Risk Factors for Contrast Media Extravasation in Intravenous Contrast-Enhanced Computed Tomography: An Observational Cohort Study.

RATIONALE AND OBJECTIVES: To identify the risk factors for contrast media (CM) extravasation and provide effective guidance for reducing its incidence. MATERIALS AND METHODS: We observed adult inpatients (n = 38 281) who underwent intravenous contrast-enhanced computed tomography between January 1, 2018, and December 31, 2022. Risk factors for CM extravasation were evaluated using univariate and multivariate logistic regression. RESULTS: Among the 38 281 inpatients who underwent enhanced computed tomography angiography, 3885 received peripherally inserted central venous catheters (PICCs) and 34 396 received peripheral short catheters. In 3885 cases of PICCs, no CM extravasation occurred, but in five cases, ordinary PICCs that are unable to withstand high pressure were mistakenly used; three of those patients experienced catheter rupture, and eventually, all five patients underwent unplanned extubation. Among 34 396 cases of peripheral short catheters, 224 (0.65%) had CM extravasation. Female sex (odds ratio [OR]=1.541, 95% confidence interval [CI]: 1.111-2.137), diabetes (OR=2.265, 95% CI: 1.549-3.314), venous thrombosis (OR=2.157, 95% CI: 1.039-4.478), multi-site angiography (OR=9.757, CI: 6.803-13.994), and injection rate ≥ 3 mL/s (OR=6.073, 95% CI: 4.349-8.481) were independent risk factors for CM extravasation. Due to peripheral vascular protection measures in patients with malignant tumor, there was a low incidence of CM extravasation (OR=0.394, 95% CI: 0.272-0.570). CONCLUSION: Main risk factors for CM extravasation are female, diabetes, venous thrombosis, multi-site angiography, and injection rate ≥ 3 mL/s. However, patients with malignant tumor have a low incidence of CM extravasation. CLINICAL IMPACT: Analysis of these risk factors can help reduce the incidence of CM extravasation.

Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study.

BACKGROUND: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). METHODS: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). RESULTS: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. CONCLUSION: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. LEVEL OF EVIDENCE: Level 4; Therapeutic/Care management.

Angiography in patients with pelvic fractures and contrast extravasation on CT following high-energy trauma.

INTRODUCTION: Pelvic fracture may be accompanied by severe bleeding. Computed tomography (CT) is a gold standard diagnostic tool in stable trauma patients. Contrast extravasation detected on CT of pelvis is a sign of hemorrhage, but its significance is not clear. We aimed to evaluate the need for angiography in patients with pelvic fracture and CT revealed contrast extravasation. We tried to identify parameters that might help to choose patients who will benefit from therapeutic angiography. METHODS: Electronic medical records of patients with pelvic fracture admitted to Level II Trauma Center during 10 years were retrospectively reviewed. Patients who had contrast extravasation on CT were included. Data base consisted of demographics, injury severity, initial physiologic parameters, laboratory data, results of CT and angiography. RESULTS: Forty out of 396 patients had contrast extravasation detected by CT. Twelve patients underwent angiography and 4 of them benefited from embolization. The sensitivity of contrast extravasation in evaluating the need for embolization was 1.0 (95% CI 0.398, 1.0), positive predictive value was 0.1 (95% CI 0.028, 0.237), and the negative predictive value was 1.0 (95% CI 0.990, 1.0). CONCLUSION: The role of angiography in stable patients with pelvic fracture and CT identified contrast extravasation remains questionable. Most of these patients are not in need of angioembolization.

Optical tissue clearing and machine learning can precisely characterize extravasation and blood vessel architecture in brain tumors.

Precise methods for quantifying drug accumulation in brain tissue are currently very limited, challenging the development of new therapeutics for brain disorders. Transcardial perfusion is instrumental for removing the intravascular fraction of an injected compound, thereby allowing for ex vivo assessment of extravasation into the brain. However, pathological remodeling of tissue microenvironment can affect the efficiency of transcardial perfusion, which has been largely overlooked. We show that, in contrast to healthy vasculature, transcardial perfusion cannot remove an injected compound from the tumor vasculature to a sufficient extent leading to considerable overestimation of compound extravasation. We demonstrate that 3D deep imaging of optically cleared tumor samples overcomes this limitation. We developed two machine learning-based semi-automated image analysis workflows, which provide detailed quantitative characterization of compound extravasation patterns as well as tumor angioarchitecture in large three-dimensional datasets from optically cleared samples. This methodology provides a precise and comprehensive analysis of extravasation in brain tumors and allows for correlation of extravasation patterns with specific features of the heterogeneous brain tumor vasculature.

