The diagnostic performance of MRI signs to distinguish Pectoralis major tendon avulsions from Myotendinous injuries.

BACKGROUND: Management of pectoralis major (PM) injuries is largely determined by the anatomic location of the injury, with tendon avulsions from the humerus requiring surgery while myotendinous (MT) injuries are typically managed non-operatively. Because physical examination cannot reliably make this distinction, MRI is often used for staging. However, correct classification can also be difficult with MRI where there is extensive soft tissue edema and distorted anatomy. OBJECTIVE: To determine the diagnostic performance of primary and secondary MRI signs of PM injury for distinguishing tendon avulsions from MT injuries in a selected sample of patients that underwent surgical repair using a practical interpretation algorithm. METHODS: In this retrospective study, 3 blinded observers independently assessed the MRI findings of 17 patients with PM injury (including 12 acute injuries, 4 chronic, and 1 of uncertain age) where subsequent surgery documented tendon avulsion (11) and MT injuries (6) by applying the primary MRI criteria of absent tendon at the humerus, retracted tendon stump, epicenter of edema, and the secondary finding of soft tissue edema contacting the anterior humeral cortex. Operative findings were used as the reference standard. Sensitivity, specificity, and positive and negative predictive value were recorded for each finding. RESULTS: The primary MRI finding of lack of a visible tendon at the insertion (sensitivity 82-100%, specificity 100%) and the secondary finding of edema contacting the anterior humeral cortex (sensitivity 64-91%, specificity 67-100%) were both useful for the distinction of tendon avulsion from MT injury, particularly in acute injuries. The presence of a retracted tendon stump and the epicenter of edema were not reliable findings. The use of a decision tree including the secondary finding of humeral edema increased the sensitivity and specificity for 2 of the 3 observers. CONCLUSION: MRI assessment of PM injury focused on the humeral insertion of the PM tendon allows accurate distinction of tendon avulsion from MT injury. CLINICAL IMPACT: This study describes a practical approach to classifying PM injuries with MRI to distinguish injuries that require surgery from those that can potentially be managed conservatively.

Prostate Cancer Metastases to Inguinal Lymph Nodes Detected by Attenuation-Corrected 11C-Acetate PET/CT.

The inguinal lymph nodes are an unusual site of metastases for prostate adenocarcinoma. We present a case in which a 61-y-old man with biochemically recurrent prostate cancer underwent attenuation-corrected (11)C-acetate PET/CT, which demonstrated multiple foci of increased activity in the left inguinal, left iliac chain, and right inguinal regions. The attenuation-corrected CT portion of the scan also showed anterior wall thickening of the rectum. The imaging findings were suggestive of metastatic involvement of the rectum below the dentate line with subsequent spread to the inguinal lymph nodes.

Groin complications in endovascular mechanical thrombectomy for acute ischemic stroke: a 10-year single center experience.

BACKGROUND: The increasing utilization of balloon guide catheters (BGCs) in thrombectomy therapy for ischemic stroke has led to concerns about large-bore sheaths causing vascular groin complications.Objective To retrospectively assess the impact of large large-bore sheaths and vascular closure devices on groin complication rates at a comprehensive stroke center over a 10-year period. METHODS: Radiological and clinical records of patients with acute ischemic stroke who underwent mechanical endovascular therapy with an 8Fr or larger sheaths were reviewed. A groin complication was defined as the formation of a groin hematoma, retroperitoneal hematoma, femoral artery pseudoaneurysm, or the need for surgical repair. Information collected included size of sheath, type of hemostatic device, and anticoagulation status of the patient. Blood bank records were also analyzed to identify patients who may have had an undocumented blood transfusion for a groin hematoma. RESULTS: A total of 472 patients with acute ischemic stroke who underwent mechanical thrombectomy with a sheath and BGC sized 8Fr or larger were identified. 260 patients (55.1%) had tissue Plasminogen Activator (tPA) administered as part of stroke treatment. Vascular closure devices were used in 97.9% of cases (n=462). Two patients were identified who had definite groin complications and a further two were included as having possible complications. There was a very low rate of clinically significant groin complications (0.4-0.8%) associated with the use of large-bore sheaths. CONCLUSIONS: These findings suggest that concerns for groin complications should not preclude the use of BGCs and large-bore sheaths in mechanical thrombectomy for acute ischemic stroke.

Treatment of a dissecting vertebral artery aneurysm with angioplasty and the pipeline embolisation device.

A 49-year-old woman was admitted with Hunt and Hess grade 1 subarachnoid haemorrhage. A cerebral aneurysm of the intracranial left vertebral artery (VA) distal to the left posterior inferior cerebellar artery (PICA) was found and treated using parent vessel occlusion with coils. The PICA was preserved. Angiography at three time points during her hospitalisation showed a normal right VA. Eight months later, angiography demonstrated a new 14 mm right VA dissecting aneurysm with 90% outflow stenosis and recurrence of the left VA aneurysm distal to the coils. A Marksman microcatheter would not traverse the stenosis despite the use of two intraluminal wires. Following Gateway balloon (1.5 mm × 9 mm) angioplasty, the Marksman passed easily. The pipeline embolisation device (PED) was successfully deployed across the aneurysm and 11 coils placed through a trapped microcatheter. The patient was discharged home 2 days later. Eighteen-month follow-up has revealed complete resolution of both aneurysms.