Endovascular repair of a giant common hepatic aneurysm.

Hepatic artery aneurysms are a rare phenomenon but their diagnosis and prompt treatment are imperative due to a high risk of mortality and complications. Appropriate management depends on patient characteristics, anatomical location of the aneurysm, operative risk and collateral arterial supply. Management options include surgical and endovascular approaches. The endovascular approach has gained popularity over recent years as it is an effective and less invasive alternative to surgical management. In this case report, we present a giant common hepatic artery aneurysm and its successful endovascular management. The patient had a complete resolution of symptoms after the procedure and remained well 8 months postprocedure.

Radioembolization for Treatment of Hepatocellular Carcinoma: Current Evidence and Patterns of Utilization.

Primary liver malignancy, of which hepatocellular carcinoma (HCC) is the most common type, is the second most common cause of death due to cancer worldwide. Given the historically poor prognosis of liver cancer, there has been major research on its treatment options, with significant advancements over the last decade. Transarterial radioembolization (TARE) is a locoregional treatment option for HCC that involves transarterial delivery of the ß-emitter yttrium-90 via resin or glass microspheres to arterialized tumor vasculature, delivering a tumoricidal dose to the tumor. The recent 2022 update of the Barcelona Clinic Liver Cancer (BCLC) treatment algorithm features a more prominent role for locoregional treatment, including the incorporation of radioembolization for very-early-stage (BCLC-0) and early-stage (BCLC-A) diseases. This review provides a contemporary summary of the evolving role of TARE in treatment of HCC in light of recent and upcoming trials.

A Systematic Review and Meta-analysis of Patient Survival and Disease Recurrence Following Percutaneous Ablation of Pulmonary Metastasis.

BACKGROUND: Pulmonary metastasectomy has been widely adopted in the treatment of metastatic disease. In recent years image guided ablation has seen increased use in the treatment of thoracic malignancies. The objective of this study was to evaluate oncological outcomes following percutaneous ablation (PA) of pulmonary metastasis. METHODS: A comprehensive search of the PubMed, MEDLINE and EMBASE databases from January 2000 to August 2021 was performed to identify studies evaluating patient survival following ablation of lung metastasis. Pooled outcomes have been presented with a random effects model to assess primary outcomes of overall survival, progression free survival and 1-year local control. Secondary outcomes included procedural mortality, major complications, and the incidence of pneumothorax. RESULTS: A total of 24 studies were identified. The pooled median overall survival was 5.13 [95% confidence interval (CI): 4.37-6.84] years, and the 1-, 3-, 5-year progression free survival rates were 53%, 26% and 20% respectively. The 1-year local control rate was 91% (95%CI: 86-95%). Periprocedural mortality was rare (0%; 95%CI: 0-1%), as were major complications excluding pneumothorax (1%; 95%CI: 1-2%). Pneumothorax developed in 44% of ablation sessions, although only half of these required chest tube placement. Most patients were able to be discharged day one post-procedurally. CONCLUSION: PA demonstrates high overall, progression free and local tumour survival in patients with lung metastasis. Complications and mortality are also rare. Consideration of its use should be made in a tumour board meeting in conjunction with surgical and radiotherapy perspectives for targeted local control of metastases.

Intracranial atherosclerotic disease and acute ischaemic stroke: A review of diagnosis and management.

Intracranial atherosclerotic disease is highly prevalent and a common cause of ischaemic stroke globally. With the increasing use of endovascular treatment for acute stroke management, computed tomography and magnetic resonance imaging have become an essential part of patient selection. In this review, we present the typical imaging findings of intracranial atherosclerosis and an overview of management as relevant to diagnostic and interventional radiologists.

Development of a machine learning-based real-time location system to streamline acute endovascular intervention in acute stroke: a proof-of-concept study.

