Deep Convolutional Neural Network-Aided Detection of Portal Hypertension in Patients With Cirrhosis.

BACKGROUND & AIMS: Noninvasive and accurate methods are needed to identify patients with clinically significant portal hypertension (CSPH). We investigated the ability of deep convolutional neural network (CNN) analysis of computed tomography (CT) or magnetic resonance (MR) to identify patients with CSPH. METHODS: We collected liver and spleen images from patients who underwent contrast-enhanced CT or MR analysis within 14 days of transjugular catheterization for hepatic venous pressure gradient measurement. The CT cohort comprised participants with cirrhosis in the CHESS1701 study, performed at 4 university hospitals in China from August 2016 through September 2017. The MR cohort comprised participants with cirrhosis in the CHESS1802 study, performed at 8 university hospitals in China and 1 in Turkey from December 2018 through April 2019. Patients with CSPH were identified as those with a hepatic venous pressure gradient of 10 mm Hg or higher. In total, we analyzed 10,014 liver images and 899 spleen images collected from 679 participants who underwent CT analysis, and 45,554 liver and spleen images from 271 participants who underwent MR analysis. For each cohort, participants were shuffled and then sampled randomly and equiprobably for 6 times into training, validation, and test data sets (ratio, 3:1:1). Therefore, a total of 6 deep CNN models for each cohort were developed for identification of CSPH. RESULTS: The CT-based CNN analysis identified patients with CSPH with an area under the receiver operating characteristic curve (AUC) value of 0.998 in the training set (95% CI, 0.996-1.000), an AUC of 0.912 in the validation set (95% CI, 0.854-0.971), and an AUC of 0.933 (95% CI, 0.883-0.984) in the test data sets. The MR-based CNN analysis identified patients with CSPH with an AUC of 1.000 in the training set (95% CI, 0.999-1.000), an AUC of 0.924 in the validation set (95% CI, 0.833-1.000), and an AUC of 0.940 in the test data set (95% CI, 0.880-0.999). When the model development procedures were repeated 6 times, AUC values for all CNN analyses were 0.888 or greater, with no significant differences between rounds (P > .05). CONCLUSIONS: We developed a deep CNN to analyze CT or MR images of liver and spleen from patients with cirrhosis that identifies patients with CSPH with an AUC value of 0.9. This provides a noninvasive and rapid method for detection of CSPH (ClincialTrials.gov numbers: NCT03138915 and NCT03766880).

[Angiographic evaluation of branching pattern and anatomy of the aortic arch]. / Arkus aorta anatomisinin ve dallanma paternindeki varyasyonlarin anjiyografik olarak degerlendirilmesi.

OBJECTIVE: The study aimed to investigate anatomical variations in branching pattern and anatomy of the aortic arch, and the prevalence of each type. METHODS: Between September 2011 and November 2013, angiographic studies of 270 patients (144 male, 126 female) were analyzed retrospectively for variations in branching pattern and anatomy of the aortic arch. Patient mean age was 59.8 years (range, 13-88). Branching variations were found and divided into subtypes. Patients were also classified according to arch anatomy. Incidence of variations and types of aortic arch were statistically analysed. RESULTS: Analysis of the 270 patients revealed six types of branching pattern. Type I, classical pattern arch with three branches (TB, LCC, LS), was observed in 198 cases (73.3%). Type II (bovine arch), the most commonly observed variation, in which LCC originates from TB, was observed in 58 cases (21.5%). Type III, in which the left vertebral artery arises from the arch, was seen in seven cases (2.6%). Type IV, a combination of types II and III, was observed in three cases (1.1%). Type V, common origin of common carotids, LS and aberrant RS, was found in three cases (1.1%). Type VI (avian type), arch with only two branches, was observed in one case (0.4%). When patients were classified according to aortic arch anatomy, Type 1, Type 2 and Type 3 were observed in 195, 40 and 35 patients respectively. CONCLUSION: Knowledge of the variations and anatomy of the aortic arch is essential during interventional procedures and neck-thorax surgery.

The detrimental effect of aging on leptomeningeal collaterals in ischemic stroke.

