Dual-layered micromesh stent technology for embolic prevention in carotid revascularization: technical experience and clinical outcomes from a high-volume interventional radiology center.

BACKGROUND: Carotid artery stenting (CAS) has become a cornerstone of carotid revascularization for stroke prevention. Despite the advantages of CAS, large-scale randomized trials involving prior (single-layer) first generation stents (FGS) demonstrated a higher risk of periprocedural cerebrovascular events compared to surgery. Dual-layer mesh-covered stents (DLSs) showed promising results in terms of 30-day embolic events in initial studies; larger-scale evidence is accumulating. This study aims to evaluate 30-day clinical efficacy of DLS against a closed-cell stent, based on large-volume data. METHODS: The study center is part of the Italian National Outcomes Evaluation Program (PNE). CAS procedures performed between November 2017 and September 2023 were eneterd into a prospectively collected database. Our The primary endpoint was survival free of death, stroke, and myocardial infarction (MI) at 30 days. In addition, technical success and periprocedural major adverse clinical event rate (with a focus on stroke) were also evaluated. RESULTS: Over a total of 1101 CAS procedures (745 males; mean age 79±7.8 years), 48.6% were symptomatic. Majority (80.2%) were treated with DLSs. Technical success was achieved in 98.9%. The FGSs group showed a significantly higher peri-procedural stroke rate when compared with CGuard and Roadsaver DLS: 4.59% vs. 1.18% vs. 2.63% (P=0.008); minor stroke rates were 4.13% vs. 0.83% and 0% P=0.01). The cumulative stroke, MI and death - free survival at 30 days was 97.46%. A statistically significant higher cumulative 30-day death/stroke/MI rate occurred in FGSs-treated patients compared to the CGuard and Roadsaver DLS-treated (6.42% vs. 1.42% and 2.63%, P=0.001). CONCLUSIONS: The use of DLS in patients undergoing CAS in our large-volume center showed a high technical success rate and minimal cerebral embolic complications by 30 days. High volumes and an experienced interventional team may contribute to these favorable outcomes.

Cardiac magnetic resonance-guided cardiac ablation: a case series of an early experience.

Radiofrequency (RF) catheter ablation has become a widely used therapeutic approach. However, long-term results in terms of arrhythmia recurrence are still suboptimal. Cardiac magnetic resonance (CMR) could offer a valuable tool to overcome this limitation, with the possibility of targeting the arrhythmic substrate and evaluating the location, depth, and possible gaps of RF lesions. Moreover, real-time CMR-guided procedures offer a radiation-free approach with an evaluation of anatomical structures, substrates, RF lesions, and possible complications during a single procedure. The first steps in the field have been made with cavotricuspid isthmus ablation, showing similar procedural duration and success rate to standard fluoroscopy-guided procedures, while allowing visualization of anatomic structures and RF lesions. These promising results open the path for further studies in the context of more complex arrhythmias, like atrial fibrillation and ventricular tachycardias. Of note, setting up an interventional CMR (iCMR) centre requires safety and technical standards, mostly related to the need for CMR-compatible equipment and medical staff's educational training. For the cardiac imagers, it is fundamental to provide correct CMR sequences for catheter tracking and guide RF delivery. At the same time, the electrophysiologist needs a rapid interpretation of CMR images during the procedures. The aim of this paper is first to review the logistic and technical aspects of setting up an iCMR suite. Then, we will describe the experience in iCMR-guided flutter ablations of two European centres, Policlinico Casilino in Rome, Italy, and Haga Teaching Hospital in The Hague, the Netherlands.

MR guided cardiac ablation: how to build an interventional magnetic resonance suite and what's the role of the imaging.

Magnetic resonance (MR) represents a new interesting imaging approach for guiding electrophysiology (EP)-based ablation procedures of atrial flutter and typical atrial fibrillation. This new approach permits to reach good results if compared with conventional EP ablation. Tissue characterization by MR permits to detect cardiac anatomy and pathological substrate like myocardial scars well visualized with late gadolinium enhancement (LGE) sequences. Intra-procedural imaging is useful to real-time follow the catheter during the ablation procedure and at the same time to visualize cardiac anatomy in addition to understanding if the ablation is correctly performed using oedema sequences. Performing cardiac ablations inside an MR room permits to reduce radiation exposure and occupational illnesses.

