Evaluation of computerized tomography utilization in comparison to digital subtraction angiography in patients with peripheral arterial disease

OBJECTIVES

Perform literature review to analyze current practices in imaging patient with peripheral arterial disease (PAD) and examine patterns in our practice in order to assess whether a lower extremity computed tomography angiography (CTA) in addition to digital subtraction angiography (DSA) enhanced the assessment of vessel calcification, percentage of stenosis; and affected outcomes in patients with peripheral arterial disease.

METHODS AND MATERIALS

The study included patients who underwent lower extremity imaging and were followed up to 12 months. This population was divided into cases who had both an angiogram and CTA performed within 30 days (n=20), and controls who underwent angiography only (n=19). Baseline characteristics, imaging results, and clinical outcomes were analyzed.

RESULTS

Thirty-nine patients met study criteria (mean age was 58.4 years, 69.2% were males, and 33.3% had diabetes). Patients mostly presented with tissue loss/rest pain (10.3%), claudication (15.4%), acute limb (10.3%), and trauma (15.4%). We have not observed any statistically significant differences in various examined blood vessels when their features (e.g. vessel diameter, stenosis, calcifications) were assessed by CTA combined with angiography versus angiography alone. The exceptions were external iliac artery, superficial femoral artery and dorsalis pedis vessels. In external iliac artery percentage of stenosis was 1.11% as determined by CT scan versus 30% by angiography (P=.009). For superficial femoral artery stenosis the percentage determined by CT was 48.68% versus 81.41% by angiography, and observed difference between two modalities was statistically significant (P=.025). For dorsalis pedis percentage of stenosis detected by CT scan was 60.63% versus 22.73% by angiography, and the differences in findings by these modalities were statistically significant (P=.039). The most frequent perioperative complication was cardiac-related (35.5%). Nineteen patients were readmitted and 8 had re-interventions within 12 months.

CONCLUSION

Both imaging modalities yielded similar results for assessing vessel calcification and percentage of stenosis regardless of anatomic vessel location. Overall, utilization of CTA in addition to angiography for large vessels above the knee (e.g. iliac artery, superficial femoral artery) and below the knee for dorsalis pedis provided more detailed information on the properties of these vessels. Therefore, during pre-operative assessments, CTA may be helpful in addition to angiography for planning surgical and endovascular interventions for symptomatic PAD treatment in larger vessels.

Adaptive treatment strategy for a vestibular schwannoma in a patient with vascular Eagle syndrome: illustrative case

BACKGROUND

Eagle syndrome, an uncommon condition, causes symptoms due to neural and/or vascular compression from an elongated styloid process or calcified stylohyoid ligament and can also complicate other planned surgical procedures.

OBSERVATIONS

A 42-year-old female with loss of balance, dizziness, and ataxic gait underwent cranial magnetic resonance imaging (MRI), revealing a right-sided Koos grade IV vestibular schwannoma. Initially, a retrosigmoid craniotomy for tumor resection was planned. However, preoperative MRI and computed tomography (CT) showed a dilated right-sided mastoid emissary vein, tortuous scalp and paraspinal veins, and bilateral elongated styloid processes. CT angiography and digital subtraction angiography indicated Eagle syndrome-related compression of both internal jugular veins and concurrent occlusion of the left internal jugular vein at the jugular foramen. Consequently, given the risk of damaging venous structures, Gamma Knife radiosurgery was chosen over resection.

LESSONS

This case highlights the importance of adapting treatment plans based on patient-specific anatomical and pathological factors. In situations in which traditional surgery poses risks to sensitive structures such as the venous system, alternative approaches like radiosurgery offer safer yet effective options. Comprehensive risk-benefit evaluations are crucial for such decisions.

Digital variance angiography in patients undergoing lower limb arterial recanalization: cost-effectiveness analysis within the English healthcare setting

Aim: Digital variance angiography (DVA) is a recently developed image processing method capable of improving image quality compared with the traditionally used digital subtraction angiography (DSA), among patients undergoing lower limb x-ray angiography. This study aims to explore the potential cost-effectiveness of DVA from an English National Health Service perspective. Materials & methods: A two-part economic model, consisting of a decision tree and a Markov model, was developed to consider the costs and health outcomes associated with the use of DVA as part of current practice imaging, compared with x-ray angiography using standard DSA. The model explored the impact of DVA on the development of acute kidney injury (AKI), chronic kidney disease and radiation-induced cancer over a lifetime horizon. Both deterministic and probabilistic analyses were performed to assess the cost per quality-adjusted life-year (QALY). Results: Base-case results indicate that DVA results in cost savings of £309 per patient, with QALYs also improving (+0.025) over a lifetime. As shown in sensitivity analysis, a key driver of model results is the relative risk (RR) reduction of contrast-associated acute kidney injury associated with use of DVA. The intervention also decreases the risk of carcinoma over a lifetime. Scenario analyses show that cost savings range from £310 to £553, with QALY gains ranging from 0.048 to 0.109 per patient. Conclusion: The use of DVA could result in a decrease in costs and an increase in QALYs over a lifetime, compared with existing imaging practice. The potential for this technology to offer an economically viable alternative to existing image processing methods, through a reduction in contrast media volume and radiation exposure, has been demonstrated.

