Lumbar epidural vein thrombosis mimicking disc herniation: A report of 3 cases.

Epidural vein thrombosis is a rare cause of lumbosciatica than can clinically and radiologically mimic other causes of nerve root compression such as disc herniation. We describe 3 unusual cases of spinal epidural plexus vein thrombosis illustrating the difficulty in preoperative diagnosis of this entity. Misinterpretation of imaging findings can lead to an erroneous diagnosis and inappropriate treatment. Knowledge of certain radiologic findings will increase the likelihood of recognizing epidural vein thrombosis.

Oral Sodium Chloride in the Prevention of Contrast-Associated Acute Kidney Injury in Elderly Outpatients: The PNIC-Na Randomized Non-Inferiority Trial.

OBJECTIVE: We aimed to test the non-inferiority of oral versus intravenous hydration in the incidence of contrast-associated acute kidney injury (CA-AKI) in elderly outpatients undergoing a contrast-enhanced computed tomography (CE-CT) scan. METHODS: PNIC-Na (NCT03476460) is a phase-2, single-center, randomized, open-label, non-inferiority trial. We included outpatients undergoing a CE-CT scan, >65 years having at least one risk factor for CA-AKI, such as diabetes, heart failure, or an estimated glomerular filtration rate (eGFR) of 30-59 mL/min/1.73 m². Participants were randomized (1:1) to oral sodium-chloride capsules or intravenous hydration. The primary outcome was an increase in serum creatinine >0.3 mg/dL or a reduction in eGFR >25% within 48 h. The non-inferiority margin was set at 5%. RESULTS: A total of 271 subjects (mean age 74 years, 66% male) were randomized, and 252 were considered for the main analysis (per-protocol). A total of 123 received oral hydration and 129 intravenous. CA-AKI occurred in 9 (3.6%) of 252 patients and 5/123 (4.1%) in the oral-hydration group vs. 4/129 (3.1%) in the intravenous-hydration group. The absolute difference between the groups was 1.0% (95% CI -4.8% to 7.0%), and the upper limit of the 95% CI exceeded the pre-established non-inferiority margin. No major safety concerns were observed. CONCLUSION: The incidence of CA-AKI was lower than expected. Although both regimens showed similar incidences of CA-AKI, the non-inferiority was not shown.

A simple nomogram identifies patients with refractory ascites with worse outcome after transjugular intrahepatic portosystemic shunt.

OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) is increasingly used in the management of refractory ascites. Controversy exists regarding the predictive factors of unfavorable outcomes, useful for patient selection. The primary aim was to identify predictive factors of 1-year survival or recurrent severe hepatic encephalopathy in patients with cirrhosis undergoing covered TIPS for refractory ascites. The secondary aim was overall survival. METHODS: Observational, retrospective, multicentric study, that included all cirrhotic patients treated with covered-TIPS for refractory ascites since 2001. Demographic, clinical, laboratory and hemodynamic data were collected at baseline and consecutively until dead, liver transplant or end of follow-up. The Cox model was used to identify predictive factors of overall survival. A Fine-Gray competing risk regression model was used to identify predictive factors of 1-year mortality or recurrent hepatic encephalopathy. A predictive nomogram was created based on those factors. RESULTS: In total 159 patients were included. Predictive factors of survival or recurrent severe encephalopathy were renal dysfunction [hazard ratio, 2.12 (95% CI, 1.11-4.04); P = 0.022], albumin [hazard ratio, 0.58 (95% CI, 0.34-0.97); P = 0.036], serum sodium [hazard ratio, 0.94 (95% CI, 0.89-0.98); P = 0.008] and international normalized ratio [hazard ratio 4.27 (95% CI, 1.41-12.88); P = 0.010]. In the competing risk analysis, predictive factors of 1-year mortality/recurrent severe encephalopathy in multivariate analysis were age [sub-distribution hazard ratio (sHR) 1.05 (95% CI, 1.02-1.09); P = 0.001], creatinine [sHR 1.55 (95% CI, 1.23-1.96); P = 0.001] and serum sodium [sHR 0.94 (95% CI, 0.90-0.99); P = 0.011] at baseline. CONCLUSIONS: Age, creatinine and sodium baseline levels strongly influence 1-year survival/recurrent severe hepatic encephalopathy in patients with cirrhosis undergoing covered TIPS for refractory ascites. A simple nomogram accurately and easily identifies those patients with worse prognosis.

