Endoscopic Glue Injection vs Glue Plus BRTO or TIPSS for Preventing Gastric Variceal Bleeding: A Randomized Controlled Trial.

BACKGROUND AND AIMS: The study sought to compare the efficacy of endoscopic injection sclerotherapy with cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (RI) (either transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year. METHODS: Consecutive cirrhosis patients with acute variceal bleeding from cardiofundal varices were randomized into 2 arms (45 in each) after primary hemostasis by EIS-CYA. In the endoscopic intervention (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6, and 12 months), while in the RI arm, patients underwent transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration followed by endoscopic surveillance. RESULTS: GV rebleed rates at 1 year were higher in the EI arm compared with the RI arm: 11 (24.4%; 95% confidence interval [CI], 12.9%-39.5%) vs 1 (2.2%; 95% CI, 0.1%-11.8%) (P = .004; absolute risk difference: 22.2%; 95% CI, 8.4%-36.6%). GV rebleed-related mortality in the EI arm (8 [17.8%; 95% CI, 8.0%-32.1%]) was significantly higher than in the RI arm (1 [2.2%; 0.1%-11.8%]) (P = .030; absolute risk difference: 15.6; 95% CI, 2.9%-29.2%); however, there was no difference in all-cause mortality between the 2 groups (12 [26.7%; 95% CI, 14.6%-41.9%] vs 7 [15.6%; 95% CI, 6.5%-29.5%]). The number needed to treat to prevent 1 GV-related rebleed at 1 year was 4.5. CONCLUSIONS: RI for secondary prophylaxis reduces rebleeding from GV and GV rebleeding-related mortality in patients with GV hemorrhage. (CTRI/2021/02/031396).

Thromboelastography-Guided versus Standard-of-Care or On-Demand Platelet Transfusion in Patients with Cirrhosis and Thrombocytopenia Undergoing Procedures: A Randomized Controlled Trial.

PURPOSE: To determine the rate of platelet transfusion in patients with cirrhosis and severe thrombocytopenia (platelet counts <50 × 109/L) undergoing high-risk invasive procedures when prescribed by thromboelastography (TEG) compared with empirical and on-demand transfusion strategies. MATERIALS AND METHODS: This was a single-center, single-blinded, randomized controlled trial. Patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures were randomized into 3 groups: TEG group, transfusions based on TEG parameters; standard of care (SOC) group, 3 units of random donor platelets before procedure; and on-demand group, transfusions based on procedural adverse events/clinician's discretion. The primary outcome was periprocedural platelet transfusion in each arm. RESULTS: Eighty-seven patients were randomized (29 in each group) with no significant differences in demographics/coagulation profile/procedures. The median platelet count was 33 × 109/L (interquartile range, 26-43 × 109/L). Percutaneous liver biopsy was the most common procedure (46, 52.9%). Significantly lower number of patients in the TEG group received platelets (4 cases, 13.8%; 95% CI, 3.9-31.7) compared with SOC group (100%; 95% CI, 88.1-100; P < .001). Four patients in the on-demand group received platelets (13.8%; 95% CI, 3.9-31.7). Minor (World Health Organization [WHO] Grade 2) procedure-related bleeding occurred in 3 (10%; 95% CI, 2.2-27.4) patients in the TEG-guided transfusion group compared with 1 (3.4%; 95% CI, 0.1-17.8) patient each in the SOC and on-demand groups (P = .43), although the study was not powered for comparison of bleeding rates. No bleeding-related mortality was observed in any of the 3 groups. CONCLUSIONS: TEG-prescribed transfusion reduced prophylactic transfusions in patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures.

Is COVID-19 an independent risk factor for the development of avascular necrosis of the hip? A retrospective study to evaluate the factors associated with avascular necrosis of the hip in patients who had COVID-19 infection.

