Checklist: Neck computed tomography in non-traumatic emergencies.

Patients attending the emergency department (ED) with cervical inflammatory/infectious symptoms or presenting masses that may involve the aerodigestive tract or vascular structures require a contrast-enhanced computed tomography (CT) scan of the neck. Its radiological interpretation is hampered by the anatomical complexity and pathophysiological interrelationship between the different component systems in a relatively small area. Recent studies propose a systematic evaluation of the cervical structures, using a 7-item checklist, to correctly identify the pathology and detect incidental findings that may interfere with patient management. As a conclusion, the aim of this paper is to review CT findings in non-traumatic pathology of the neck in the ED, highlighting the importance of a systematic approach in its interpretation and synthesis of a structured, complete, and concise radiological report.

Lista de verificación: tomografía computarizada de cuello en urgencias no traumáticas / Checklist: Neck computed tomography in non-traumatic emergencies

A los pacientes que acuden a urgencias con síntomas inflamatorio/infecciosos a nivel cervical o con masas que pueden comprometer el tracto aerodigestivo o las estructuras vasculares, es necesario hacerles una tomografía computarizada (TC) de cuello con contraste. Su interpretación radiológica se ve dificultada por la complejidad anatómica y la interrelación fisiopatológica entre los diferentes sistemas que lo componen, en un área de estudio relativamente pequeña. Estudios recientes proponen realizar una evaluación sistemática de las estructuras cervicales, utilizando para ello un listado de verificación de 7 elementos, para identificar correctamente la patología, y detectar los hallazgos incidentales que pueden interferir en el manejo del paciente. El objetivo de este trabajo es revisar los hallazgos de la TC en la patología no traumática del cuello en urgencias siguiendo una lectura sistemática, tras la cual se pueda realizar un informe radiológico estructurado, completo y conciso.(AU)

Patients attending the emergency department (ED) with cervical inflammatory/infectious symptoms or presenting masses that may involve the aerodigestive tract or vascular structures require a contrast-enhanced computed tomography (CT) scan of the neck. Its radiological interpretation is hampered by the anatomical complexity and pathophysiological interrelationship between the different component systems in a relatively small area. Recent studies propose a systematic evaluation of the cervical structures, using a 7-item checklist, to correctly identify the pathology and detect incidental findings that may interfere with patient management. As a conclusion, the aim of this paper is to review CT findings in non-traumatic pathology of the neck in the ED, highlighting the importance of a systematic approach in its interpretation and synthesis of a structured, complete, and concise radiological report.(AU)

Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation.

BACKGROUND AND AIMS: Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation. MATERIAL AND METHODS: Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete. RESULTS: Mean blood loss during cesarean section after REBOA (3507.5 mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was <2 days. CONCLUSION: The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.

Utilidad de la oclusión aórtica con balón REBOA para el control de las hemorragias puerperales en pacientes con anomalías de la implantación placentaria / Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation

Antecedentes y objetivo: Las anomalías en la implantación placentaria, que conforman el espectro de la placenta acreta, son causa de alta morbimortalidad maternal por la hemorragia masiva que se produce en estas pacientes durante el parto. La colocación previa de balones de oclusión aórticos ayuda a controlar el sangrado, disminuyéndolo y facilitando la intervención quirúrgica. Existe un nuevo balón de oclusión aórtico denominado REBOA que minimiza los riesgos y las complicaciones asociadas a la colocación de los balones aórticos tradicionales además de lograr el control de las hemorragias. El objetivo del presente estudio es evaluar la utilidad, la eficacia y la seguridad del balón REBOA en las hemorragias puerperales por anomalías en la implantación placentaria. Material y métodos: Desde noviembre del 2019 hasta noviembre del 2021 se han colocado, por parte de radiología intervencionista, 6 balones REBOA en 6 mujeres que iban a ser tratadas mediante cesárea programada de acretismo placentario. Resultado: En el estudio realizado, las pérdidas de volumen sanguíneo durante la cesárea tras la colocación del balón REBOA son similares a las reportadas en la literatura con otros balones aórticos, con una media de 3.507,5ml. La media de requerimientos transfusionales fue de 3,5 concentrados de hematíes. El uso del balón REBOA proporcionó al equipo quirúrgico unas condiciones adecuadas para realizar la cirugía. No hubo complicaciones derivadas de su colocación y la estancia media en UCI de las pacientes fue inferior a 2 días. Conclusión: El balón REBOA, gracias a sus características técnicas, se plantea como una nueva alternativa segura y útil para el control de las hemorragias masivas en las pacientes con acretismo placentario.(AU)

