The Use of Rapid Sequence Magnetic Resonance Imaging of the Brain as a Screening Tool for the Detection of Gross Intracranial Pathology in Children Presenting to the Emergency Department With a Chief Complaint of Persistent or Recurrent Headaches.

OBJECTIVE: The purpose of the study, was to assess the utility of rapid sequence brain magnetic resonance imaging (RS-MRI), as a screening tool to detect gross intracranial pathology in children that present to the emergency department, with a chief complaint of persistent or recurrent headaches. Rapid sequence MRI of the brain is a radiation-free technique that is used to evaluate ventricular size in children with shunted hydrocephalus, who present to the emergency department with symptomatology consistent with shunt malfunction. METHODS: The study evaluated RS-MRI radiographic findings of 105 children that presented to a busy tertiary care pediatric emergency/trauma center between May 1, 2013, and May 31, 2015. The inclusion criteria for the study are as follows: (1) patient's age up to 12 years, (2) patient history of persistent or recurrent headaches, (3) no history of recent specialized intracranial imaging studies. The exclusion criteria are as follows: (1) a history of recent head injury or trauma, (2) known intracranial pathology, (3) clinical findings consistent with intracranial pathology, (4) patients that required intraprocedural sedation. A detailed explanation was given to the patient's parents/guardian, specifying that this was a "screening test" for detection of gross intracranial abnormalities and not a complete radiological evaluation that would rule out all pathology. Appropriate informed consent was obtained by the attending emergency medicine specialist, and was documented in the patient's medical record. RESULTS: A total of 105 RS-MRI examinations were performed with an average imaging time of 75 seconds. None of the children required intraprocedural sedation, and there were no failed examinations. One patient was excluded from the study due to a pilocytic astrocytoma (not disclosed initially). There were 81 (77%) of 105 normal studies and 24 (23%) of 105 abnormal studies. One patient returned to the emergency department 2 times and was enrolled twice during the 2-year study. Of the 24 abnormal studies, 18 (75%) of 24 cases were diagnosed with sinusitis, and 1 (4.1%) of 24 cases was diagnosed with an abnormal brain mass with mild hydrocephalus due to obstruction of the caudal aspect of the fourth ventricle. CONCLUSIONS: Rapid sequence MRI is a radiation-free useful alternative to computer tomography of the brain, when used as a screening tool for children with persistent or recurrent headaches presenting to the emergency department. This rapid imaging modality was particularly useful in identifying children with sinus disease, and contributed significantly to patient/family satisfaction with the care they receive during the emergency department visit. Additionally, RS-MRI screening was successful in detecting a serious neurosurgical emergency in one child with a cerebellar mass causing increased intracranial pressure. Further studies with large sample size are needed to corroborate our findings.

Does modern ischemic stroke therapy in a large community-based dedicated stroke center improve clinical outcomes? A two-year retrospective study.

BACKGROUND: To compare modern endovascular therapies in the acute ischemic stroke patients leading to more comprehensive acute stroke algorithm. METHODS: A 2-year retrospective nonrandomized study on 76 patients who were placed into 5 different treatment groups for acute ischemic stroke. These groups included: group 1 (no treatment) (n = 24), group 2 (intravenous tissue plasminogen activator [tPA] only) (n = 18), group 3 (intra-arterial [IA] tPA) (n = 9), group 4 (Mechanical Embolus Removal in Cerebral Ischemia [MERCI]; retrieval only) (n = 17), and group 5 (combined IA/MERCI) (n = 8). Age range for all groups was 29-92 years. There were 39 women (51.3%) and 37 men (48.7%). The mean age for all patients was 70.1 years. The pre- and post-National Institutes of Health Stroke Scale (NIHSS) values were obtained for each group on arrival and discharge from the hospital. The results of the 4 treatment cohorts were compared with the no treatment group, providing the relative efficacy of these procedures compared with conservative medical therapy alone. RESULTS: Group 1 presented with an admission NIHSS value of 11.1 and 8.9 on discharge from the hospital. There was a NIHSS reduction of 2.2 without treatment. Group 2 had an admission NIHSS value of 11.8 and a discharge value of 4.7, resulting in an NIHSS reduction of 7.1. Group 3 had an admission NIHSS value of 16.1 and 7.4 at discharge, resulting in an NIHSS reduction of 8.7. Group 4 had an admission NIHSS value of 15.9 and discharge NIHSS value of 3.1, with an NIHSS reduction of 12.8. Group 5 had an admission NIHSS score of 15.7 and 10.6 at discharge, with an NIHSS reduction of 5.1. Four patients expired during their admission, 2 from group 1 (control group) and 2 from group 5 (combined IA/MERCI group). There was a statistically significant difference for the 5 groups at the P < .05 level in change in NIHSS scores: F (4, 24) = 9.10, P = .000. CONCLUSIONS: Modern endovascular therapies for acute ischemic stroke do improve clinical outcomes when implemented in the setting of a dedicated comprehensive stroke team.