PURPOSE: The cumulative effect of hyper-coagulative COVID-19 disease and using steroids leads to increased avascular necrosis (AVN) hip incidence. This study aims to correlate the various factors of COVID-19 infection with the occurrence of AVN hip. METHODS: It is a retrospective cross-sectional study of non-traumatic AVN hip patients with a history of COVID-19 infection. A total number of 50 patients satisfied the inclusion criteria. The following details were obtained: (a) patient's demographics, (b) COVID-19: interval of infection and groin pain, duration of symptoms, severity, steroid intake, (c) AVN hip: involved side, Ficat-Arlet staging. RESULTS: The mean age was 36.3 years (range: 20-60), and body mass index (BMI) was 25.13 kg/m2 (range: 18.50-31.50). There were 45 males and five females. Sixty percent (30) of patients managed at home, 24% (12) required admission into the ward, 2% (1) were in ICU only, and 14% (7) admitted to both ICU and ward. The mean interval of COVID-19 infection and onset of hip pain was 359.02 days (range: 10-822 days). Thirty-eight percent (19) patients required steroids (injection and oral), 46% (23) took steroids (oral only), whereas 16% (8) recovered without steroids. The stage of AVN correlated with the severity of COVID-19 infection (p-value -0.038) and significant improvement in VAS and HHS after treatment in each stage. The mean follow-up was 9.79 months (6-19 months). CONCLUSION: A low-dose steroid intake with moderate to severe COVID-19 infection produces an additive effect on the development of AVN hip. Most affected individuals were adult males, and stage II AVN was the most common, managed with bisphosphonates and core decompression for short intervals.

Compensated Advanced Chronic Liver Disease in Nonalcoholic Fatty Liver Disease: Two-Step Strategy is Better than Baveno Criteria.

BACKGROUND: Advanced fibrosis and cirrhosis (compensated advanced chronic liver disease [cACLD]) are clinically indistinguishable and increase risk of developing clinically significant portal hypertension. Baveno VII recommends using elastography to rule out and diagnose cACLD with liver stiffness measurement (LSM) cut-offs of 10/15 kPa. METHODS: In a retrospective analysis of 330 nonalcoholic fatty liver disease (NAFLD) patients, performance of the Baveno VII cut-offs for diagnosing cACLD was compared with newly suggested lower cut-offs (8/12 kPa). A model for detecting cACLD among those with LSM between 8 and 12 kPa was developed and compared with recently published models. RESULTS: Seventy (21.2%) of the 330 NAFLD patients had biopsy-proven cACLD. The Baveno VII cut-offs (10/15 kPa) had a lower sensitivity of 72.8% (60.9-82.8%) and a specificity of 93.4% (89.7-96.1%). Sensitivity and specificity of lower cut-offs (8/12 kPa) were 91.4% (82.3-96.8%) and 88.5% (83.9-92.1%), respectively. Modeling based on the presence of diabetes (odds ratio [OR] 3.625[1.161-11.320], p = 0.027) and serum aspartate aminotransferase (AST) levels (OR 1.636[1.098-2.436], p = 0.015) correctly identified 75.7% of patients with LSM between 8 and 12 kPa. Our model performed best with an area under receiver operator curve (AUROC) of 0.725 (95%CI 0.609-0.822), compared to Papatheodoridi (AUROC 0.626, CI 0.506-.736) and Zhou (AUROC 0.523, CI 0.403-0.640) models. A two-step strategy comprising application of lower LSM cut-offs followed by the predictive model correctly identified the presence of cACLD in 83% of the patients as compared to 75% by the Baveno VII cut-offs. CONCLUSION: A two-step strategy employing lower LSM cut-offs and modeling based on diabetes and AST levels outperforms Baveno VII cut-offs for identifying cACLD in NAFLD patients.

Poor Performance of Non-invasive Tests for Advanced Fibrosis in Nonalcoholic Fatty Liver Disease: A Multicentric Asian Study.

