Imaging criteria to predict Shamblin group in carotid body tumors - revisited.

PURPOSE: This study aims to compare the imaging findings of carotid body tumors on contrast-enhanced computed tomography (CT) with the intraoperative Shamblin grade and to evolve an imaging-based scoring system that can accurately predict the Shamblin grade. METHODS: Preoperative contrast-enhanced CT scans of 40 patients who underwent surgical excision of carotid body tumors in our institution between 2004 and 2017 were retrospectively reviewed. The angle of contact with the internal carotid artery (ICA), tumor volume, presence of peritumoral tuft of veins, loss of tumor adventitia interface and distance from the skull base were assessed and compared with the intraoperative Shamblin grades of the tumor. Ordinal logistic regression was used to determine which parameters could be predictors of the Shamblin grades. Receiver operator characteristic (ROC) curves were used to score the tumor volumes. RESULTS: Among the 42 tumors evaluated, 6 (14.3%) were surgically classified as Shamblin I, 15 (35.7%) as Shamblin II, and 21 (50%) as Shamblin III tumors. Pairwise comparison between the three Shamblin groups showed a statistically significant difference for angle of contact with ICA, maximum tumor dimension, presence of peritumoral tuft of veins and loss of tumor adventitia interface (p = 0.001, p = 0.001, p = 0.038 and p = 0.003, respectively). However, tumor volumes and distance from skull base were not significantly different between the Shamblin groups (p = 0.136 and p = 0.682). A scoring system, including four of the above mentioned parameters (angle of contact with ICA, tumor volume, presence of peritumoral tuft of veins, and loss of tumor adventitia interface) was developed with a maximum score of 8 and a minimum of 2. A statistically significant difference was found between the final scores among the three Shamblin groups (p < 0.001). Using ROC curves, a final score of ≥6 was found to separate Shamblin grade III tumors from grade I and II tumors (sensitivity, 95.24%; specificity, 71.43%). All patients with documented intraoperative estimated blood loss of >1000 mL had Shamblin grade III tumors. Postoperative complications like stroke, ICA thrombosis and lower cranial nerve palsies were seen only with Shamblin grade II and III tumors. CONCLUSION: The simple scoring system we have proposed correlates well with the Shamblin grade and helps in identifying patients who have a higher risk of developing complications.

Radiation dose reference card for interventional radiology procedures: Experience in a tertiary referral centre.

BACKGROUND: Fluoroscopy-guided interventions can potentially increase radiation risk to patients, if awareness on angiographic imaging technique and radiation dose is neglected. AIM: To develop patient radiation dose reference card from standardized imaging techniques for various radiology interventions performed using flat detector based angiography system. MATERIALS AND METHODS: Real-time monitoring of angiographic exposure parameters and radiation dose were performed for 16 types of radiological interventions. Effective dose (ED) was estimated from dose area product (DAP) using PCXMC Monte Carlo simulation software. Radiation risk levels were estimated based on Biological Effects of Ionising radiation (BEIR) report VII predictive models for an Asian population. RESULTS: Pulse rates of 7.5 pps and 0.6 mm Copper filtration during fluoroscopy and 4 frames per second (fps) and 0.1-0.3 mm Cu filtration during image acquisitions were found to reduce radiation dose. Owing to increased number of image acquisitions, DAP was highest during diagnostic spinal angiography 186.7 Gycm2 (44.0-377.5). This resulted in highest ED of 59.4 mSv with moderate risk levels (1 in 1000 to 1 in 500). Most of the radiological interventions had low radiation risk levels (1 in 10,000 to 1 in 1000). CONCLUSION: The patient radiation dose reference card is valuable to the medical community and can aid in patient counselling on radiation induced risk from radiological interventions.

Transjugular Intrahepatic Portosystemic Shunt Through the Strut of a Previously Placed Stent: Technical Feasibility and Long-Term Follow-Up Results.

