Comaneci device-assisted embolization of wide-necked carotid aneurysms with an unfavorable ratio.

BACKGROUND: Endovascular treatment is the technique of choice for most intracranial aneurysms. However, the treatment of morphologically complex wide-necked aneurysms with an unfavorable anatomy is still a therapeutic challenge. The purpose of the study is to describe the initial experience with the Comaneci embolization assist device for the treatment of wide-necked aneurysms with an unfavorable ratio for direct embolization. METHODS: We report a retrospective single-center analysis taken from a prospective database of consecutive aneurysms of the anterior circulation treated using the Comaneci device in the period from March 2017 to March 2019. RESULTS: Eighteen aneurysms were collected from 16 patients (9 women and 7 men) treated using the Comaneci device. The mean age was 48.4 years (range 36-81). Twelve patients had SAH, three were incidental aneurysms and one had compressive symptoms. A complete asymptomatic occlusion rate of 88.8% was obtained. The major complication rate was 5.55%. CONCLUSION: The Comaneci embolization assist device is a safe, effective option for endovascular treatment of complex aneurysms with an unfavorable ratio.

Simultaneous Angioplasty and Mechanical Thrombectomy in Tandem Carotid Occlusions. Incidence of Reocclusions and Prognostic Predictors.

OBJECTIVES: The best revascularization technique for tandem carotid occlusions is not clearly defined. The primary objective of this study is to describe our technical and clinical results, analyzing the main predictors of functional independence. The secondary objective is the analysis of stent reocclusion rate. METHODS: A single-center series of 250 mechanical thrombectomies in the anterior circulation was studied. A subsequent analysis of 40 carotid occlusions was performed. The demographics, etiology, angiographic results, antithrombotic drugs, and 3-month follow-up were registered. A bivariate analysis was performed to establish the association of the study variables with major clinical complications (death, symptomatic hemorrhagic transformation and early recurrence) and the functional prognosis. In addition, the relationship between the preprocedure antiaggregation regimen and the reocclusions was studied, as well as its clinical impact. Independent predictive factors were studied using a multivariate logistic regression model. RESULTS: Complete recanalization was achieved in 30 cases (75%). Simultaneous stent placement was decided in 32 cases (80%). Functional independence was reached in 19 cases (47.5%), and 3 (7.5%) died at 3 months. Seven major complications were reported (17.5%). In patients with satisfactory revascularization where a carotid stent was used, 9 reocclusions (28.1%) were detected during the follow-up, 2 of them symptomatic. The only factor related independently with functional independence was the administration of single antiaggregation (odds ratio = .31; 95% confidence interval .002-.595; P = .021). CONCLUSIONS: Urgent endovascular treatment of tandem carotid occlusions has shown to be effective and safe in our series. The administration of single antiaggregation is a predictor of functional independence. In patients treated with carotid stent, the reocclusion rate is high, but generally asymptomatic.

Spontaneous Haematomas in Anticoagulated Covid-19 Patients: Diagnosis and Treatment by Embolization.

PURPOSE: To assess the safety and efficacy of embolization for spontaneous bleeding in anticoagulated patients with COVID-19. MATERIAL AND METHODS: Single center retrospective study in 9 patients with COVID-19 who experienced bleeding complications following anticoagulation. The study included 8 men and 1 woman aged from 48 to 80 years (mean 69.7 years), who had a total of 10 soft tissue haematomas: 1 in the thigh, 1 in the anterior abdominal wall, 6 retroperitoneal and 2 thoracic haematomas. All patients were referenced for vascular embolization, mostly with Onyx-18. RESULTS: A total of 10 haematomas were embolized in 9 patients. Technical success was achieved in all patients. No complications or adverse events were noted. One patient required percutaneous drainage of an infected haematoma 88 days after embolization. The mean hemoglobin level before embolization was 8,64 mg/dL and increased to 9,08 mg/dL after embolization (p = 0,3). After embolization all patients recovered haemodynamic stability and blood pressure levels improved. Seven patients resumed anticoagulation therapy after embolization. There were no recurrences or new bleedings in all treated patients. No patients required any additional invasive therapies or surgery. Mean intensive unit care and hospital stay was 6.7 and 35.2 days, respectively. All patients were discharged and were well at follow-up clinic visits 2-7 months after embolization. Seven patients performed a control CT scan 1-6 months after embolization, showing complete resolution of the haematoma. CONCLUSION: Embolization is safe and effective to treat spontaneous haematomas in anticoagulated patients with COVID-19, allowing to resume anticoagulation therapy. Level of evidence IV Level 4, case-series.