Intraperitoneal Barium From Gastrointestinal Perforations: Reassessment of the Prognosis and Long-Term Effects.

OBJECTIVE. The purpose of this study was to reassess the outcome and potential consequences of intraperitoneal barium leakage during radiologic evaluation of the gastrointestinal tract. MATERIALS AND METHODS. This retrospective study included 18 patients who had significant intraperitoneal leakage of barium from gastrointestinal perforations that were not suspected or diagnosed before the radiologic procedures. This complication occurred during a barium enema examination in nine patients, an upper gastrointestinal study in seven, and a small bowel series in two patients. All patients underwent urgent laparotomy for repair of perforation, with vigorous peritoneal lavage and antibiotic therapy. RESULTS. All patients had an uneventful recovery and were followed for 4-17 years (mean, 8.5 years). Radiographs obtained during this interval showed that a significant amount of residual barium was retained in the abdominal cavity. Six patients had a total of 10 subsequent abdominal operations for unrelated conditions, and some had developed barium granulomas and peritoneal adhesions. However, none of the patients in this series experienced intestinal obstruction or any clinical symptoms related to barium deposits in the abdominal cavity. CONCLUSION. Intraperitoneal leakage of barium is a rare complication of radiologic gastrointestinal examinations, and this series of 18 cases reflects 3 decades of experience at two major medical centers. The presented data indicate that the commonly held and perpetuated concept about the high rate of morbidity and mortality of this complication would not be valid in the modern era of medical and surgical management.

The role of computed tomography angiography as initial imaging tool for acute hemorrhage in the head and neck.

OBJECTIVES: Acute hemorrhage in the head and neck (AHNH) is life-threatening due to asphyxiation and hemorrhagic shock. When conservative measures fail, some patients benefit from endovascular therapy (EVT). While CTA is routinely used to localize bleeding and plan EVT in gastrointestinal hemorrhage, the diagnostic value of CTA in AHNH and role of CTA in treatment-planning are uncertain. METHODS: We retrospectively reviewed neck CTAs from June 2015 to October 2018 indicated for AHNH. When performed, digital subtraction angiography (DSA) findings and EVT were documented. Extravasation or pseudoaneurysm on DSA was considered positive for bleed localization. RESULTS: Thirty CTA exams were performed for AHNH in 18 patients (mean age = 56.6, male% = 55.6%). Eleven out of 30 exams (36.7%) had immediate DSA follow-up within 24 h. Etiologies of hemorrhage included malignancy 11/18 (61.1%) and coagulopathy (4/18, 22.2%) among others. CTA reports identified definite or possible source of bleeding in 7/30 (23.3%) exams. Seven out of 7 (100%) patients with definite or possible source of bleeding on CTA underwent DSA and 4/23 (17.4%) patients underwent DSA despite negative CTA. With DSA as the gold standard, CTA had a sensitivity of 70% and a specificity of 100%. CONCLUSIONS: CTA has high specificity and reasonable sensitivity for detecting arterial source of bleeding in patients presenting with AHNH. Patients with negative CTA may avoid catheter angiography in most cases; however, false-negative CTA should not preclude angiography in high-risk patients.

Cement arteriovenogram after hip arthroplasty. / Arteriovenograma de cemento óseo en artroplastia de cadera.

Modern cement implantation techniques during hip arthroplasty rely on high intramedullary pressures which can result in cement extrusion towards femoral nutrient vessels, and thus, the occurrence of a particular image in postoperative radiographs (bone cement arterio-venogram). We report a case series of 14 patients in whom a bone cement arterio-venogram was observed after undergoing a cemented hip arthroplasty. No local or systemic complications developed after cementing nor during a mean follow-up of three years. Bone cement arterio-venogram is a radiologic sign that indicates a good cement pressurisation during surgery and is not associated to medical complications or periprosthetic femoral fractures.

Urethrogram: Does Postoperative Contrast Extravasation Portend Stricture Recurrence?

