Fibrocartilaginous embolism: a rare cause leading to spinal cord infarction?

PURPOSE: Fibrocartilaginous nucleus pulposus components herniation and embolism rarely causes acute ischaemic events involving the spinal cord. Few reports have suggested this as a mechanism leading to anterior spinal artery syndrome. The purpose of this study was to evaluate the topography and pattern of this rare myelopathy by MRI. METHODS: A retrospective observational case series of patients, admitted to our Institute between 2008 and 2021, with a diagnosis of fibrocartilaginous embolism based on typical clinical and radiological features. RESULTS: Five patients were identified (2 men and 3 women; range 13-38 years). No one had pre-existing vascular risk factors. All referred potential precipitating event in the 24 h prior to symptom onset. MRI findings showed increased signal intensity of the spinal cord on T2-weighted images in all cases and degenerative disc changes opposite to it in four of them. The outcome was poor: three showed only partial sensitivity and motor improvement (mRs 4, 3, and 2, respectively); one completely recovered except for isolated hand paresis (mRs 1); and one remained severely neurologically affected (mRs 5). CONCLUSIONS: Fibrocartilaginous embolism must be a differential diagnosis in case of otherwise unexplained spinal cord infarction in adult and paediatric low risk population. Neuroradiological findings such as abnormal spinal cord signal intensity and degenerative disc changes can aid in early diagnosis of this rare myelopathy. The prevalent myelopathy location was thoracic. All signal alterations were detected in the anterior region of the spinal cord in the territories of the anterior spinal artery.

Aponeurotic-Cutaneous Tract Exeresis in Patients With Persistent Lymphorrhea After Kidney Transplantation: A Valid Approach in a Day Surgery Setting.

BACKGROUND: Lymphatic disorders (LDs) are the most common minor complications after kidney transplantation (KT), with an incidence rate between 0.6% and 33.9%, which appears to be related to both surgical and medical factors. LDs mostly resolve spontaneously, but occasionally a surgical approach may be required. MATERIALS AND METHODS: We report our experience with 7 KT recipients who developed persistent lymphorrhea (>150 mL/24 h) between October 2017 and March 2019. All cases were treated as outpatients with parietal fistulectomy (PF). The fibrotic aponeurotic-cutaneous tract was thoroughly excised, and the residual aponeurotic defect was closed by watertight suturing. Serial abdominal ultrasounds (US) were carried out after the procedure. RESULTS: A small perirenal graft lymphocele of <2 cm was detected by US in all patients after 48 to 72 hours, without any evidence of either vascular or ureteral compression. During the subsequent scheduled US follow-up, lymphoceles did not increase in size, and additional interventions were not needed. Neither superficial nor deep surgical-site infections were recorded in such patients. CONCLUSIONS: PF was found to be a safe and effective minimally invasive approach for persistent lymphorrhea after KT. It could be easily performed with local anesthesia in a day surgery setting and did not require patient hospitalization.

Renal artery embolization of non-functioning graft: an effective treatment for graft intolerance syndrome.

BACKGROUND: Percutaneous renal artery embolization is a valid non-invasive technique alternative to nephrectomy for patients with symptomatic non-functioning allograft (graft intolerance syndrome-GIS). The purpose of this article is to report the experience of our centre. METHODS: We analysed retrospectively 15 patients with symptomatic non-functioning renal allograft treated with percutaneous embolization from 2003 to 2017. Occlusion was obtained with the injection of calibrated microspheres of increasing size (from 100 to 900 µm) and completed with 5 to 8 mm metal coils placement in the renal artery. RESULTS: Technical success was achieved in all cases at the end of the procedure. Clinical success was obtained in 11 patients (73%). In four cases, nephrectomy was necessary: in one case because of septic fever and in three cases because of GIS persistence. In one case, it was possible to perform another procedure to embolize a perirenal collateral from a lumbar artery. Four patients (27%) reported minor complications which spontaneously resolved during the hospital stay. CONCLUSIONS: According to the scientific literature, we believe that, in selected patients, percutaneous renal artery embolization is a valid treatment option for GIS thanks to its efficacy, repeatability, minimal invasiveness and the absence of severe complications.

Direct thrombectomy for stroke in the presence of absolute exclusion criteria for thrombolysis.