MRI-guided thoraco-abdominal percutaneous needle biopsy: our initial experience.

OBJECTIVE: The aim of this study is to describe the technique and to report early results of thoraco-abdominal biopsies in the Interventional Magnetic Resonance Imaging Suite (IMRIS). MATERIALS AND METHODS: We prospectively evaluated patients with indications for MRI-guided biopsy between January 2021 and May 2022. Exclusion criteria were indication for US-/CT-guided biopsy, contraindication to percutaneous biopsy, inability to lie flat for at least 30 min, claustrophobic, severe obesity, or non-MRI compatible devices. Biopsies were performed by 3 interventional radiologists, with at least 8 years of experience in oncological interventional radiology. Epidemiological, clinical, procedural, and histopathological data were retrospectively collected. RESULTS: From an initial population of 117 patients, 57 patients (32 male, mean age 64 ± 8 y) were finally enrolled. All 57 patients suspected thoraco-abdominal malignant lesions finally underwent MRI-guided percutaneous biopsy. The mean duration of the entire procedure was 37 min (range 28-65 min); the mean duration of the total needle-in-patient time was 10 min (range 6-19 min). Technical and clinical success were obtained for all the biopsies performed. Malignancy was demonstrated in 47/57 (82%) cases and benignancy in the remaining 10/57 (18%) cases. No major complications were detected after the biopsies; two minor compliances (severe pain) occurred and were managed conservatively. CONCLUSION: Our initial experience demonstrated the technical feasibility and the accuracy of MRI-guided biopsies of thoraco-abdominal masses. The reported data associated with the best comfort for the patient and for the operator make the use of MRI a valid alternative to other methods, especially in lesions that are difficult to approach via US or CT. CLINICAL RELEVANCE STATEMENT: Interventional MRI is one of the most important innovations available for interventional radiologists. This method will broaden the diagnostic and therapeutic possibilities, allowing treatment of lesions up to now not approachable percutaneously. For this, it is necessary to start publishing the data of the few groups that are developing the method. KEY POINTS: • To evaluate the use of MRI as a guide for percutaneous biopsies of various districts. • Our preliminary experience confirms experience demonstrated the technical feasibility and the accuracy of MRI-guided biopsies of thoraco-abdominal masses. • Interventional MRI can become the reference method for percutaneous biopsies in particular for lesions with difficult percutaneous approach.

Interventional Magnetic Resonance Imaging Suite (IMRIS): How to build and how to use.

Over the last ten years, the number of minimally invasive interventional procedures has been increasing steadily. Magnetic resonance imaging (MRI) is still far less frequently used for image-guided percutaneous procedures or as an intervention method than computed tomography (CT) and ultrasound (US). However, MRI has many advantages, such as lack of ionizing radiation, real-time MR-fluoroscopy placement high resolution, no bone and gas artifacts, the ability to display lesions that are difficult to observe on CT and US visualization of blood vessels without a contrast agent, free selection of imaging planes and in the case of procedures such as thermos or cryoablation it is possible to make an intraprocedural assessment of the process without the application of a contrasting agent (Marini et al. in Diagn Interv Imaging 102: 531-538, 2021; Li et al. in BMC Cancer 21: 366, 2021; Barkhausen et al. in Rofo 189: 611, 2017). Furthermore, in addition to its use in Interventional Radiology, MRI is also becoming a reality in cardiology thanks to the possibility of overcoming all the limits related to the fusion technology used up to now in cardiac ablations (Chubb et al. Arrhythm Electrophysiol Rev 6: 85, 2017). Some suites have been built in Northern Europe and in the United States, but based only on personal experience and industry indication. In our hospital, we have built a new Interventional Magnetic Resonance Imaging Suite (IMRIS), the first in Southern Europe and we have defined what the necessary requirements and equipment were for the safety of the patient and the operator.

Virtual histology-intravascular ultrasound as a diagnostic alternative for morphological characterization of carotid plaque: comparison with histology and high-resolution magnetic resonance findings.