OBJECTIVE: To demonstrate our hypothesis that the presence of extravasation on postoperative urethrogram is inconsequential for disease recurrence in urethroplasty postoperative follow-up. MATERIALS AND METHODS: We utilized the Trauma and Urologic Reconstructive Network of Surgeons database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as <17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during 1 year of follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting anatomic and functional recurrence of urethral stricture disease. RESULTS: Among 1101 patients with cystoscopy follow-up, 54 (4.9%) had extravasation on initial postoperative urethrogram. Among those 54, 74.1% developed an anatomic recurrence vs 13% without extravasation (P <.001). Similarly, functional recurrence was 9.3% with extravasation vs 3.2 % without extravasation (P = .04). Patients with extravasation more often reported a postoperative urinary tract infection (12.9% vs 2.7%; P <.01) or wound infection (7.4% vs 2.6%; P = .04). Sensitivity of postoperative urethrogram in predicting any recurrence was 27.3%, specificity 98.7%, positive predictive value 77.8%, and negative predictive value 89.3%. Fourty-five of 54 patients with extravasation had a recurrence of some kind, equating to a 22.2% urethroplasty success rate at 1 year. CONCLUSION: Postoperative urethrogram has a high specificity but low sensitivity for anatomic and functional recurrence during short term follow-up. The positive predictive value of urinary extravasation is high: patients with extravasation incur a high risk of anatomic recurrence within 1 year and such patients may warrant increased monitoring.

Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients.

To investigate computed tomography and angiography findings and clinical outcomes after transcatheter arterial embolization for acute upper gastrointestinal bleeding from advanced gastric cancers.From January 2005 to December 2014, 58 patients with pathologically proven gastric cancer were treated at our institution with transcatheter arterial embolization due to acute upper gastrointestinal bleeding recalcitrant to endoscopic treatment. The electronic medical records for each patient were reviewed for clinical presentation, endoscopy history, computed tomography and angiographic findings, blood transfusion requirements, and follow-up results.Angiography findings were positive in 13 patients (22.4%): contrast extravasation was found in 9 patients and pseudoaneurysm in 4 patients. All patients with positive angiograms underwent selective embolization treatment. Those with negative angiography findings underwent empirical embolization. Gelfoam, n-butyl cyanoacrylate, coils, or a combination of these were used as embolic agents. The overall clinical success rate was 72.4% (42/58), and the success rate for patients with positive angiography was 53.8% (7/13). The median survival was 97.5 days (range, 7-1415 days), and the 1-month survival rate was 89.6% (52/58). The 1-month survival rate of the clinical success group was 95.2% (40/42), which was significantly higher than that of the clinical failure group (P = .04). The clinical success group also required significantly fewer transfusions (2.43 units, range 0-24 units) (P = .02).Transcatheter arterial embolization is a highly effective treatment for advanced gastric cancer with active bleeding. It should be considered as an additional treatment, especially when endoscopic or surgical treatment fails or when these approaches are difficult.

Extravasation and fluid collection on computed tomography imaging in patients with colonic diverticular bleeding.

OBJECTIVE: We evaluated the characteristics of patients with diverticular bleeding in whom emergency endoscopy should be proactively performed and those in whom it is unnecessary for spontaneous hemostasis following conservative treatment. METHODS: This study involved 132 patients in whom diverticular bleeding was diagnosed on lower gastrointestinal endoscopy. We evaluated the rate of identification of the bleeding diverticulum during endoscopy and the rate of spontaneous hemostasis following conservative treatment. RESULTS: In 26 patients (20%), bleeding diverticulum was identified during endoscopy. Extravasation or fluid collection on CT imaging was an important factor of successful identification of the bleeding source on endoscopy. Of the 104 patients in the conservative treatment group, 91 (87%) were able to be discharged after spontaneous hemostasis. Univariate analysis revealed a high rate of spontaneous hemostasis in patients without extravasation and fluid collection on CT imaging, those without adhesion of blood during endoscopy, those without diabetes, and those with a hemoglobin level ≥10 g/dL. CONCLUSION: In patients with colonic diverticular bleeding, extravasation or fluid collection on CT is an important factor related to the identification of the bleeding diverticulum. Patients without characteristic CT findings had a high rate of spontaneous hemostasis after conservative treatment. BACKGROUND: Diverticular bleeding is the most frequent cause of lower gastrointestinal bleeding accounting for 20%-40% of all cases in Japan and 20%-48% of all those in the Western countries[1, 2]. The prevalence of colonic diverticula tends to increase with age; thus, the overall prevalence of diverticular bleeding is expected to increase in the future. In Japan, the Japanese Gastroenterological Association published guidelines on colonic diverticulitis in 2017; these guidelines recommend the performance of lower gastrointestinal endoscopic examination within 24 h in patients with lower gastrointestinal bleeding suspected to be diverticular bleeding[3]. It has been reported that, for patients with lower gastrointestinal bleeding, urgent endoscopy helps avoid embolotherapy, colectomy, massive blood transfusion, and repeat bleeding[1, 4, 5]. However, it is often difficult to identify the bleeding point [6]; further, there are many challenging cases wherein it is difficult to decide whether urgent endoscopy should be performed in situations where there is insufficient medical staff, such as during nighttime and on holidays. Bleeding is reported to stop spontaneously with conservative treatment alone in 70% of diverticular bleeding cases[7, 8]. In particular, when determining the treatment policy for diverticular bleeding and in the case of patients at high risk of complications following endoscopy, such as older patients, those with poor performance status or cardiovascular disease, and those in whom spontaneous hemostasis can be expected, urgent endoscopy should be avoided, and elective endoscopy should be selected. Therefore, the type of cases wherein urgent endoscopy is effective and the type wherein it is unnecessary need to be clarified. Thus far, there have been very few reports of the characteristics of patients with diverticular bleeding in whom spontaneous hemostasis was achieved. We aimed to assess the characteristics of patients in whom emergency endoscopy should be proactively performed and those for whom it is unnecessary. Thus, we retrospectively analyzed the identification rate for the responsible diverticulum in patients with diverticular bleeding and the rate of spontaneous hemostasis following conservative treatment.

