Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial.

BACKGROUND: Placenta previa remains one of the major causes of massive postpartum hemorrhage and maternal mortality worldwide. OBJECTIVE: To determine whether internal iliac artery balloon occlusion during cesarean delivery for placenta previa could reduce postpartum hemorrhage and other maternal complications. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary university obstetric unit in Hong Kong. Pregnant women who were diagnosed to have placenta previa at 34 weeks (defined as lower placenta edge within 2 cm from the internal os) and required cesarean delivery were invited to participate. Eligible pregnant women were randomized into internal iliac artery balloon occlusion (Occlusion) group or standard management (Control) group. Those randomized to the Occlusion group had internal iliac artery balloon catheter placement performed before cesarean delivery and then balloon inflation after delivery of the baby. The primary outcome was the reduction of postpartum hemorrhage in those with internal iliac artery balloon occlusion. Secondary outcome measures included hemoglobin drop after delivery; amount of blood product transfusion; incidence of hysterectomy; maternal complications including renal failure, ischemic liver, disseminated intravascular coagulation, and adult respiratory distress syndrome; length of stay in hospital; admission to intensive care unit; and maternal death. RESULTS: Between May 2016 and September 2018, 40 women were randomized (20 in each group). Demographic and obstetric characteristics were similar between the 2 groups. In the Occlusion group, 3 women did not receive the scheduled procedure, as it was preceded by antepartum hemorrhage that required emergency cesarean delivery, and 1 woman had repeated scan at 36 weeks showing the placental edge was slightly more than 2 cm from the internal os. Intention-to-treat analysis found no significant differences between the Occlusion and the Control groups regarding to the median intraoperative blood loss (1451 [1024-2388] mL vs 1454 [888-2300] mL; P = .945), the median length of surgery (49 [30-62] min vs 37 [30-51] min; P = .204), or the need for blood transfusion during operation (57.9% vs 50.0%; P = .621). None of the patients had rebleeding after operation, complication related to internal iliac artery procedure, or any other maternal complications. Reanalyzing the data using on-treatment approach showed the same results. CONCLUSION: The use of prophylactic internal iliac artery balloon occlusion in placenta previa patients undergoing cesarean delivery did not reduce postpartum hemorrhage or have any effect on maternal or neonatal morbidity.

Percutaneous Portal Vein Embolization Using a Simplified Sheathless 18-Gauge Trocar Needle Approach: Review of Efficacy and Safety.

PURPOSE: Portal vein (PV) embolization (PVE) is traditionally performed via a PV sheath with selective embolization of PV branches. Here, the efficacy and safety of PVE with the use of only an 18-gauge needle is reported. MATERIALS AND METHODS: Consecutive patients who underwent PVE from 2009 through 2017 were retrospectively reviewed. Forty-five patients (mean age, 60 y ± 7.6; 38 men) underwent 45 PVE procedures. Hepatocellular carcinoma, cholangiocarcinoma, and metastases accounted for 26 (58%), 13 (29%), and 6 (13%) patients, respectively. PVE was performed by puncturing a branch of right PV with an 18-gauge needle under US guidance. Via the same needle, direct portography was performed, followed by PVE with an N-butyl cyanoacrylate/Lipiodol mixture. Percentage increase of future liver remnant (FLR) volume and increase in ratio of FLR to total liver volume were estimated as measures of efficacy. Complications were reported according to Society of Interventional Radiology classification. Fluoroscopy time, procedure time, and dose-area product (DAP) were recorded. RESULTS: Technical success rate was 100%. The median DAP, fluoroscopy time, and procedure time were 74,387 mGy·cm2 (IQR, 90,349 mGy·cm2), 3.5 min (IQR, 2.10 min), and 24 min (IQR, 10.5 min). Among the 23 patients with complete CT volumetry data, mean increase in the ratio of FLR to total liver volume and percentage increase of FLR volume were 12.5% ± 7.7 and 50% ± 33, respectively. There were 3 minor complications (asymptomatic nonocclusive emboli in FLR) and 3 major complications (1 hepatic vein emboli, 1 subphrenic collection, and 1 hepatic infarct). CONCLUSIONS: PVE via a sheathless 18-gauge needle approach is feasible, with satisfactory FLR hypertrophy.