Background and aims: Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation. Material and methods: Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete. Results Mean blood loss during cesarean section after REBOA (3507.5mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was < 2 days. Conclusion The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.(AU)

Pediatric chest x-ray in covid-19 infection.

BACKGROUND: The outbreak of COVID-19 has become pandemic. Pediatric population has been less studied than adult population and prompt diagnosis is challenging due to asymptomatic or mild episodes. Radiology is an important complement to clinical and epidemiological features. OBJECTIVE: To establish the most common CXR patterns in children with COVID-19, evaluate interobserver correlation and to discuss the role of imaging techniques in the management of children. MATERIALS AND METHODS: Forty-four patients between 0 and 16 years of age with confirmed SARS-Cov-2 infection and CXR were selected. Two paediatric radiologists independently evaluated the images and assessed the type of abnormality, distribution and evolution when available. RESULTS: Median age was 79.8 months (ranging from 2 weeks to 16 years of age). Fever was the most common symptom (43.5 %). 90 % of CXR showed abnormalities. Peribronchial cuffing was the most common finding (86.3 %) followed by GGOs (50 %). In both cases central distribution was more common than peripheral. Consolidations accounted for 18.1 %. Normal CXR, pleural effusion, and altered cardiomediastinal contour were the least common. CONCLUSION: The vast majority of CXR showed abnormalities in children with COVID-19. However, findings are nonspecific. Interobserver correlation was good in describing consolidations, normal x-rays and GGOs. Imaging techniques have a role in the management of children with known or suspected COVID-19, especially in those with moderate or severe symptoms or with underlying risk factors.

Radiation dose optimisation for conventional imaging in infants and newborns using automatic dose management software: an application of the new 2013/59 EURATOM directive.

Objective: The new 2013/59 EURATOM Directive (ED) demands dosimetric optimisation procedures without undue delay. The aim of this study was to optimise paediatric conventional radiology examinations applying the ED without compromising the clinical diagnosis. METHODS: Automatic dose management software (ADMS) was used to analyse 2678 studies of children from birth to 5 years of age, obtaining local diagnostic reference levels (DRLs) in terms of entrance surface air kerma. Given local DRL for infants and chest examinations exceeded the European Commission (EC) DRL, an optimisation was performed decreasing the kVp and applying the automatic control exposure. To assess the image quality, an analysis of high-contrast resolution (HCSR), signal-to-noise ratio (SNR) and figure of merit (FOM) was performed, as well as a blind test based on the generalised estimating equations method. RESULTS: For newborns and chest examinations, the local DRL exceeded the EC DRL by 113%. After the optimisation, a reduction of 54% was obtained. No significant differences were found in the image quality blind test. A decrease in SNR (-37%) and HCSR (-68%), and an increase in FOM (42%), was observed. CONCLUSION: ADMS allows the fast calculation of local DRLs and the performance of optimisation procedures in babies without delay. However, physical and clinical analyses of image quality remain to be needed to ensure the diagnostic integrity after the optimisation process. Advances in knowledge: ADMS are useful to detect radiation protection problems and to perform optimisation procedures in paediatric conventional imaging without undue delay, as ED requires.