BACKGROUND: Non-invasive tests (NITs) are useful to assess advanced fibrosis (AF) in nonalcoholic fatty liver disease (NAFLD). Data from Asian countries suggest that these tests have poor performance. We aimed to assess diagnostic accuracy of established thresholds of biomarker-based NITs and Transient Elastography (TE) in identifying AF and evaluated the utility of a two-step test approach. METHODS: Biopsy-proven 641 NAFLD patients (55.2% males, median age 42 years) were included from three different centers of Asia. AF (≥ F3) was identified as per histological staging (24.8%). RESULTS: TE had the highest area under the receiver operating characteristic curve (AUROC) 0.82 (0.79-0.86), and all other biomarker-based NITs had low AUROC (< 0.7). NITs performed poorly at established thresholds. The combination of NITs utilizing liver stiffness measurement (LSM) and biomarkers, Agile 3+ and FAST, demonstrated acceptable diagnostic accuracy (AUROC 0.82 and 0.78, respectively), but none were superior to LSM alone. LSM measured using appropriate M and XL probes remained accurate regardless of body mass index (BMI); NFS and APRI scores were less accurate at higher BMI ranges. A two-step approach using NFS rule-out criteria (< - 2.97 to rule out) followed by LSM (< 7.3 kPa to rule out and ≥ 12.7 kPa to rule in) correctly classified 62.4% of patients, with only 10.2% of patients incorrectly classified. CONCLUSION: NITs have not been validated to identify AF in the Asian NAFLD population, and internationally accepted thresholds yield high false-negative rates. LSM and LSM-based combination tests remain the most accurate.

Multimodality imaging evaluation of pseudotumors in chronic renal dysfunction: exposing the masquerade!

Focal renal lesions in the background of chronic kidney disease (CKD) present a diagnostic challenge. Contrast administration is usually avoided in such a setting, undermining the usefulness of computed tomography and magnetic resonance imaging. Focal regenerating nodules may occur in the background of CKD and closely mimic renal neoplasms. The aim of the present article was to highlight the salient manifestations of such CKD pseudotumors on different imaging modalities and also to depict the differentiating features from malignancy. Radiologists must be aware of the imaging appearance of this uncommonly talked about entity so as to avoid inadvertent surgery or cause undue anxiety to the patient.

Myotendinous pseudomasses: an imaging review.

A mass or a tumor may not always be an underlying cause for a clinically apparent swelling. A wide range of myotendinous disorders can present as pseudomasses. These include muscle/myofascial hernia, tendon tears, benign hypertrophy, accessory muscles, tendon xanthomas, diffuse myositis, and exertional compartment syndromes. We have briefly reviewed these lesions highlighting their typical radiological findings and have also highlighted the role of different imaging modalities and the role of dynamic imaging. Although rare, radiologists should be aware of these entities to avoid mislabeling a pseudomass as a mass or malignancy and to detect the abnormality in not-so-apparent masses.

Prophylactic bilateral internal iliac balloon occlusion to control hemorrhage in placenta accreta spectrum: a boon for obstetricians.

BACKGROUND: Placenta accreta spectrum (PAS) is abnormal placental adhesion beyond superficial myometrium, which may lead to severe life-threatening hemorrhage requiring massive blood transfusions in the peripartum period. Prophylactic balloon catheterization of bilateral internal iliac arteries with or without additional embolization with Cesarean hysterectomy in patients with PAS prevent excessive intraoperative hemorrhage and may also obviate the need for hysterectomy. PURPOSE: To study the efficacy of intervention radiological procedures in controlling intraoperative hemorrhage in patients with PAS. MATERIAL AND METHODS: This ethically approved prospective study was conducted between November 2017 and October 2019 and written informed consent was obtained from all patients. Consecutive patients diagnosed with PAS during the antepartum period were evaluated. A total of 18 patients with PAS underwent prophylactic balloon catheterization of the bilateral internal iliac arteries followed by delivery of the infant. Interventional and intraoperative data of these patients were collected and compared with retrospectively collected data of patients (control group) who underwent hysterectomy without prophylactic balloon occlusion over the past four years (January 2016-November 2019). RESULTS: Significantly lower intraoperative blood loss (2.8 L vs. 4.7 L; P = 0.048) and pure red blood cell (PRBC) requirement (P = 0.026) between patients who had hysterectomy with and without interventional radiological management was observed. Significantly higher blood loss (P = 0.006) and fluid requirement (P = 0.007) was observed with a higher degree of placental invasion. Only 1 (6%) major procedure-related complication was observed. CONCLUSION: Interventional radiological procedures are effective in significantly reducing intraoperative blood loss and blood product requirement in patients with PAS.

Clinical Utility of Transient Elastography in the Management of Patients with Budd-Chiari Syndrome Undergoing Endovascular Intervention.