BACKGROUND: Intravenous thrombolysis (IVT)-ineligible patients undergoing direct thrombectomy tended to have poorer functional outcome as compared with IVT-eligible patients undergoing bridging therapy. We aimed to assess radiological and functional outcomes in large vessel occlusion-related stroke patients receiving direct thrombectomy in the presence of absolute exclusion criteria for IVT vs relative exclusion criteria for IVT and vs non-exclusion criteria for IVT. METHODS: A cohort study on prospectively collected data from 2282 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke cohort for treatment with direct thrombectomy (n = 486, absolute exclusion criteria for IVT alone; n = 384, absolute in combination with relative exclusion criteria for IVT; n = 777, relative exclusion criteria for IVT alone; n = 635, non-exclusion criteria for IVT). RESULTS: After adjustment for unbalanced variables (model 1), ORs for 3-month death was higher in the presence of absolute exclusion criteria for IVT alone (vs relative exclusion criteria for IVT alone) (1.595, 95% CI 1.042-2.440) and in the presence of absolute exclusion criteria for IVT alone (vs non-exclusion criteria for IVT) (1.235, 95% CI 1.014-1.504). After adjustment for predefined variables (model 2: age, sex, pre-stroke mRS ≤ 1, NIHSS, occlusion in the anterior circulation, onset-to-groin time, and procedure time), ORs for 3-month death was higher in the presence of absolute exclusion criteria for IVT alone (vs relative exclusion criteria for IVT alone) (1.235, 95% CI 1.014-1.504) and in the presence of absolute exclusion criteria for IVT alone (vs non-exclusion criteria for IVT) (1.246, 95% CI 1.039-1.495). No significant difference was found between the groups as regards any type of intracerebral hemorrhage and parenchymal hematoma within 24 h, successful and complete recanalization after procedure, and modified Rankin Scale score 0-2 at 3 months. After adjustment for predefined variables of model 2, ORs for death were higher in the presence of recent administration of IV heparin (OR: 2.077), platelet count < 100,000/mm3 (OR: 4.798), bacterial endocarditis (OR: 15.069), neoplasm with increased hemorrhagic risk (OR: 6.046), and severe liver disease (OR: 6.124). CONCLUSIONS: Radiological outcomes were similar after direct thrombectomy in patients with absolute, relative, and non- exclusion criteria for IVT, while an increase of fatal outcome was observed in the presence of some absolute exclusion criterion for IVT.

Implementing a Ureteric Magnetic Stent in the Kidney Transplant Setting: Report of 100 Consecutive Cases.

BACKGROUND: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease. The double-J-stent has been used to prevent urological complications (UCs), but it requires cystoscopy extraction. The novel magnetic black star (MBS) stent provided with a customized retrieval device (9 or 15 Fr) has been developed to spare cystoscopy. Scope of the paper is to analyze MBS in 100 consecutive KTs. METHODS: We report a retrospective analysis of 100 consecutive KT performed between April 2015 and September 2018 using MBS (4.8 Fr, 15 cm) to protect Lich-Gregoir ureteroneocystotomy. MBS was removed 4 weeks after KT by either the 9 Fr (61 cases) or the 15 Fr (39 cases) retrieval device. RESULTS: Intraoperative MBS insertion was straightforward in all cases, and its extraction was carried out in the outpatient setting in 93 patients. Extraction time was <30 seconds in 45 out of 61 patients (73.8%) and in 38 out of 39 patients (97.4%) using the 9 Fr and the 15 Fr retrieval device, respectively. In 15 patients, MBS removal took between 30 seconds and 3 minutes. Only 2 cases required extraction by cystoscopy. We observed 2 UC (ureteric leak and stenosis), 8 urinary tract infections, and 9 stent-related symptoms. 7 patients experienced distressing pain according to Visual Analog Scale for Pain. CONCLUSIONS: In our cohort, MBS appeared to be safe and cost-effective. We advocate its routine implementation in KT because of an easy and comfortable extraction in the outpatient setting even by nondedicated staff, without detrimental impact on UC and urinary tract infection rates.

Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery.

BACKGROUND: Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries. CASE REPORT: We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction. CONCLUSIONS: Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.

Endovascular Treatment of Acute Basilar Artery Occlusion: Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) Study Group Experience.