BACKGROUND: Stroke is the third most common cause of death and one of the most common cause of long-term disability in the Western world. Carotid plaque morphology is the main predictor of cerebrovascular accidents, more than the degree of stenosis. AIMS: The primary aim was to validate virtual histology- intravascular ultrasound (VH-IVUS) as a diagnostic tool for carotid plaque characterization, by comparison with histology, through ex-vivo evaluation of carotid plaques. The secondary target was to compare VH-IVUS with high-resolution MRI (HR-MRI) through in-vivo evaluation of carotid artery plaques. MATERIALS AND METHODS: In the ex-vivo study, data were acquired from six carotid arteries explanted from six symptomatic male patients with a mean age of 72 W 9.64 years. Sectional images obtained with the IVUS catheter were compared with digitalized histological images. Twelve consecutive patients (eight men, four women, mean age of 75 W 6.33 years), candidates for carotid artery stenting, were included in the in-vivo study. All histological and HR-MR images were converted to a digital format and the exact percentages of the four plaque components were determined. RESULTS: Forty-two images were used for correlation between VH-IVUS and histology. Quantitative analysis of different plaque components revealed a good concordance (0.82) between the two methods [95% confidence interval (CI) 0.69-0.92]. Precision rates of VH-IVUS for concordance with true histology of different plaque components were 99.4% for fibrous tissue, 85.9% for fibrolipid tissue, 71.4% for calcium and 83.4% for necrosis. Comparison between HR-MRI and VH-IVUS was performed on 27 images. Concordance between the two methods was 0.84 (95% CI 0.69-0.92). Precision rates were, respectively, 85.3, 95.2, 90.2 and 82.0%. CONCLUSION: We believe that VH-IVUS may be useful when a quick intraprocedural evaluation of a carotid plaque before or after stent placement is required, but is not suitable for the accurate in-vivo differentiation between stable and unstable plaques prone to rupture, due to the suboptimal assessment of the necrotic component, fibrous cap thickness and rupture signs. We do believe, however, that these results need further evaluation in larger populations to be confirmed.

Intravascular ultrasound assisted carotid artery stenting: randomized controlled trial. Preliminary results on 60 patients.

AIMS: The primary aim is the evaluation of the usefulness of intravascular ultrasound (IVUS) in the identification of otherwise unnoticed complications during carotid stenting. The secondary aim is the evaluation of the impact of IVUS assistance in the procedural outcomes and long-term patency rates of carotid artery stenting. MATERIALS AND METHODS: Sixty patients who underwent carotid artery stenting (CAS) during a 14-month period were evaluated prospectively. Thirty patients (50%) underwent IVUS assisted CAS, 30 patients (50%) underwent CAS using angiography as the unique diagnostic tool. All patients were enrolled through a primary duplex ultrasound evaluation; as a secondary evaluation, 54 patients (90%) underwent a preprocedural magnetic resonance angiography, whereas six patients (10%) underwent computed tomography-angiography. Patients with preocclusive stenoses (>85%) were excluded. Mean follow-up was 23 W 5.3 months. RESULTS: No periprocedural or late complications were observed. No statistical significance was observed in long-term stent patency between the two groups. Mean procedural time length of IVUS-assisted procedures was 10.3 W 5 min longer than non-IVUS-assisted procedures. Virtual histology (VH) IVUS evaluation of plaque morphology led to a different stent choice in three patients. In two cases, the IVUS assessment revealed a suboptimal stent deployment, solved by angioplasty; in one patient VH-IVUS detected plaque protrusion through stent cells, immediately treated by manual aspiration. CONCLUSIONS: Though not recommended as a routine intraprocedural evaluation, IVUS may be useful for a real-time CAS control when treating challenging plaques, such as 'soft' or lipidic ones or those prone to rupture, or whenever an intraprocedural morphologic evaluation is required for the appropriate stent choice, or when higher embolic risk is evaluated.

Diagnostic imaging and spending review: extreme problems call for extreme measures.

