Contemporary endovascular management of splenic vascular pathologies.

The spleen is a commonly injured organ and the splenic vasculature is also susceptible to inflammation and trauma, often resulting in aneurysm formation. Splenic artery aneurysms carry a high risk of rupture and are associated with high mortality and morbidity. Due to the advances in endovascular techniques and devices, endovascular management of splenic vascular pathologies is now considered a first-line strategy. Endovascular embolisation and advance techniques including balloon- or stent-assisted coil embolisation enables minimally invasive management option while preserving splenic function.

Women in interventional radiology: insights into Australia's gender gap.

AIM: To assess differences in the exposure, teaching, knowledge, appreciation, and interest in interventional radiology (IR) between male and female doctors prior to specialisation and to identify potential predisposing factors to the gender inequality in interventional radiology. MATERIALS AND METHODS: A prospective cross-sectional multicentre study was conducted using in-person and web-based distribution of a voluntary, anonymous questionnaire to junior doctors yet to commence specialisation at 11 health services across two Australian states. RESULTS: Complete responses were provided by 333 junior doctors (21.9% response rate). Women were significantly less likely than men to consider a career in IR (13.1% versus 29.7%, p < 0.001). No other statistically significant gender disparities were identified, as both men and women reported low levels of prior teaching and exposure to IR, strong belief in the importance of IR, and suboptimal knowledge of IR. CONCLUSIONS: The gender gap amongst practising Australian interventional radiologists is perpetuated by a consistent gender gap in upcoming junior doctors' desire to pursue IR. This disparity exists despite junior doctors receiving the same exposure and opportunities in interventional radiology, possibly suggesting that preconceived stereotypes or psychosocial factors deter females from pursuing this procedural, male-dominated subspecialty. Future qualitative studies are required to confirm this hypothesis, in conjunction with prospective, experimental trials to determine whether changes in education, mentorship, and advocacy can promote gender equality.

Prostate artery embolisation: an all-comers, single-operator experience in 159 patients with lower urinary tract symptoms, urinary retention, or haematuria with medium-term follow-up.

AIM: To describe the authors' experience with prostate artery embolisation (PAE) to treat lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) or refractory haematuria of prostatic origin (RHOPA). MATERIALS AND METHODS: PAE was attempted in 159 patients. Procedural details, pre/post-PAE symptom scores, and pre/post-PAE magnetic resonance imaging (MRI) data were recorded. Statistical analysis was performed to determine clinical outcomes and factors predicting clinical success. RESULTS: Technical success was achieved in 156 patients. In patients with LUTS, the International Prostate Symptom Score (IPSS) improved from a mean of 22 at baseline to 9.5 at 6-months post-PAE, then to 10.7, 10, 11.3, and 11 at 1, 2, 3, and 4 years. The quality of life (QoL) score improved from 4.6 at baseline to 2, 2.2, 2.4, 3.1, and 2.5 at the same time points. The International Index of Erectile Function (IIEF-5) scores remained stable. There was no significant difference in IPSS between bilateral or unilateral embolisation to 2 years, or between BPH alone or BPH with biopsy-proven prostate cancer to 3 years post-PAE. Percentage improvement in IPSS at 1 year correlated with percentage reduction in prostate volume on first post-PAE MRI. Percentage improvement in IPSS at 3 years correlated with initial IPSS. PAE facilitated urinary catheter removal in 13/24 patients in retention. PAE controlled bleeding in 12/12 patients with RHOPA. CONCLUSION: PAE is safe and effective in the management of symptomatic BPH. Patients with the highest baseline IPSS and reduction in prostate volume on first post-PAE MRI are likely to derive most benefit from embolisation.

Current evidence for endovascular therapy in stroke and remaining uncertainties.