Irreversible Electroporation of the Femoral Neurovascular Bundle: Imaging and Histologic Evaluation in a Swine Model.

PURPOSE: To evaluate imaging, histologic changes, and safety of irreversible electroporation (IRE) on the femoral neurovascular bundle in a swine model. MATERIALS AND METHODS: The study was approved by the institutional animal ethics committee. IRE was performed on the right femoral neurovascular bundle of 9 swine, which were subsequently sacrificed at 24 hours (n = 4, acute group), 7 days (n = 4, subacute group), or 21 days (n = 1, delayed group). Clinical observation, computed tomography (CT), and pathologic examination were carried out. RESULTS: After the procedure, 7 of 9 subjects were able to stand and walk, and the remaining 2 subjects could eventually do so within 1 week. The femoral vessels were patent on CT and gross examination. There was microscopic evidence of venous thrombosis in 75% of the subacute group. Except for mild perineural inflammation observed in 1 subject in the subacute group, the femoral nerves were intact on gross and histologic examination. Significant damage to the surrounding muscle and soft tissue was identified on CT and histology, manifesting as necrosis, hematoma, and inflammation. CONCLUSIONS: The ablative effect of IRE on muscle and soft tissue manifested as necrosis, hemorrhage, and inflammation. Histologic changes were observed in the perineural tissue and veins in a few subjects. The clinical implication of such changes and safety of clinical use of IRE for lesions encasing the neurovascular bundle in humans are yet to be determined.

Understanding the Clinical Implications of Intracranial Arterial Calcification Using Brain CT and Vessel Wall Imaging.

Background and Purpose: Intracranial arterial calcification (IAC) has been the focus of much attention by clinicians and researchers as an indicator of intracranial atherosclerosis, but correlations of IAC patterns (intimal or medial) with the presence of atherosclerotic plaques and plaque stability are still a matter of debate. Our study aimed to assess the associations of IAC patterns identified on computed tomography (CT) with the presence of plaque detected on vessel wall magnetic resonance imaging and plaque stability. Materials and Methods: Patients with stroke or transient ischemic attack and intracranial artery stenosis were recruited. IAC was detected and localized (intima or media) on non-contrast CT images. Intracranial atherosclerotic plaques were identified using vessel wall magnetic resonance imaging and matched to corresponding CT images. Associations between IAC patterns and culprit atherosclerotic plaques were assessed by using multivariate regression. Results: Seventy-five patients (mean age, 63.4 ± 11.6 years; males, 46) were included. Two hundred and twenty-one segments with IAC were identified on CT in 66 patients, including 86 (38.9%) predominantly intimal calcifications and 135 (61.1%) predominantly medial calcifications. A total of 72.0% of intimal calcifications coexisted with atherosclerotic plaques, whereas only 10.2% of medial calcifications coexisted with plaques. Intimal calcification was more commonly shown in non-culprit plaques than culprit plaques (25.9 vs. 9.4%, P = 0.008). The multivariate mixed logistic regression adjusted for the degree of stenosis showed that intimal calcification was significantly associated with non-culprit plaques (OR, 2.971; 95% CI, 1.036-8.517; P = 0.043). Conclusion: Our findings suggest that intimal calcification may indicate the existence of a stable form of atherosclerotic plaque, but plaques can exist in the absence of intimal calcification especially in the middle cerebral artery.

CT brain artefact due to air bubbles in the oil cooling system: characteristic band-like configuration on sagittal reformatted image.