AIMS AND OBJECTIVES: To evaluate technical feasibility, long-term primary patency and clinical outcome of the transjugular intrahepatic portosystemic shunt (TIPS) through the struts of the previously placed stents. MATERIALS AND METHODS: Retrospective evaluation of seven consecutive patients (three male and four female, age range 13-65 years, median 28) out of a total 95 patients, who underwent TIPS through the strut of the previously placed stents of hepatic vein (HV), inferior vena cava (IVC) or TIPS in a single tertiary care hospital. Six of the patients were diagnosed with Budd-Chiari syndrome (BCS) and one with alcohol-induced chronic liver disease (CLD). Kaplan-Meier test was used to calculate 18- and 60-month primary patency rate of TIPS stent. RESULTS: TIPS through the strut of a previously placed stent was technically successful in all the patients (100%). The TIPS was direct intrahepatic portosystemic shunt (DIPS) in 5/7 cases, due to occluded HV. Mean portosystemic pressure gradient (PPG) reduced from 24 mmHg ± 5.9 (range, pre-TIPS 15-31 mmHg) to 8.57 mmHg ± 4.4 (range, post-TIPS, 3-14 mmHg). One patient required three sessions of TIPS revisions. Another patient needed TIPS revision after 5 years of TIPS creation. All the patients showed improvement in clinical symptoms and in mean Child-Turcotte-Pugh (CTP) score and modified end-stage liver disease (MELD) score during mean follow-up period 40.57 month ± 34.9 (range 3-100 month). Primary patency rates of TIPS stent measured with Kaplan-Meier estimate at 18- and 60-month follow-up were 80% (95% CI, 37-97%) and 40% (95% CI, 10-97%), respectively. CONCLUSION: TIPS through the strut of a previously placed stent is technically feasible with good long-term primary patency and clinical outcome.

Percutaneous gastrostomy placement by intervention radiology: Techniques and outcome.

BACKGROUND: Interventional radiology (IR) has played an important role in the technical evolution of gastrostomy, from the first surgical, endoscopical to percutaneous interventional procedures. AIM: This study is done to assess the technical feasibility and outcome of IR-guided percutaneous gastrostomy for patients requiring nutritional support for neuromuscular disorders or head and neck malignancies, as well as to describe simplified and newer technique for pull-type gastrostomy. MATERIALS AND METHODS: This is a retrospective study including 29 patients who underwent IR-guided percutaneous gastrostomy over a period of 8 years in a tertiary-level institution. Either pull or push-type gastrostomy was performed in these patients as decided by the interventional radiologist. The procedures were assessed by analyzing the indications, technical aspects, and complications. STATISTICAL ANALYSIS: Descriptive summary statistics and frequencies were used to assess the techniques and related complications. RESULTS: The sample consists of 27 patients (93%) with pull technique and 2 patients (7%) with push technique. The technical success rate was 100%. Most of the complications were minor 24% (7/29), including superficial skin infections around the tube site, self-resolving pneumoperitoneum, tube-related complications such as block, leakage, deformation, and dislodgement. Three patients (10.3%) had major complications. One patient (3.4%) developed massive pneumoperitoneum and mild peritonitis due to technical failure in the first attempt and needed re-puncture for successful placement, and other two patients (6.9%) developed peristromal focal abscess. One patient died on the third postoperative day due to type II respiratory failure. CONCLUSION: IR-guided percutaneous gastrostomy is a safe and effective procedure in selected patients.

Diagnostic Accuracy of Qualitative and Quantitative Computed Tomography Analysis for Diagnosis of Pathological Grade and Stage in Upper Tract Urothelial Cell Carcinoma.