Class 1 level A evidence now supports endovascular thrombectomy as best practice in the management of large vessel occlusion acute ischaemic stroke. However, significant questions pertaining to initial imaging, radiological assessment, patient selection and therapeutic limits remain unanswered. A specific cohort of patients who benefit from endovascular thrombectomy has been established, although current uncertainties regarding selection of those not meeting top-tier evidence criteria may potentially deny certain patients the benefit of intervention. This is of particular relevance in patients presenting in a delayed manner. Whilst superior outcomes are achieved with reduced time to endovascular reperfusion, denying patients intervention based on symptom duration alone may not be appropriate. Advanced understanding of ischaemic stroke pathophysiology supports an individualized approach to patient evaluation, given variance in the rate of ischaemic core progression and the extent of salvageable penumbra. Physiological imaging techniques may therefore be utilized to better inform patient selection for endovascular thrombectomy and evidence suggests that a transition from time-based to tissue-based therapeutic thresholds may be of greater value. Multiple ongoing randomized controlled trials aim to further define the benefit of endovascular thrombectomy and it is hoped that these results will advance, and possibly broaden, patient selection criteria to ensure that maximum benefit from the intervention may be achieved.

eDoctor: machine learning and the future of medicine.

Machine learning (ML) is a burgeoning field of medicine with huge resources being applied to fuse computer science and statistics to medical problems. Proponents of ML extol its ability to deal with large, complex and disparate data, often found within medicine and feel that ML is the future for biomedical research, personalized medicine, computer-aided diagnosis to significantly advance global health care. However, the concepts of ML are unfamiliar to many medical professionals and there is untapped potential in the use of ML as a research tool. In this article, we provide an overview of the theory behind ML, explore the common ML algorithms used in medicine including their pitfalls and discuss the potential future of ML in medicine.

Kernicterus with abnormal high-signal changes bilaterally in the globus pallidus: A case report.

Kernicterus is a relatively rare consequence of hyperbilirubinemia. There is an important role for MRI imaging for this entity in the appropriate clinical context as there are distinct signal changes in the globus pallidus. A case report and image findings are presented

Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset.

BACKGROUND AND OBJECTIVES: Benefit from endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) is well demonstrated. Furthermore, emerging evidence supports efficacy in appropriately selected patients treated beyond current recommendations of 6 h. We evaluated clinical outcomes in patients undergoing late EVT at our institution. METHODS: Retrospective review of prospectively collected clinical database on 355 patients who underwent EVT for LVO AIS. Data collected consisted of patient demographics, radiological findings and outcome details. Outcomes, including 90-day functional status, recanalization, symptomatic intracranial haemorrhage (sICH) and 90-day mortality, for patients undergoing EVT <6 h, >6 h, and >7.3 h, were compared. RESULTS: A total of 355 patients underwent EVT for LVO AIS at our institution during the review period, with 74 (21%) patients treated ≥6 h from symptom onset. Successful recanalization was achieved in 285 (80%) patients, with 228 (81%) achieving a mTICI ≥2b in the <6 h group, and 57 (77%) in the >6 h group (P = 0.429). Ninety-day functional independence (mRS 0-2) was achieved in 162 (46%) patients, with 130 (46%) achieving a mRS of 0-2 in the <6 h group, and 32 (43%) in the >6 h group (P = 0.643). No significant differences were found in rates of sICH or 90-day mortality. No significant differences in functional independence, recanalization rates, sICH or mortality were identified in patients treated with EVT >7.3 h compared to <7.3 h. CONCLUSIONS: In appropriately selected patients, EVT >6 h was associated with comparable outcomes to those treated <6 h. These data support a physiological approach to patient selection.

Retrievable IVC filters - Friend or foe.

Venous thromboembolism is a common condition with widely varied outcomes. Pulmonary embolism is associated with a case-fatality rate of up to 8%, increasing up to 18-fold in massive PE. Pharmacological treatment of VTE with anticoagulant medication (AC) is the first line therapy of choice. Retrievable inferior vena cava filters (IVCF) are indicated as a short-term replacement for AC in certain circumstances. Most of the evidence concerning IVCF pertains to permanent filters and older filter models. Limited evidence for retrievable IVCF results in poor consensus regarding indications, follow-up and retrieval. Complications increase with dwell-time and retrieval success rates decline. Professional bodies advocate strict guideline adherence and robust strategies for filter monitoring to maximise retrieval rate.

Examining the End-User Experience of the National Integrated Medical Imaging System (NIMIS).