BACKGROUND: Delivery of acute stroke endovascular intervention can be challenging because it requires complex coordination of patient and staff across many different locations. In this proof-of-concept paper we (a) examine whether WiFi fingerprinting is a feasible machine learning (ML)-based real-time location system (RTLS) technology that can provide accurate real-time location information within a hospital setting, and (b) hypothesize its potential application in streamlining acute stroke endovascular intervention. METHODS: We conducted our study in a comprehensive stroke care unit in Melbourne, Australia that offers a 24-hour mechanical thrombectomy service. ML algorithms including K-nearest neighbors, decision tree, random forest, support vector machine and ensemble models were trained and tested on a public WiFi dataset and the study hospital WiFi dataset. The hospital dataset was collected using the WiFi explorer software (version 3.0.2) on a MacBook Pro (AirPort Extreme, Broadcom BCM43x×1.0). Data analysis was implemented in the Python programming environment using the scikit-learn package. The primary statistical measure for algorithm performance was the accuracy of location prediction. RESULTS: ML-based WiFi fingerprinting can accurately predict the different hospital zones relevant in the acute endovascular intervention workflow such as emergency department, CT room and angiography suite. The most accurate algorithms were random forest and support vector machine, both of which were 98% accurate. The algorithms remain robust when new data points, which were distinct from the training dataset, were tested. CONCLUSIONS: ML-based RTLS technology using WiFi fingerprinting has the potential to streamline delivery of acute stroke endovascular intervention by efficiently tracking patient and staff movement during stroke calls.

Application of a computational model in simulating an endovascular clot retrieval service system within regional Australia.

INTRODUCTION: The global demand for endovascular clot retrieval (ECR) has grown rapidly in recent years creating challenges to healthcare system planning and resource allocation. This study aims to apply our established computational model to predict and optimise the performance and resource allocation of ECR services within regional Australia, and applying data from the state of South Australia as a modelling exercise. METHOD: Local geographic information obtained using the Google Maps application program interface and real-world data was input into the discrete event simulation model we previously developed. The results were obtained after the simulation was run over 5 years. We modelled and compared a single-centre and two-centre ECR service delivery system. RESULTS: Based on the input data, this model was able to simulate the ECR delivery system in the state of South Australia from the moment when emergency services were notified of a potential stroke patient to potential delivery of ECR treatment. In the model, ECR delivery improved using a two-centre system compared to a one-centre system, as the percentage of stroke patients requiring ECR was increased. When 15% of patients required ECR, the proportion of 'failure to receive ECR' cases for a single-centre system was 17.35%, compared to 3.71% for a two-centre system. CONCLUSIONS: Geolocation and resource utilisation within the ECR delivery system are crucial in optimising service delivery and patient outcome. Under the model assumptions, as the number of stroke cases requiring ECR increased, a two-centre ECR system resulted in increased timely ECR delivery, compared to a single-centre system. This study demonstrated the flexibility and the potential application of our DES model in simulating the stroke service within any location worldwide.

Artificial intelligence in clinical decision support and outcome prediction - applications in stroke.

Artificial intelligence (AI) is making a profound impact in healthcare, with the number of AI applications in medicine increasing substantially over the past five years. In acute stroke, it is playing an increasingly important role in clinical decision-making. Contemporary advances have increased the amount of information - both clinical and radiological - which clinicians must consider when managing patients. In the time-critical setting of acute stroke, AI offers the tools to rapidly evaluate and consolidate available information, extracting specific predictions from rich, noisy data. It has been applied to the automatic detection of stroke lesions on imaging and can guide treatment decisions through the prediction of tissue outcomes and long-term functional outcomes. This review examines the current state of AI applications in stroke, exploring their potential to reform stroke care through clinical decision support, as well as the challenges and limitations which must be addressed to facilitate their acceptance and adoption for clinical use.

Chronic lymphocytic infiltration with pontine perivascular enhancement responsive to steroids (CLIPPERS) and its association with Epstein-Barr Virus (EBV)-related lymphomatoid granulomatosis: a case report.

BACKGROUND: Chronic lymphocytic infiltration with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a neuro-inflammatory syndrome first described in 2010. It has a relationship with lymphoproliferative disorders that has not been fully elucidated. This case represents an unusual progression of CLIPPERS to Epstein-Barr Virus (EBV)-related lymphomatoid granulomatosis (LYG). The exact connection between CLIPPERS and LYG remains poorly understood. CASE PRESENTATION: We present a case of a 75-year-old man who was diagnosed with CLIPPERS with initial response to immunosuppression but later progressed to EBV-related LYG. EBV polymerase chain reaction (PCR) was detected in his cerebrospinal fluid (CSF), and repeat imaging revealed findings that were uncharacteristic for CLIPPERS; thereby prompting a brain biopsy which led to a diagnosis of EBV-related LYG. This case highlights the following learning points: 1) CLIPPERS cases are often part of a spectrum of lymphomatous disease, 2) CLIPPERS can be associated with EBV-related lymphoproliferative disorders such as LYG, and 3) EBV detection in CSF should prompt earlier consideration for brain biopsy in patients. CONCLUSIONS: Our case highlights the difficulty in distinguishing CLIPPERS from other steroid-responsive conditions such as neoplastic and granulomatous diseases. Given the association of CLIPPERS with EBV-related LYG as demonstrated in this case, we recommend testing for EBV in CSF for all patients with suspected CLIPPERS. An early referral for brain biopsy and treatment with rituximab should be considered for patients with suspected CLIPPERS who test positive for EBV in their CSF.

