features were able to sharply discriminate cases with hot (inflamed) vs cold (desert) TIME, which also exhibited opposite OS (long vs short, HR:0.09, 95 % CI 0.04-0.23, P < 0.001) and DFS (long vs short, HR:0.31, 95 % CI 0.16-0.58, P < 0.001). Moreover, we identified 6 prognostic radiomic features among which ClusterProminence displayed the highest statistical significance (HR:0.13, 95 % CI 0.06-0.31, P < 0.001). These findings were independently validated in an additional cohort of NSCLC (HR:0.11, 95 % CI 0.03-0.40, P = 0.001). Finally, in our training cohort we developed a multiparametric prognostic model, interlacing TIME and clinico-pathological characteristics with CT-SFs (ROC curve AUC:0.83, 95 % CI 0.71-0.92, P < 0.001) or CT-RFs (AUC: 0.91, 95 % CI 0.83-0.99, P < 0.001), which appeared to outperform pTNM staging (AUC: 0.66, 95 % CI 0.51-0.80, P < 0.05) in the risk assessment of NSCLC. CONCLUSION: Higher order CT extracted features associated with specific TIME profiles may reveal a radio-immune signature with prognostic impact on resected NSCLC.

Radiofrequency ablation (RFA) of T1a renal cancer with externally cooled multitined expandable electrodes.

INTRODUCTION: To retrospectively evaluate the mid-term outcomes of percutaneous radiofrequency ablation (RFA) with multitined expandable electrodes externally cooled with saline solution in patients with T1a renal cell carcinoma (RCC). MATERIALS AND METHODS: In this retrospective study, we evaluated 39 RCC in 35 patients treated with CT-guided RFA in 41 procedures (2011-2017). All patients were staged T1a, N0, M0 prior to RFA. Mean tumor size was 24.48 mm. A 4-tined expandable RFA electrode cooled with pump-circulating saline was used. Efficacy was evaluated verifying complete tumor necrosis (no contrast enhancement on imaging) at the end of the procedure and on subsequent controls. Follow-up observation period was 5 years. Minor/major complications, hospitalization days, serum creatinine and GFR pre- and post-RFA (compared using paired t test) and post-operative pain (evaluated with NRS after treatment) were considered as safety indicators. Overall survival was also calculated (Kaplan-Meier method). RESULTS: Of 35 patients, 30/35 had 1 treatment (primary effectiveness rate 86%), 4/35 had 2 treatments and 1/35 had 3 treatments for residual disease. There were no relapses and no mid-long-term complications; 3 minor (8%) and 1 major (2.7%) complications during perioperative period were reported. Mean before and after RFA serum creatinine rates were, respectively, 1.08 mg/dl and 1.11 mg/dl (p value: 0.4117). NRS median value is 0.8. Hospitalization days median value is [2.8 ± 1.9] days. 91.4% of all patients survived, with a median overall survival time of 65 months. CONCLUSIONS: Mid-term results show that CT-guided RFA with multitined expandable electrodes externally cooled with saline solution is an effective and safe treatment in patients with RCC-staged T1aN0M0. Data reported in our study are in line with data reported in the literature from patients treated with other devices.

Intestinal duplications: incidentally ileum duplication cyst in young female.

Gastrointestinal tract duplication is a rare congenital malformation in young patients and in adults, that occur anywhere from the mouth to the anus and their macroscopic structure may be cystic or tubular. Intestinal duplication does not show specific symptoms, indeed they can present with a variety of symptoms including abdominal distension and pain, sickness, hemorrhage, chronic respiratory disorders, as well as non-painful abdominal mass. Nonetheless, intestinal duplication can remain completely asymptomatic and be diagnosed as an incidental finding. Presentation with acute complications such as intestinal invagination or mechanical occlusion is quite rare. We present a case of asymptomatic ileum duplication cyst in young female who referred to the emergency department for trauma and was screened by eco-Focus Assessment Sonography for Trauma (eco-FAST), followed by MR and CT. The patient underwent ileal resection and prophylactic appendicectomy with ileo-cecal termino-lateral anastomosis. In this case, the intestinal duplication cyst was an asymptomatic incidental finding.

The value of high-resolution computed tomography (HRCT) to determine exercise ventilatory inefficiency and dynamic hyperinflation in adult patients with cystic fibrosis.

INTRODUCTION: In Cystic Fibrosis (CF), exercise ventilatory inefficiency and dynamic hyperinflation (DH) cause exercise limitation and induce poor exercise tolerance. High-resolution computed tomography (HRCT) of the lung can detect pulmonary abnormalities in CF patients. We aimed to identify the determinants of exercise ventilatory inefficiency and DH using HRCT-derived metrics. METHODS: Fifty-two adult CF patients were prospectively enrolled; all participants underwent cardio-pulmonary exercise test (CPET) and HRCT. Radiological impairment was evaluated by the Brody II scoring system. Slope and intercept of the minute ventilation/CO2 production (V'E/V'CO2) regression line and the ratio of inspiratory capacity/total lung capacity (IC/TLC) at rest and at peak of exercise were measured. RESULTS: Four groups of patients were identified based on the combination of ventilatory efficiency (Vef) or inefficiency (Vin) and the presence/absence of DH. Compared to other groups, CF adults with Vin and DH had worse functional status and higher total (T), bronchiectasis (B) and air trapping (AT) scores at HRCT. Significant correlations were found between V'E/V'CO2 intercept and V'E/V'CO2 slope (ρ - 0.455, p = 0.001) and between V'E/V'CO2 intercept and Δ inspiratory capacity (IC) (ρ - 0.334, p = 0.015). Regression analysis identified AT score (cut-off 7.9, odds ratio-OR 3.50) as the only independent predictor of Vin and T (cut-off 53.6, OR 4.98), B (cut-off 16.1, OR 4.88), airways wall thickening (AWT) (cut-off 13, OR 3.41), and mucous plugging (MP) scores (cut-off 11.7, OR 4.18) as significant predictors of DH. CONCLUSION: In adult CF cohort, values of HRCT metrics are determinants of Vin (AT) and DH (T, B, AWT, MP).