Comparison of Ultrasound-Accelerated versus Pigtail Catheter-Directed Thrombolysis for the Treatment of Acute Massive and Submassive Pulmonary Embolism.

PURPOSE: To compare the technical and clinical effectiveness of ultrasound-accelerated endovascular thrombolysis (USAT) versus pigtail catheter-directed thrombolysis (PCDT) for the treatment of acute pulmonary embolism (PE). MATERIALS AND METHODS: A single-center retrospective study of patients treated with USAT or PCDT for acute massive or submassive PE between January 2010 and December 2016 was performed by reviewing electronic medical records. Sixty treatments were reviewed (mean patient age, 56.7 y ± 14.6), including 52 cases of submassive PE (21 treated with USAT, 31 with PCDT) and 8 cases of massive PE (3 treated with USAT, 5 with PCDT). Endpoints included pulmonary artery pressure (PAP), Miller PE severity index, tissue plasminogen activator (TPA) dose, infusion duration, procedural variables, and complications. RESULTS: Demographics, PE severity, and right:left ventricular diameter ratios were similar between groups. USAT and PCDT significantly reduced mean PAP (reductions of 7.4 mm Hg [P = .002] and 8.2 mm Hg [P < .001], respectively) and Miller index scores (reductions of 45.8% [P < .001] and 53% [P < .001], respectively) with similar effectiveness (P = .47 and P = .15, respectively). Procedure (P < .001) and fluoroscopy (P = .001) times were significantly longer in the USAT group. The USAT group underwent fewer sessions (2.2 ± 0.6 vs 2.4 ± 0.6; P = .17) with shorter infusion times (23.9 h ± 8.8 vs 30.4 h ± 12.6; P = .065) and a lower total dose of TPA (27.1 mg ± 11.3 vs 30.4 mg ± 12.6; P = .075) compared with the PCDT group, but the differences were not significant. Complications (P = .07) and 30-day mortality rates (P = .56) were not significantly different between groups. CONCLUSIONS: USAT and PCDT demonstrated comparable effectiveness and safety in the treatment of patients with acute PE.

Value of prior imaging review before ordering renal sonography in the evaluation of abnormal renal function.

BACKGROUND: To determine the prognostic relevance of prior imaging studies in the evaluation of patients referred for renal ultrasound (US) examination to investigate abnormal renal function tests. METHODS: We conducted a retrospective study of 208 consecutive renal US examinations performed for abnormal renal function tests. RESULTS: 68% (142/208) of patients reviewed for the study had prior abdominal imaging with 15% (21/142) receiving that imaging within 1 month prior to the renal US study and 56% (80/142) within the prior year. Of all patients with prior imaging studies, only 6/142 (4%) demonstrated any significant interval change, with development of hydronephrosis, which was also clinically evident as a substantial rise in serum creatinine level. CONCLUSIONS: Review of prior imaging studies, in addition to other pertinent clinical data, should result in a significant reduction in the number of unnecessary renal US examinations performed in patients with abnormal renal function. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:537-541, 2017.

Intermittent right coronary artery obstruction.

Although prospectively electrocardiogram-triggered acquisition is frequently used for coronary CT angiography examinations in routine clinical practice to achieve low radiation dose, the use of retrospectively electrocardiogram-gated techniques may be useful for cases that potentially have a dynamic temporal element or involve the valves. In this case of a valvular fibroelastoma, CT could demonstrate dynamic obstruction of the right coronary ostium.

Hereditary angioedema: imaging manifestations and clinical management.

Hereditary angioedema is a genetic disorder typically related to insufficient or dysfunctional C1-esterase inhibitor. Patients present with episodic swelling of various body parts, such as the face, neck, bowel, genitals, and extremities. Acute or severe symptoms can lead to patients presenting to the emergency room, particularly when the neck and abdominopelvic regions are affected, which is often accompanied by radiologic imaging evaluation. Patients with hereditary angioedema can pose a diagnostic challenge for emergency department physicians and radiologists at initial presentation, and the correct diagnosis may be missed or delayed, due to lack of clinical awareness of the disease or lack of its consideration in the radiologic differential diagnosis. Timely diagnosis of hereditary angioedema and rapid initiation of appropriate therapy can avoid potentially life-threatening complications. This article focuses on the spectrum of common and characteristic acute imaging manifestations of hereditary angioedema and provides an update on important recent developments in its clinical management and treatment.

Ruptured extratesticular epidermal inclusion cyst mimicking polyorchidism with torsion on sonography.

The sonographic appearance of epidermal inclusion cysts varies in accordance with the contents of the cyst, ranging from an anechoic lesion to a hyperechoic solid appearing mass. Supernumerary testes are an uncommon congenital abnormality, in which more than two testes are present. We present a rare case of a ruptured scrotal extratesticular epidermal inclusion cyst, which had the sonographic appearance of a supernumerary testicle with torsion.

Renal cyst completely filled with milk of calcium on CT appears as a simple cyst on sonography.