Recommendations for the diagnosis and radiological follow-up of pituitary neuroendocrine tumours.

Pituitary neuroendocrine tumours (PitNETs) constitute a heterogeneous group of tumours with a gradually increasing incidence, partly accounted for by more sensitive imaging techniques and more extensive experience in neuroradiology in this regard. Although most PitNETs are indolent, some exhibit aggressive behaviour, and recurrence may be seen after surgical removal. The changes introduced in the WHO classification in 2017 and terminological debates in relation to neuroendocrine tumours warrant an update of the guidelines for the diagnosis, preoperative and postoperative management, and follow-up of response to treatment of PitNETs. This multidisciplinary document, an initiative of the Neuroendocrinology area of the Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition] (SEEN), focuses on neuroimaging studies for the diagnosis, prognosis and follow-up of PitNETs. The basic requirements and elements that should be covered by magnetic resonance imaging are described, and a minimum radiology report to aid clinicians in treatment decision-making is proposed. This work supplements the consensus between the Neuroendocrinology area of the SEEN and the Sociedad Española de Anatomía Patológica [Spanish Society of Pathology] (SEAP) for the pathological study of PitNETs.

Cyanocobalamin Ultraflexible Lipid Vesicles: Characterization and In Vitro Evaluation of Drug-Skin Depth Profiles.

Atopic dermatitis (AD) and psoriasis are the most common chronic inflammatory skin disorders, which importantly affect the quality of life of patients who suffer them. Among other causes, nitric oxide has been reported as part of the triggering factors in the pathogenesis of both conditions. Cyanocobalamin (vitamin B12) has shown efficacy as a nitric oxide scavenger and some clinical trials have given positive outcomes in its use for treating skin pathologies. Passive skin diffusion is possible only for drugs with low molecular weights and intermediate lipophilicity. Unfortunately, the molecular weight and hydrophilicity of vitamin B12 do not predict its effective diffusion through the skin. The aim of this work was to design new lipid vesicles to encapsulate the vitamin B12 to enhance its skin penetration. Nine prototypes of vesicles were generated and characterized in terms of size, polydispersity, surface charge, drug encapsulation, flexibility, and stability with positive results. Additionally, their ability to release the drug content in a controlled manner was demonstrated. Finally, we found that these lipid vesicle formulations facilitated the penetration of cyanocobalamin to the deeper layers of the skin. The present work shows a promising system to effectively administer vitamin B12 topically, which could be of interest in the treatment of skin diseases such as AD and psoriasis.

Fibrin-Platelet Clots in Acute Ischemic Stroke. Predictors and Clinical Significance in a Mechanical Thrombectomy Series.

Introduction: The histological composition of the clot influences its mechanical properties, affects the efficacy of endovascular treatment (EVT), and could determine the clinical outcome of patients with acute ischemic stroke (AIS). Insights into clot composition may guide therapeutic decision-making prior to EVT and facilitate revascularization therapies. Material and Methods: Consecutive patients with AIS recorded in a prospective single-center reperfusion registry from December 2015 to December 2019 and treated with EVT were included. Baseline, laboratory [including post-procedural C-reactive protein (CRP)], radiological, and angiographic variables were analyzed. We aimed to study the relationship between histological composition of the clot with basal neuroimaging, laboratory markers, and recanalization technique. The secondary outcome was to analyze the correlation between clot composition and functional outcome at 3 months assessed by the modified Rankin scale (mRS). Results: From the study period, 360 AIS patients treated with EVT were included, of whom 189 (53%) fulfilled the inclusion criteria. One hundred (53%) cases of fibrin-predominant clot (FPC) were recorded. Full recanalization in FPC cases was achieved with higher probability when stent retrievers (SR) were selected as the first-line device (68.2%, p = 0.039). Patients with FPC had higher levels of CRP (p = 0.02), lower frequency of the hyperdense middle cerebral artery (HMCA) in baseline imaging (p = 0.039), and higher rates of mortality (p = 0.012). The multivariate analysis showed that the absence of HMCA (OR = 0.420; 95% CI 0.197-0.898; p = 0.025) and higher levels of CRP (OR = 1.01; 95% CI 1.003-1.019; p = 0.008) were predictors of FPC. Leukocytes and platelet counts were not associated with clot histology. Conclusions: The absence of HMCA and higher levels of CRP were markers of FPC. In patients with FPC, complete recanalization was most likely to be achieved when a SR was selected as first line of treatment. Mortality was higher in patients within this histologic group.

