Effects of Venous Angioplasty on Cerebral Lesions in Multiple Sclerosis: Expanded Analysis of the Brave Dreams Double-Blind, Sham-Controlled Randomized Trial.

PURPOSE: To evaluate if jugular vein flow restoration in various venographic defects indicative of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients can have positive effects on cerebral lesions identified using magnetic resonance imaging (MRI). MATERIALS AND METHODS: The Brave Dreams trial ( ClinicalTrials.gov identifier NCT01371760) was a multicenter, randomized, parallel group, double-blind, sham-controlled trial to assess the efficacy of jugular venoplasty in MS patients with CCSVI. Between August 2012 and March 2016, 130 patients (mean age 39.9±10.6 years; 81 women) with relapsing/remitting (n=115) or secondary/progressive (n=15) MS were randomized 2:1 to venography plus angioplasty (n=86) or venography (sham; n=44). Patients and study personnel (except the interventionist) were masked to treatment assignment. MRI data acquired at 6 and 12 months after randomization were compared to the preoperative scan for new and/or >30% enlargement of T2 lesions plus new gadolinium enhancement of pre-existing lesions. The relative risks (RR) with 95% confidence interval (CI) were estimated and compared. In a secondary assessment, venograms of patients who underwent venous angioplasty were graded as "favorable" (n=38) or "unfavorable" (n=30) for dilation according to the Giaquinta grading system by 4 investigators blinded to outcomes. These subgroups were also compared. RESULTS: Of the 130 patients enrolled, 125 (96%) completed the 12-month MRI follow-up. Analysis showed that the likelihood of being free of new cerebral lesions at 1 year was significantly higher after venoplasty compared to the sham group (RR 1.42, 95% CI 1.00 to 2.01, p=0.032). Patients with favorable venograms had a significantly higher probability of being free of new cerebral lesions than patients with unfavorable venograms (RR 1.82, 95% CI 1.17 to 2.83, p=0.005) or patients in the sham arm (RR 1.66, 95% CI 1.16 to 2.37, p=0.005). CONCLUSION: Expanded analysis of the Brave Dreams data that included secondary/progressive MS patients in addition to the relapsing/remitting patients analyzed previously showed that venoplasty decreases new cerebral lesions at 1 year. Secondary analysis confirmed the efficacy of the Giaquinta grading system in selecting patients appropriate for venoplasty who were more likely to be free from accumulation of new cerebral lesions at MRI.

Ochronosis as Etiology of Requiring Total Knee Arthroplasty-A Case Series.

Alkaptonuria is a rare hereditary metabolic disorder that leads to the accumulation of homogentisic acid accumulation and weakens the collagen, creating fissuring and articular cartilage degeneration. Therefore, we are reporting a multicenter case series of three patients (four arthroplasties) who presented with signs and symptoms of ochronotic arthropathy-and eventually underwent total knee arthroplasty (TKA)-and provide a review of the current literature on total joint arthroplasty in ochronotic osteoarthritis. Each patient achieved excellent Knee Society Scores (KSS) after at least a five-year follow-up-regardless of receiving cemented or cementless prostheses-and suffered no complications. There have been a number of case reports published on patients who had TKA and were found to have a diagnosis of ochronosis. We believe that surgery for symptomatic patients who are surgical candidates for TKA should not be delayed for concerns of complications. However, future studies should compare outcomes to those who undergo TKA without ochronotic arthropathy.

Recommendations for multimodal noninvasive and invasive screening for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency: a position statement of the International Society for Neurovascular Disease.

Under the auspices of the International Society for Neurovascular Disease (ISNVD), four expert panel committees were created from the ISNVD membership between 2011 and 2012 to determine and standardize noninvasive and invasive imaging protocols for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency (CCSVI). The committees created working groups on color Doppler ultrasound (US), magnetic resonance (MR) imaging, catheter venography (CV), and intravascular US. Each group organized a workshop focused on its assigned imaging modality. Non-ISNVD members from other societies were invited to contribute to the various workshops. More than 60 neurology, radiology, vascular surgery, and interventional radiology experts participated in these workshops and contributed to the development of standardized noninvasive and invasive imaging protocols for the detection of extracranial venous abnormalities indicative of CCSVI. This ISNVD position statement presents the MR imaging and intravascular US protocols for the first time and describes refined color Doppler US and CV protocols. It also emphasizes the need for the use of for noninvasive and invasive multimodal imaging to diagnose adequately and monitor extracranial venous abnormalities indicative of CCSVI for open-label or double-blinded, randomized, controlled studies.