Arterial contrast extravasation in severe seat belt-related female breast trauma on CT: Conservative management at a level 1 trauma centre.

Seat belt-related female breast trauma (SFBT) is an uncommon cause of haemorrhage following motor vehicle collision. Classification systems have been used to grade the severity of SFBT, ranging from mild class I to severe class IV injuries with evidence of active haemorrhage. In the case of class IV injuries, contrast extravasation represents active haemorrhage, prompting angiographic embolisation or surgery to arrest the bleed. Contrary to the majority of reports published in the literature, our institution has been successful with conservative management of class IV SFBT. None of the patients required specific intervention to control haemorrhage from SFBT.

Managing chemotherapy extravasation in totally implantable central venous access: Use of subcutaneous wash-out technique.

BACKGROUND: Totally implanted venous access is widely used in chemotherapy administration. With over 1 million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment. METHODS: We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Subcutaneous wash-out treatments were carried out exclusively, without the application of antidotes or the use of specific antidotes. RESULTS: We documented seven cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The five patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these five patients, chemotherapy was restarted within 1 month following extravasation. CONCLUSION: This study would argue for the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.

Renal Excretion of Contrast on CT Myelography: A Specific Marker of CSF Leak.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the sensitivity and specificity of renal/ureteric opacification on postmyelographic CT as a sign of CSF leak. MATERIALS AND METHODS: We performed a retrospective review of postmyelographic CT scans from 49 consecutive patients seen between January 2008 and August 2018 with imaging and/or clinical findings related to intracranial hypotension. Each scan was evaluated by both a neuroradiology fellow and a board-certified neuroradiologist for the presence of contrast in the renal excretory system. A similar assessment was also performed on 90 consecutive control subjects who underwent CT myelography for alternative indications. RESULTS: Among the 49 patients with suspected CSF leak, 21 (43%) had an overt CSF leak on postmyelographic CT (group 1) and 28 (57%) did not (group 2). Overall, renal contrast was identified in 7/49 patients (14.3%): 5 (24%) patients in group 1, and 2 (7%) patients in group 2. Renal contrast was not seen in any of the 90 controls on postmyelographic CT. CONCLUSIONS: Renal contrast was exclusively seen in patients with a clinically or radiographically suspected CSF leak. Given its 100% specificity, identification of this finding should prompt a second look for subtle myelographic contrast extravasation or an underlying CSF-venous fistula. Our results suggest that this sign may be considered an additional diagnostic criterion for CSF leak in the absence of an identifiable leak.

The role of multiphase CT in patients with acute postoperative bleeding after liver transplantation.