PURPOSE: To quantify liver stiffness measurement (LSM) changes after endovascular intervention for Budd-Chiari syndrome (BCS) and evaluate whether LSM changes predict restenosis after endovascular intervention. MATERIALS AND METHODS: Patients with BCS who underwent endovascular intervention and had at least 2 LSM values available after the intervention were included. ΔLSM was the difference between LSMs estimated at the last and second last hospital visits. In patients with restenosis, 2 LSM values before restenosis were included. ΔLSM% was calculated as the ratio of ΔLSM to the LSM at the second last visit and expressed as a percentage. Odds ratio (OR) with confidence interval (CI) and area under the receiver operating characteristic curves (AUROCs) were calculated for the predictors of restenosis. RESULTS: The median baseline and postinterventional 1-week, 3-month, 6-month, and 12-month LSM values were 47.2 kPa (33.8-68.4 kPa), 29.2 kPa (24.5-43.0 kPa), 26.2 kPa (18.6-38.9 kPa), 20.9 kPa (13.3-29.8 kPa), and 17.3 kPa (11.8-25.4 kPa), respectively. Of the 118 patients, including 67 men, restenosis developed in 10 patients after a median (interquartile range) duration of 19 months (11-46 months). ΔLSM% was higher (more positive) in patients with restenosis than in those without restenosis (44.7 [8.3-134.3] vs -6.6 [-19.4 to 14.9], P = .001). ΔLSM% was a significant predictor of restenosis with an OR of 1.032 (95% CI, 1.015-1.050; P < .001). The AUROC for ΔLSM% was 0.831 (95% CI, 0.750-0.893; P = .001), and a ΔLSM% increment of 13.2% predicted restenosis with a sensitivity and specificity of 80.0% and 74.1%, respectively. CONCLUSIONS: LSM gradually decreases after endovascular intervention, and transient elastography is a promising test for detecting restenosis after the endovascular treatment of patients with BCS.

CT findings in renovascular injuries following abdominal trauma: a pictorial review.

Renal vascular injuries are more devastating than parenchymal injuries alone, thus account for higher injury grade and require prompt recognition. Revised AAST organ injury scale (OIS) for renal trauma has incorporated CT-diagnosed vascular injuries into renal injury grading which includes pseudoaneurysm and arteriovenous fistula, along with addition of some new descriptors of renovascular injury. Dual-phase contrast-enhanced CT (with both arterial and venous phase) can easily pick up renovascular injuries and is the modality of choice for imaging renovascular trauma. Radiologist should be well versed with the imaging findings of renovascular injuries so that accurate injury grading can be done and further management can be planned at the earliest.

Imaging in extremity vascular trauma: can MDCT angiography predict the nature of injury?

OBJECTIVE: This study aims to evaluate the utility of computed tomography angiography (CTA) signs of vascular injury in the differentiation of vessel transection from pure thrombosis with intact vessel wall. METHODS: Retrospective analysis was done on 146 consecutive patients who had undergone CTA and surgical exploration from January 2015 to September 2019. Twelve imaging parameters were assessed. Chi-square was used to test the difference between groups. In addition, a scoring system was devised where one point each was added for the presence of 5 signs and absence of 3 signs. ROC analysis was done for the variables which had shown significant difference between groups and for the composite score. RESULTS: On surgical exploration, 87 patients had transection of vessel, while 59 had thrombosis. Significant difference was found among the two groups in non-opacification, pseudoaneurysm, extravasation (p = 0.04 each), thrombosed cord (p < 0.001), collaterals (p = 0.001) and hematoma (p = 0.002), while other signs did not show significant difference. The AUC value for each of these variables was < 0.650, while for the score, AUC was .843(.773-.913). A cut-off value of ≥ 1.5 gave 83.1% sensitivity and 70% specificity for diagnosing transection. CONCLUSION: CTA is a useful tool to classify the nature of vascular injury. It is advisable to use a composite score for maximum diagnostic value.

Novel Coaxial Technique of Percutaneous Nephrostomy in Young Children: A Feasibility Study.

