Medicare for All: Considerations for Neuroradiologists.

The year 2019 featured extensive debates on transforming the United States multipayer health care system into a single-payer system. At a time when reimbursement structures are in flux and potential changes in government may affect health care, it is important for neuroradiologists to remain informed on how emerging policies may impact their practices. The purpose of this article is to examine potential ramifications for neuroradiologist reimbursement with the Medicare for All legislative proposals. An institution-specific analysis is presented to illustrate general Medicare for All principles in discussing issues applicable to practices nationwide.

Randomized controlled trial of sheaths in diagnostic neuroangiography.

PURPOSE: To determine the value of arterial sheaths in diagnostic neuroangiography in a randomized controlled trial. MATERIALS AND METHODS: A total of 842 patients (411 men, 431 women; mean age, 59.4 years; age range, 29.5-94.3 years) undergoing diagnostic neuroangiography were randomly assigned to groups in which a sheath was introduced immediately after puncture of the femoral artery (sheath group) or in which a diagnostic catheter was introduced without a sheath (control group). Two hundred twenty-four (26.7%) of 839 patients were receiving anticoagulants immediately prior to the procedure. RESULTS: Complications (mostly small hematomas of the groin) occurred in 106 (12.6%) of 842 patients, with no difference between groups (53 [12.6%] of 421 patients in both; P >.99). Ease of catheter manipulation was greater in the sheath group than in the control group. Incidence of bleeding at the femoral puncture site during the procedure was less in the sheath group (seven [1.7%] of 421 patients) versus the control group (150 [35.6%] of 421 patients), with a P value less than.001. Because of bleeding, sheath insertion was necessary in 165 (39.2%) of 421 patients in the control group. This crossover group also had a higher rate of local complications (28 [17.0%] of 165 patients) than the sheath and control groups. Serious complications, such as stroke (one [0.12%] of 842 patients) and transient ischemic attacks (five [0.60%] of 842 patients), occurred with equal frequency in both the sheath and control groups. CONCLUSION: Use of arterial sheaths lessens the incidence of intraprocedural bleeding at the femoral puncture site and increases ease of catheter manipulation without increasing the number of groin complications.

Intracranial pressure monitoring during intraarterial papaverine infusion for cerebral vasospasm.

PURPOSE: Intraarterial papaverine infusions are performed to reverse cerebral arterial vasospasm resulting from subarachnoid hemorrhage, but such infusions may lead to increases in intracranial pressure (ICP). This study was undertaken to determine when ICP monitoring is indicated during papaverine treatment. METHODS: Seventy-eight vessels were treated in 51 sessions in 28 patients with symptomatic vasospasm. ICP, papaverine doses, and infusion rates were recorded during treatment sessions. The procedural data, Hunt and Hess scores, Fisher grades, Glasgow Coma Scale scores, and ages for all subjects were reviewed and analyzed retrospectively. RESULTS: Baseline ICP ranged from 0 to 34 mm Hg. With typical papaverine doses of 300 mg per territory and infusion times ranging from 5 to 60 minutes per vessel, ICP increases above baseline during papaverine infusion ranged from 0 to 60 mm Hg. Significant (> or = 20 mm Hg) ICP increases during therapy were observed even in patients with low baseline ICP and with papaverine infused at the slowest rate. Patients with a baseline ICP of more than 15 mm Hg were much more likely to have significant ICP increases than were patients with a baseline ICP of 0 to 15 mm Hg. Hunt and Hess scores, Fisher grades, age, and Glasgow Coma Scale scores on admission and immediately before treatment did not correlate with ICP increases during papaverine infusion. Patients with ICP increases of more than 10 mm Hg during therapy were more likely to experience adverse clinical events than were patients with ICP increases of < or = 10 mm Hg. Reduction in the rate of papaverine infusion, or termination of infusion, resulted in reversal of drug-induced ICP elevation. CONCLUSION: ICP monitoring during intraarterial papaverine infusions for cerebral vasospasm is recommended for all patients and is particularly important for patients with elevated baseline ICP. Continuous ICP monitoring facilitates safe and time-efficient drug delivery.

Increase in diameters of vasospastic intracranial arteries by intraarterial papaverine administration.

OBJECT: This study was conducted to determine if there is a change in intracranial arterial diameters after papaverine infusion for vasospasm and to determine whether the change occurs in proximal, intermediate, and distal arteries. METHODS: The authors measured arterial diameters retrospectively in all patients who received intraarterial papaverine for treatment of vasospasm between November 1992 and August 1995. Patients who received papaverine in the same session with or following angioplasty were excluded. Measurements were made in a blinded manner with the aid of a magnification loupe at 12 predetermined sites on each angiogram before and after papaverine infusion. Eighty-one treatments in 34 patients were included. Angiograms obtained at the time of presentation with subarachnoid hemorrhage (SAH) were examined in 26 of the 34 patients. Nine carotid territories visualized by repeated angiography on the day after infusion were examined to determine the duration of the papaverine effect. CONCLUSIONS: In all treatment groups an increase was found in the average arterial diameters ranging from 2.8 to 73.9%, with a mean increase of 26.5%. Increases in diameter were observed in proximal, intermediate, and distal arteries. The timing of treatments ranged from Day 3 to Day 19 post-SAH, and there was no relationship between timing and arterial responsiveness (r = -0.06). There was a moderately good correlation between the degree of vasospasm in an artery and its responsiveness to papaverine (r = -0.54, -0.66, and -0.66, for proximal, intermediate, and distal arteries, respectively). The effect of papaverine did not persist until the following day in patients in whom repeated angiography was performed.