The number of diagnostic imaging tests has increased dramatically over the past decade and about 5 billion diagnostic examinations are performed worldwide each year. According to Health Ministry, Italy, is in second place for the number of CT and MR tests per thousand inhabitants in 2014 with a score of 83.3 (only Germany has a higher score, 95.2) that is a long way off from the European average of 46.5. It has also the highest ratio of magnetic resonances per person with 24,6 machines per million inhabitants, followed only by Greece and Finland. The development of the New Health Information System (NSIS) in 2010 made uniformly readable the non-homogeneous clinical data from all the different Italian regions and permitted a detailed analysis of all diagnostic imaging within the public outpatient care setting in Italy in 2012. Despite that MRI examinations represented only the 10% of the total number of imaging tests performed, their cost reached 30% of the health-care expenditure for outpatient diagnostic imaging with an overwhelming contribution coming from musculoskeletal MR which accounted for the 73% of the performed MR tests. It is reasonable to assume that these phenomena are likely due to a lack of appropriateness in MR requests that is difficult to analyze due to an absence or invalid query on the prescriptions which together accounted for the 98.7% of cases. Taking into account the above-mentioned situation, this is possibly why the Ministry of Health decided to perform "linear cuts" in expenditure for some diagnostic examinations.

Pulse-dose radiofrequency can reduce chronic pain in trapezio-metacarpal osteoarthritis: A mini-invasive therapeutic approach.

AIM: To assess the efficiency of pulse-dose radiofrequency (PDRF) in the management of chronic pain in patients with trapezio-metacarpal osteoarthritis (OA). METHODS: Seventy-five patients with trapezio-metacarpal OA were treated with the PDRF between October 2011 and September 2013. A 22-gauge cannula with a 5-cm length was introduced with percutaneous access in the lateral region of the affected trapezio-metacarpal joint. The PDRF procedure was performed with 1200 pulses at 45 V and 20 msec duration, followed by a 480 msec silent phase. The follow-up visits were performed at 1 month, 3 and 6 months after the PDRF procedure. All patients underwent a second treatment between 7 and 9 months after the first PDRF procedure with a new follow-up scheme at 1, 3, 6 and 9 months. RESULTS: Mean visual analogue scale (VAS) scores before the procedures was 8.5 ± 1.1. A great reduction in pain intensity was reported at 3 months after the PDRF procedure (mean VAS scores 3.1 ± 0.9, P < 0.05). Pain intensity began to increase back to pre-procedural values after 4 months (mean VAS scores at 6 months was 7.9 ± 1.3, P < 0.05). After the second PDRF treatment the mean VAS scores decreased to 3.3 ± 0.8 at 3 months, but increased to 8.1 ± 1.6 at 9 months. (P < 0.05). No complications after the procedures were observed. CONCLUSIONS: The PDRF may be a safe, repeatable and effective short-term pain management technique in patients with trapezio-metacarpal OA. Larger, randomized controlled studies are indicated to better clarify the efficacy and utility of the PDRF.

Management of pain on hallux valgus with percutaneous intra-articular Pulse-Dose Radiofrequency.

AIM: The purpose of our study was to investigate the role of intra-articular pulse-dose radiofrequency in management of painful hallux valgus refractory to conservative therapies. METHOD: Between November 2010 and April 2012, 51 patients (15 male, 36 female) with a median age of 71.4 years were included in our clinical trial. Under fluoroscopic guidance we introduced a 22 gauge 10 cm length cannula by a percutaneous access in the first metatarsophalangeal joint and its tip was placed intra-articularly. After removing the spindle, a radiofrequency needle with a 5 mm active tip was introduced. The following parameters were used: 1200 pulses at high voltage (45 V) with 20 msec duration followed by 480 msec silent phases. RESULTS: A great reduction in pain intensity was documented at 1 week, 1 month and 3 months after procedures. Pain intensity increased between 5 and 8 months after treatments, so we performed a second procedure in all patients between 7 months and 9 months since the first treatment. Also in this case we obtained a great reduction of pain intensity in the first 3 months after the procedure. Pain intensity returned at preprocedural values after 9 months after second procedure. No complications were observed. CONCLUSION: Our experience shows pulse-dose radiofrequency is a safe, repeatable and effective technique for managing patients with symptomatic hallux valgus in the short and medium term. Pulse-dose radiofrequency may improve pain control and quality of life in patients with hallux valgus refractory to conservative therapies.

Pulse-Dose Radiofrequency in Athletic Pubalgia: Preliminary Results.