Aims: The conventional Seldinger and trocar techniques of percutaneous nephrostomy (PCN) have inherent limitations in infants and younger children. We studied the role of a novel coaxial technique of PCN in children under the age of 5 years in comparison to the conventional techniques. Materials and Methods: This was a single-center feasibility trial based on 24 consecutive patients (n = 24 kidneys) under the age of 5 years, conducted over 12 months, substratified into Group I (n = 10): PCN with conventional Seldinger (n = 2) and trocar (n = 8) techniques and Group II (n = 14): PCN with proposed coaxial technique. In the proposed technique, catheter was inserted through the bore of a 14-G needle. The observation parameters included successful placement of PCN into the renal pelvis with free drainage of urine, number of needle punctures, duration of procedure, need for fluoroscopy, and procedural complications. Results: Proposed technique was successful in all cases with single-needle puncture, while conventional techniques were successful in 8/10 (80%) cases with multiple needle punctures required in 3/10 (33.3%) cases (P = 0.163 and 0.059, respectively). Proposed technique was associated with lower median procedure time (6 min vs. 10.5 min; P < 0.001) and lower incidence of fluoroscopy use (0/14, 0% vs. 5/10, 50%; P = 0.006) than the conventional techniques. No complications were seen with either technique. Conclusion: The proposed coaxial technique is a feasible alternative to the conventional techniques of PCN in young children. It reduces the procedure time and the need for fluoroscopy in these patients.

Long-Term Outcomes of Endovascular Interventions in More than 500 patients with Budd-Chiari Syndrome.

PURPOSE: To assess and compare the long-term outcomes of various endovascular interventions in patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: In this single-center retrospective study, 510 consecutive patients with BCS who had undergone a total of 618 endovascular procedures from January 2001 to December 2019 were included. Details of the type of endovascular intervention, technical success, clinical success, patency rate, complications, and survival outcomes were analyzed. RESULTS: The overall technical success rate was 96% (593 of 618 procedures; 500 in treatment-naïve patients and 93 repeat interventions for recurrent disease). Endovascular procedures included recanalization procedures (angioplasty and stent placement) in 355 patients (71%) and transjugular intrahepatic portosystemic shunt (TIPS) creation in 145 (29%). Major postprocedure complications occurred in 14 patients (2.8%). Vascular/stent restenosis occurred in 95 patients (19%), and successful repeat intervention was performed in 82 of those 95 (86.3%). An additional 11 of these 82 (13.4%) underwent a third intervention for restenosis. In the recanalization and TIPS groups, the 1- and 5-y cumulative patency rates were 87% and 74% and 95% and 68%, respectively. The 1- and 5-y survival rates were 96% and 89% and 90% and 76%, respectively. CONCLUSIONS: Endovascular interventions for BCS are feasible and safe in the majority of patients, with excellent short- and long-term patency and survival rates.

What Is the Comparative Ability of 18F-FDG PET/CT, 99mTc-MDP Skeletal Scintigraphy, and Whole-body MRI as a Staging Investigation to Detect Skeletal Metastases in Patients with Osteosarcoma and Ewing Sarcoma?