Effect of intraarterial papaverine on cerebral circulation time.

PURPOSE: To measure the mean cerebral circulation time (CCT) in patients with symptomatic vasospasm stemming from subarachnoid hemorrhage and to determine any change after papaverine treatment. METHODS: We studied 27 patients who received intraarterial papaverine from November 1992 to August 1995 to determine the CCT in 59 carotid territories. CCT was measured from the first image in which contrast was seen above the supraclinoid internal carotid artery to the peak filling of parietal cortical veins. Angiograms at the time of presentation were examined in 19 of the 27 patients. A control population of 19 patients (30 carotid territories) was also studied. RESULTS: The mean CCT on presentation was 6.8 seconds +/- 1.1. The prepapaverine mean CCT was 6.1 seconds +/- 1.2. The immediate postpapaverine mean CCT was 3.8 seconds +/- 0.8. CCT decreased in 58 of 59 territories treated with papaverine; the mean change was -35.7%. In eight of these patients, CCT rose on the following day to 6.1 seconds +/- 1.1. In the control group, mean CCT was 5.9 seconds +/- 0.8. The mean CCT in patients with subarachnoid hemorrhage was slightly prolonged on presentation relative to that in control subjects. CONCLUSION: Intraarterial papaverine produces a consistent decrease in CCT in patients with vasospasm.

Predictive value of technetium Tc 99m-labeled red blood cell scintigraphy for positive angiogram in massive lower gastrointestinal hemorrhage.

PURPOSE: This study was performed to evaluate whether the time interval from injection of technetium Tc 99m (99mTc)-labeled red blood cells to the time of a radionuclide "blush" (positive scan) can be used to improve the efficacy in predicting a positive angiogram. METHOD: A retrospective review revealed 160 patients who received 99mTc-labeled red blood cell scintigraphy for evaluation of massive lower gastrointestinal hemorrhage between 1989 and 1994. Patients were included who demonstrated signs of shock on admission, had an initial decrease in hematocrit of > or = 6 percent, or required a minimum transfusion of two units of packed red blood cells. Scanning duration was 90 minutes, with imaging every 2 minutes. Time interval from injection to a positive scan was analyzed to determine predictability of a positive angiography. RESULTS: Of 160 patients, 86 demonstrated positive scans, of whom 47 underwent angiography. These 47 patients were divided into two groups according to scan results. Group 1 (n = 33) had immediate appearance of blush; Group 2 (n = 14) had blush after two minutes. In Group 1, 20 of 33 patients had a positive angiogram, yielding a positive predictive value of 60 percent (P = 0.033). Of the 14 patients with negative angiograms (13 from Group 1, and 1 with a negative scan), 6 had radiographic occlusion of the inferior mesenteric artery and 1 had spasm of the right colic artery, with scans that blushed in the respective distributions. Excluding these seven patients yielded a positive predictive value of 75 percent (P = 0.0072) for angiography. In patients with a delayed blush (Group 2), 13 of 14 had negative angiograms, yielding a negative predictive value of 93 percent (92 percent excluding those with nonvisualization of the inferior mesenteric artery). Twenty of 21 (95 percent) positive angiograms occurred in Group 1 patients. Of the 27 patients with negative angiograms, 13 were Group 2 patients. CONCLUSION: Patients with immediate blush on 99mTc-labeled red blood cell scintigraphy required urgent angiography. Patients with delayed blush have low angiographic yields. These data suggest that patients with delayed blush or negative scans may be observed and evaluated with colonoscopy.

Ultrasonography in children of cystic abdominal masses not related to the genitourinary system.

A variety of cystic abdominal masses not related to the genitourinary tract may be encountered in the pediatric population. Ultrasound is the most informative imaging modality in the workup of these masses which include lymphangiomas, duplication cysts, enteric cysts, mesothelial cysts, pseudocysts, choledochal cysts, and gastrointestinal teratomas. The clinical and sonographic characteristics of these lesions are presented.

Pulmonary nodular amyloidosis in a patient with Sjögren's syndrome diagnosed by transthoracic biopsy.

A variety of pulmonary diseases may accompany Sjögren's syndrome. We report a rare case of pulmonary nodular amyloidosis in a woman with Sjögren's syndrome that was diagnosed by fluoroscopic transthoracic needle biopsy.