Bilateral Inferior Petrosal Sinus Sampling Without Lateralization Is Less Accurate for the Diagnosis of Cushing Disease

Context

During bilateral inferior petrosal sinus sampling (BIPSS), the side-to-side adrenocorticotropic hormone (ACTH) ratio, referred to as sampling lateralization, was used to predict pituitary adenoma localization.

Objective

To investigate the potential different diagnostic accuracy of BIPSS for differentiating Cushing disease (CD) and ectopic ACTH secretory syndrome (EAS) patients with low lateralization (inferior petrosal sinus [IPS]:IPS ≤ 1.4) and high lateralization (IPS:IPS > 1.4).

Methods

This single-center retrospective study (2011-2021) included (all patients had BIPSS results and confirmed pathologic diagnoses) 220 consecutive CD patients (validation set), 30 EAS patients, and 40 of the CD patients who had digital subtraction angiography (DSA) videos (discovery set).

Results

In the discovery set, the low-lateralization CD group (n = 11) had a higher median plasma ACTH concentration (62.2, IQR 44.7-181.0 ng/L) than the high-lateralization CD group (n = 29) (33.0, IQR 18.5-59.5, P = .013). Lower IPS to peripheral ratios were observed in the low-lateralization group during BIPSS, both before and after stimulation (P = .013 and P = .028). The sensitivity of BIPSS before stimulation in differentiating CD from EAS was lower in the low-lateralization group than the high-lateralization group (54.6% vs 93.1%, P = .003), as validated in the validation set. DSA videos revealed higher vascular area difference visible in the 2 sides of the pituitary in low lateralization (median 1.2 × 105 pixels, IQR 0.5-1.8) than the high-lateralization group (0.4 × 105 pixels, IQR 0.1-0.7, P = .008). The vascular area ratio of the 2 sides was also significantly higher in low (1.55, IQR 1.31-2.20) than high lateralization (1.19, IQR 1.07-1.35, P = .010).

Conclusion

Our study suggested that low lateralization in CD patients may reduce the diagnostic sensitivity of BIPSS, which might be potentially associated with peripituitary vascular anatomy.

Intracranial dural arteriovenous fistulas: association with cerebral venous thrombosis, baseline aggressiveness, and clinical outcomes. A retrospective multicenter study on 263 consecutive patients and literature review

OBJECTIVE

The pathogenesis of intracranial dural arteriovenous fistulas (icDAVFs) is controversial. Cerebral vein thrombosis (CVT) and venous hypertension are recognized predisposing factors. This study aimed to evaluate the incidence of association between icDAVF and CVT and describe baseline aggressiveness and clinical outcomes for icDAVFs associated with CVT. The authors also performed a literature review of studies reporting icDAVF associated with CVT.

METHODS

Two hundred sixty-three consecutive patients in two university hospitals with confirmed icDAVFs were included. A double-blind imaging review was performed to determine the presence or absence of CVT close or distant to the icDAVF. Location, type (using the Cognard classification), aggressiveness of the icDAVF, clinical presentation, treatment modality, and clinical and/or angiographic outcomes at 6 months were also collected. All prior brain imaging was analyzed to determine the natural history of onset of the icDAVF.

RESULTS

Among the 263 included patients, 75 (28.5%) presented with a CVT concomitant to their icDAVF. For 18 (78.3%) of 23 patients with previous brain imaging available, CVT preceding the icDAVF was proven (6.8% of the overall population). Former/active smoking (OR 2.0, 95% CI 1.079-3.682, p = 0.022) and prothrombogenic status (active inflammation or cancer/coagulation trouble) were risk factors for CVT associated with icDAVF (OR 3.135, 95% CI 1.391-7.108, p = 0.003). One hundred eighty-seven patients (71.1%) had a baseline aggressive icDAVF, not linked to the presence of a CVT (p = 0.546). Of the overall population, 11 patients (4.2%) presented with spontaneous occlusion of their icDAVF at follow-up. Seven patients (2.7%) died during the follow-up period. Intracranial DAVF + CVT was not associated with a worse prognosis (modified Rankin Scale score at 3-6 months: 0 [interquartile range {IQR} 0-1] for icDAVF + CVT vs 0 [IQR 0-0] for icDAVF alone; p = 0.055).