[Treatment of an abdominal aorta aneurysms with endovascular stent grafts and embolizing materials: an experimental study]. / Tratamiento de un aneurisma de aorta abdominal con prótesis endovascular y materiales embolizantes: estudio experimental.

OBJECTIVE: To create an animal model to stabilize the aneurysmal sac and prevent type II leaks in the endovascular treatment of aneurysms of the abdominal aorta (AAA) by placing an endoprosthesis (stent-graft) and filling the aneurysmal sac. MATERIAL AND METHODS: AAA were experimentally induced in pigs and sheep; AAA were subsequently treated with endovascular stent grafts and stabilized in the same procedure by introducing ethibloc and onyx through a vascular catheter placed within the aneurysmal sac. All animals underwent aortography, and MR angiography and abdominal CT were performed on randomly selected animals. Histological studies included both macroscopic and microscopic examination. Two sheep were analyzed one year after the procedure. We evaluated the characteristics of the materials employed, their diffusion in the collateral arteries, and their efficacy in stabilizing the aneurysmal sac. RESULTS: The procedure was successfully carried out in all animals. Survival in the pigs was 100 %, whereas greater instability under anesthesia in the sheep led to 50 % perioperative mortality. Both ethibloc and onyx were considered easy to use and stable over time. CONCLUSION: The sac of an AAA treated with an endovascular stent graft and its collateral vessels can be treated in the same procedure with materials introduced through a catheter.

Tratamiento de un aneurisma de aorta abdominal con prótesis endovascular y materiales embolizantes: estudio experimental / Treatment of an abdominal aorta aneurysms with endovascular stent grafts and embolizing materials: an experimental study

Objetivo: estabilizar el saco aneurismático y evitar la formación de fugas tipo II en el tratamiento endovascular de los aneurismas de aorta abdominal (AAA), creando experimentalmente un modelo animal y tratándolo mediante la colocación de endoprótesis y la ocupación del saco aneurismático. Material y métodos: se crearon AAA de forma experimental en cerdos y en ovejas. Se trataron con prótesis endovasculares y se estabilizaron, en el mismo procedimiento, introduciendo ethibloc y onix a través de un catéter vascular situado dentro del saco aneurismático. En todos se realizaron controles con aortografía y, de forma aleatoria, con angiorresonancia magnética y tomografía computarizada abdominal. Se efectuaron estudios macroscópicos e histopatológicos. Se analizaron 2 ovejas 1 año después. Se valoraron las características de los materiales empleados, su difusión en las arterias colaterales y su eficacia para rellenar el saco del aneurisma. Resultados: en todos los animales se consiguió, con éxito, la realización del procedimiento. La supervivencia de los cerdos fue del 100 %, mientras que de una mayor labilidad de las ovejas para la anestesia, resultó una mortalidad perioperatoria del 50 %. De los materiales empleados, tanto ethibloc como onix son fáciles de utilizar y resultan estables con el paso del tiempo. Conclusión: es posible rellenar el saco de un AAA tratado con endoprótesis y sus colaterales, en el mismo procedimiento, con materiales introducidos a través de un catéter (AU)

Objective: to create an animal model to stabilize the aneurysmal sac and prevent type II leaks in the endovascular treatment of aneurysms of the abdominal aorta (AAA) by placing an endoprosthesis (stent-graft) and filling the aneurysmal sac. Material and methods: AAA were experimentally induced in pigs and sheep; AAA were subsequently treated with endovascular stent grafts and stabilized in the same procedure by introducing ethibloc and onyx through a vascular catheter placed within the aneurysmal sac. All animals underwent aortography, and MR angiography and abdominal CT were performed on randomly selected animals. Histological studies included both macroscopic and microscopic examination. Two sheep were analyzed one year after the procedure. We evaluated the characteristics of the materials employed, their diffusion in the collateral arteries, and their efficacy in stabilizing the aneurysmal sac. Results: the procedure was successfully carried out in all animals. Survival in the pigs was 100 %, whereas greater instability under anesthesia in the sheep led to50 % perioperative mortality. Both ethibloc and onyx were considered easy to use and stable over time. Conclusion: the sac of an AAA treated with an endovascular stent graft and its collateral vessels can be treated in the same procedure with materials introduced through a catheter (AU)