BACKGROUND: Skeletal metastases of bone sarcomas are indicators of poor prognosis. Various imaging modalities are available for their identification, which include bone scan, positron emission tomography/CT scan, MRI, and bone marrow aspiration/biopsy. However, there is considerable ambiguity regarding the best imaging modality to detect skeletal metastases. To date, we are not sure which of these investigations is best for screening of skeletal metastasis. QUESTION/PURPOSE: Which staging investigation-18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT), whole-body MRI, or 99mTc-MDP skeletal scintigraphy-is best in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in detecting skeletal metastases in patients with osteosarcoma and those with Ewing sarcoma? METHODS: A prospective diagnostic study was performed among 54 of a total 66 consecutive osteosarcoma and Ewing sarcoma patients who presented between March 2018 and June 2019. The institutional review board approved the use of all three imaging modalities on each patient recruited for the study. Informed consent was obtained after thoroughly explaining the study to the patient or the patient's parent/guardian. The patients were aged between 4 and 37 years, and their diagnoses were proven by histopathology. All patients underwent 99mTc-MDP skeletal scintigraphy, 18F-FDG PET/CT, and whole-body MRI for the initial staging of skeletal metastases. The number and location of bone and bone marrow lesions diagnosed with each imaging modality were determined and compared with each other. Multidisciplinary team meetings were held to reach a consensus about the total number of metastases present in each patient, and this was considered the gold standard. The sensitivity, specificity, PPV, and NPV of each imaging modality, along with their 95% confidence intervals, were generated by the software Stata SE v 15.1. Six of 24 patients in the osteosarcoma group had skeletal metastases, as did 8 of 30 patients in the Ewing sarcoma group. The median (range) follow-up for the study was 17 months (12 to 27 months). Although seven patients died before completing the minimum follow-up, no patients who survived were lost to follow-up. RESULTS: With the number of patients available, we found no differences in terms of sensitivity, specificity, PPV, and NPV among the three staging investigations in patients with osteosarcoma and in patients with Ewing sarcoma. Sensitivities to detect bone metastases for 18F-FDG PET/CT, whole-body MRI, and 99mTc-MDP skeletal scintigraphy were 100% (6 of 6 [95% CI 54% to 100%]), 83% (5 of 6 [95% CI 36% to 100%]), and 67% (4 of 6 [95% CI 22% to 96%]) and specificities were 100% (18 of 18 [95% CI 82% to 100%]), 94% (17 of 18 [95% CI 73% to 100%]), and 78% (14 of 18 [95% CI 52% to 94%]), respectively, in patients with osteosarcoma. In patients with Ewing sarcoma, sensitivities to detect bone metastases for 18F-FDG PET/CT, whole-body MRI, and 99mTc-MDP skeletal scintigraphy were 88% (7 of 8 [95% CI 47% to 100%]), 88% (7 of 8 [95% CI 47% to 100%]), and 50% (4 of 8 [95% CI 16% to 84%]) and specificities were 100% (22 of 22 [95% CI 85% to 100%]), 95% (21 of 22 [95% CI 77% to 100%]), and 95% (21 of 22 [95% CI 77% to 100%]), respectively. Further, the PPVs for detecting bone metastases for 18F-FDG PET/CT, whole-body MRI, and 99mTc-MDP skeletal scintigraphy were 100% (6 of 6 [95% CI 54% to 100%]), 83% (5 of 6 [95% CI 36% to 100%]), and 50% (4 of 8 [95% CI 16% to 84%]) and the NPVs were 100% (18 of 18 [95% CI 82% to 100%]), 94% (17 of 18 [95% CI 73% to 100%]), and 88% (14 of 16 [95% CI 62% to 98%]), respectively, in patients with osteosarcoma. Similarly, the PPVs for detecting bone metastases for 18F-FDG PET/CT, whole-body MRI, and 99mTc-MDP skeletal scintigraphy were 100% (7 of 7 [95% CI 59% to 100%]), 88% (7 of 8 [95% CI 50% to 98%]), and 80% (4 of 5 [95% CI 28% to 100%]), and the NPVs were 96% (22 of 23 [95% CI 78% to 100%]), 95% (21 of 22 [95% CI 77% to 99%]), and 84% (21 of 25 [95% CI 64% to 96%]), respectively, in patients with Ewing sarcoma. The confidence intervals around these values overlapped with each other, thus indicating no difference between them. CONCLUSION: Based on these results, we could not demonstrate a difference in the sensitivity, specificity, PPV, and NPV between 18F-FDG PET/CT, whole-body MRI, and 99mTc-MDP skeletal scintigraphy for detecting skeletal metastases in patients with osteosarcoma and Ewing sarcoma. For proper prognostication, a thorough metastatic workup is essential, which should include a highly sensitive investigation tool to detect skeletal metastases. However, our study findings suggest that there is no difference between these three imaging tools. Since this is a small group of patients in whom it is difficult to make broad recommendations, these findings may be confirmed by larger studies in the future. LEVEL OF EVIDENCE: Level II, diagnostic study.

Utility of admission perfusion CT for the prediction of suboptimal outcome following uncomplicated minor traumatic brain injury.