CONTEXT: Chronic pubalgia affects around 10% of athletes. OBJECTIVE: To determine the role of pulse-dose radiofrequency (PDRF) in athletes with chronic pubalgia and investigate the causes with imaging. DESIGN: Prospective nonrandomized single-group study. PATIENTS: PDRF was performed on 32 patients with a chronic pain that had been refractory to conservative therapies during the last 3 mo. INTERVENTION: The genital branches of the genitofemoral, ilioinguinal, and iliohypogastric nerves and the obturator nerve were the goals of treatment. A 10-cm, 20-gauge cannula was inserted with a percutaneous access on the upper and lower edges of the iliopubic branch. After the spindle was removed, a radiofrequency needle with a 10-mm "active tip" was inserted. The radiofrequency technique was performed with 1200 pulses at 45 V and 20-ms duration, followed by a 480-ms silent phase. MAIN OUTCOME MEASURES: The follow-up with a clinical examination was performed at 1, 3, 6, and 9 mo after the procedure. During the follow-up visits, the patients were asked to rate their pain on a 0-10 VAS scale. RESULTS: All of the enrolled patients completed the study. Mean VAS score before the treatment was 8.4 ± 0.6. Twenty-four patients had a reduction of pain VAS scores more than 50% during all follow-up visits and started training and physiotherapy in the days after the radiofrequency procedure. Six patients, each treated 2 times, had a reduction more than 50% of VAS scores and could start training and physiotherapy only after the 2nd procedure. One patient had no pain relief with 2 treatments. Pain intensity decreased up to 9 mo in 31 patients (mean VAS scores 3.4 ± 0.5 at 6 mo and 3.8 ± 0.9 at 9 mo). No complications were observed. CONCLUSIONS: PDRF is an effective and safe technique in management of chronic pubalgia in athletes.

Role of MRI with hepatospecific contrast agent in the identification and characterization of focal liver lesions: pathological correlation in explanted livers.

AIM: To assess the diagnostic performance of magnetic resonance imaging (MRI) with gadoxetic acid in the identification of hepatocellular carcinoma (HCC) nodules by comparison with histological findings. METHODS: In a cohort of patients suffering from cirrhosis of various etiologies (chronic hepatitis C virus (HCV) or hepatitis B virus (HBV), alcohol abuse, cryptogenic forms), we selected 17 patients affected by HCC who were eligible for liver transplantation on the basis of a computed-tomography (CT) total-body examination. Such patients also underwent an MRI examination under basal conditions, and with four dynamic phases, as well as a hepatobiliary phase acquired after at least 20 min and recognized by the excretion of contrast agent into the bile duct, following intravenous administration of 0.05 mol/kg of gadoxetic acid (gadoxetate disodium, Primovist(®); Bayer, Osaka, Japan). The MRI images were then evaluated in a double-blinded experimental setup by two radiologists experienced in imaging of the liver. The diagnosis of HCC was made in the presence of nodular lesions that showed typical or atypical enhancement patterns. The liver was subsequently explanted (on average 47.4 days after MRI evaluation), dissected into 1-cm samples, and histologically evaluated according to the classification of Edmondson-Steiner. RESULTS: At the histopathological examination, 46 nodules were identified, on average 2.7 nodules for each patient. Of these, 37 were hepatocellular carcinomas, 3 were characterized by histologically unrecognizable complete necrosis, and 6 showed high-grade dysplasia. MRI with hepatospecific contrast medium showed inter-observer average values of sensitivity, specificity, and diagnostic accuracy of 94.6, 90, and 93.6 %, respectively. In one case, a nodule was not identified by MRI with gadoxetic acid, even in the hepatospecific phase (false negative (FN)). This result could be implicated to the long time interval between the analysis and the explant (88 days). In another case, there was an overdiagnosis of a HCC with a typical nodular pattern (false positive (FP)), but which most likely should have been attributed to a previous echinococcus cyst. MRI analysis, in combination with the study of the hepatobiliary phase, also showed a greater sensitivity, the same specificity, and a greater diagnostic accuracy compared to MRI evaluated only in the dynamic phases (with an average percentage between the two operators, respectively, of 75.7, 90, and 78 %). CONCLUSIONS: MRI with gadoxetic acid shows a diagnostic accuracy superior to contrast-enhanced MRI, allowing for the diagnosis of additional lesions, and it could be considered as an imaging method to carry out a more appropriate management of waiting lists for liver transplants.

Degenerative lumbar spinal stenosis treatment with Aperius™ PerCLID™ system and Falena® interspinous spacers: 1-year follow-up of clinical outcome and quality of life.

