Digital Subtraction Myelography is Associated with Less Radiation Dose than CT-based Techniques.

PURPOSE: Both CT myelogram (CTM) and digital-subtraction myelogram (DSM) can be used to evaluate patients for possible cerebrospinal fluid (CSF) leaks. DSM is a relatively new technique. No data exists on the radiation dose associated with this procedure, and how it compares with CTM. MATERIALS AND METHODS: All patients who underwent DSM for spontaneous intracranial hypotension (SIH) refractory to blood patching from Dec 2016 - Sept 2019 were retrospectively assessed. DSM dose factors were then recorded (cumulative fluoroscopy time, total kerma area product (KAP, mGy.cm2), cumulative air kerma (mGy), as well as CTM dose factors (included CTDIvol (mGy) and dose-length product (DLP, mGy.cm). These indices were then used to calculate the effective dose for both procedures using standardized conversion factors. RESULTS: 61 DSMs were performed in 42 patients, 33 of which also underwent CTM. The median effective dose was 6.6 mSv per DSM study (range: 1.2 - 17.7). On a per-patient basis (i.e. those patients who underwent more than one DSM (as the initial one was negative), the median total effective dose was 13 mSv for their total DSM imaging (range: 2.6 -31.7). For the CTM, the median effective dose was 19.7 mSv (range: 3.2 - 82.4 mSv). CONCLUSION: The radiation dose with DSM appears to be significantly lower than that of CTM (p = 0.0005), when looking at CTM doses both from our institution and in the published literature.

Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion.

OBJECTIVE: Coverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction. METHODS: A multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome. RESULTS: Sixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage. CONCLUSIONS: FD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.

#Fake news: a systematic review of mechanical thrombectomy results among neurointerventional stroke surgeons on Twitter.

OBJECTIVE: Twitter is a popular social media platform among physicians. Neurointerventionalists frequently document their lifesaving mechanical thrombectomy cases on Twitter with very favorable results. We fear that there may be some social media publication bias to tweeted mechanical thrombectomy cases with neurointerventionalists being more likely to tweet cases with favorable outcomes. We used these publicly documented cases to analyze post-intervention Twitter-reported outcomes and compared these outcomes with the data provided in the gold standard literature. METHODS: Two reviewers performed a search of Twitter for tweeted cases of acute ischemic strokes treated with mechanical thrombectomy. Data were abstracted from each tweet regarding baseline characteristics and outcomes. Twitter-reported outcomes were compared with the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke (HERMES) trial individual patient meta-analysis. RESULTS: When comparing the tweeted results to HERMES, tweeted cases had a higher post-intervention rate of modified Thrombolysis In Cerebral Infarction (mTICI) scale score of 2c/3 (94% vs 71%, respectively; p<0.0001) and rate of National Institutes of Health Stroke Scale (NIHSS) score ≤2 (81% vs 21%, respectively; p<0.0001). There were no reported complications; thus, tweeted cases also had significantly lower rates of complications, including symptomatic intracerebral hemorrhage (0% vs 4.4%, respectively; p<0.0001), type 2 parenchymal hemorrhage (0% vs 5.1%, respectively; p<0.0001), and mortality (0% vs 15.3%, respectively; p<0.0001). CONCLUSIONS: There is a significant difference between social media and reality even within the 'MedTwitter' sphere, which is likely due to a strong publication bias in Twitter-reported cases. Content on 'MedTwitter', as with most social media, should be accepted cautiously.

Prophylactic Placement of Internal Iliac Balloons in Patients with Abnormal Placental Implantation: Maternal and Foetal Outcomes.

PURPOSE: To report on outcomes following the use of prophylactic internal iliac artery occlusion balloons in patients with abnormal placental implantation. METHODS: A retrospective analysis was undertaken of patients with abnormal placental implantation who underwent prophylactic iliac balloon placement prior to delivery in a University Maternity Hospital. Various clinical and technical factors were analysed, including technical success of balloon placement, blood loss and number of blood units transfused, duration of surgery, length of stay, hysterectomy rates, complications related to the balloon insertion, foetal pH and infant Apgar scores. RESULTS: Twenty-two patients with placenta accreta or a variant thereof underwent caesarean section after first undergoing prophylactic placement of bilateral internal artery balloons. Average follow-up duration was 2.08 years. The average gestational age was 37 weeks 6 days, and the mean gravidity was 2.8. The mean number of previous caesarean sections was 2.4, while the mean maternal age was 35 years. The mean intraoperative blood loss was 1.4 L, and the mean number of blood units transfused was 2. Mean duration of surgery was 90 min, mean total length of hospital stay 7.5 days, while the mean duration of ICU/HDU stay was 1.2 days. The balloons were inflated in 60% of cases and two patients (2/22-9%) underwent subsequent hysterectomy. There were no major maternal complications due to the procedure. CONCLUSION: Prophylactic placement of arterial balloons prior to caesarean section in patients with placenta accreta is well tolerated and leads to satisfactory maternal and foetal outcomes with minimal complications.

Adult blunt renal trauma: routine follow-up imaging is excessive.

OBJECTIVE: To determine the yield of follow-up imaging in patients sustaining renal trauma at our level-1 trauma center and hence, whether the 2013 European Association of Urology guidelines are clinically applicable. METHODS: All patients who attended Cork University Hospital with a diagnosis of renal injury from 2000-2012 were identified. Review of all medical records and radiologic imaging was undertaken. Injuries were graded using the American Association for the Surgery of Trauma Organ Injury Scale and were grouped as low-grade injuries (I, II, and III) or high-grade injuries (IV and V). RESULTS: One hundred and two patients (105 renal units) were identified with a median age of 23 years (interquartile range, 18-39 years). The mechanism of injury was blunt force in 98 of 102 cases (96%). Injuries were diagnosed at the time of admission using contrast-enhanced computed tomography (CT) imaging. Low-grade injuries accounted for 78 of 102 cases (77%); all were managed conservatively with a complication rate of 2 of 78 (3%). Twenty-four patients (23%) had high-grade injuries; 2 cases required nephrectomy, 22 of 24 (92%) were managed conservatively with a complication rate of 5 of 24 (21%). All patients with complications were symptomatic, prompting repeat imaging. Overall, 38 of 102 patients (37%) underwent at least 1 follow-up CT: 20 of 78 (25%) of low-grade injuries and 18 of 24 (75%) of high-grade injuries. Concurrent thoracoabdominal injuries mandated the need for repeat CT evaluation in 21 of 38 patients (55%). Thirty-one (30%) patients were reimaged by renal ultrasonography. CONCLUSION: Selective reimaging of renal injuries based on clinical and laboratory criteria would have detected all complications. The 2013 European Association of Urology guidelines on urologic trauma are clinically appropriate in a major tertiary-trauma unit.