Aneurisma subclavio. Hallazgo casual y tratamiento endovascular / Subclavian aneurysm. A chance finding and endovascular treatment

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Pseudoaneurisma de la arteria peronea tras la embolectomía con catéter de balón / Pseudoaneurysms in the fibular artery following embolectomy with a balloon catheter

Introducción. Los pseudoaneurismas de la arteria peronea son una patología rara asociada a traumatismos de la pierna, a cirugía traumatológica o a lesiones de la pared arterial secundarias a embolectomía con balón. Pueden ser asintomáticos o, por el contrario, debutar con dolor y sensación de masa, lo que puede asociar una fístula arteriovenosa o un síndrome compartimental. El tratamiento endovascular mediante embolización representa una solución novedosa a este tipo de lesiones. Caso clínico. Mujer de 71 años que con el diagnóstico de isquemia arterial aguda en el miembro inferior derecho de probable origen cardioembólico fue intervenida de tromboembolectomía transfemoral derecha; recuperó los pulsos distales y fue dada de alta a los cinco días de la intervención. Acudió al servicio de urgencias a los 10 días del alta con clínica de dolor en la región aquílea del miembro inferior derecho y edema, y mediante eco-Doppler se diagnosticó un pseudoaneurisma de la arteria peronea derecha. Se le realizó arteriografía a través de la arteria femoral contralateral; se cateterizó selectivamente la arteria peronea, que confirmó la presencia del pseudoaneurisma, y se procedió a su embolización con coils

Introduction. Pseudoaneurysms of the fibular artery are a rare pathological condition associated with traumatic injuries to the legs, trauma surgery or lesions in the walls of the artery secondary to balloon embolectomies. They can be asymptomatic or, in contrast, they may begin with pain and the presence of a mass, which can be associated to an arteriovenous fistula or compartment syndrome. Endovascular treatment by embolisation is a novel solution to this type of lesion. Case report. We report the case of a 71-year-old female who was diagnosed as having acute arterial ischaemia in the lower right limb that probably had cardioembolic origins; the patient was submitted to a right transfemoral thromboembolectomy. Distal pulses were restored and she was discharged from hospital five days after the operation. She visited the emergency department again 10 days after discharge with symptoms of pain in the Achilles region of the right lower limb and oedema; Doppler ultrasound recording was used to reach a diagnosis of pseudoaneurysm of the right fibular artery. Arteriography was performed through the contralateral femoral artery; the fibular artery was selectively catheterised, which confirmed the presence of a pseudoaneurysm and this was then embolised using coils

Tomografía computarizada multicorte en el diagnóstico de la estenosis carotídea / Multi-slice computerised tomography in the diagnosis of carotid stenosis

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Reparación combinada quirúrgica y endovascular del arco aórtico y la aorta torácica / Combined surgical and endovascular repair of the aortic arch and thoracic aorta