PURPOSE: Evaluation of the efficacy of the Falena(®) and Aperius™ PerCLID™ interspinous devices in the treatment of degenerative lumbar spinal stenosis with neurogenic intermittent claudication refractory to conservative treatment. MATERIALS AND METHODS: We retrospectively analyzed data from 24 patients (20 male and 4 female patients; 61 ± 7 years old), treated with an implantation of the AperiusTM PerCLID™ system, and from 35 patients (29 male and 6 female patients; 65 ± 9 years old) treated with the Falena(®) interspinous device.Patient pain intensity was evaluated by a 10-point visual analog scale (VAS), with a score (ranging from 0 = no pain to 10 = unbearable pain) that was collected before the procedure, at baseline; and at months 1, 6 and 12 after the interventional procedure. The assessment of quality of life (QOL) impairment was evaluated by the Oswestry Disability Index (ODI) questionnaire, which was administered beforehand at baseline; and at months 1, 6 and 12 after the interventional procedure. The vertebral canal area was measured by magnetic resonance imaging (MRI) scans before the treatment and at the one-year follow-up. RESULTS: All patients completed the study with no complications. Both the Falena group and Aperius group of surgery patients showed a statistically significant reduction of their VAS and ODI scores at the 6- and 12-month follow-up (p < 0.0001). A statistically significant increase in the vertebral canal area was observed both in the group that received Falena (p < 0.0001) and in the group that received Aperius (p = 0.0003). At the 1-year follow-up, we observed that there was a higher increase of vertebral canal area in those patients whom were treated with the Falena device (p < 0.001). CONCLUSIONS: The implantation of Falena(®) and Aperius™ PerCLID™ interspinous devices is an effective and safe procedure, in the medium term.

Bone Marrow Lipid Profiles from Peripheral Skeleton as Potential Biomarkers for Osteoporosis: A 1H-MR Spectroscopy Study.

RATIONALE AND OBJECTIVES: To characterize the lipidic profile of bone marrow in the calcaneus and femoral neck of healthy, osteopenic, and osteoporotic women, by using magnetic resonance spectroscopy (MRS) at 3T. The final goal was to identify specific metabolites with the potential ability to discriminate between healthy, osteopenic, and osteoporotic subjects. MATERIALS AND METHODS: Sixty-two and thirty three postmenopausal women recruited to investigate calcaneus and femoral neck, respectively, underwent a bone mineral density (BMD) measurement to be classified as healthy subjects (n = 22), osteopenic (n = 45), or osteoporotic (n = 28) patients. MRS spectra were used to quantify and compare bone marrow fat resonances between the three BMD groups. Between-group differences were tested using a Welch analysis of variance. Multiple comparisons were made with the Games-Howell correction. Relationships between pairs of variables were assessed with linear correlation analysis. Reproducibility analysis was performed for all the lipid resonances in both sites. RESULTS: The reproducibility was satisfactory. In femoral neck, methylene (L13), glycerol (L41, L43), and total lipid resonances were significantly lower in healthy as compared to osteoporotic subjects. On the other hand, in calcaneus, L13/glycerol significantly discriminated between osteopenic and osteoporotic subjects whereas L13/(unsaturated lipid) discriminated between healthy and osteopenic group. However, the reproducibility of both unsaturated lipid and glycerol resonances were less optimal. CONCLUSIONS: MRS of bone marrow lipid profiles from peripheral skeletal sites may be a promising tool for screening of large population to identify individuals with or at risk for developing osteoporosis. Moreover, it provides information about the metabolic changes occurring in bone marrow with the development of osteoporosis, which are skeletal site dependent.

Proposal for a Vascular Computed Tomography-Based Grading System in Posterior Circulation Stroke: A Single-Center Experience.