OBJECTIVE: The aim of this study was to compare grade and stage of upper tract urothelial cell carcinoma (UCC) using computed tomography. MATERIALS AND METHODS: With institutional review board approval, 48 patients with 49 UCC (44 high grade and 5 low grade, 26 ≤ T1 and 23 ≥ T2) underwent nephroureterectomy and preoperative computed tomography between 2013 and 2015. Two blinded radiologists assessed for tumor appearance (filling defect/mass or wall thickening/stricture), margin (smooth or spiculated/irregular), texture (homogeneous, heterogeneous), hydronephrosis, and calcification. A third blinded radiologist established consensus. A fourth blinded radiologist measured size and first-order histogram texture features. Comparisons were performed using χ test, multivariable logistic regression, and receiver operator characteristic analysis. RESULTS: There was no difference in size of tumors compared by grade or stage (P = 0.80 and 0.13, respectively).Among subjective variables, only tumor texture was significantly different between low- and high-grade UCC (P = 0.03; κ = 0.45). Tumors characterized as spiculated/irregular margin (P = 0.003; 0.30) and heterogeneous (P < 0.001; κ = 0.45) were associated with T2 disease or higher.Entropy was greater in higher grade (6.23 ± 0.46 vs 5.72 ± 0.28) and T2 disease or higher (6.40 ± 0.33 vs 5.95 ± 0.48), (P = 0.03 and 0.02, respectively) with no differences in Kurtosis or Skewness (P > 0.05). Area under the receiver operator characteristic curve for entropy to diagnose high-grade and T2 tumors or higher was 0.83 (confidence interval, 0.64-1.0) and 0.79 (confidence interval 0.59-0.98), respectively. CONCLUSIONS: Heterogeneity, assessed qualitatively and quantitatively, is accurate for diagnosis of higher grade and stage of disease in upper tract UCC. Spiculated/irregular margins are also associated with T2 disease or higher.

Radiofrequency Ablation of Osteoid Osteoma in Common and Technically Challenging Locations in Pediatric Population.

CONTEXT: Percutaneous radiofrequency ablation (RFA) of osteoid osteoma has a high technical and clinical success rate. However, there is limited data on its use in the pediatric population, especially in technically challenging locations. OBJECTIVE: The objective of this study was to assess the safety and efficacy of CT-guided percutaneous RFA of osteoid osteoma in pediatric population. SUBJECTS AND METHODS: From June 2009 to May 2014, thirty patients with osteoid osteoma were treated with CT-guided RFA in common (25 cases) and technically challenging (five cases: four near articular surface and one in sacrum) locations. Therapy was performed under general anesthesia with a three-array expandable RF probe for 6 min at 90°C and power of 60-100 W. The patients were discharged next day under instruction. The treatment success was evaluated in terms of pain relief before and after (1 day, 1 month, and 6 months) treatment. RESULTS: Technical success was achieved in all patients (100%). Primary clinical success was 96.66% (29 of total 30 patients) despite the pediatric population and atypical location. One patient had persistent pain after 1 month duration and were treated successfully with a second procedure (secondary success rate was 100%). One patient had immediate complication of weakness of right hand and fingers extension. No delayed complications were observed. CONCLUSIONS: CT-guided RFA is relatively safe and highly effective for treatment of osteoid osteoma in pediatric population, even in technically difficult locations. ADVANCE IN KNOWLEDGE: Our study showed that if technical success is 100% and if strict desired temperature (90°C) can be maintained for desired time (6 min) using controlled power (wattage) delivery (60-100 W), then high clinical success can be achieved even in pediatric population similar to adult population.

Role of penumbra mechanical thrombectomy device in acute dural sinus thrombosis.

BACKGROUND: In dural venous sinus thrombosis (DVST), the mortality ranges 5-30%. Deep venous system involvement and septic dural sinus thrombosis have a higher mortality rate. In acute occlusion, collateral flow may not be established, which may result in significant edema and mass effect. Endovascular interventions may be considered as a treatment option in appropriate high-risk patients with DVST. MATERIALS AND METHODS: Eight patients with magnetic resonance imaging (MRI)-confirmed dural sinus thrombosis, who did not respond to the conventional standard medical treatment, were subsequently treated with mechanical thrombectomy using the Penumbra System®. In all cases, medical treatment including anticoagulants were continued following the procedure for a minimum period of 1 year. RESULTS: Recanalization of the dural sinus thrombosis was achieved in all 8 cases. There were no immediate or late endovascular-related complications. One death occurred due to an unrelated medical event. At 6 months, there was notable improvement in the modified Rankin Score (mRS), with 5/8 (62%) patients achieving mRS of 2 or less. The follow-up ranged between 3 months and 26 months (mean: 14.5 months), and there were no new neurological events during the follow-up period. CONCLUSION: Cerebral venous sinus thrombosis is a rare but life-threatening condition that demands timely diagnosis and therapy. In cases of rapidly declining neurological status despite standard therapy with systemic anticoagulation and anti-edema measures, mechanical thrombectomy could be a lifesaving and effective option. In this study, good outcomes were observed in the majority of patients at long-term follow up.