Catheter venography for the assessment of internal jugular veins and azygous vein: position statement by expert panel of the International Society for Neurovascular Disease.

This document by an expert panel of the International Society for Neurovascular Disease is aimed at presenting current technique and interpretation of catheter venography of the internal jugular veins, azygous vein and other veins draining the central nervous system. Although interventionalists agree on general rules, significant differences exist in terms of details of venographic technique and interpretations of angiographic pictures. It is also suggested that debatable findings should be investigated using multimodal diagnostics. Finally, the authors recommend that any publication on chronic cerebrospinal venous insufficiency should include detailed description of venographic technique used, to facilitate a comparison of published results in this area.

Risk Factors for Unexpected Admission Following Outpatient Rotator Cuff Repair: A National Database Study.

Introduction  Rotator cuff repair (RCR) procedures are some of the most common orthopaedic surgeries performed in the United States. Compared to other orthopaedic procedures, RCRs are of relatively low morbidity. However, complications may arise that result in readmission to an inpatient healthcare facility. The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission after RCR. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent elective RCR from 2015-2019. Univariate and multivariate analyses were utilized to assess patient demographics, comorbidities, and peri-operative variables predicting unplanned 30-day readmission. Results Of the identified 45,548 patients that underwent RCR, 597 (1.3%) required readmission within 30 days of the procedure. Multivariate analysis identified male sex (OR 1.36, 95% CI: 1.10, 1.67), hypertension (OR 1.29, 95% CI:1.03, 1.62), chronic obstructive pulmonary disease (COPD) (OR 2.07, 95% CI: 1.46, 2.93), American Society of Anesthesiologists (ASA) Class III (OR 1.85, 95% CI: 1.07, 3.18), ASA Class IV (OR 5.38, 95% CI: 2.70, 10.72), and total operative time (OR 1.002, 95% CI: 1.000, 1.004) as independent risk factors for unplanned readmission. Conclusion Unplanned 30-day readmission after RCR is infrequent. However, certain patients may be at increased risk for unplanned 30-day admission to an inpatient facility. This study confirmed male sex, COPD, hypertension, ASA Class III, ASA Class IV, and total operative time to be independent risk factors for readmission following outpatient RCR.

Increased Regular Season Soft Tissue Injury Rates in National Football League (NFL) Players May Be Associated With the Canceled 2020 NFL Preseason Due to COVID-19.

Introduction The purpose of this study is to evaluate the rates of regular season soft tissue injuries in National Football League (NFL) players during the 2020 season, which had a canceled preseason due to the COVID-19 pandemic. Methods This study retrospectively reviewed the injury rates of the 2020-2021 NFL regular season in comparison to the 2018-2019 NFL regular season using publicly available injury data. The focus of our analysis was comparing the following soft tissue injuries: hamstring, groin, calf, quadriceps, thigh, knee - anterior cruciate ligament (ACL), pectoral, and Achilles. The week of injury occurrence, duration of injury in weeks, position of the injured player, and age of the NFL player at injury were obtained. Injury rates were calculated per 1000 athletic exposures with 95% confidence intervals (CIs). A chi-square test and Student's t-test were utilized as appropriate. Results There were 1370 total injuries in the 2018-2019 regular NFL season and 2086 total injuries reported in the 2020-2021 regular NFL season. The total number of injuries per 1000 athletic exposures was significantly higher in the 2020-2021 NFL season compared to the 2018-2019 NFL season (88.57 versus 58.17, p < 0.001). The rates of injuries per 1000 athletic exposures for hamstring (9.98 versus 5.31, p = 0.043), groin (5.56 versus 2.46, p = 0.007), calf (4.08 versus 1.61, p = 0.006), quadriceps (2.00 versus 0.72, p = 0.030), and thigh (1.23 versus 0.30, p = 0.012) injuries were significantly higher in the 2020-2021 regular NFL season compared to the 2018-2019 NFL regular season. Conclusions The 2020-2021 NFL season had a significantly higher incidence of soft tissue injuries compared to the 2018-2019 regular NFL season, which may have been associated with the absent preseason due to the COVID-19 pandemic and an abrupt increase in the athletic workload of players.