BACKGROUND: Acute basilar artery occlusion (BAO) is considered among the most severe medical emergencies, with very high morbidity and mortality. The aims of this study are to present 5 years experience of 12 centers in Lombardy region on BAO endovascular treatment and to evaluate prognostic factors that may improve clinical outcomes and recanalization rates. MATERIALS AND METHODS: Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) registry is a retrospective multicentric collection of patients with acute BAO who underwent endovascular treatment between 2010 and 2015. A total of 102 patients (mean age 65 years) were included. Clinical, procedural, and neuroradiological data were collected. Angiographic results (Treatment in Cerebral Ischemia scale [TICI] score 2b-3) were assessed by each center's interventional neuroradiologist. Good clinical outcome was considered as a modified Rankin Scale score ranging between 0 and 2 in a 3-month follow-up. RESULTS: Thirty-nine percent of patients showed good clinical outcome at 3 months. Mortality rate was 30%. TICI 2b-3 was achieved in 62% of patients. Univariate analysis showed that age, National Institutes of Health Stroke Scale (NIHSS) at onset, time to recanalization, and TICI score were all statistically significant clinical outcome predictors (P < .05). Multivariate logistic regression showed that time to recanalization, age, and NIHSS at onset were significant independent predictors of good outcome. CONCLUSIONS: BAO treatment needs more efforts to assure patients better clinical outcomes. Mechanical thrombectomy is feasible and effective in patients with acute BAO. These results must be confirmed by further prospective studies within randomized controlled settings.

Sustainable management and supply of natural and recycled aggregates in a medium-size integrated plant.

The consumption of natural aggregates in civil engineering applications can cause severe environmental impacts on a regional scale, depleting the stock of bulk resources within a territory. Several methods can improve the environmental sustainability of the whole aggregates' supply process, including natural and recycled aggregates' productive chains, for instance promoting the use of recycled aggregates (RA). However, when quarrying and recycling activities are considered as stand-alone processes, also the RA supply chain may not be as sustainable as expected, due to the high environmental loads associated to transportation, if high distances from the production to the use sites are involved. This work gives some insights on the environmental impact assessment of the aggregates' industry in the Italian context, through a comparative assessment of the environmental loads of natural and recycled aggregates' productive chains. An integrated plant for the extraction of virgin aggregates and recycling of construction and demolition waste (C&DW) was analyzed as significant case study, with the aim to identify the influence of sustainable solutions on the overall emissions of the facility. A Life Cycle Assessment (LCA) approach was used, using site-specific data and paying particular attention on transportation-related impacts, land use, avoided landfill and non-renewable resources preservation. From this work it was possible to evaluate the influence of transportation and PV energy use on the overall environmental emissions of natural and recycled aggregates' productive chains.

Endovascular Treatment of Extracranial Internal Carotid Pseudoaneurysm: Description of Three Cases.

The aim of this study is to explore the possibility of endovascular treatment of internal carotid artery pseudoaneurysm (PSA). These lesions are difficult to treat with a surgical approach, especially if they are located extracranially and close to the skull base. Endovascular stent placement in symptomatic and unstable extracranial internal carotid PSA was found to be safe and effective. Depending on hemodynamic aspects, complete local exclusion of aneurysmal formation is achieved in few months. We present three patients with carotid dissection and PSA formation that have been successfully treated by stent placement.

Can early serum lipase measurement be routinely implemented to rule out clinically significant pancreatic fistula after pancreaticoduodenectomy?

INTRODUCTION: Postoperative pancreatic fistula (POPF) is the most significant cause of morbidity and mortality after pancreaticoduodenectomy (PD). We evaluated the role of postoperative serum lipase concentration in ruling out POPF in the immediate post-operative period. MATERIALS AND METHODS: We retrospectively analysed 98 consecutive PD performed between January 2009 and December 2014, investigating the correlation between postoperative day 1 (POD1) serum lipase concentration and POPF development. RESULTS: 29 patients (29.5%) developed POPF [grade A, 17 (17.3%); grade B, 8 (8.1%); grade C, 4 (4%)]. A receiver operating characteristic (ROC) analysis was conducted to determine the threshold value of POD1 serum lipase associated with clinically significant POPF (AUC = 0.76, 95% CI 0.64-0.86, P = 0.01). Such threshold was ≤ 44.5 U/L and its sensitivity and specificity were 92% and 66%, respectively. The positive and negative predictive values (PPV, NPV) were 31% and 98%, respectively. CONCLUSION: Early routinely measurement of serum lipase proved to be helpful in ruling out clinically relevant POPF (CR-POPF). In our cohort, a POD1 cut-off of ≤ 44.5 U/L allowed early and accurate identification of patients with low probability to develop clinically significant POPF, who can eventually be selected for enhanced post-operative recovery with significant clinical and economic benefits.