Bilateral EKOS EndoWave catheter thrombolysis of acute bilateral pulmonary embolism in a hemodynamically unstable patient.

Pulmonary embolism is a common and sometimes devastating disease caused by many factors, most commonly deep venous thrombosis. Treatment is typically systemic anticoagulation depending on patient clinical presentation. For patients with life threatening pulmonary embolism, IV tPA (Activase, Genentech, South San Francisco, CA) is the most common medication given emergently at the time of presentation. Computed tomography angiography (CTA) of the chest has advanced the diagnosis and potential treatment options for patients with life threatening pulmonary embolism. Combination percutaneous transcatheter directed pharmacological and mechanical thrombolysis has become extremely useful in these difficult cases.

Endovascular treatment of an acutely ruptured abdominal aorta from tumor invasion by an unresectable retroperitoneal leiomyosarcoma.

Retroperitoneal leiomyosarcomas account for <1% of all tumors diagnosed in the U.S. They are usually unresectable at the time of diagnosis due to their vague clinical presentation. Aortic rupture from tumor invasion by retroperitoneal leiomyosarcomas is extremely rare and has only been described in one case report. We describe a case of an unresectable retroperitoneal leiomyosarcoma eroding into the infrarenal abdominal aorta resulting in an acute contained intratumoral hemorrhage successfully treated with a percutaneous placed abdominal aortic endograft. This article discusses the endovascular treatment of this rare medical emergency performed quickly and effectively in our endovascular suite. Endovascular specialists should be familiar with this lifesaving endovascular option in the setting of an acute aortic rupture.

Mesenchymal Hamartoma of the Liver in an Infant With Beckwith-Wiedemann Syndrome: A Rare Condition Mimicking Hepatoblastoma.

Patients with Beckwith-Wiedemann syndrome (BWS) are known to be at an increased risk for childhood malignancies, particularly Wilms tumor and hepatoblastoma. We report a case of genetically confirmed BWS in a 5-month-old girl who presented with a 9.5-cm abdominal mass associated with elevated α-fetoprotein levels. The clinical impression was strongly suggestive of hepatoblastoma. Histologic examination of the surgically excised mass revealed mesenchymal hamartoma of the liver (MHL), a benign hepatic neoplasm.

Hepatic angiosarcoma presenting as an acute intraabdominal hemorrhage treated with transarterial chemoembolization.

Primary malignant neoplasms of the liver are some of the most uncommon malignancies in many parts of the world. They include hepatocellular carcinoma and stromal tumors such as hepatic angiosarcoma. It is a lethal tumor with life expectancy of less than six months. Once discovered, it is often too late for surgical intervention. Like other vascular tumors of the liver and spleen, intraperitoneal hemorrhage is a well-documented finding of angiosarcoma which can be lethal if not diagnosed and treated immediately. As in our case, intraperitoneal hemorrhage from primary tumor rupture was the only clinical presentation of this neoplasm. Approximately 15% of patients present with acute hemoperitoneum from either tumor rupture or peritoneal metastasis. Although several therapeutic options are available, we describe apalliative therapy for hepatic angiosarcoma utilizing transcatheter arterial chemoembolization (TACE) techniques incorporating the newer embolization agent Embospheres to locally target and treat this aggressive tumor.

Coil embolization of multiple hepatic artery aneurysms in a patient with undiagnosed polyarteritis nodosa.

Hepatic aneurysms are a rare sequela of vascular abnormalities in the liver, including trauma, infection, necrotizing vasculitis such as polyarteritis nodosa (PAN), and iatrogenic and arterial mediolysis. Presentation with intra-abdominal hemorrhage is associated with a high mortality rate. We describe life-saving transcatheter coil embolization of multiple isolated ruptured hepatic pseudoaneurysms in a patient with no history or clinical findings of PAN. We present angiographic findings and intra-arterial transcatheter embolization techniques in the treatment of ruptured large hepatic artery aneurysms. Endovascular specialists should recognize that PAN could present with classic angiographic findings and, in some cases, as life-threatening ruptured isolated hepatic artery aneurysms as its first presentation.