A higher D-dimer threshold for predicting pulmonary embolism in patients with COVID-19: a retrospective study.

PURPOSE: COVID-19 raises D-dimer (DD) levels even in the absence of pulmonary embolism (PE), resulting in an increase in computed tomography pulmonary angiogram (CTPA) requests. Our purpose is to determine whether there are differences between DD values in PE-positive and PE-negative COVID-19 patients and, if so, to establish a new cutoff value which accurately determines when a CTPA is needed. METHODS: This study retrospectively analyzed all COVID-19 patients who underwent a CTPA due to suspected PE between March 1 and April 30, 2020, at Ramón y Cajal University Hospital, Madrid (Spain). DD level comparisons between PE-positive and PE-negative groups were made using Student's t test. The optimal DD cutoff value to predict PE risk in COVID-19 patients was calculated in the ROC curve. RESULTS: Two hundred forty-two patients were included in the study. One hundred fifty-one (62%) were men and the median age was 68 years (IQR 55-78). An increase of DD (median 3260; IQR 1203-9625 ng/mL) was detected in 205/242 (96%) patients. 73/242 (30%) of the patients were diagnosed with PE on CTPA. The DD median value was significantly higher (p < .001) in the PE-positive group (7872, IQR 3150-22,494 ng/mL) compared with the PE-negative group (2009, IQR 5675-15,705 ng/mL). The optimal cutoff value for DD to predict PE was 2903 ng/mL (AUC was 0.76 [CI 95% 0.69-0.83], sensitivity 81%). The overall mortality rate was 16% (39/242). CONCLUSION: A higher threshold (2903 ng/mL) for D-dimer could predict the risk of PE in COVID-19 patients with a sensitivity of 81%.

Spanish multicenter real - life registry of retrievable vena cava filters (REFiVeC).

BACKGROUND: The treatment of venous thromboembolic disease the treatment of choice is systemic anticoagulation. However, the interruption of the inferior vena cava with filters has been recommended when anticoagulation fails or there is a contraindication. Due to the rising inferior vena cava filter (IVCF) complications, physicians are encouraged to retrieve them when there is no longer recommended. In daily practice, it may be a difficult close follow-up of these patients. In this study, the primary objective was to evaluate the IVCF retrieval rate of all implanted filters in a Spanish registry. Secondary objectives were to analyze the causes of failed retrieval, procedure-related complications, and outcomes at a 12-month follow-up. RESULTS: Three hundred fifty-six vena cava filters were implanted in 355 patients. The types of filter were: Gunther Tulip (Cook Medical) 160 (44.9%), Optease (Cordis) 77 (21.6%), Celect (Cook Medical) 49 (13, 7%), Aegisy (Lifetech Scientific) 33 (9.2%), Option ELITE (Argon Medical devices) 16 (4.4%), Denali filter (BD Bard) 11 (3.08%), ALN filter (ALN) 10 (2.8%). Removal was achieved in 274/356 (76,9%). eighty-two (23,1%) IVCF were not retrieved due to the following: 41 (11,5%) patients required ongoing filtration, 24 IVCF (6,7%) patients died before retrieval, and 17 (4,7%) impossibility of retrieval because of a tilted and embedded filter apex. There were no major complications observed. CONCLUSIONS: The global retrieval rate of IVCF was achieved in 76.9%, and the adjusted retrieval rate was of 94.15% with no major complications. IVCF tilting was associated with failure of filter removal in less than 5% of cases. This study demonstrates that the retrieval procedure of IVCF is controlled by the clinician and not by the interventional radiologist.

Diffusion-weighted magnetic resonance imaging in peritoneal carcinomatosis from suspected ovarian cancer: Diagnostic performance in correlation with surgical findings.