Intraoperative evaluation of a pulsatile oropharyngeal mass during adenotonsillectomy.

Iatrogenic injury to the internal carotid artery (ICA) is a rare complication of pharyngeal surgery that most commonly occurs in children with an anomalous course to the internal carotid artery. Most aberrant arteries are asymptomatic. They can remain undiscovered preoperatively or be found incidentally on radiographic studies completed for an unrelated reason. Evaluation of definitive internal carotid artery injuries is well documented in the trauma literature. We present a case of a suspected intraoperative injury to the internal carotid artery during routine pharyngeal surgery. Ultimately no injury was found, however, aberrant internal carotid arteries were coincidentally discovered.

Endovascular management of an intracardiac bullet.

Intravascular bullets may cause diagnostic and management difficulties. We describe a bullet overlying the cardiac silhouette on X-ray which was identified to be at the cavoatrial junction on cavography. The bullet was removed via endovascular techniques utilizing occlusion balloon and reverse trendelenberg position.

Combined endovascular and open repair of a penetrating innominate artery and tracheal injury.

Endovascular therapy affords the opportunity to decrease surgical morbidity and improve operative planning in complex penetrating injuries of the chest. In this case report we describe a hemodynamically stable patient with a single gunshot wound to the base of the neck (zone I), with combined vascular and tracheal injuries. We present a novel approach to the repair of this type of injury using combined endovascular and open techniques.

CT signs of urethral injury.

Computed tomography (CT) is the accepted frontline imaging modality for blunt abdominopelvic trauma. However, urethral injuries are traditionally diagnosed with retrograde urethrography. The CT appearances of urethral injuries and the signs associated with posterior urethral injuries are not well described in the literature. CT scans of patients with pelvic fractures and urethrographically proved posterior urethral injuries were evaluated. CT scans of patients with similar pelvic fractures who did not have urethral injuries were also evaluated. The CT findings of elevation of the prostatic apex, extravasation of urinary tract contrast material above the urogenital diaphragm (UGD), and extravasation of urinary tract contrast material below the UGD were specific for type I, II, and III urethral injuries, respectively. If extraperitoneal bladder rupture is present along with periurethral extravasation of contrast material, the possibility of type IV and IVA urethral injuries should be considered. In addition, the CT findings of distortion or obscuration of the UGD fat plane, hematoma of the ischiocavernosus muscle, distortion or obscuration of the prostatic contour, distortion or obscuration of the bulbocavernosus muscle, and hematoma of the obturator internus muscle were more common in patients with pelvic fractures and associated urethral injuries than in patients with uncomplicated pelvic fractures.

Intravascular ultrasound in the diagnosis and treatment of chronic cerebrospinal venous insufficiency.

Multiple imaging modalities have been used for the evaluation of chronic cerebrospinal venous insufficiency (CCSVI). These include Doppler ultrasound, magnetic resonance venography, computed tomographic venography, and catheter venography. Although each of these tests is considered to contribute valuable information to the evaluation, each modality has deficiencies, which can impact treatment. Intravascular ultrasound (IVUS) has a role in this evaluation owing to its ability to accurately assess vessel circumference and cross-sectional area in real time. This can aid in identifying significant stenoses and optimizing balloon sizing during angioplasty. In addition, intraluminal abnormalities that may be difficult to see with venography can be identified with IVUS, which can further determine when angioplasty for CCSVI is indicated. Finally, IVUS can identify potential complications of angioplasty, including dissection and thrombus formation, allowing for rapid treatment. As a result, IVUS is an important part of an evaluation for CCSVI and, when available, should be used to identify patients who may benefit from endovascular treatment.

Lower extremity claudication resulting from uterine leiomyoma-associated common iliac artery compression.

BACKGROUND: Rarely, uterine leiomyomas have been associated with deep venous thrombosis secondary to compression. Affected vessels include the inferior vena cava and the common iliac, iliac, and distal veins. Arterial compression has not been reported previously. Bilateral uterine artery embolization for symptomatic leiomyomata provides relief of bulk-related symptoms and reduction in menstrual flow. CASE: A 42-year-old woman presented with menorrhagia secondary to a myomatous uterus. Claudication of the right lower extremity was attributed to imaging-confirmed leiomyoma pressure-associated compression of the right common iliac artery. Examination disclosed an absent right common femoral artery pulse. Bilateral uterine artery embolization resulted in long-term resolution of the claudication. CONCLUSION: Claudication of the lower extremity may result from pressure-associated compression of the common iliac artery caused by uterine leiomyomas, and may be amenable to bilateral uterine artery embolization.