Introducción. Los aneurismas de la aorta torácica y las disecciones aórticas son patologías muy graves que afectan a una población importante y que con frecuencia se tratan de forma conservadora por miedo a la morbimortalidad que acompaña a sus procedimientos quirúrgicos. Las técnicas endovasculares son una alternativa menos radical, aunque en ocasiones necesita de gestos quirúrgicos para mantener la perfusión de los troncos supraaórticos (TSA). Objetivo. Presentar las distintas técnicas combinadas abierta y endovascular que se utilizan en la patología del arco aórtico. Desarrollo. Siguiendo la clasificación de Balm, se exponen las distintas posibilidades de revascularización extraanatómica de los TSA previa a la ligadura de sus orígenes y la oclusión endovascular de éstos durante el tratamiento endovascular de la patología del arco. Todos los procedimientos evitan el pinzamiento aórtico y la bomba de circulación extracorpórea, y algunos de ellos incluso la estereotomía media. Conclusiones. El desarrollo de las técnicas y los dispositivos endovasculares para la aorta torácica, en combinación con cirugías menos radicales puede ser una alternativa interesante para aquellos pacientes no subsidiarios de reparaciones convencionales. Serán necesarios más estudios para comprobar la viabilidad de estas técnicas emergentes y la supervivencia que consiguen, ya que hasta la fecha la experiencia se reduce a series muy cortas de casos seleccionados cuyos resultados son dispares

Introduction. Thoracic aortic aneurysms and aortic dissections are very serious pathologies that affect an important number of patients and which are often treated with conservative therapy for fear of the high morbidity and mortality rate that accompanies their surgical procedures. Endovascular techniques are a less drastic alternative, although sometimes surgical actions are needed to maintain perfusion in the supra-aortic trunks (SAT). Aim. To present the different combined (open and endovascular) techniques that are used to treat pathologies of the aortic arch. Development. Following Balm’s classification, we describe the different possibilities open for extra-anatomical revascularisation of SAT prior to ligation of their origins and their endovascular occlusion during endovascular treatment of arch pathologies. All the procedures avoid aortic clamping and the need for a heart-lung bypass machine and some of them even make median sternotomy unnecessary. Conclusions. The development of endovascular techniques and devices for the thoracic aorta, in combination with less drastic surgery, can represent an interesting alternative for patients who are not going to benefit from conventional repairs. Further studies are needed to determine the feasibility of these promising techniques and the survival rates achieved, since to date our experience is limited to very short series of particular cases, the results of which are inconsistent

Rotura espontánea aortoilíaca:presentación de dos casos / Spontaneous aortoiliac rupture: two case reports

Introducción. La rotura espontánea de la aorta abdominal y, sobre todo, de las arterias ilíacas, es un hecho que raramente se publica en la bibliografía, ya que es la aorta torácica la queda afectada con mayor frecuencia. Casos clínicos. Presentamos nuestra experiencia con dos casos: una paciente de 78 años con una importante patología asociada y con rotura espontánea de la aorta abdominal infrarrenal, y un paciente de 65 años con rotura de la arteria ilíaca común izquierda. Ambos ingresaron y se trataron de urgencia en nuestro servicio; se les practicó la implantación de una endoprótesis aortoilíaca izquierda, una oclusión de la ilíaca primitiva derecha y una derivación femorofemoral en el caso de la rotura aórtica e iliofemoral izquierda en el caso de la rotura ilíaca. La paciente falleció en el posoperatorio inmediato debido a un fracaso multiorgánico, mientras que el paciente evolucionó favorablemente. Se realiza una revisión de la bibliografía en relación con las úlceras arterioscleróticas penetrantes de aorta, causantes en su evolución de estas roturas, y sobre los actuales métodos diagnósticos, especialmente la tomografía computarizada y la resonancia magnética. Conclusión. Es importante pensar en la existencia de estas úlceras arterioscleróticas penetrantes, que en su evolución pueden ocasionar la perforación de la pared arterial y provocar, sobre todo en los pacientes con una patología asociada importante, una elevada mortalidad que puede incluso ser similar a la de la rotura de los aneurismas de aorta. (AU)

Pseudoaneurisma de arteria humeral. Tratamiento mediante embolización / Humeral artery pseudoaneurysm. Treatment through immobilization

El pseudoaneurisma de arteria humeral es una rara complicación de la punción de la misma con fines tanto diagnósticos como terapéuticos. Presentamos dos casos estudiados mediante Doppler pulsado color y confirmados con arteriografía. La embolización mediante cateterización selectiva arterial es una alternativa a considerar frente a la cirugía