Patterns of Hydrocephalus in Rural Haiti: A Computed Tomography-Based Study.

INTRODUCTION/OBJECTIVE: Hydrocephalus is a common neurosurgical disorder that can lead to significant disability or death if not promptly identified and treated. Data on the burden of hydrocephalus in low-income countries are limited, given a lack of radiologic resources for the diagnosis of this condition. Here, we present an analysis of patterns of hydrocephalus from a large sample of computed tomography (CT) scans of the head performed at a public hospital in rural Haiti, a low-income country in the Caribbean. METHODS: We analyzed reports from 3614 CT scans of the head performed between July 2013 and January 2016 for findings that were consistent with a diagnosis of hydrocephalus (report indicating "hydrocephalus," "ventriculomegaly," or "enlargement of the ventricles"). Extracted data included demographics, study indication, radiologic findings, and reported etiology of hydrocephalus. RESULTS: In total, 119 scans had findings concerning for hydrocephalus (3.5% of all scans, 6.3% of abnormal scans; age range 0-90 years; median age 35.5 years; 49.6% male). Pediatric patients (<18 years of age) accounted for 39% of cases. In total, 113 of 119 (95%) scans had indications for possible neurosurgical intervention. Among these 113 scans, 36 (30%) scans demonstrated communicating hydrocephalus, 66 (55%) scans demonstrated noncommunicating hydrocephalus (primarily due to intraventricular hemorrhage [27 scans, 23%] or brain tumors [24, 20%]), and 11 (9%) scans were indeterminate regarding whether the hydrocephalus was communicating versus noncommunicating. CONCLUSIONS: In a large sample of CTs performed in a rural low-income setting, hydrocephalus was common, predominantly noncommunicating, and often associated with potentially operable intracranial lesions. Data of this nature can inform research, policy, and clinical collaborations that strengthen the neurosurgical capacity of low-income countries.

Head CT findings at a public hospital in rural Haiti.

BACKGROUND: Neuroimaging is often unavailable in low-income countries, creating challenges for precise diagnosis of neurologic disease in individual patients, and impeding acquisition of precise neuroepidemiologic data for program and policy development. METHODS: We analyzed reports from 3614 head CTs performed between July 2013 and January 2016 at Hôpital Universitaire de Mirebalais, a public academic hospital in rural Haiti, extracting patients' age, study indication, and radiologic findings. RESULTS: The most common indications for head CT were headache (27%), trauma (19.9%), abnormal neurological exam (12.2%), and stroke (11.3%). The most common categories of neurologic abnormalities were traumatic (31%), vascular (25.8%), and infectious (12%). Of 291 strokes, 64% were ischemic (median age at diagnosis 60.8years, SD 17.4) and 36% were hemorrhagic (median age 52.0, SD 15.5). In patients undergoing head CT for seizures or epilepsy, 17.5% had evidence of neurocysticercosis. In patients with head trauma, 42.6% had intracranial hemorrhage or fracture. Atrophy was noted on 10% of CTs (median age 57.1; SD 23.8), and was characterized as out of proportion to age in 2% (median age 34.1, SD 15.3). CONCLUSIONS: Median age of stroke patients in this rural low-income population is lower than in high-income countries and proportion of stroke due to intracerebral hemorrhage is higher. Neurocysticercosis is present in nearly one fifth of patients with seizures/epilepsy. These findings can inform policies and programs for prevention and treatment of neurologic disease in low-income settings.

Percutaneous excision: a viable alternative to manage benign breast lesions.

OBJECTIVE: Benign breast masses, such as fibroadenomas, are common, and their management is variable, depending on symptoms and patient concerns. We undertook this study to determine the safety, efficacy, and patient acceptance of percutaneous excision of benign breast masses by using a hand-held vacuum-assisted device. METHODS: By using sonographic guidance, percutaneous removal was performed in 40 patients with 42 lesions by using a 9-gauge (n = 13) or 12-gauge (n = 29) probe (ATEC; Suros Surgical). Technical success, procedural complications, and patient experience were recorded at the time of excision and at 48 hours. Clinical, imaging, and/or surgical follow-up was obtained for 39 of 42 lesions (93%). Three of 42 lesions (7%) were lost to follow-up. RESULTS: Of 42 lesions, maximal diameters ranged from 0.6-4.0 cm (mean 1.6 cm), with lesion volumes between 0.05 and 11.2 mL (mean [SD] 1.4 ± 2.1 mL, median 7 mL). The procedure was well tolerated by all patients, and no residual mass was visible in any case at the conclusion of the procedure. All the patients preferred this approach to open surgical biopsy. After percutaneous excision, surgery was performed on 3 of 42 lesions (7%) for atypia (n = 2) or malignancy (n = 1), with a residual mass found only for the malignant case. Of the 26 of 42 lesions (62%) with imaging follow-up, 24 (92%) had no lesion recurrence. Overall, the procedure either completely removed the mass and/or relieved the patient's symptoms of a mass in 36 of 39 lesions (92%) for which clinical, imaging, and/or surgical follow-up was available. Three lesions were lost to follow-up. CONCLUSION: Ultrasound-guided percutaneous excision of benign breast masses is a safe, effective, and well-tolerated minimally invasive procedure for the diagnosis and removal of benign breast masses. It may serve as an alternative to surgical excision for women with a known benign or probably benign breast mass who desire excision but prefer to avoid surgery or who are poor surgical candidates.

Segmentation and registration of three-dimensional rotational angiogram on live fluoroscopy to guide atrial fibrillation ablation: a new online imaging tool.