Social media in interventional radiology.

INTRODUCTION: Social media provides opportunities for Interventional Radiologists to share research, communicate with colleagues, provide health information and advertise their clinical practice. This study aims to examine the online and social media presence of currently practicing Australian Interventional Radiologists. METHODS: Systematic Google searches were undertaken in May 2019 and updated in May 2020 to identify practicing Interventional Radiologists in Australia. Comprehensive searches of practice websites and social media platforms (Facebook, LinkedIn, Twitter, ResearchGate, YouTube) were undertaken for each Interventional Radiologist. RESULTS: There were 265 Interventional Radiologists identified as currently practising in Australia, including 209 Interventional Radiologists (excluding Interventional Neuroradiologists), 49 Interventional Neuroradiologists and 7 that practise across both Interventional Radiology and Interventional Neuroradiology. 72% of Interventional Radiologists had at least one social media account, with LinkedIn the most widely used social media platform (60%). There was a significant negative correlation between the total number of social media accounts and years in practice (P = 0.04). Across the states, a higher population per IR was positively correlated with a higher average number of social media accounts per IR (P = 0.04). Interventional Neuroradiologists had a significantly higher average number of social media accounts compared to Interventional Radiologists (1.94 vs 1.29, P < 0.01). CONCLUSIONS: Most Australian Interventional Radiologists have a readily identifiable social media presence. There is potential for further utilisation of social media for academic, educational and business purposes.

Review of deep learning algorithms for the automatic detection of intracranial hemorrhages on computed tomography head imaging.

Artificial intelligence is a rapidly evolving field, with modern technological advances and the growth of electronic health data opening new possibilities in diagnostic radiology. In recent years, the performance of deep learning (DL) algorithms on various medical image tasks have continually improved. DL algorithms have been proposed as a tool to detect various forms of intracranial hemorrhage on non-contrast computed tomography (NCCT) of the head. In subtle, acute cases, the capacity for DL algorithm image interpretation support might improve the diagnostic yield of CT for detection of this time-critical condition, potentially expediting treatment where appropriate and improving patient outcomes. However, there are multiple challenges to DL algorithm implementation, such as the relative scarcity of labeled datasets, the difficulties in developing algorithms capable of volumetric medical image analysis, and the complex practicalities of deployment into clinical practice. This review examines the literature and the approaches taken in the development of DL algorithms for the detection of intracranial hemorrhage on NCCT head studies. Considerations in crafting such algorithms will be discussed, as well as challenges which must be overcome to ensure effective, dependable implementations as automated tools in a clinical setting.

Environmental sustainability in neurointerventional procedures: a waste audit.

BACKGROUND: Operating rooms contribute between 20% to 70% of hospital waste. This study aimed to evaluate the waste burden of neurointerventional procedures performed in a radiology department, identify areas for waste reduction, and motivate new greening initiatives. METHODS: We performed a waste audit of 17 neurointerventional procedures at a tertiary-referral center over a 3-month period. Waste was categorized into five streams: general waste, clinical waste, recyclable plastic, recyclable paper, and sharps. Our radiology department started recycling soft plastics from 13 December 2019. Hence, an additional recyclable soft plastic waste stream was added from this time point. The weight of each waste stream was measured using a digital weighing scale. RESULTS: We measured the waste from seven cerebral digital subtraction angiograms (DSA), six mechanical thrombectomies (MT), two aneurysm-coiling procedures, one coiling with tumour embolization, and one dural arteriovenous fistula embolization procedure. In total, the 17 procedures generated 135.3 kg of waste: 85.5 kg (63.2%) clinical waste, 28.0 kg (20.7%) general waste, 14.7 kg (10.9%) recyclable paper, 3.5 kg (2.6%) recyclable plastic, 2.2 kg (1.6%) recyclable soft plastic, and 1.4 kg (1.0%) of sharps. An average of 8 kg of waste was generated per case. Coiling cases produced the greatest waste burden (13.1 kg), followed by embolization (10.3 kg), MT (8.8 kg), and DSA procedures (5.1 kg). CONCLUSION: Neurointerventional procedures generate a substantial amount of waste, an average of 8 kg per case. Targeted initiatives such as engaging with suppliers to revise procedure packs and reduce packaging, digitizing paper instructions, opening devices only when necessary, implementing additional recycling programs, and appropriate waste segregation have the potential to reduce the environmental impact of our specialty.