Flow-diverter stenting in post-traumatic pseudoaneurysm of cavernous internal carotid artery with epistaxis.

This paper is a case report of a young patient after a major head trauma causing multiple skull base fractures. The trauma occasioned pseudoaneurysm (PSA) from intracavernous C4 segment of left internal carotid artery (ICA) protruding in the sphenoidal sinus. After two months, two episodes of massive epistaxis occurred. Consequently, the post-traumatic PSA was treated, after carotid occlusion test, with flow-diverter stent positioning. A computed tomography angiography study performed in the following days showed complete resolution of the post-traumatic PSA lesion and ICA patency.

Flow-diverter stenting of post-traumatic bilateral anterior cerebral artery pseudoaneurysm: A case report.

The use of flow-diverter (FD) stents in recent years has positively changed the therapeutic approach to some vascular diseases, especially of certain types of aneurysms. This paper describes the case of a young patient after a major head trauma causing multiple skull fractures. The trauma occasioned two pseudoaneurysms from the A1 segment of the right anterior cerebral artery and from the A2 segment of the left anterior cerebral artery. Both lesions were treated with two Pipeline devices (ev3, Irvine, CA, USA) in two different sessions. The CT study and angiographic investigations performed in the following month showed a complete resolution of the post-traumatic pseudoaneurysmal lesions. Although the use of FD stents is described in the literature, particularly in the treatment of selected aneurysms, this paper shows good technical results in the use of these stents in cases of intracranial post-traumatic pseudoaneurysms with clinical improvement.

Role of percutaneous transcatheter embolization (PTE) in the treatment of spontaneous bleeding associated with anticoagulant therapy.

PURPOSE: To evaluate safety and clinical efficacy of percutaneous transcatheter embolization (PTE) in the treatment of spontaneous bleedings (SBs) in patients submitted to chronic anticoagulation therapy. MATERIALS AND METHODS: From January 2007 to December 2012, 20 patients (mean age 75.8 years, range 68-91 years) with 23 SBs were retrospectively evaluated. Active bleeding was documented by contrast enhanced-multidetector row computed tomography (CE-MDCT). PTE was performed using different embolic agents. Technical success (TS), clinical success (CS), late success (LS) and mortality rate (M) related to the angiographic procedure and complications were evaluated. RESULTS: CE-MDCT and digital subtraction angiography (DSA) identified active bleeding sites in 18 cases (18/20). In two cases (2/20) DSA did not confirm the arterial bleeding diagnosed on CE-MDCT. Twenty-three sessions of PTE were performed. TS, CS, LS and M were, respectively, 100, 85, 15 and 0%. No major complications were observed. CONCLUSIONS: PTE could be considered a safe and effective "first line" approach to treat SB associated with anticoagulation therapy.

C-arm cone-beam computed tomography needle path overlay for percutaneous biopsy of pulmonary nodules.

PURPOSE: The aim of this study was to evaluate the feasibility of percutaneous transthoracic needle biopsy of pulmonary nodules under cone-beam computed tomography (CBCT) with "XperGuide" navigation guidance. MATERIALS AND METHODS: From February 2010 to January 2012, 100 patients (63 men and 37 women; mean age 67.27 years; range 21-88 years) with 100 lung nodules (44 ≤ 3 cm, 56 > 3 cm) underwent CBCT-XperGuide guided percutaneous transthoracic needle biopsies. Technical success, diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and complications were evaluated. RESULTS: Of 100 nodules (mean size 5.19 cm), 68 were diagnosed as malignant, 27 as benign, and five as indeterminate. Technical success was 95 %. Only 33 of 100 patients underwent surgery: the final pathological diagnosis was concordant with the biopsy diagnosis in 26 cases and discordant in 7 cases (false negatives). Accuracy, sensitivity, specificity, PPV and NPV were 92.6, 90.9, 100, 100 and 72 %, respectively. CONCLUSIONS: CBCT-XperGuide navigation is a new, accurate and safe imaging guidance for percutaneous lung biopsies.