PURPOSE: To retrospectively review the imaging characteristics of CT artefacts due to air bubbles within the oil cooling system of the X-ray tube housing. MATERIALS AND METHODS: Air bubbles were introduced into the oil cooling system of the X-ray tube housing during tube replacement in one of the CT scanners in the authors' institution. All 126 CT brain studies performed in this period were retrospectively reviewed. One hundred and four studies were negative for artefacts. Artefacts were confirmed in 5 and considered probable in 17 studies, respectively. The imaging characteristics of artefacts in these 22 cases were analysed. RESULTS: All artefacts manifested as ill-defined hypoattenuations in the periventricular/subcortical white matter of bilateral cerebral hemispheres with/without involvement of the internal capsule and basal ganglia. The posterior fossa was also involved in two (40%) confirmed and four (24%) probable studies. A band-like configuration of hypoattenuations on sagittal images was observed in five (100%) confirmed and eight (47%) probable studies. CONCLUSION: Air bubble artefacts manifested as hypoattenuations in the periventricular/subcortical white matter of the supratentorial brain. A characteristic band-like configuration was observed in the sagittal reformatted image, which is useful for differentiating it from periventricular small vessel disease.

Efficacy of 18F-FDG PET/CT in investigation of elevated CEA without known primary malignancy.

AIM: To evaluate the efficacy of 18flurodeoxyglucose positron emission tomography/computer tomography (18F-FDG PET/CT) in investigating patients with elevated carcinoembryonic antigen (CEA) and without known primary malignancy, and the impact of PET/CT findings on patient management. SETTING AND DESIGN: PET/CT scans done in a tertiary hospital between December 2007 and February 2012 for elevated CEA in patients without known primary malignancy were retrospectively reviewed. MATERIALS AND METHODS: The PET/CT findings, patients' clinical information, level of CEA, histological diagnosis, and subsequent management were retrieved by the electronic patient record for analysis. STATISTICAL ANALYSIS: Data were analyzed using SPSS version 19. RESULTS: One hundred and one PET/CT scans were performed for patients with elevated CEA. Fifty-eight of these were performed for patients with known primary malignancy and were excluded; 43 PET/CT scans were performed for patients without known primary malignancy and were included. Thirty-three (77%) had a positive PET/CT. Among the 32 patients with malignancy, 15 (47%) suffered from lung cancer and 8 (25%) suffered from colorectal cancer. The sensitivity (97%), specificity (82%), positive predictive value (94%), negative predictive value (90%), and accuracy (93%) were calculated. Thirty (91%) patients had resultant change in management. The mean CEA level for patients with malignancy (46.1 ng/ml) was significantly higher than those without malignancy (3.82 ng/ml) (P < 0.05). In predicting the presence of malignancy, a CEA cutoff at 7.55 ng/ml will achieve a sensitivity of 91% and a specificity of 73%. CONCLUSION: PET/CT, in our study population, appears to be sensitive, specific, and accurate in investigating patients with elevated CEA and without known primary malignancy. In addition to diagnosis of underlying primary malignancy, PET/CT also reveals occult metastases which would affect patient treatment options. Its role in investigating patients with elevated CEA and without known primary, compared with other investigation modalities, remains to be studied.

Hepatic tuberculosis: a rare cause of fluorodeoxyglucose hepatic superscan with background suppression on positron emission tomography.

Fluorodeoxyglucose (FDG) hepatic superscan refers to the diffuse intense uptake of 18F-FDG in the liver on positron emission tomography (PET), with reduced physiological activity in the brain and heart. The common causes include lymphoma and metastasis. In this case report, we describe the imaging features of tuberculosis as a rare cause of FDG hepatic superscan. PET imaging may be the only clue to a diagnosis of hepatic tuberculosis, as other imaging modalities may demonstrate only nonspecific hepatomegaly. It is important to consider this entity in the differential diagnosis of patients presenting with FDG hepatic superscan and proceed with liver biopsy for a definitive diagnosis.