The National Integrated Medical Imaging System (NIMIS) is used to store and retrieve medical imaging studies in Ireland. The purpose of this audit was to obtain feedback from its end-users in relation to key NIMIS functionality and to understand their perception of its existing interface while identifying potential improvements. The results showed that, while the majority of respondents are satisfied with NIMIS, they identified a number of areas of concern. These included difficulty in identifying the appropriate code for a study, 88 (34%); dissatisfaction with ordering and viewing scans, 82 (32%); and a need for improved communication between end-users and local Radiology departments, with 104 (40%) unsure when to contact the department and 137 (53%) dissatisfied with the feedback they received in relation to requests. Respondents indicated that addressing these issues would improve the NIMIS end-user experience while allowing it to continue to meet current and future clinical needs.

Added Value of Stroke Protocol MRI Following Negative Initial CT in the Acute Stroke Setting.

The aim of the study was to determine the added value of stroke protocol MRI following negative initial CT brain in the acute stroke setting. A retrospective study was performed over a 6 month period in a tertiary referral stroke centre. Patients were selected from the stroke and radiology databases. Inclusion criteria: clinical stroke syndrome, negative initial CT with subsequent MRI study with diffusion weighted sequences. Ninety two patients were reviewed and 73 (M:F of 39:34, mean age 62.1 ± 14.0 years) met the inclusion criteria. Twenty MRI studies (27.4%) were positive for acute/subacute ischaemia in the setting of a normal initial CT. The average time interval between initial CT and MRI brain imaging was 4.7 ± 2.6 days. Whilst CT continues to be the first line imaging investigation for acute stroke, MRI has substantial added value following negative initial CT in the diagnosis of stroke.

Rendezvous endovascular common carotid artery stenting (RECCAS) technique for symptomatic steno-occlusive disease.

This report describes a patient who presented with acute but transient right arm weakness and altered sensation secondary to severe stenosis of the left common carotid artery (CCA) origin. Endovascular stenting of the stenosed origin was achieved utilising a novel rendezvous technique through combined retrograde common carotid artery and anterograde transfemoral approaches. This technique has numerous potential advantages over traditional transfemoral endovascular and open retrograde common carotid artery approaches. It allows increased procedural control and success in traversing the stenosis and provides a smooth transition for the stent delivery catheter. An open cutdown procedure or open surgical technique is not required. Our patient recovered well from the procedure with no complications within the three-month follow up period.

Applications of cardiac computed tomography in electrophysiology intervention.

Cardiac electrophysiology is an evolving specialty that has seen rapid advances in recent years. Concurrently, there has been much progress in the field of cardiac imaging. Electrophysiologists are increasingly requesting cross-sectional imaging in advance of many procedures. Pulmonary vein isolation and left atrial appendage (LAA) occlusion are now an established treatment options for atrial fibrillation. In patients undergoing pulmonary vein isolation, applications of computed tomography (CT) include evaluating the left atrial and pulmonary venous anatomy, excluding LAA thrombus and assessing for pulmonary vein stenosis. In those undergoing LAA occlusion, CT may be of value in assessing the size, position, and morphology of the LAA as well as for determining correct positioning of the device and evaluating for peri-device leak. Implantable cardiac devices are now commonly used in the management of cardiac failure and cardiac arrhythmias. Applications of CT prior to device implantation include detecting myocardial scar, evaluating for mechanical dyssynchrony as well as visualising the coronary venous anatomy.

A retrospective analysis of oesophageal thickening diagnosed as an incidental finding at Computed Tomography with endoscopic and histological correlation.

PURPOSE: A retrospective analysis of oesophageal thickening diagnosed as an incidental finding at Computed Tomography (CT) with endoscopic and histological correlation. MATERIALS AND METHODS: Retrospective review of CT studies at a University Teaching Hospital in a 3-month period was performed and those who had a correlating upper gastrointestinal endoscopy within 6 months of the CT were included in the study. The findings were correlated with results from endoscopy to histology. The CT images were reviewed by two Consultant Radiologists with a sub-speciality interest in Abdominal Imaging prior to correlation with endoscopic and histology results from the patient's medical records. RESULTS: Three hundred and sixty-one patients met the inclusion, of which 20% (n = 72) were felt to have a thickened distal oesophagus on CT. Of these, 30.6% (n = 22) had a mass or abnormal mucosal thickening on endoscopy, found to be malignant on subsequent biopsy in 50% (n = 11) and Barrett's epithelium in 50% (n = 11), a statistically significant finding compared to those who had a normal CT. CONCLUSION: Endoscopic evaluation is recommended for incidental oesophageal thickening detected at Computed Tomography to exclude underlying malignancy.