OBJECTIVE: The aim of this study is to investigate the role of a computed tomography angiography (CTA)-based approach in patients undergoing mechanical thrombectomy for vertebrobasilar stroke treatment. METHODS: A CTA and digital subtraction angiography (DSA) retrospective analysis of patients with acute vertebrobasilar stroke treated with thrombectomy was performed. A modified Rankin Scale score of 3 or lower at 3 months was considered as favorable outcome. The posterior circulation ASPECTS (pc-ASPECTS) was evaluated on CTA and vertebrobasilar segments involved in the occlusion were assessed using a 6-point posterior circulation computed tomography angiography (pc-CTA) vascular score aimed at evaluating the posterior circulation vascular pattern including collaterals. The primary end point was the correlation between pc-CTA and outcome; secondary end points included the concordance between CTA-DSA images and the correlation between pc-ASPECTS and outcome. RESULTS: Fifteen patients with vertebrobasilar stroke were retrospectively analyzed. All patients in coma showed a bad outcome (P = .01) and all patients with an alert state showed a good outcome (P = .004). An excellent interobserver agreement for pc-CTA (P = .001) was observed with poor interobserver agreement for pc-ASPECTS (P = .21). No significant correlations between pc-ASPECTS and clinical outcome were observed. Patients with good outcome had a lower pc-CTA (P = .02). The patency of the distal third of the basilar artery and both posterior cerebral arteries was related with good outcome. CONCLUSION: The pc-CTA seems to have prognostic value in patients with vertebrobasilar stroke undergoing mechanical thrombectomy. It may be used as an additional prognostic triage technique in this subgroup of stroke patients.

Long-term follow-up of endovascular treatment of renal artery aneurysms with covered stent deployment.

BACKGROUND: The aim of this study was to assess the technical success and clinical long-term results of renal artery aneurysm (RAA) treatment using covered stents. METHODS: We performed a retrospective study on endovascular treatment of nine patients with 10 RAAs, arising from the main renal artery or from the proximal portion of large segmental arteries. All procedures were performed in our department between 2004 and 2011. The aneurysms were excluded using covered stents. Our follow-up included laboratories indexes, Computed Tomography-angiography (CTA) at 1-6-12-24 months and 48-month Duplex-ultrasound examination. RESULTS: Study population included 4 males and 5 females (mean age: 63.5±7.3 y.o.). Six were affected by fibromuscular dysplasia and associated renal artery stenosis. The population showed a significant decrease of arterial blood pressure (from baseline values of 163.9±19.4/98.9±9.2 mmHg to 128.9±6.5/79.4±4.6 mmHg at 24 months follow-up) and of drug posology (baseline 3.7±0.7 drugs to 1.6±0.7 drugs at 24 months). Also they showed a significant decrease of serum creatinine levels (baseline 1.9±1.4 mg/dL vs.1.1±0.4 mg/dL at 12 months) and increase of glomerular filtration rate (from baseline values 46.9±23 mL/min/1.73 m2 to 69.1±20 mL/min/1.73 m2 at 24 months follow-up). CTA demonstrated patency of the cover stents, absence of endoleaks and re-stenosis in all patients. Only in one patient the inferior segmental artery was sacrificed due to the presence of its early origin, resulting in a small area of renal parenchyma infarction with no significant clinical consequences. CONCLUSIONS: The procedure revealed to be safe for renal function, feasible and effective for the exclusion of the aneurismal sac and restoring vessel patency.

Structured multidisciplinary discussion of HRCT scans for IPF/UIP diagnosis may result in indefinite outcomes.

Recent ATS/ERS/JRS/ALAT guidelines for the diagnosis and management of Idiopathic Pulmonary Fibrosis (IPF) have defined key features and specific high-resolution computerized tomography (HRCT) patterns for the diagnosis of UIP. The aim is the sorting of patients with suspected IPF into three subgroups, confident, possible or inconsistent with UIP patterns, after a multidisciplinary discussion (MDD). Specialists in respiratory diseases, radiologists and pathologists should reach IPF diagnosis based on either patients' clinical, radiological and laboratory data, either submitting patients to surgical biopsy. After ATS/ERS/JRS/ALAT recommendations have been applied, it has been identified a subgroup of patients showing uniform apical-basal distribution of honeycombing and reticular abnormalities that could not be categorized as confident, or possible nor inconsistent with UIP. These patients were subsequently diagnosed with IPF after MDD and lung biopsy. Inclusion of this pattern in the recommendation for IPF diagnosis would be worth considering.