PURPOSE: To compare the perfusion parameters of patients with uncomplicated mild traumatic brain injury (mTBI) with healthy controls and to assess whether admission perfusion CT parameters can be used to predict outcome at 6 months post-injury in patients with uncomplicated mTBI. METHODS: Institute ethical committee approval was obtained for this prospective cohort study and informed written consent obtained from all subjects. Patients who sustained mTBI and had no abnormalities on non-contrast CT from June 2010 to January 2012 (20 months) and 10 healthy controls were included and underwent perfusion CT at admission. Outcome was determined at 6 months follow-up using the extended Glasgow Coma Outcome Scale score. RESULTS: Forty-nine patients were included, of which 16 (32.7%) had symptoms at 6 months post-injury (suboptimal outcome). The mean cerebral blood flow and volume were lower in both the gray and white matter of all three arterial territories in the study group than in the control group (p value < 0.05). In the study group, these values were lower in those with suboptimal outcome than in those with optimal outcome (no symptoms). Cerebral blood flow showed higher area under the curve for predicting the outcome. CONCLUSION: Perfusion parameters are altered even in patients with uncomplicated mTBI. A single ROI (region of interest) evaluation of the gray matter in the posterior cerebral artery territory on admission perfusion CT could provide a quick and efficient way to predict patients who would have a suboptimal outcome at 6 months post-injury.

Revised AAST scale for splenic injury (2018): does addition of arterial phase on CT have an impact on the grade?

PURPOSE: To determine whether an additional arterial phase (AP) leads to a change in the grade of splenic injury according to the 2018 revision of the AAST Organ Injury Scale, which has incorporated vascular injuries into the grading system and also to study its impact on management. METHODS: In this retrospective study, 527 patients who sustained blunt abdominal trauma and had underwent dual-phase CT (AP and portal venous phase (PVP)) from December 2014 to October 2016 (23 months) were included. Two experienced radiologists independently graded the splenic injury according to the revised system in 2 blinded ways (AP + PVP and PVP alone). Receiver operator characteristic (ROC) curves were generated for grade of injury on both the phases for all splenic interventions. RESULTS: Splenic injuries were detected in 154 patients, and splenic vascular injuries were detected in 52 of them. Of these, 22 vascular injuries were detected only on the AP, leading to a change in the grade of injury according to the new system in 18 patients. The AUC for ROC curves was generated for the grade of injury on AP + PVP vs. PVP alone for angioembolization (0.80 vs. 0.71, p value 0.002), and all splenic interventions (0.89 vs. 0.83, p value 0.003) showed higher AUC for AP + PVP. CONCLUSION: Addition of AP leads to a significant change in the grading of splenic injuries according to the revised grading system due to increased detection of vascular injuries. Accurate classification of splenic injuries using additional AP would lead to better triage of patients for splenic interventions or conservative management.

Congenital Intrahepatic Arterioportal Fistula: Extremely Rare Cause of Melena and Chronic Diarrhea in Children.

Congenital intrahepatic arterioportal fistulas are rare causes of presinusoidal portal hypertension in children. A rare case of arterioportal fistula in an infant is being reported. This report also highlights the need for long-term surveillance in such cases, despite being a benign pathology.

Dabigatran as an oral anticoagulant in patients with Budd-Chiari syndrome post-percutaneous endovascular intervention.

BACKGROUND AND AIM: Anticoagulants play an important role in the management of Budd-Chiari syndrome. There is a paucity of data on the efficacy and safety of direct-acting oral anticoagulants-dabigatran, among patients with Budd-Chiari syndrome. METHODS: In a retrospective analysis of prospectively maintained data, the stent patency rates, major bleeding episode, and a composite endpoint of major bleed and/or mortality rates were compared between Budd-Chiari syndrome patients treated with dabigatran (n = 36) or vitamin K antagonists (n = 62) following endovascular intervention. RESULTS: The baseline characteristics, including sites of block and types of interventions, were similar between the two groups. The mean duration of follow-up in the dabigatran and vitamin K antagonist groups was 10.5 ± 6.7 and 14.1 ± 6.9 months (P = 0.006), respectively. The endovascular stent patency rates were comparable between the dabigatran and vitamin K antagonist groups at 6 months (91% vs 96.5%) and 12 months (91% vs 93%), P = 0.296 (log-rank test), respectively. Major bleeding events were comparable between the dabigatran and vitamin K antagonist groups at 6 months (3.5% vs 2%) and 12 months (3.5% vs 6.5%), P = 0.895 (log-rank test), respectively. The composite endpoint of mortality and major bleed was comparable between dabigatran and vitamin K antagonists at 6 months (4% vs 5%) and 12 months (4% vs 8%), P = 0.875 (log-rank test), respectively. CONCLUSIONS: Dabigatran, as compared with vitamin K antagonists, is associated with similar stent patency rates and complications among patients with Budd-Chiari syndrome post-endovascular intervention.