BACKGROUND: Aging is associated with decreased penumbral salvage in patients with ischemic stroke. Another critical factor that determines the fate of penumbra tissue is the degree of collateral circulation, which decreases significantly with aging in experimental models of stroke. In this study, we sought to identify whether these observations could be translated to humans and, therefore, analyzed the effect of patient age on extent of leptomeningeal collaterals in patients with ischemic stroke. METHODS: Computed tomography angiography (CTA) source images were used to assess the degree of collateral circulation in a retrospective series of patients with proximal middle cerebral artery (MCA) occlusion. Bivariate and multivariate analyses were used to explore the relationship between patient age and degree of collateral circulation. RESULTS: A total of 70 patients were included into the study. Older age (P = .005), history of hypertension (P = .036), higher admission National Institutes of Health Stroke Scale (NIHSS) scores (P = .013), and increased time to CTA (P = .013) were associated with inadequate collaterals in bivariate analyses. In multivariate analysis, older age (P = .008) and higher NIHSS scores (P = .032) remained as the only significant independent variables that were associated with inadequate collaterals. A 10-year increment in patient age increased the odds of inadequate collateral circulation by 1.87 (95% confidence interval: 1.18-2.97). CONCLUSION: Our findings show that there is a significant interplay between patient age and adequacy of leptomeningeal collateral circulation in patients with proximal MCA occlusion. The relationship could contribute to adverse tissue outcome and thereby to unfavorable clinical outcome observed in elderly patients with ischemic stroke.

Increased Incidence of Pancreatic Steatosis Detected Using Computed Tomography at Initial Diagnosis of Coronavirus Disease 2019.

BACKGROUND: It is known that hepatic steatosis, diabetes, obesity, and metabolic syndrome are poor prognostic criteria for coronavirus disease 2019. Closely associated with these factors, pancreatic steatosis has yet to be clarified regarding its incidence in patients with coronavirus disease 2019 and its effect on prognosis. This study aimed to compare the incidence of pancreatic steatosis detected in non-contrast chest computed tomography examinations of patients with coronavirus disease 2019 pneumonia at the time of diagnosis with that of the general population. METHODS: In the present retrospective study, which included 399 patients, densities of 5 different regions of the pancreas and 4 different regions of the spleen were measured, and the mean value of the measured densities was obtained. The difference between the mean pancreatic attenuation and splenic attenuation was defined as pancreatic steatosis if pancreatic attenuation-splenic attenuation ≤-5. RESULTS: The median pancreatic density in patients with coronavirus disease 2019 was significantly lower than in those who tested negative (P = .034). In patients who were coronavirus disease 2019 positive, the incidence of pancreatic steatosis was statistically significantly higher (54.3% vs. 43.0%, P = .031). CONCLUSIONS: According to the non-contrast chest computed tomography examination of the patients with coronavirus disease 2019 performed at the time of admission, the incidence of pancreatic steatosis was higher than that of the normal population of a similar age group. Given that patients with pancreatic steatosis and the accompanying metabolic syndrome are more prone to inflammation, the findings suggest that these patients underwent more chest computed tomography examinations at the time of diagnosis. Therefore, pancreatic steatosis may be a poor prognostic factor in coronavirus disease 2019.

Radiofrequency Ablation for Colorectal Cancer Liver Metastases: Outcomes and Prognostic Factors Associated with Survival.

BACKGROUND: To determine the long-term outcomes of radiofrequency ablation with respect to overall survival, disease-free survival, and complications in patients with colorectal cancer liver metastases. Additionally, we sought to examine whether various patient- and treatment-related characteristics were associated with prognosis. METHODS: Fifty-nine patients with colorectal cancer liver metastases who had undergone percutaneous radiofrequency ablation treatment were included in this study. A total of 138 lesions were treated with radiofrequency ablation in the first and second sessions. Tumor diameters ranged from 10 to 60 mm (mean, 2.45 mm). Treatment efficacy, complications, and overall survival and disease-free survival were analyzed. RESULTS: The primary success rate of radiofrequency ablation was 94.4%. At the end of the first month, the residual disease was detected in 12 lesions, 10 of which underwent secondary radiofrequency ablation treatment, resulting in a cumulative secondary success rate of 98.4%. The 1-, 3-, and 5-year overall survival rates in 59 patients with colorectal cancer liver metastases were 94.9%, 52.5%, and 40.6%, respectively. The median survival was 42 months in patients with metastasis size of ≤3 cm, while it was 25 months in patients with metastasis size of >3 cm (P = .001). The 1-, 3-, and 5-year disease-free survival rates were 44%, 10.2%, and 6.7%, respectively. Metastatic tumor status (solitary or multiple) was a significant prognostic factor in determining overall survival and disease-free survival; furthermore, extrahepatic recurrence during follow-up was a prognostic factor affecting overall survival. Minor complications developed in four radiofrequency ablation procedures (6.7%). CONCLUSION: Radiofrequency ablation remains a safe and effective treatment option improving survival in select cases of colorectal cancer liver metastases.

