Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy.

Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Can we reduce anesthesia exposure? Neonatal brain MRI: Swaddling vs. sedation, a national survey.

STUDY OBJECTIVE: Neonatal magnetic resonance imaging (MRI) is a diagnostic modality that requires minimal motion to acquire quality images. Sedation or even general anesthesia may be necessary to achieve acceptable scans. There is a growing body of literature, especially in animal studies, that links neurotoxicity with anesthetic exposure to the developing brain. There is no study outlining strategies used by neonatal intensive care units (NICU) to achieve quality MRI images with limited exposure to medications identified as possibly harmful to the developing brain. DESIGN: A 15-question survey was sent to all NICU programs in the United States (US) with fellowship programs. SETTING: MRI suite. PATIENTS: Neonates. INTERVENTIONS: None. MEASUREMENTS: The programs were queried regarding their preferred method for obtaining MRIs of the brain and how successful they were in obtaining quality images. MAIN RESULTS: Of the 96 programs surveyed, 58 responded (response rate of 60%). To obtain brain MRIs, 64%(n=37) used feed and swaddle; 32% (n=19) use sedation; and 3% (n=2) used general anesthesia (GA). Success rate of obtaining quality MRI images varied by technique. In the feed and swaddle group, 81% reported that a failure to obtain useful images occurred <25%; 11% reported that it occurred 25-75%; and 5% reported that it occurred >75%. In the sedation and GA group, 100% reported failure to obtain useful images occurred rarely. CONCLUSIONS: The majority of NICUs in the US that responded to the survey utilized feed and swaddle as their primary technique for obtaining MRIs of the brain and reported a high success rate. Given the growing concern over the possible neurotoxic effects of anesthetic drugs on the developing brain, more centers should consider this technique as a first line method to obtain brain MRIs, with sedation and GA reserved for failed feed and swaddle attempts and special circumstances.

Anesthesia for patients on buprenorphine.

Opioid abuse is a devastating, costly, and growing problem in the United States, and one for which treatment can be complicated by barriers such as access to care and legal issues. Only 12% to 15% of the opioid-dependent population is enrolled in methadone maintenance programs. A significant breakthrough occurred with passage of the Drug Addiction Treatment Act of 2000 (DATA 2000). For the first time in approximately 80 years, physicians could legally prescribe opioid medications for the treatment of opioid addiction. The opiate, so designated, was buprenorphine (Subutex).

Resolution of eating disorders after right temporal lesions.

We report two patients whose eating disorder resolved after right temporal lobe lesions. The first case report involves a woman with a history of bulimia nervosa and partial seizures arising from the occipital and right temporal regions. The second case is a woman with a history of anorexia nervosa that resolved after a head injury that resulted in right-sided inferofrontal and temporal encephalomalacia. Not only did both patients' eating disorders resolve, but their moods and libidos improved.

Selective emotional detachment from family after right temporal lobectomy.

Behavioral changes, such as mood disorders, anxiety, psychosis, and nonepileptic seizures often occur after temporal lobectomy. We report a man who selectively lost emotional attachments to family members after right temporal lobectomy. However, emotional responsiveness to strangers was normal or increased.

Volumetric CT: creating a new paradigm for image acquisition and review.

With the advent of fast, thin-slice CT, volumetric imaging is a practical and dose-efficient reality. However, the acquisition of many image slices at 0.5 mm thickness requires a new paradigm in image review. This article describes a hierarchical approach to handling the vast data set. The use of volume rendering and multiplanar reformatting techniques are critical in the process. Implementation of this approach at Long Beach Memorial Medical Center has resulted in greater clinical use of CT and improved diagnostic accuracy, while maintaining an acceptable throughput.

Epilepsy in The Alienist and Neurologist, 1880-1920.

PURPOSE: To study the history of epilepsy from 1880 to 1920. METHODS: We reviewed all 40 volumes of The Alienist and Neurologist and identified articles concerning primarily epilepsy. We analyzed three of these articles in greater detail. RESULTS: The Alienist and Neurologist published "Original Contributions,""Selections," (abstracts from other journals written by the editorial board), "Editorials," and (book) "Reviews." Of 258 epilepsy articles, there were 40 Original Contributions, 164 Selections, 39 Editorials, and 15 Reviews. These articles included 71 on therapy (41 medication, 13 surgery, and 17 other therapies); 66 general discussions; 46 on etiology or symptoms; 34 case studies; 28 social/legal articles; and 13 autopsy or pathology articles. CONCLUSIONS: Analysis of The Alienist and Neurologist provides a unique and valuable perspective on the clinical practice and academic world of epileptology during the decades around the turn of the twentieth century.