Radiofrequency ablation of osteoid osteoma in common and technically challenging locations in pediatric population.

CONTEXT: Percutaneous radiofrequency ablation (RFA) of osteoid osteoma has a high technical and clinical success rate. However, there is limited data on its use in the pediatric population, especially in technically challenging locations. OBJECTIVE: To assess the safety and efficacy of computed tomography (CT)-guided percutaneous RFA of osteoid osteoma in pediatric population. PATIENTS AND METHODS: From June 2009 to May 2014, 30 patients with osteoid osteoma were treated with CT-guided RFA in common (25 cases) and technically challenging (five cases: four near articular surface and one in sacrum) locations. Therapy was performed under general anesthesia with a three-array expandable RF probe for 6 min at 90°C and power of 60-100 W. The patients were discharged next day under instruction. The treatment success was evaluated in terms of pain relief before and after (1 day, 1 month, and 6 months) treatment. RESULTS: Technical success was achieved in all patients (100%). Primary clinical success was 96.66% (29 of total 30 patients), despite the pediatric population and atypical location. One patient had persistent pain after 1 month and was treated successfully with a second procedure (secondary success rate was 100%). One patient had immediate complication of weakness of right hand and fingers extension. No delayed complications were observed. CONCLUSIONS: CT-guided RFA is relatively safe and highly effective for treatment of osteoid osteoma in pediatric population, even in technically difficult locations.

Role of endovascular embolization in treatment of acute bleeding complications in haemophilia patients.

OBJECTIVE:: Bleeding complications either spontaneously or post-operatively are very common in patients with haemophilia. Sometimes these bleeding complications remain unresponsive despite being on high dose of clotting factor replacement. The aim was to assess the role of endovascular embolization in patients with haemophilia in (a) treating haemorrhagic complications due to local causes refractory to clotting factors substitution and (b) reducing intraoperative blood loss in elective pseudotumour surgery. METHODS:: 10 patients seen between January 2000 and April 2015 with severe haemophilia A or B who had unexplained profuse persistent bleeding or required large pseudotumour excision and were taken up for digital subtraction angiography and embolization were included in the study. Data of all these patients were reviewed using the computerized hospital information system and picture archiving and communication system. Details including indications for the procedure, patient preparation for the procedure, imaging findings, details of angiography with intervention, if any, and outcome as well as follow-up data were analyzed. RESULTS:: In 6 of these 10 cases, bleeding was spontaneous, in 2 cases due to trivial fall and in 2 cases due to post-operative bleeding. Angiography in these patients revealed vascular blush, abnormal hypervascularity or active extravasation. In all 10 patients, an embolization procedure was performed, with bleeding controlled in 8 patients. There were no procedure-related complications during the procedure, post-procedure bleeding or haematoma at the site of arterial access. One patient had recurrence of bleeding for whom surgical exploration was required, and one patient had significant bleeding intraoperatively which was controlled with high-dose clotting factors, blood transfusion and fresh frozen plasma intraoperatively. CONCLUSION:: Endovascular embolization is a safe, effective and cost-saving procedure in arresting bleeding in selected patients with severe haemophilia who are unresponsive to adequate clotting factor replacement and where local vascular causes could be contributing to the bleeding. Pre-operative embolization is also a good procedure to reduce intraoperative blood loss in patients with large pseudotumours. ADVANCES IN KNOWLEDGE:: Angiography and embolization in patients with haemophilia is technically challenging and should be performed by highly skilled interventional radiologists, which limits its wider use and familiarity among multidisciplinary teams managing haemophilia. By bringing the knowledge of this effective treatment to the specialist groups who care for patients with haemophilia, its wider application may be possible which can save life and/or reduce morbidity.