Organic preservation of fossil musculature with ultracellular detail.

The very labile (decay-prone), non-biomineralized, tissues of organisms are rarely fossilized. Occurrences thereof are invaluable supplements to a body fossil record dominated by biomineralized tissues, which alone are extremely unrepresentative of diversity in modern and ancient ecosystems. Fossil examples of extremely labile tissues (e.g. muscle) that exhibit a high degree of morphological fidelity are almost invariably replicated by inorganic compounds such as calcium phosphate. There is no consensus as to whether such tissues can be preserved with similar morphological fidelity as organic remains, except when enclosed inside amber. Here, we report fossilized musculature from an approximately 18 Myr old salamander from lacustrine sediments of Ribesalbes, Spain. The muscle is preserved organically, in three dimensions, and with the highest fidelity of morphological preservation yet documented from the fossil record. Preserved ultrastructural details include myofilaments, endomysium, layering within the sarcolemma, and endomysial circulatory vessels infilled with blood. Slight differences between the fossil tissues and their counterparts in extant amphibians reflect limited degradation during fossilization. Our results provide unequivocal evidence that high-fidelity organic preservation of extremely labile tissues is not only feasible, but likely to be common. This is supported by the discovery of similarly preserved tissues in the Eocene Grube Messel biota.

Endovascular management of an unsual case of spontaneous Retroperitoneal Haemorrhage due to Fibromuscular Dysplasia.

BACKGROUND: Fibromuscular dysplasia (FMD) is an uncommon vascular disease that results in stenosis, dissection or aneurysmal degeneration. However, it can sometimes manifest atypically, as we show in this case. CASE PRESENTATION: A 24-year old patient with no relevant medical history with severe left hypochondrium pain. The physical examination showed blood pressure levels of 160/90 mmHg. An abdominopelvic CT evidenced left retroperitoneal haematoma associated with active bleeding and left renal artery stenosis. Given these findings, it was decided to perform an endovascular treatment. Significant stenosis was seen during the arteriography in both renal arteries, suggesting fibromuscular dysplasia and development of a collateral neovascular network responsible for the retroperitoneal haematoma. It was embolised in association with angioplasty of the left renal artery. The patient had a favourable outcome; however, high blood pressure levels persisted. A new bilateral renal angioplasty was performed, which returned blood pressure values to normal. The patient was discharged without needing antihypertensives. CONCLUSIONS: FMD is a rare disease that can show multiple clinical presentations and need individualized treatment options. Endovascular techniques are in the first therapeutic line regarding fibromuscular dysplasia.

Histopathological and Bacteriological Analysis of Thrombus Material Extracted During Mechanical Thrombectomy in Acute Stroke Patients.

PURPOSE: Management of stroke secondary to septic emboli (SE) remains challenging, due to both the lack of specific recommendations and the gravity of the underlying pathology.The aim of this study is to describe the presence of SE in a series of mechanical thrombectomies (MT), analyzing technical complexity and outcomes with respect to the patients by means of histological analysis and microbiological study of the clot. METHODS: All the retrieved clots were studied under an established protocol, including histopathological and bacteriological study with hematoxylin-eosin, Gram and Gomori trichrome staining.Technical complexity in SE with respect to the series was evaluated by analyzing time of the procedures, number of passes and use of intracranial definitive stents. RESULTS: Over a 24-month period, bacteria were detected in the retrieved clot of four out of 65 patients (incidence 6.2%). Two cases were eventually diagnosed with infective endocarditis, while the remaining two were diagnosed with urinary tract infection and respiratory septicemia, respectively. Three of the four patients (75%) required an intracranial definitive stent in order to achieve successful recanalization.These procedures were significantly longer (137.7 vs. 59.8 min, p < 0.001), needed a higher number of passes (5.8 vs. 2.2, p < 0.001), and delivery of an intracranial stent more frequently (75% vs. 1.6%, p = 0.008), with respect to the rest of the series. CONCLUSIONS: In our series, systematic histopathological and bacteriological study of the MT samples allowed a higher proportion of SE diagnosis in comparison with previous reports.

Relationship between Northwick Park neck pain questionnaire and cervical spine MR imaging findings.