Imaging features of poorly controlled congenital adrenal hyperplasia in adults.

Congenital adrenal hyperplasia (CAH) is a genetic autosomal recessive condition most frequently as a result of a mutation in the 21-hydroxylase enzyme gene. Patients with poorly controlled CAH can manifest characteristic imaging findings as a result of adrenocorticotrophic hormone stimulation or the effects of cortisol precursor excess on various target organs. We present a spectrum of imaging findings encountered in adult patients with poorly treated CAH, with an emphasis on radiological features and their clinical relevance.

Inferior vena cava filter insertion and retrieval patterns in a tertiary referral centre in Ireland.

BACKGROUND: Inferior vena cava (IVC) filters are widely used in clinical practice to prevent large, clinically significant pulmonary emboli. Modern filters are designed to be retrievable within a specific time window; however, many become lost to follow-up. AIM: To examine the insertion and retrieval patterns of IVC filters in a tertiary referral teaching hospital in Ireland. METHODS: A retrospective review of all IVC filter insertions and retrievals was performed in a tertiary referral university teaching hospital which incorporates the national referral centre for pelvic and acetabular trauma, over a 22-month period. RESULTS: Fifty-seven patients underwent IVC filter insertion with 100% technical success. The most common indication was prophylaxis in patients at high risk of deep venous thrombosis or pulmonary emboli (64.9%), followed by patients with contra-indication to anticoagulation (24.6%) and breakthrough thromboembolic events despite anticoagulation (10.5%). IVC filter retrievals were attempted in 48.9% of patients with a success rate of 86.9%. The mean dwell time for retrieved IVC filters was 159.4 days. CONCLUSION: Inferior vena cava filter insertion and retrieval patterns in our centre were comparable to trends reported internationally with scope for improvement in terms of filter retrieval rates and minimising filter dwell time. Particular vigilance is required in younger patients where the indication for filter insertion was prophylactic.

Percutaneous renal artery angioplasty and stenting: indications, technique and results.

BACKGROUND: Percutaneous interventions for renal arterial disease can be used to treat a variety of conditions including both atherosclerotic and non-atherosclerotic renal artery stenosis (RAS) as well as endovascular management of renal artery aneurysms (RAA). AIM: We sought to examine the indications, techniques and results of percutaneous renal angioplasty and stenting in our institution over a 6-year period and review the current evidence for practice. METHODS: Patient demographics, procedure indications, technical procedural details, complications, baseline and follow-up renal profile indices were analysed. RESULTS: The most common indication for intervention was atherosclerotic RAS (69.2%) followed by RAS secondary to fibromuscular dysplasia (15.3%) and RAA (15.3%). There was a 100% technical success in our cohort of patients. The majority of patients (84.6%) had cross-sectional imaging in the form of computed tomography or magnetic resonance angiography prior to intervention. CONCLUSION: When performed in appropriate settings following close liaison with referring physicians, percutaneous renal angioplasty and stenting remains an important treatment modality for renovascular disease.

Multimodality imaging features of hereditary multiple exostoses.

Hereditary multiple exostoses (HME) or diaphyseal aclasis is an inherited disorder characterised by the formation of multiple osteochondromas, which are cartilage-capped osseous outgrowths, and the development of associated osseous deformities. Individuals with HME may be asymptomatic or develop clinical symptoms, which prompt imaging studies. Different modalities ranging from plain radiographs to cross-sectional and nuclear medicine imaging studies can be helpful in the diagnosis and detection of complications in HME, including chondrosarcomatous transformation. We review the role and imaging features of these different modalities in HME.