PURPOSE: Ovarian cancer (OC) is the commonest cause of death by gynaecological cancer in developed countries. Peritoneal carcinomatosis (PC) complete debulking without residual disease of >1 cm is the best prognostic predictor in advanced OC. PC is assessed with Computed tomography (CT). CT accuracy and cytoreduction success predictive ability are limited. PET/CT is not an imaging standard for PC. PC shows high signal foci in Diffusion-weighted magnetic resonance imaging (DWI MRI). We assessed the diagnostic performance (DP) and tumour burden correlation of Whole body DWI with background suppression MRI (WB-DWIBS/MRI) in PC of suspected OC using the Peritoneal Cancer Index (PCI), referring to cytoreduction surgery as the standard reference. METHOD: Fifty patients with suspicion of disseminated OC underwent cytoreduction and WB-DWIBS/MRI. The PCI scores tumour burden (0-3) in 13 anatomical regions (global range of 0-39). Two radiologists (Rad1/Rad2) assessed the PCI preoperatively and with surgical findings. We evaluated regional and global DP, the interobserver agreement (Cohen´s kappa coefficient), statistical differences (McNemar test) and tumour burden (Pearson's test). RESULTS: 72% (36/50) were epithelial OC and 78% (39/50) achieved complete cytoreduction. Global-PCI correlation was 0.762 (Rad1) with DP: Sensitivity 0.84, specificity 0.89, accuracy 0.89, and kappa 0.41. Average global-PCI was 7. The pelvis and right hypochondrium showed the highest positive rate and DP, while the intestinal regions presented the lowest. Previous studies reported higher sensitivity than CT or PET/CT, although only a few used the PCI. CONCLUSIONS: WB-DWIBS/MRI is reliable to depict, quantify and to predict complete cytoreductive surgery in OC PC.

The elbow: review of anatomy and common collateral ligament complex pathology using MRI.

The elbow is a complex joint whose stability is imparted by osseous and soft-tissue constraints. Anatomical and biomechanical knowledge of the supporting structures that provide stability to the medial and lateral elbow is essential to correctly interpret the pathological findings. Conventional MRI and MR arthrography are the imaging modalities of choice in the evaluation of elbow ligament injuries. Elbow instability can be classified according to timing (acute, chronic, or recurrent), the direction of displacement, the degree of displacement, and the articulations involved. This article reviews the MR imaging protocols recommended for each diagnosis and the normal anatomy and biomechanical aspects of the medial and lateral collateral ligament complex. We also present multiple cases of typical and atypical patterns of injury.

Dilatación transparietohepática de estenosis biliar benigna: experiencia de 5 años / Transparieto-hepatic dilation of benign biliary stenosis: 5 years experience

Objetivo: Valorar los resultados de la dilatación percutánea transparietohepática de las estenosis biliares benignas durante un período de 5 años. Diseño: Estudio retrospectivo para evaluar la técnica, las complicaciones y los resultados clínicos, analíticos y radiológicos. Pacientes: Se recogieron datos de 13 pacientes diagnosticados de estenosis biliar benigna que se trataron mediante dilatación percutánea en nuestro centro entre los años 2002–2006. Se excluyó a los pacientes diagnosticados de enfermedad maligna y a aquellos pacientes a los que se les colocó una prótesis. Siete de los pacientes han sido receptores de trasplante hepático. Un paciente había recibido dilatación endoscópica en 2 ocasiones con persistencia de la estenosis. Resultados: Se comprobó mejoría clínica y radiológica en el 60% de los casos y analítica en el 69% de los casos (el 61% de normalización). El 30% de los casos presentó reestenosis, de los que el 50% fueron subsidiarios de rescate mediante redilatación. Las complicaciones que se presentaron (30,7%) se resolvieron de forma conservadora. No se observaron diferencias significativas entre el grupo de trasplante y el grupo sin trasplante. Conclusiones: La dilatación de las estenosis benignas de la vía biliar por vía transparietohepática es una técnica bastante segura, tiene una alta tasa de resolución a medio plazo y permite evitar la cirugía en más de un 75% de los pacientes. Los resultados deben confirmarse en muestras mayors (AU)