The study was aimed at determining the association between the self-report of pain and disability by means of Northwick neck pain questionnaire (NPQ) and cervical spine MR imaging findings. A random sample of 251 patients, 132 men and 119 women aged 43+/-13 years, submitted with neck pain were investigated. Patients with previous discitis, surgery, neoplasm or hospitalized for cervical spine trauma were excluded. All patients completed the NPQ and were studied with sagittal gradient-echo T1 and turbo spin-echo T2, axial gradient-echo T2* and heavily T2 weighted MR myelographic weighted images. MR images of the two most affected disc levels were read, offering an MR imaging score from 0 to 30. There was no statistically significant correlation between NPQ and MR imaging scores. From the NPQ items, only difficulty in sleeping and numbness were related to the MR imaging score. Disc extrusion was the only MR finding almost significantly associated with NPQ (P=0.054). Neck injury did not increase NPQ scores. In patients with neck pain, NPQ scores do not correlate with MR imaging findings. NPQ and cervical spine MR imaging show different facets of the multidimensional complex of neck pain.

Relationship between low back pain, disability, MR imaging findings and health care provider.

OBJECTIVE: To determine the association between the self-report of pain and disability and findings on lumbar MR images, and to compare two different health care providers in Spanish patients with low back pain (LBP). DESIGN: Cross-sectional MATERIAL AND METHODS: A total of 278 patients, 137 men and 141 women aged 44+/-14 years submitted with low back pain (LBP) were studied. One hundred and nine patients were from the National Health System (NHS) and 169 from private practice. Patients with previous discitis, surgery, neoplasm or traumatic episodes were excluded. Every patient completed a disability questionnaire with six core items, providing a score of disability from 2 to 28. All patients had sagittal spin-echo T1 and turbo spin-echo T2, axial proton-density and MR myelography weighted images. MR images of the two most affected disc levels were read, offering an MR imaging score from 0 to 30. RESULTS: Patients with a combination of LBP and sciatica showed the highest levels of disability (p=0.002). MR imaging scores only correlated with pain interference with normal work (p=0.04), but not with other disability questions. Patients from the NHS showed greater disability scores than private ones (p=0.001) and higher MR imaging scores (p=0.01). CONCLUSION: In patients with LBP, MR imaging only correlates with pain interference with work but not with other disability questions. Differences are found between private and NHS patients, the latter being more physically affected.

Concomitant lower thoracic spine disc disease in lumbar spine MR imaging studies.

Our objective was to study the coexistence of lower thoracic-spine disc changes in patients with low back pain using a large field of view (FOV) in lumbar spine MR imaging. One hundred fifty patients with low back pain were referred to an MR examination. All patients were studied with a large FOV (27 cm), covering from the coccyx to at least the body of T11. Discs were coded as normal, protrusion, and extrusion (either epiphyseal or intervertebral). The relationship between disc disease and level was established with the Pearson chi(2) test. The T11-12 was the most commonly affected level of the lower thoracic spine with 58 disc cases rated as abnormal. Abnormalities of T11-12 and T12-L1 discs were significantly related only to L1-L2 disease ( p=0.001 and p=0.004, respectively) but unrelated to other disc disease, patient's gender, and age. No correlation was found between other discs. Magnetic resonance imaging of the lumbar spine can detect a great amount of lower thoracic disease, although its clinical significance remains unknown. A statistically significant relation was found within the thoracolumbar junctional region (T11-L2), reflecting common pathoanatomical changes. The absence of relation with lower lumbar spine discs is probably due to differences in their pathomechanisms.

Upper thoracic-spine disc degeneration in patients with cervical pain.

OBJECTIVE: To study the relationship of upper thoracic spine degenerative disc contour changes on MR imaging in patients with neck pain. The relation between upper thoracic and cervical spine degenerative disc disease is not well established. DESIGN AND PATIENTS: One hundred and fifty-six patients referred with cervical pain were studied. There were 73 women and 77 men with a mean age of 48.6 +/- 14.6 years (range, 19 to 83 years). All MR studies were performed with a large 23-cm FOV covering at least from the body of T4 to the clivus. Discs were coded as normal, protrusion/bulge or extrusion. RESULTS: Degenerative thoracic disc contour changes were observed in 13.4% of patients with cervical pain. T2-3 was the most commonly affected level of the upper thoracic spine, with 15 bulge/protrusions and one extrusion. Upper degenerative thoracic disc contour changes presented in older patients than the cervical levels (Student-Newman-Keuls test, P < 0.001). Degenerative disc contour changes at the C7-T1, T1-2, T2-3 and T3-4 levels were significantly correlated ( P = 0.001), but unrelated to any other disc disease, patient's gender or age. Degenerative cervical disc disease was closely related together ( P < 0.001), but not with any thoracic disc. CONCLUSION: A statistically significant relation was found within the upper thoracic discs, reflecting common pathoanatomical changes. The absence of relation to cervical segments is probably due to differences in their pathomechanisms.