Portal Vein Pull-Through Technique and Thrombectomy for Extensive Portal Vein Thrombosis.

BACKGROUND: Herein, a different technique is presented describing complete dissection of the entire portal vein (PV), superior mesenteric vein (SMV), and splenic vein, thus enabling a complete thrombectomy without the risk of uncontrolled hemorrhage due to blind thrombectomy. METHODS: In cases where a thrombectomy would not be an option because of extensive thrombosis involving the confluence of the PV and SMV, small branches of the SMV, including the inferior mesenteric vein, were divided. Both the SMV and splenic vein were encircled separately. Then, the side branches of the PV above the pancreas, left gastric vein on the left side, and superior pancreatoduodenal vein on the right side were divided. The lateral and posterior part of the PV were dissected within the pancreas both from above and below, allowing the main PV completely free from attachments. At this point, the splenic vein and SMV were clamped, and the main PV was divided above the pancreas and then pulled back through the pancreatic tunnel. The thrombus was easily dissected of the vein under direct visualization, and afterward the PV was redirected to its original position. Then, the liver transplant was carried out in a regular fashion. RESULTS: This technique was applied to 2 patients. The first was a 43-year-old man who underwent a right lobe living donor liver transplant because of hepatitis B virus-related cirrhosis. The patient is still alive and well with stable liver function after 15 years of follow-up. The second was a 69-year-old woman who underwent a right lobe living donor liver transplant because of hepatitis C virus and hepatocellular carcinoma. She survived the procedure and her liver function was entirely normal afterward. She died of pneumonia and sepsis 5 months after transplant. CONCLUSIONS: This technique enables complete dissection of the entire PV, SMV, and splenic vein. Thus, complete thrombectomy under direct visualization without the risk of uncontrolled hemorrhage can be performed.

An imaging-based artificial intelligence model for non-invasive grading of hepatic venous pressure gradient in cirrhotic portal hypertension.

The hepatic venous pressure gradient (HVPG) is the gold standard for cirrhotic portal hypertension (PHT), but it is invasive and specialized. Alternative non-invasive techniques are needed to assess the hepatic venous pressure gradient (HVPG). Here, we develop an auto-machine-learning CT radiomics HVPG quantitative model (aHVPG), and then we validate the model in internal and external test datasets by the area under the receiver operating characteristic curves (AUCs) for HVPG stages (≥10, ≥12, ≥16, and ≥20 mm Hg) and compare the model with imaging- and serum-based tools. The final aHVPG model achieves AUCs over 0.80 and outperforms other non-invasive tools for assessing HVPG. The model shows performance improvement in identifying the severity of PHT, which may help non-invasive HVPG primary prophylaxis when transjugular HVPG measurements are not available.

Small bowel wall thickening: MDCT evaluation in the emergency room.

Small bowel wall thickening detected on computed tomography is a frequent finding in patients referring to emergency room with acute abdominal pain. In this pictorial review, we aim to discuss patterns of small bowel wall thickening and to explain hints for differential diagnosis with imaging findings.

Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase.

Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis. A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA-CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA-CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.

Role of steroid injection for skin thickness and edema in rhinoplasty patients.