Objective: To assess the results of percutaneous transparieto-hepatic dilation of benign biliary stenosis achieved over a period of 5 years. Design: A retrospective study to assess the technique, complications and the clinical, analytical and radiology results. Patients: Data was gathered on 13 patients diagnosed in our Hospital between the years 2002 and 2006 with benign biliary stenosis and who had been treated using percutaneous dilation. Patients diagnosed with malignant disease and those who had a prosthesis were excluded. Seven of the patients had received a liver transplant. One patient had an endoscopic dilation on two occasions, with the stenosis persisting. Results: A clinical and radiological improvement was observed in 60% of the cases, and an analytical improvement in 69% (61% normal). Re-stenosis occurred in 30% of the cases, of which 50% were rescue support using re-dilation. The complications presented (30.7%) were resolved conservatively. No significant differences were observed between the transplanted and the non-transplanted groups. Conclusions: Transparieto-hepatic dilation of benign biliary stenosis is a fairly safe technique and has a high rate of resolution in the medium term, and avoids the use of surgery in 75% of patients. The results need to be confirmed in larger samples (AU)

[Transparieto-hepatic dilation of benign biliary stenosis: 5 years experience]. / Dilatación transparietohepática de estenosis biliar benigna: experiencia de 5 años.

OBJECTIVE: To assess the results of percutaneous transparieto-hepatic dilation of benign biliary stenosis achieved over a period of 5 years. DESIGN: A retrospective study to assess the technique, complications and the clinical, analytical and radiology results. PATIENTS: Data was gathered on 13 patients diagnosed in our Hospital between the years 2002 and 2006 with benign biliary stenosis and who had been treated using percutaneous dilation. Patients diagnosed with malignant disease and those who had a prosthesis were excluded. Seven of the patients had received a liver transplant. One patient had an endoscopic dilation on two occasions, with the stenosis persisting. RESULTS: A clinical and radiological improvement was observed in 60% of the cases, and an analytical improvement in 69% (61% normal). Re-stenosis occurred in 30% of the cases, of which 50% were rescue support using re-dilation. The complications presented (30.7%) were resolved conservatively. No significant differences were observed between the transplanted and the non-transplanted groups. CONCLUSIONS: Transparieto-hepatic dilation of benign biliary stenosis is a fairly safe technique and has a high rate of resolution in the medium term, and avoids the use of surgery in 75% of patients. The results need to be confirmed in larger samples.

Portal vein thrombosis after laparoscopic splenectomy in benign hematologic diseases.

INTRODUCTION: Portal vein thrombosis is an unfrequent, but potentially deadly, complication of the laparoscopic splenectomy procedure. The laparoscopic approach has shortened the duration of hospital stay; portal vein thrombosis may appear after the patient has left the hospital, determining a later diagnosis. Because of the mild, nonspecific symptoms, the diagnosis can even be missed and only achieved when chronic complications take place. OBJECTIVES: In this study, we aimed to determine the appearance of portal vein thrombosis in a consecutive series of patients who underwent laparoscopic splenectomy by performing a contrast-enhanced computed tomography (CT) scan postoperatively. MATERIALS AND METHODS: A transversal study was established, performing in 2005 a contrast-enhanced CT scan on 20 patients who underwent laparoscopic splenectomy between 1999 and 2005 at Ramón y Cajal University Hospital (Madrid, Spain). The presence of thrombosis in the splenoportomesenteric axis was investigated. RESULTS: Two (2) cases (10%) of portal vein thrombosis were detected: 1 symptomatic case, 7 days after surgery, was treated with anticoagulation, resulting in the disappearance of the thrombus in a new CT scan 6 months later; the second case was asymptomatic and was discovered during the performance of this study. CONCLUSIONS: The contrast-enhanced CT scan shows the best accuracy for the diagnosis of portal vein thrombosis, and it must be performed when any clinical manifestation appear; also, it must still be determined if a contrast-enhanced CT scan should be systematically performed in high-risk thromboembolic patients. An ultrasound Doppler may present many diagnostic errors. It is probably advisable to prolong the antithromboembolic prophylaxis.

[Hypogastric artery embolization as a palliative treatment for bleeding secondary to intractable bladder or prostate disease]. / Embolización de arterias hipogástricas como tratamiento paliativo del sangrado secundario a enfermedad vesical o prostática intratable.