Effect of subcutaneous butylscopolamine administration in the reduction of peristaltic artifacts in 1.5-T MR fast abdominal examinations.

In abdominal MR imaging, ghost artifacts from noncyclic bowel movements can reduce the quality of the images. Although pharmacologic suppression of motion is effective, no study has being conducted to analyze the influence of drug motion suppression on fast breath-hold 1.5-T examinations of the upper abdomen. A prospective, randomized, double-blind trial was conducted in 50 patients. Patients were randomly distributed into two groups: The control group received only an oral solution, whereas the other group received the oral solution plus a subcutaneous injection of 20 mg of butylscopolamine 10 min before the MR examination. Breath-hold T1-weighted gradient-recalled-echo (GRE) MR images were obtained in a 1.5-T superconductive unit. Quantitative image analysis was performed with region-of-interest (ROI) measurements of the signal intensity of the liver and in background air anterior and lateral to the patient. A qualitative analysis of the subjective quality of the T1-weighted images was also done, and the adverse reactions were registered. The groups were homogeneous regarding age, gender, and weight distribution. No significant differences in the signal intensity of the liver and in the incoherent noise measurements were found between the two groups. Gastrointestinal noise showed significant differences between groups, with lower values for the butylscopolamine group compared with the control group. There was also a statistically significant difference in the image quality between groups, and optimal studies were only found in the butylscopolamine group, where most patients had a good-quality evaluation. Regarding adverse events, there were non-significant differences between groups. In conclusion, administration of an antiperistaltic agent to reduce the movements of the gastrointestinal tract diminishes the motion artifacts generated on MR imaging of the abdomen, even at high field strength and with fast imaging sequences. Images of the upper abdomen obtained after pharmacologic suppression of the gastrointestinal movement are of significantly superior quality.

Craniopharyngiomas: identification of different semiological patterns with MRI.

Our objectives were to analyze different semiological patterns in craniopharyngiomas studied with CT and MR sequences. Retrospective study of 26 patients with confirmed craniopharyngiomas. All cases were examined with CT and MR imaging using a variety of pulse sequences (spin echo, inversion recovery, gradient echo in-phase and opposed-phase). The analyzed component patterns were classified as solid, calcium, proteic-like, cerebrospinal fluid (CSF)-like, hematic-like, and fatty patterns. The different patterns were related by means of contingency tables and the Fisher exact test and also to epidemiological findings and tumor size. A solid pole was detected in all patients, whereas a cystic component was present in 92.3% of the cases. Calcification was visualized in 65.3%, proteic-like in 53.8%, CSF-like in 23%, hematic-like in 19.2%, and fatty component in 15.3%. There were no statistical associations between patterns, with the exception that in no case did CSF-like and proteic-like patterns coexist ( P=0.004). Tumor size was related to components. Hematic-like (17.0+/-18.9 vs 3.9+/-2.6 mm, non-present vs present) and CSF-like (16.9+/-19.6 vs 6.5+/-4.0 mm) patterns were observed most frequently in smaller tumors, whereas larger tumors usually had proteic-like (5.9+/-5.4 vs 21.1+/-21.0 mm) and calcified (4.6+/-1.9 vs 19.1+/-19.9 mm) patterns. Computed tomography and a combination of different MR images frequently allow the detection of different semiological patterns in these tumors. Semiological patterns were correlated only to tumor size.

La conización en el diagnóstico y tratamiento de la neoplasia intraepitelial de cuello uterino en la actualidad / Conization in actuality of diagnosis and treatment of intraepitelial cervix neoplam

La conización de cuello uterino se acepta en la actualidad como método diagnóstico y terapéutica, si bien es constante la aparición de tratamientos más conservadores. Su ventaja como método diagnóstico es la obtención de una muestra de tejido para el examen histológico; como método terapéutico, es la certeza de haber tratalo la lesión en su totalidad. Se estudiaron las historias clínicas de 80 pacientes con diagnóstico de neoplasia intraepitelial de cuello uterino a las que se les realizó conización, analizando los datos epidemiológicos así como los estudios citológicos, colposcópico y anatomopatológico del material obtenido por biopsia dirigida. Se destaca que el estudio anatomopatológico de las piezas de conización, mostró patología de mayor jerarquía que la diagnosticada en los estudios previos en 19 pacientes (frecuencia relativa 23,75%). Los hallazgos reafirman la conización de cuello uterino como método diagnóstico y terapéutico