The urachus revisited: multimodal imaging of benign & malignant urachal pathology.

The urachus is a fibrous tube extending from the umbilicus to the anterosuperior bladder dome that usually obliterates at week 12 of gestation, becoming the median umbilical ligament. Urachal pathology occurs when there is incomplete obliteration of this channel during foetal development, resulting in the formation of a urachal cyst, patent urachus, urachal sinus or urachal diverticulum. Patients with persistent urachal remnants may be asymptomatic or present with lower abdominal or urinary tract symptoms and can develop complications. The purpose of this review is to describe imaging features of urachal remnant pathology and potential benign and malignant complications on ultrasound, CT, positron emission tomography CT and MRI.

Synovial sarcoma mimicking a traumatic pseudoaneurysm in the upper extremity.

Synovial sarcomas are a rare but aggressive malignancy that primarily affects young patients. Diagnosis is often difficult and delayed due to its insidious onset, heterogenous presentation and mimicry of other pathologies. We present the case of a patient with a history of a slow-growing left arm mass that arose after a traumatic fracture of the humerus. Multimodal imaging was undertaken and reported the mass as being consistent with a vascular malformation of the brachial artery. The patient underwent surgical repair of the artery and intraoperative biopsies confirmed a diagnosis of synovial sarcoma. This case highlights the importance of maintaining suspicion for soft-tissue sarcomas in young patients presenting with a mass, and demonstrates the way in which these tumours may mimic other pathologies both clinically and radiologically. Early referral to a specialist sarcoma centre is key for further investigative workup.

Endovascular treatment of a hepatic artery pseudoaneurysm using a novel pericardium covered stent.

Visceral and renal artery aneurysms (VRAAs) and pseudoaneurysms are rare. Their increasing incidence is largely thought to be due to advances in medical imaging. Twenty percent of VRAAs occur in hepatic arteries, with approximately fifty percent of these represented by pseudoaneurysms, which are prone to spontaneous rupture. Many treatments for VRAAs exist, with the endovascular approach being favoured. Treatment aims to preserve visceral perfusion and exclude the aneurysm; however, complex aneurysms may require parent artery or end-organ sacrifice. Covered stents allow rapid aneurysm exclusion while preserving parent artery patency, a favourable outcome when parent artery or end-organ sacrifice is undesirable. The AneuGraft pericardium covered stent (PCS) combines the benefits of a low-profile covered stent with those of a low immunogenic material. We describe the endovascular treatment of a patient with a hepatic artery pseudoaneurysm, where parent artery sacrifice was considered unacceptable. The AneuGraft PCS was used to provide immediate and complete exclusion, with dual antiplatelet therapy for 1 week, followed by single antiplatelet use. The procedure was a technical success, with preservation of the hepatic arteries and complete exclusion of the pseudoaneurysm. There were no complications immediately following the procedure or on post-procedural follow-up. The pseudoaneurysm remained excluded at 6-week CT angiogram (CTA) follow-up. This case describes a safe and effective method for completely excluding a complex pseudoaneurysm, utilising the AneuGraft PCS, allowing for the potential management of a wider range of aneurysms with unfavourable morphology.

Vertebroplasty for acute painful osteoporotic vertebral compression fractures: An update.

Vertebral compression fractures (VCFs) are a common cause of back pain and disability and are usually osteoporotic in nature. Therapy aims to adequately control pain and allow early mobilisation and return of function while preventing additional fractures. A proportion of patients do not achieve adequate pain relief using conservative measures alone. Unwanted adverse effects from medications may also ensue. Vertebroplasty represents an alternative treatment option for VCFs. Patients with acute VCFs (≤6 weeks old) may gain the most benefit from vertebroplasty as healed fractures are not as amenable to cement injection. High-quality studies have reported conflicting results regarding the use of vertebroplasty in the treatment of acute VCFs. Despite high-quality evidence, varying study designs and heterogenous patient cohorts make interpretation of this data difficult. Only one sham-controlled randomised controlled trial (RCT) has evaluated vertebroplasty exclusively in patients with acute VCFs, reporting favourable results. Pooled data from RCTs also suggest vertebroplasty to be safe. This article provides a concise and critical review of the current literature regarding vertebroplasty for the treatment of acute VCFs.