Outcomes of catheter-directed treatment of lower extremity deep vein thrombosis of patients presenting to a tertiary care hospital.

BACKGROUND: Lower extremity deep vein thrombosis (DVT) is a common illness with an annual incidence of 1 per 1000 adults. The major long-term complication of DVT is post-thrombotic syndrome (PTS) which occurs in up to 60% of patients within 2 years of an episode of DVT. AIMS: We aim to evaluate the outcomes of catheter-directed treatment (CDT) for symptomatic acute or subacute lower extremity DVT. MATERIALS AND METHODS: A retrospective 12-year study was conducted on the outcomes of CDT on 54 consecutive patients who presented with acute or subacute lower extremity DVT to our hospital. STATISTICAL ANALYSIS: Descriptive summary statistics and the Chi-square test were used to measure the outcomes of CDT. RESULTS: Grade 3 thrombolysis was achieved in 25 (46.3%) patients, grade 2 thrombolysis in 25 (46.3%) patients, and grade 1 thrombolysis in 4 (7.4%) patients. Significant recanalization (grade 2 or 3 thrombolysis) was possible in 50 (92.6%) patients. There was no statistically significant difference in the percentage of significant recanalization that could be achieved between patients who underwent CDT before and after 10 days. There was no significant difference between the thrombolysis achieved between urokinase and r-tPA. PTS was seen in 33% of the patients. Major complications were seen in 5.5% of the patients. CONCLUSION: CDT is a safe and effective therapeutic technique in patients with acute and subacute lower extremity DVT, if appropriate patient selection is made.

Acute Portal Vein Thrombosis, No Longer a Contraindication for Transjugular Intrahepatic Porto-Systemic Shunt (TIPS) Insertion.

Portal vein thrombosis, once considered as a contraindication to transjugular intrahepatic porto-systemic shunt (TIPS) is now considered as an indication. We report a case with clinical and technical success in a patient with Budd Chiari syndrome and acute portal venous thrombosis. Though it is a well-established option, with the best of our knowledge, we could not find a report from India.

Endovascular treatment of isolated arterial pulmonary malinosculation.

We report the endovascular management of a series of four cases of isolated systemic supply to normal lung or isolated arterial pulmonary malinosculation of the left lung. In these cases, the basal segments of the left lung lacked normal pulmonary arterial supply and instead received systemic arterial blood from the descending thoracic aorta. The relevant anatomy and literature are also reviewed.

Percutaneous sclerotherapy of congenital slow-flow vascular malformations of the orbit.

PURPOSE: This manuscript describes the clinical features, imaging findings, treatment details, and short-term outcomes of a series of congenital slow-flow vascular malformations. METHODS: This was a prospective study of congenital slow-flow vascular malformations involving the orbital region treated at a single institution with percutaneous sclerotherapy. RESULTS: Ten patients presented during the study period, comprising eight venous malformations, one lymphatic malformation, and one veno-lymphatic malformation. Nine patients underwent percutaneous sclerotherapy under digital subtraction angiography guidance, of which three developed marked rise in intraocular pressure requiring lateral canthotomy. The treatments were performed in the presence of an ophthalmologist who measured the intraorbital pressure during and after the procedure. On follow-up, some of the patients required repeat sessions of sclerotherapy. All patients had improvement of symptoms on follow up after the procedure. CONCLUSION: Congenital slow-flow vascular malformations of the orbital region are rare lesions that should be treated using a multidisciplinary approach. Monitoring of the intraorbital pressure is required both during and after the procedure to decide about the need for lateral canthotomy to reduce the transiently increased intraorbital pressure.

Use of a vascular sheath for introduction of radiofrequency ablation probe during radiofrequency ablation of osteoid osteoma.

Radiofrequency ablation (RFA) has now become a preferred treatment option for osteoid osteoma. Accurate placement of RFA probe into the nidus of osteoid osteoma is important for good clinical outcome. Various methods and techniques have been described in the literature available. We describe the technique of using a vascular access sheath for introduction of RFA probe after bone drilling, which prevents loss of access to drill track and also serves as a pathway for accurate placement of RFA probe, thereby reducing the risk of damage to the RFA probe tip itself and the surrounding soft tissue.