OBJECTIVES: The aim of this study was to observe the effect of the triamcinolone acetonide injections in thick skinned patients with ultrasonographic measurements and to compare these results with the postoperative nasal skin thickness of patients that were not injected with steroids. METHODS: A prospective study was planned with 42 thick nasal skinned rhinoplasty candidates in our clinic. Skin thickness of specific points along nose was measured and documented. On the 10th day after surgery, triamcinolone acetonide injections were performed into the supratip region of 21 patients in the study group. No injections were made for the control group. Nasal ultrasonographic measurements were repeated 40 days after the surgery for all 42 patients by the same radiologist and results were evaluated. RESULTS: Seventeen women (40.5%) and 25 men (59.5%) were included in the study. Patients' ages ranged from 18 to 53 with an average age of 27.9. In study group, all injections sites showed thinning on the 40th day after surgery. These findings were statistically significant at B (rhinion), D (middle of supratip), and G (middle of the tip). In the control group, all injection sites except A (nasion) displayed thickening on the 40th day after surgery. These findings were statistically significant at B (rhinion), D (middle of supratip), H (left side of the tip), and J (left alar region). CONCLUSION: Triamcinolone acetonide injections are effective in the prevention of edema and provide thinning of the post-rhinoplasty skin envelope.

Noncontrast-enhanced MRI-based Noninvasive Score for Portal Hypertension (CHESS1802): An International Multicenter Study.

BACKGROUND AND AIMS: This study aimed to determine the performance of the non-invasive score using noncontrast-enhanced MRI (CHESS-DIS score) for detecting portal hypertension in cirrhosis. METHODS: In this international multicenter, diagnostic study (ClinicalTrials.gov, NCT03766880), patients with cirrhosis who had hepatic venous pressure gradient (HVPG) measurement and noncontrast-enhanced MRI were prospectively recruited from four university hospitals in China (n=4) and Turkey (n=1) between December 2018 and April 2019. A cohort of patients was retrospectively recruited from a university hospital in Italy between March 2015 and November 2017. After segmentation of the liver on fat-suppressed T1-weighted MRI maps, CHESS-DIS score was calculated automatically by an in-house developed code based on the quantification of liver surface nodularity. RESULTS: A total of 149 patients were included, of which 124 were from four Chinese hospitals (training cohort) and 25 were from two international hospitals (validation cohort). A positive correlation between CHESS-DIS score and HVPG was found with the correlation coefficients of 0.36 (p<0.0001) and 0.55 (p<0.01) for the training and validation cohorts, respectively. The area under the receiver operating characteristic curve of CHESS-DIS score in detection of clinically significant portal hypertension (CSPH) was 0.81 and 0.9 in the training and validation cohorts, respectively. The intraclass correlation coefficients for assessing the inter- and intra-observer agreement were 0.846 and 0.841, respectively. CONCLUSIONS: A non-invasive score using noncontrast-enhanced MRI was developed and proved to be significantly correlated with invasive HVPG. Besides, this score could be used to detect CSPH in patients with cirrhosis.

A rare cause of abdominal pain: Catheter in the middle hepatic vein.

Hemodialysis catheters are vital for chronic renal failure patients. Permanent tunneled dialysis catheters may be inserted through the jugular, subclavian, and femoral veins. In this paper, we aimed to present the computed tomography findings of a chronic renal failure patient who had referred our clinic with abdominal pain and dyspnea symptoms. This patient had a formerly inserted hemodialysis catheter for chronic renal failure and her catheter was found to be extending towards the middle hepatic vein with the tip leaning onto the parenchyma. Hemodialysis catheters can provide instant vascular access and can also be used for the consecutive procedures. Permanent hemodialysis catheters are ideal for long-term use when placing an arteriovenous fistula is contraindicated or is no longer possible under conditions like advanced heart failure, peripheral artery disease or short life expectancy. The internal jugular, subclavian, the femoral veins, and the inferior vena cava can be used for catheter insertion. The tip of the catheters inserted in the neck or the thorax must extend to the vena cava superior. Catheter malposition may both lead to fatal outcomes and ineffective dialysis. It is important to obtain chest X-rays after the procedure, particularly to detect catheter malposition.

Imaging findings of lipomatosis: a comprehensive review.

Lipomatosis is a benign and non-encapsulated mature form of fat tissue proliferation, which can be isolated or multiple, symmetrical or infiltrative, and may be associated with several syndromes. Lipomatosis has been reported to involve almost every part and organ in the body. In this review, we present imaging findings at common locations of lipomatosis and summarize lipomatosis-related syndromes.