Milk of calcium within a renal cyst typically layers in the dependent aspect of the cyst and appears echogenic with posterior shadowing and reverberation echoes on sonography. We present a rare case of a renal cyst completely filled with milk of calcium, which appeared sonolucent with enhanced through transmission.

Ovarian vein thrombosis: analysis of patient age, etiology, and side of involvement.

OBJECTIVE: To analyze the age distribution, underlying etiology, and side of involvement in patients diagnosed with ovarian vein thrombosis (OVT). METHODS: A retrospective study was conducted at Christiana Care Health System to identify all patients with an imaging diagnosis of OVT from January 2003 to September 2010. The data collected on this patient population included patient age, etiology, imaging modality used for diagnosis, side of involvement, as well as renal vein and inferior vena cava involvement. RESULTS: A total of 26 patients were diagnosed with OVT. The age distribution in patients with ovarian vein thrombosis ranged from 21 to 91. Ovarian vein thrombosis was diagnosed by computed tomography (CT) in 85 percent (22/26) of patients and magnetic resonance imaging (MRI) in 15 percent (4/26) of patients. The most common etiologies were underlying malignancy (27 percent, 7/26) and non-pregnancy related pelvic surgery (23 percent, 6/26). The postpartum state accounted for only 12 percent (3/26) of the cases. Thrombosis occurred in left ovarian vein in 50 percent (13/26), in the right ovarian vein in 42 percent (11/26), and bilaterally in 8 percent (2/26) of patients. Associated thrombus in the left renal vein was observed in 12 percent (3/26), and in the inferior vena cava in 15 percent (4/26) of patients. CONCLUSION: In our clinical practice, ovarian vein thrombosis is primarily diagnosed with computed tomography (CT) and less frequently via magnetic resonance imaging (MRI). In contrast to most of the published data, which emphasizes occurrence of OVT in women of child bearing age and postpartum state, in our series we found it occurred over a broad age distribution. There were a wide range of underlying etiologies. Half of the cases of ovarian vein thrombosis unilaterally involved the left ovarian vein, unlike the overwhelming right sided predominance reported by most other studies.

Yoga induced acute ulnar nerve compression by a ganglion cyst in Guyon's canal.

Acute ulnar neuropathy at the wrist can be difficult to diagnose, as it is an uncommon neuropathy with variable clinical presentations and numerous etiologies. We present a case of acute ulnar neuropathy of the deep motor branch caused by a ganglion cyst in Guyon's canal. Interestingly, this case of acute loss of motor function occurred after the patient participated in yoga (specifically the downward dog position), and resolved spontaneously over time after stopping yoga, without surgical excision of the ganglion, suggesting exacerbation or protrusion of an occult ganglion cyst due to increased activity and compression of the hypothenar eminence.

Epiploic appendagitis: a clinically valuable imaging diagnosis.

Epiploic appendagitis occurs more commonly than previously thought and the clinical presentation can mimic other serious acute abdominal processes such as diverticulitis and appendicitis. Epiploic appendagitis can be confidently diagnosed via CT scan in nearly all cases. As a result of the accurate diagnosis unnecessary antibiotics, laboratory testing, dietary restrictions, surgical consultation, hospitalization, overtreatment, and unnecessary costs to the patient and health care system can be avoided. Patients with epiploic appendagitis can be conservatively managed as outpatients.

Percutaneous closure of recurrent noncoronary Sinus of Valsalva aneurysm rupture: utility of computed tomography in procedural planning.

This case demonstrates the benefit of CT angiography in procedure planning and device selection for percutaneous closure of Sinus of Valsalva aneurysm rupture. As there is no dedicated equipment for closure, appropriate device selection is paramount. Amplatzer Muscular VSD Occluder device was chosen based on the anatomy of the defect that was readily appreciable by CT angiography, but was not well visualized with transesophageal echocardiography and thoracic aortography. CT angiography can provide anatomic information vital to percutaneous procedure planning and device selection. It is complementary to other imaging modalities.

Utility of aortic cuffs in converting initially ineligible patients due to unfavorable neck anatomy into successful candidates for endovascular aortic aneurysm repair: A Case Series.

Endovascular repair of the abdominal aortic aneurysm has been established as a successful alternative to open surgical repair, provided that the criteria necessary for such an approach are fulfilled. Anatomic criteria include suitable diameter, length, and angle of the aneurysm proximal neck. We present three cases in which patients were initially ineligible for endovascular repair because of unfavorable neck anatomy but in whom the use of aortic cuffs allowed for successful endograft placement and aneurysm exclusion.

CT angiography signs of lower extremity vascular trauma.

OBJECTIVE: Specific CT angiography (CTA) signs of vascular injury can be readily detected, and additional information regarding osseous and soft-tissue injuries can also be routinely obtained. In this article, we illustrate the important CTA signs of lower extremity vascular injury. CONCLUSION: CTA is efficient and accurate in the evaluation of clinically significant lower extremity arterial injuries after trauma.