A rare presentation of subacute progressive ascending myelopathy secondary to cement leakage in percutaneous vertebroplasty.

Percutaneous vertebroplasty is used to manage osteoporotic vertebral body compression fractures. Although it is relatively safe, complications after vertebroplasty ranging from minor to devastatingly major ones have been described. Cement leakage into the spinal canal is one such complication. Subacute progressive ascending myelopathy is an infrequent neurologic complication after spinal cord injury, typically presenting as ascending neurologic deficit within weeks after the initial insult. The precise cause of subacute progressive ascending myelopathy still remains an enigma, considering the rarity of this disorder. The authors present the case of a 62-yr-old woman with osteoporotic vertebral fracture who underwent percutaneous vertebroplasty and developed T6 complete paraplegia because of cement leakage. A few weeks later, the neurologic level ascended to higher cervical level (C3). To date, no case of subacute progressive ascending myelopathy secondary to cement leakage after percutaneous vertebroplasty has been reported. Literature is reviewed regarding subacute progressive ascending myelopathy, and the rehabilitation challenges in the management of this patient are discussed.

An epidermal cyst in the floor of the mouth: a rare presentation.

Epidermal cysts rarely occur in the head and neck region as compared to the dermoid cysts and when they do occur in this region, they present in the floor of the mouth. We are reporting a rare case of an epidermal cyst in the floor of the mouth, with a brief review of the literature.

Neurological complications in carotid body tumors: a 6-year single-center experience.

OBJECTIVE: Carotid body tumors are considered rare. However, there has been an increase in the number of these tumors managed at our center in recent years. Delayed presentation with large tumors is common. We studied the clinical profile, interventions, and outcomes of these tumors and assessed the factors influencing operative neurological morbidity and recurrence. METHODS: This retrospective study was conducted at the Christian Medical College in Vellore, a tertiary care center in south India. We analyzed the inpatient and outpatient records of patients diagnosed to have carotid body tumors undergoing excision from January 1, 2005 to December 31, 2011. Patients diagnosed to have vagal paragangliomas were excluded. RESULTS: Thirty-four of 48 tumors were excised from 32 patients (11 female, 21 male). Average age at presentation was 38.2 years, and three patients had familial bilateral tumors. All patients presented with a painless neck mass. There were 27 Shamblin group III, six Shamblin group II, and one Shamblin group I tumor. Eleven Shamblin group II/III tumors were associated with transient cranial nerve palsy or paresis (32.3%). Two Shamblin group III tumors were associated with perioperative stroke (5.8%). Preoperative embolization was done in 17 tumors, 12 of which were associated with neurological complications (two stroke, nine nerve palsy, one hemianopia). One patient underwent thrombolysis for a middle cerebral artery thrombus and recovered completely on follow-up, and another with a capsuloganglionic infarct managed conservatively had minimal persistent disability. Three patients had persistent nerve palsy (8.8%). Although complications were more common in patients with higher Shamblin group tumors, the difference was not statistically significant. CONCLUSIONS: The overall rate of neurological complications is higher with tumors of higher Shamblin groups. Preoperative embolization was not effective in reducing neurological complications. The rates of postoperative stroke and permanent cranial nerve palsy after resection of large tumors are acceptable.

Pictorial essay: Interventional radiology in the management of hemodialysis vascular access - A single-center experience.

Chronic kidney disease (CKD) is a worldwide public health problem and is associated with high morbidity and mortality. The majority of patients with CKD stage 5 (CKD-5), who cannot undergo renal transplant, depend on maintenance hemodialysis by surgically created access sites. Native fistulae are preferred over grafts due to their longevity. More than half of these vital portals for dialysis access will fail over time. Screening procedures to select high-risk patients before thrombosis or stenosis appears have resulted in aggressive management. These patients are referred for angiographic evaluation and/or therapy. We present the patterns of dialysis-related interventions done in our institution.