PURPOSE: The aim of this study was to investigate the role of multiphase computed tomography (CT) in patients with acute postoperative bleeding after liver transplantation(LT). METHODS: We retrospectively analyzed multiphase CT images in 270 post-LT bleeding patients between November 2013 and December 2017, with special attention to contrast extravasation (type I, focal or stipple; type II, jet). Patients were classified into conservative management trial and primary therapeutic intervention groups by initial treatment strategy, and then conservative management trial group was subdivided into successful conservative management and conservative management failure groups. On multiphase CT, we evaluated contrast extravasation volume, rate, and patterns (focal or stipple vs. jet). The concordances of the bleeding source determined by multiphase CT to the actual bleeding source were analyzed. RESULTS: Of 270 patients, 134 contrast extravasation sites were identified in 116 (43.0%) patients. Most (94.8%, 146/154) of patients without contrast extravasation was successfully managed by conservative management. The mean volume and rate of contrast extravasation significantly increased in order of successful conservative management, conservative management failure, and primary therapeutic intervention groups (all p < 0.01). In subgroup analysis, jet pattern contrast extravasation was more commonly observed with conservative management failure group (p = 0.01). In addition, the change in pattern of contrast extravasation from type I to II was significantly related to the conservative management failure (OR 10.3; 95% CI 1.8-60.4; p = 0.01). There was substantial agreement in localization of bleeding source between multiphase CT and surgery or angiography (Cohen Kappa = 0.78). CONCLUSION: Multiphase CT is helpful in the assessment for need of therapeutic intervention and to determine the treatment of choice in recipient with post-LT bleeding.

Incidence and Clinical Risk of Cement Extravasation in Adult Patients Undergoing Prophylactic Vertebroplasty During Surgical Spine Reconstruction.

OBJECTIVE: To measure the incidence and severity of cement extravasation in adult patients undergoing prophylactic vertebroplasty as part of a spinal reconstruction procedure. METHODS: Consecutive adult patients treated with prophylactic vertebroplasty during a spinal reconstruction procedure were reviewed over a 46-month period. Patients without a postoperative computed tomography scan were excluded. Spine reconstruction was defined as any procedure involving ≥6 levels of fusion or a 3-column osteotomy. Cement extravasation was graded using a novel grading system. Fisher exact tests were performed to identify independent predictors of cement extravasation. RESULTS: Inclusion and exclusion criteria were met by 34 patients comprising 112 vertebral bodies (VB). All 34 patients (100%) had computed tomography evidence of cement extravasation. Of 112 VBs, 103 (92.0%) demonstrated cement extravasation. Thirteen VBs (11.6%) in 9 patients (26.5%) had cement extending to the vena cava or end-organs or cement causing spinal canal stenosis (grade 4 and 5 extravasation). No permanent clinical sequelae were found in these 9 patients. Upper thoracic vertebrae (C7-T6) had significantly higher rates of grade 4 and 5 extravasation than lower thoracic-lumbar vertebrae (T7-L5) (P = 0.004). CONCLUSIONS: Although no patients in this study experienced known long-term consequences of prophylactic vertebroplasty, 26.5% of patients had cement extravasation that threatened end-organs or neural elements. These results prompted us to change our practice from cementing upper thoracic VBs to using hooks instead. Cement injection is associated with serious risks and should be performed selectively. Larger prospective studies are needed to verify these results.

A Creeping Malaise Leading to Calamity: Herpes Esophagitis Perforation.

Herpes simplex virus is an uncommon cause of esophagitis and particularly so in immunocompetent individuals. Although the common presentation tends to be odynophagia and/or dysphagia, fever, and retrosternal chest pain, there are variations and rarely it can present more ominously as esophageal rupture. We report a rare case of esophageal perforation with penetration into the vertebral space secondary to chronic herpes simplex virus esophagitis in a 71-year-old immunocompetent woman. This is the second known such occurrence. The patient had a long stay in the hospital but recovered from the condition and was followed up for 1 year after initial presentation.

Extravasación intraabdominal de líquido posterior a artroscopía de cadera: Reporte de un caso / Intraabdominal fluid extravasation after hip arthroscopy: Case report

Intraabdominal fluid extravasation (IAFE) is a rare complication of hip arthroscopy which has a wide range of clinical presentations, from mild abdominal distention to abdominal compartment syndrome and cardiorespiratory arrest. There are few detailed reports of cases in literature, therefore, considering risk factors, high pathological suspicion and training in ultrasound are key points to prevent complications and health costs. In this report, the case of a 29 year old male patient with severe abdominal pain during the immediate postoperative period of an arthroscopic hip surgery is presented, which led to a review of the literature on the subject.

La extravasación intraabdominal de líquido es una complicación poco frecuente de la artroscopia de cadera que presenta un amplio rango de manifestaciones clínicas, desde leve distensión abdominal hasta síndrome compartimental y paro cardiorrespiratorio. Hay escasos reportes de casos en la literatura, por lo que la alta sospecha considerando factores de riesgo y el ultrasonido son claves para prevenir sus complicaciones y costos asociados. En este reporte, se presenta el caso de un paciente masculino de 29 años con dolor abdominal intenso durante el postoperatorio inmediato de una artroscopia de cadera, lo que llevó a una revisión de la literatura sobre el tema.