OBJECTIVES: Bleeding secondary to severe vesicoprostatic pathology (mainly neoplasic disease and radiation cystitis) may be a serious clinical management problem due to its morbidity and associated increased resources demand in the form of admissions, transfusions and other measures. We review a series of patients embolized for this purpose, its efficacy, tolerability and adverse events. METHODS: We review 8 patients who underwent hypogastric arteries embolization between July 1998 and December 2001, analyzing indications, efficacy and duration, tolerability, and consequences. Right femoral artery access was undertaken in all except one case that needed bilateral femoral accesses. Embolization was achieved by means of coils and particles. All procedures were performed under local anaesthesia. RESULTS: 9 procedures were performed in 8 patients. 3 patients presented with hematuria due to radiation cystitis, 3 from prostatic carcinoma, and 2 with urethrorragy from urethral relapses after cystectomy. 7/9 embolizations were effective achieving immediate complete or almost complete bleeding control; in one case control was partial; another one had limited or no effect. Selective embolization of distal arteries was performed in 3 cases; all the remainders underwent direct hypogastric trunk embolization sparing the superior gluteal artery. Effect lasted between 1 and 31 months. 4 patients died, 3 of them without haematuria, 1 because of an intercurrent disease, and the others from disease progression. 2 patients underwent posterior surgery, one due to recurrent haematuria, and the other, a case of urethral tumour, due to partial failure; partial cystectomy and urethrectomy were performed respectively. 2 patients needed administration of morphic derivatives after embolization, all the others were managed with magnesium metamizol. Only one patient referred mild transitory gluteal claudication. CONCLUSIONS: Percutaneous arterial embolization is an effective instrument to treat patients with haematuria or urethrorragy and severe lower urinary tract pathology in whom curative treatments are not applicable due to their general status, life expectancy, or tumor status.

Embolización de arterias hipogástricas como tratamiento paliativo del sangradosecundario a enfermedad vesical o prostática intratable / Hypogastric arteries embolization as palliative treatment for bleeding secondary to prostatic or bladder diseases

OBJETIVOS: El sangrado secundario a patología severa vesicoprostática (fundamentalmente enfermedad neoplásica y cistitis rádica) puede constituir un serio problema de manejo clínico por su morbilidad y exigencia de recursos en forma de ingresos, transfusiones y otras medidas. Se revisa el resultado de una casuística de pacientes embolizados por este motivo, su eficacia, tolerancia y efectos adversos. MÉTODO: Se revisan 8 pacientes a los que se practicó embolización de arterias hipogástricas o de sus ramas entre julio de 1998 y diciembre de 2001, analizando el motivo de la misma, efectividad y duración, tolerancia y secuelas. El acceso se realizó por arteria femoral derecha salvo en un caso que precisó de acceso por ambas femorales. La embolización se consiguió mediante coils y partículas. Todos los procedimientos se realizaron con anestesia local. RESULTADOS: Se realizaron 9 procedimientos en los 8 pacientes. 3 pacientes presentaban hematuria por cistitis rádica, 3 por carcinoma prostático y 2 uretrorragia después de cistectomía por carcinoma vesical y recidivas uretrales. La efectividad inmediata fue completa o casi completa en 7 de 9 embolizaciones, parcial en una y escasa o nula en otra. En 3 casos se realizó embolización selectiva de arterias distales y en el resto se embolizaron directamente los troncos hipogástricos, salvando la arteria glútea superior. La duración del efecto osciló entre 1 y 31 meses.4 pacientes fallecieron, 3 de ellos sin hematuria, uno por un proceso intercurrente y el resto por progresión de su enfermedad de base. Dos pacientes fueron intervenidos posteriormente por reaparición de la hematuria en uno y efectividad parcial en el otro que presentaba tumor uretral, practicándose cistectomía en el primer caso y uretrectomía en el segundo. Dos pacientes precisaron de la administración de mórficos tras la embolización, manejándose en el resto con metamizol magnésico. Sólo un paciente refirió discreta claudicación glútea de forma transitoria. CONCLUSIÓN: La embolización arterial percutánea constituye un arma eficaz en pacientes con hematuria o uretrorragia y patología severa del tracto urinario inferior en los que por su estado general, perspectivas de vida o estadio tumoral no son aplicables tratamientos curativos (AU)