A Randomized Control Trial of Thromboelastography-Guided Transfusion in Cirrhosis for High-Risk Invasive Liver-Related Procedures.

BACKGROUND AND AIM: Hemostasis in cirrhosis is dynamic and balanced. Thromboelastography (TEG) assesses global coagulation status. We aimed to assess whether TEG-guided blood product transfusions result in lower blood product requirements in patients with cirrhosis undergoing invasive liver-related procedures as compared to the conventional standard of care (SOC). METHODS: In this open-label, randomized controlled trial, cirrhosis patients with coagulopathy, undergoing invasive liver-related procedures, were randomized to either TEG-guided blood product transfusion or SOC. The primary outcome was difference in the amount of fresh frozen plasma (FFP) and platelet units transfused between the two groups. The secondary outcome was procedure-related bleeding complications within 5 days and any complications until 28 days. RESULTS: From November 2017 till June 2019, 58 patients were recruited (29: TEG and 29: SOC). Most common procedures performed were percutaneous liver biopsy (n = 48), followed by transjugular intrahepatic portosystemic shunt (n = 2), percutaneous acetic acid injection (n = 2), and transarterial chemoembolization (n = 2). There were no differences in baseline demographics, hemostatic profile, and types of procedures between the two groups. Only nine patients in TEG group received transfusions compared to all patients in SOC (31% vs 100%; P < 0.001). In TEG group, six (20.7%) received FFP (P = 0.753 vs. SOC), two (6.9%) received platelets (P < 0.001 vs. SOC), and 1(3.4%) patient received both FFP and platelet (P ≥ 0.999 vs. SOC) transfusion. None of the patients in either group developed procedure-related bleeding complications until 5 days post-procedure. The complication rates at 28-day follow-up were similar between the groups. CONCLUSION: TEG-guided blood product transfusion strategy reduces blood product transfusion without increased risk of bleeding in cirrhotic patients undergoing invasive liver-related procedures (CTRI/2017/12/010822).

Acute-on-Chronic Liver Failure in Budd-Chiari Syndrome: Profile and Predictors of Outcome.

BACKGROUND AND AIM: There is a paucity of data on the clinical presentations and outcome of Budd-Chiari syndrome (BCS) patients presenting as acute-on-chronic liver failure (BCS-ACLF). We aimed to describe the profile and outcomes of endovascular interventions in patients with BCS-ACLF. METHODS: All BCS-ACLF patients presenting between October 2007 and April 2019 satisfying the Asian Pacific Association for the Study of the Liver (APASL) definition were studied. We compared 30- , 90- and, 180-day survival among BCS-ACLF patients who underwent endovascular intervention with those who did not, and with a historical cohort of Child-C BCS patients without ACLF who underwent endovascular intervention. RESULTS: Twenty-eight (5%) of 553 BCS patients presented as ACLF as per APASL definition. The majority (60.7%) were males, and mean age was 29.6 ± 11.2 years. The most common site of the block was isolated involvement of hepatic veins-HV (68%), followed by combined inferior vena cava (IVC) and HV block (25%) and isolated IVC block (7%). The acute precipitants were stent thrombosis (17.9%), acute HV thrombosis (10.7%), acute viral hepatitis (7.1%), and antituberculosis drug with hepatitis B virus reactivation (3.6%). In 60.7% patients, no acute precipitant could be identified. The 30- , 90- , and 180-day survival in BCS-ACLF post-endovascular intervention (n = 15), BCS-ACLF without endovascular intervention (n = 13), and Child-C BCS without ACLF who underwent endovascular intervention (n = 25) were (93%, 87%, and 87%), (46%, 28%, and 0%) and (96%, 92%, and 88%), respectively (log-rank test, p value < 0.001). On multivariate Cox proportional analysis, endovascular intervention and the presence of hepatic encephalopathy were independent predictors of mortality. CONCLUSION: Budd-Chiari syndrome can present as acute-on-chronic liver failure. Endovascular intervention is associated with an improved outcome.