Chemical composition and biological activity of the essential oil of Origanum vulgare ssp. hirtum from different areas in the Southern Apennines (Italy).

The chemical composition of the essential oils of Origanum vulgare ssp. hirtum, growing wild in three different localities in the Southern Apennines, was studied by GC-FID and GC/MS analyses. In total, 103 compounds were identified. The oils were mainly composed of phenolic compounds and all oils belonged to the chemotype carvacrol/thymol. The three essential oils were evaluated for their in vitro phytotoxic activity by determining their influence on the germination and initial radicle elongation of Sinapis arvensis L., Phalaris canariensis L., Lepidium sativum L., and Raphanus sativus L. The seed germination and radicle growth were affected in various degrees. Moreover, the antifungal activity of the three essential oils was assayed against three species causing pre- and postharvest fruit decay (Monilinia laxa, M. fructigena, and M. fructicola). At 1000 ppm, the three oils completely inhibited fungal growth. The hemolytic activity of the oils was assayed and showed no effect on the cell membranes of bovine erythrocytes.

Lhermitte-Duclos disease. A case report.

Lhermitte-Duclos disease is a rare pathologic condition consisting of a dysplastic gangliocytoma of the cerebellum. Its association with phacomatosis and an autosomal dominant neoplastic syndrome, Cowden's syndrome is also known. Modern neuroimaging contributes to a correct diagnosis and pre- and postoperative evaluation. Here we describe the morphologic and metabolic aspects of the disease as shown by conventional MRI, diffusion imaging and spectroscopy in a 31-year-old woman. In addition, the specific neuroradiologic characteristics are presented and discussed in the light of the main pathologic and clinical features, such as hypertrophy of the cerebellar folia associated with white matter atrophy.

Errors and malpractice in interventional radiology.

Interventional radiology is an invasive specialty with the potential for errors as with other invasive specialties. A critical analysis of the different types of errors may help radiologist undertake the corrective measures. Standardize interventional procedures with protocols applicable to clinical practice are necessary to avoid the malpractice and, therefore, the related medical-legal issues. In this article, we present an overview of principal differences between errors and malpractice with particular regard to the issues in interventional radiology. Specific topics discussed in this article are the approaches to preventing errors and, thus, to avoiding the malpractice in interventional radiology.

Percutaneous treatment of traumatic upper-extremity arterial injuries: a single-center experience.

PURPOSE: To assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries. MATERIALS AND METHODS: Between January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly. RESULTS: Immediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%. CONCLUSIONS: Percutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Emergency endovascular treatment of sac rupture for type IIIa endoleak in thoracic aortic aneurysm previously excluded with endovascular repair.

Elective endovascular treatment of thoracic aortic pathology has been applied in a variety of conditions. The complications of thoracic aortic stenting are also well recognized. Endoleak after endovascular repair of thoracic aortic aneurysms is the most frequent complication; among them, type III is the least frequent. Endovascular treatment of type III endoleak is generally performed under elective conditions; less frequently, in emergency. We report a successful emergency endovascular management of post-thoracic endovascular repair for thoracic aortic aneurysm rupture due to type IIIa endoleak.

Single-antenna microwave ablation under contrast-enhanced ultrasound guidance for treatment of small renal cell carcinoma: preliminary experience.

The purpose of this study was to determine the safety, effectiveness, and feasibility of microwave ablation (MWA) of small renal cell carcinomas (RCCs) in selected patients. Institutional review board and informed consent were obtained. From December 2007 to January 2009, 12 patients (8 male, 4 female) were enrolled in a treatment group, in which percutaneous MWA of small RCCs was performed under contrast-enhanced ultrasound guidance. The tumors were 1.7-2.9 cm in diameter (mean diameter, 2.0 cm).Therapeutic effects were assessed at follow-up with computed tomography. All patients were followed up for 3-14 months (mean, 6 months) to observe the therapeutic effects and complications (according to SIR classification). Assessment was carried out with CT imaging. No severe complications or unexpected side effects were observed after the MWA procedures. In all cases technical success was achieved. Clinical effectiveness was 100%; none of the patients showed recurrence on imaging. In conclusion, our preliminary results support the use of MWA for the treatment of small renal tumors. This technology can be applied in select patients who are not candidates for surgery, as an alternative to other ablative techniques.