External carotid arterial injury.

Carotid vascular trauma has high mortality. The two primary causes of death are associated head injury and vascular injuries that cause exsanguination or stroke. In the past two decades interventional radiology, i.e. techniques of transcatheter embolisation, has become a vital component of the care of these cases. External carotid artery injuries are complex and are often inaccessible causes of exsanguinating haemorrhage. Transcatheter techniques have been shown to be highly effective in controlling this haemorrhage. An overview of injuries of the external carotid artery and its branches is presented.

Triage and outcome of patients with mediastinal penetrating trauma.

BACKGROUND: A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT). METHODS: Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera. RESULTS: Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries. CONCLUSIONS: In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.

Hematuria as an indicator for the presence or absence of urinary calculi.

The purpose of this study was to determine whether the presence of hematuria or its absence can predict the presence or absence of urinary calculi as determined by computed tomography (CT) scan in patients presenting to the ED with acute abdominal colic. We reviewed the urine analysis and CT scans of all patients presenting to the ED over a 12-month period with acute colic and a clinical suspicion of urinary calculi. Urine samples were drawn on arrival in the ED before CT scanning. Two hundred seventy-seven patients were included in the study. The prevalence of urinary stones as detected by CT was 57.4%. The positive predictive value, negative predictive value, and accuracy for hematuria as a marker for stone disease was 60.9%, 72.4%, and 62.1%, respectively. A total of 3.24% of patients had some degree of obstruction, all of whom had hematuria. The absence of hematuria is not a reliable exclusion criterion for urinary calculi. The detection of urinary stones without hematuria does not imply obstruction.

Comparing the interpretations of CT pulmonary angiograms by attending and resident radiologists: can residents identify life-threatening pulmonary emboli in hospitalized patients?

OBJECTIVE: CT pulmonary angiography is now often the first-line investigation for pulmonary emboli. When these studies are performed after hours in teaching hospitals, they are often initially interpreted by trainees. It is of great significance whether the interpretations of trainees and certified radiologists with regard to the presence of pulmonary emboli on CT pulmonary angiograms correspond, because of the morbidity and mortality of both the condition and its treatment. MATERIAL AND METHODS: Twenty-five consecutive CT pulmonary angiograms (CTPAs) of hospitalized patients were viewed at lung and soft tissue windows both on a workstation and on hard copies, at the observers' discretion. Each CTPA was divided into 28 arterial zones based on pulmonary anatomy (including the subsegmental arteries), giving a total of 700 arterial zones, and analyzed retrospectively and independently by two cross-sectional imaging specialists and four residents. Each arterial segment was rated with regard to pulmonary embolus as either high, intermediate, or low probability or not visualized. The kappa (Kappa) test, which tests for interobserver agreement, was used for statistical analysis. RESULTS: At the time of the scan all patients were hospitalized for underlying conditions. Of the 25 patients studied, 9 were referred from the ICU, 7 experienced severe acute shortness of breath and respiratory failure, 5 were post-partum women, 2 had had a recent stroke, 1 patient had antithrombin III deficiency, and 1 had a diagnosis of breast cancer. The incidence of pulmonary emboli was 44%. For the main pulmonary arteries interobserver agreement was good (Kappa=0.61) and for the segmental pulmonary arteries it was fair (Kappa=0.26). For the subsegmental arteries interobserver agreement was poor (Kappa=0.16). The zones where interobserver agreement was greatest (Kappa>0.4) were the left main, left lower lobe, and the right main pulmonary arteries. Interobserver agreement was poorest (Kappa<0.05) in the left interlobar, left lower lobe lateral basal segment, right lower lobe superior segment, and left lower lobe superior segment branches. None of the patients expired due to pulmonary emboli. CONCLUSION: Most life-threatening pulmonary emboli requiring urgent treatment are the more central emboli. This study demonstrates that trainees and certified radiologists can make similar conclusions regarding these central pulmonary emboli in hospitalized patients and that preliminary interpretations by trainees should not therefore adversely affect patient care.