BACKGROUND: Three-dimensional rotational atriography (3DATG) was developed to supplement two-dimensional fluoroscopy with 3D volume reconstruction of the left atrium (LA), pulmonary veins (PV), and other structures. Until recently, 3DATG images could only be viewed separately and were not suitable to directly guide atrial fibrillation (AF) ablation. OBJECTIVE: The purpose of this study was to evaluate the feasibility and accuracy of intraprocedural 3DATG. METHODS: Three-dimensional rotational atriography with right atrial contrast injection was obtained using a Philips Allura Xper FD10 system in 30 patients with symptomatic AF who also underwent preprocedural computed tomographic (CT) scan. RESULTS: The majority (93%) of 3DATG image reconstructions were useful for guidance of catheter ablation. Nearly all PVs (94%), LA appendage (89%), and esophagus (100%) were successfully segmented. Measured PV ostial diameters compared using 3DATG and CT showed close concordance. Registration and re-registration of 3DATG overlay image was easily achieved with thoracic landmarks and validated by catheter placement demonstrating minimal discrepancy. Endoscopic views allowed for improved visualization of ostial position, dimensions, and navigation within the antrum. Lesion tagging on 3DATG overlay enhanced ablation guidance. Radiation exposure with 3DATG was significantly reduced compared with preprocedural CT scan (2.1 +/- 0.3 mSv vs 13.8 +/- 2.4 mSv, P <.001). CONCLUSION: Intraprocedural 3DATG imaging during AF ablation with online segmentation and superimposition on live fluoroscopy is feasible. Overlay provides valuable and accurate information on 3D surface outline and endoscopic PV location. Three-dimensional rotational atriography overlay is a new imaging method with reduced radiation exposure that may replace preprocedural CT scan for catheter navigation and ablation of AF.

CT-guided core needle biopsy of breast lesions visible only on MRI.

OBJECTIVE: As breast MRI has become more widely used, the need to biopsy suspicious lesions visible only on MRI has increased. A small percentage of these lesions are not amenable to MR-guided biopsy. We report our technique of CT-guided core needle biopsy of breast lesions. CONCLUSION: CT-guided core needle biopsy is a safe and effective method for sampling breast lesions visible only on MRI when MR-guided biopsy is not feasible.

Prospective assessment of computer-aided detection in interpretation of screening mammography.

OBJECTIVE: The purpose of this study was to prospectively assess the usefulness of computer-aided detection (CAD) in the interpretation of screening mammography and to provide the true sensitivity and specificity of this technique in a clinical setting. SUBJECTS AND METHODS: Over a 26-month period, 5,016 screening mammograms were interpreted without, and subsequently with, the assistance of the iCAD MammoReader detection system. Data collected for actionable findings included dominant feature (calcification, mass, asymmetry, architectural distortion), detection method (radiologist only, CAD only, or both radiologist and CAD), BI-RADS assessment code, associated histopathology for those undergoing biopsy, and tumor stage for malignant lesions. The study population was cross-checked against an independent reference standard to identify false-negative cases. RESULTS: Of the 5,016 cases, the recall rate increased from 12% to 14% with the addition of CAD. Of the 107 (2%) patients who underwent biopsy, 101 (94%) were prompted by the radiologist and six (6%) were prompted by CAD. Of the 124 biopsies performed on actionable findings in the 107 patients, findings in 79 (64%) were benign and in 45 (36%) were in situ or invasive carcinoma. Three study participants who were not recalled by the radiologist with the assistance of CAD developed cancer within 1 year of the screening mammogram and were considered to be false-negative cases. The radiologist detected 43 (90%) of the 48 total malignancies and 45 (94%) of the 48 malignancies with the assistance of CAD. CAD missed eight cancers that were detected by the radiologist, which presented as architectural distortions (n = 3), irregular masses (n = 4), and a circumscribed mass (n = 1). CAD detected two in situ cancers as a faint cluster of calcifications that had not been perceived by the radiologist and one mass that was dismissed by the radiologist, accounting for at least a 4.7% increase in cancer detection rate. Sensitivity of screening mammography with the use of CAD (94%) represented an absolute and relative 4% increase over the sensitivity of the radiologist alone (90%). Specificity of screening mammography with and without the use of CAD was 99%. CONCLUSION: Routine use of CAD while interpreting screening mammograms significantly increases recall rates, has no significant effect on positive predictive value for biopsy, and can increase cancer detection rate by at least 4.7% and sensitivity by at least 4%. This study provides "true" values for sensitivity and specificity for use of CAD in interpretation of screening mammography as measured prospectively in the context of a working clinical setting.

Effect of tamoxifen on breast tissue density in premenopausal breast cancer.

It has been established that hormone replacement therapy (HRT) increases breast tissue density on mammography in up to 30% of women receiving treatment. The effects of selective estrogen receptor modulators (SERMs) on breast tissue have received limited attention, although there have been several reports of tamoxifen decreasing mammographic tissue density in some women undergoing adjuvant or prophylactic breast cancer treatment. We report a case of a premenopausal woman treated with tamoxifen for 5 years whose mammographic density decreased while on tamoxifen and returned to her baseline density following termination of the drug. A regression of breast tissue may be reflective of sensitivity to tamoxifen and possibly, indicative of therapeutic benefit associated with treatment. Furthermore, induction of a more radiolucent pattern by tamoxifen may independently benefit women by enhancing mammographic detection. The clinical significance of resumption of a dense breast pattern following discontinuation of tamoxifen remains to be determined.