Combination of pharmacotherapy and lidocaine analgesic block of the peripheral trigeminal branches for trigeminal neuralgia: a pilot study / Combinação de farmacoterapia e bloqueio analgésico com lidocaína sobre os ramos periféricos trigeminais no tratamento da neuralgia do trigêmeo: um estudo piloto

Classical trigeminal neuralgia (CTN) is treated predominantly by pharmacotherapy but side effects and unsuccessful occurs. The current study was carried out to evaluate the therapeutic effect of combination of pharmacotherapy and lidocaine block. Thirteen patients with CTN managed with pharmacotherapy were recruited and assigned either to no additional treatment (Group I) or to additional analgesic block (Group II). The primary endpoint was the reduction in the frequency of pain episodes in a month assessed at 30 and 90 days. Comparisons of measurements of pain, general health and depression scales were secondary endpoints. The results from the follow-up visits at 30 and 90 days showed the Group II to have larger reduction in the frequency of pain and exhibited a bigger improvement in the scores of the pain, general health and depression scales. The results from this preliminary study suggest a clinical benefit of the combination of pharmacotherapy and lidocaine block.

A neuralgia clássica do trigêmio (NTC) é tratada predominantemente por drogas, porém efeitos colaterais e falhas terapêuticas ocorrem. Avaliamos o efeito terapêutico da combinação entre farmacoterapia e bloqueio analgésico utilizando a lidocaína. Treze pacientes portadores de NTC tratados com farmacoterapia foram divididos em dois grupos: Grupo I pacientes que mantiveram somente tratamento medicamentos e Grupo II pacientes que associaram bloqueio anestésico. O objetivo primário do estudo foi à redução da freqüência da dor 30 e 90 dias após o bloqueio. Secundariamente avaliamos o impacto sobre as escalas de depressão, dor e qualidade de vida. O grupo II teve uma redução significativa na freqüência da dor e uma melhora nos escores de qualidade de vida, dor e escala de depressão. Os resultados sugerem um benefício clinico da combinação de farmacoterapia e bloqueio anestésico no tratamento da NTC.

Downstaging disease in patients with hepatocellular carcinoma outside up-to-seven criteria: Strategies using degradable starch microspheres transcatheter arterial chemo-embolization.

AIM: To evaluate the downstaging rates in hepatitis C virus-patients with hepatocellular carcinoma (HCC), treated with degradable starch microspheres transcatheter arterial chemoembolization (DSM-TACE), to reach new-Milan-criteria (nMC) for transplantation. METHODS: This study was approved by the Ethics Committee of our institution. From September 2013 to March 2014 eight patients (5 men and 3 women) with liver cirrhosis and multinodular HCC, that did not meet nMC at baseline, were enrolled in this study. Patients who received any other type of treatment such as termal ablation or percutaneous ethanol injection were excluded. DSM-TACE was performed in all patients using EmboCept(®) S and doxorubicin. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed measuring the longest enhancing axial dimension of each tumor according to the modified Response Evaluation Criteria In Solid Tumors measurements, and medical records were reviewed. RESULTS: DSM-TACE was successfully performed in all patients without major complication. We treated 35 lesions (mean 4.3 per patient). Six of eight patients (75%) had their HCC downstaged to meet nMC. Every patient whose disease was downstaged eventually underwent transplantation. The six patients who received transplant were still living at the time of this writing, without recurrence of HCC. Baseline age (P = 0.25), Model for End-stage Liver Disease score (P = 0. 77), and α-fetoprotein level (P = 1.00) were similar between patients with and without downstaged HCC. CONCLUSION: DSM-TACE represents a safely and effective treatment option with similar safety and efficacy of conventional chemoembolization and could be successfully performed also for downstaging disease in patients without nMC, allowing them to reach liver transplantation.

Combination of pharmacotherapy and lidocaine analgesic block of the peripheral trigeminal branches for trigeminal neuralgia: a pilot study.

Classical trigeminal neuralgia (CTN) is treated predominantly by pharmacotherapy but side effects and unsuccessful occurs. The current study was carried out to evaluate the therapeutic effect of combination of pharmacotherapy and lidocaine block. Thirteen patients with CTN managed with pharmacotherapy were recruited and assigned either to no additional treatment (Group I) or to additional analgesic block (Group II). The primary endpoint was the reduction in the frequency of pain episodes in a month assessed at 30 and 90 days. Comparisons of measurements of pain, general health and depression scales were secondary endpoints. The results from the follow-up visits at 30 and 90 days showed the Group II to have larger reduction in the frequency of pain and exhibited a bigger improvement in the scores of the pain, general health and depression scales. The results from this preliminary study suggest a clinical benefit of the combination of pharmacotherapy and lidocaine block.