CONCLUSIONS

This was one of the largest studies focused on the incidence of CVT associated with icDAVF. For 6.8% of the patients, a natural history of CVT leading to icDAVF was proven, corresponding to 78.3% of patients with previous imaging available. This work offers further insights into icDAVF pathophysiology, aiding in identifying high-risk CVT patients for long-term follow-up imaging. Annual imaging follow-up using noninvasive vascular imaging (CT or MR angiography) for a minimum of 3 years after the diagnosis of CVT should be considered in high-risk patients, i.e., smokers and those with prothrombogenic status.

Evaluating the diagnostic accuracy of 3D contrast-enhanced magnetic resonance angiography versus digital subtraction angiography in spinal dural arteriovenous fistulas

OBJECTIVE

Spinal dural arteriovenous fistulas (SDAVFs) often go undiagnosed, leading to irreversible spinal cord dysfunction. Although digital subtraction angiography (DSA) is the gold standard for diagnosing SDAVF, DSA is invasive and operator dependent, with associated risks. MR angiography (MRA) is a promising alternative. This study aimed to evaluate the performance of MRA as an equal alternative to DSA in investigating, diagnosing, and localizing SDAVF.

METHODS

Prospectively collected data from a single neurosurgeon at a large tertiary academic center were searched for SDAVFs. Eligibility criteria included any patient with a surgically proven SDAVF in whom preoperative DSA, MRA, or both had been obtained. The eligible patients formed a consecutive series, in which they were divided into DSA and MRA groups. DSA and MRA were the index tests that were compared to the surgical SDAVF outcome, which was the reference standard. Accurate diagnosis was considered to have occurred when the imaging report matched the operative diagnosis to the correct spinal level. Comparisons used a two-sample t-test for continuous variables and Fisher-Freeman-Halton's exact test for categorical variables, with p < 0.05 specifying significance. Univariate, bivariate, and multivariate analyses were conducted to investigate group associations with DSA and MRA accuracy. Positive predictive value, sensitivity, and accuracy were calculated.

RESULTS

A total of 27 patients with a mean age of 63 years underwent surgery for SDAVF. There were 19 male (70.4%) and 8 female (29.6%) patients, and the mean duration of symptoms at the time of surgery was 14 months (range 2-48 months). Seventeen patients (63%) presented with bowel or bladder incontinence. Bivariate analysis of the DSA and MRA groups further revealed no significant relationships between the characteristics and accuracy of SDAVF diagnosis. MRA was found to be more sensitive and accurate (100% and 73.3%) than DSA (85.7% and 69.2%), with a subanalysis of the patients with both preoperative MRA and DSA showing that MRA had a greater positive predictive value (78.6 vs 72.7), sensitivity (100 vs 72.7), and accuracy (78.6 vs 57.1) than DSA.

CONCLUSIONS

In surgically proven cases of SDAVFs, the authors determined that MRA was more accurate than DSA for SDAVF diagnosis and localization to the corresponding vertebral level. Incomplete catheterization at each vertebral level may result in the failure of DSA to detect SDAVF.

Hypoglossal Canal Dural Arteriovenous Fistula: A Rare Cause of Ocular Proptosis

It is exceedingly rare for dural arteriovenous fistulae (DAVFs) outside of the cavernous sinus to present with ophthalmological symptoms and signs. Hypoglossal canal DAVFs (HC-DAVFs) have only previously been reported as individual cases or small case series. Further, only an estimated 31% of HC-DAVFs present with ophthalmological findings. We report a noteworthy case of an HC-DAVF in a 74-year-old male who presented with proptosis, chemosis, and reduced visual acuity. He was treated endovascularly with liquid embolic filling. This report aims to highlight HC-DAVF as an important differential diagnosis for patients presenting with symptoms suggestive of arterialisation of the ophthalmic veins.

Correlation between Ultrasound Peak Systolic Velocity and Angiography for Grading Internal Carotid Artery Stenosis

(1) Background: The success of carotid revascularization depends on the accurate grading of carotid stenoses. Therefore, it is important for every vascular center to establish its protocols for the same. In this study, we aimed to determine the peak systolic velocity (PSV) thresholds that can predict moderate and severe internal carotid artery (ICA) stenoses. (2) Methods: To achieve this, we enrolled patients who underwent both duplex ultrasound (DUS) and invasive carotid artery digital subtraction angiography (DSA). The degree of ICA stenosis was assessed using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) protocols. The PSV thresholds were determined using receiver operating characteristic (ROC) curves. (3) Results: Our study included 47 stenoses, and we found that the PSV cut-off for predicting ≥70% NASCET ICA stenoses was 200 cm/s (sensitivity 90.32%, specificity 93.75%). However, PSV did not correlate significantly with ≥50% NASCET ICA stenoses. On the other hand, the optimal PSV threshold for predicting ≥80% ECST ICA stenoses was 180 cm/s (sensitivity 100%, specificity 81.82%). (4) Conclusions: Based on our findings, we concluded that PSV is a good and simple marker for the identification of severe stenoses. We found that PSV values correlate significantly with severe NASCET and ECST stenoses, with 200 cm/s and 180 cm/s PSV thresholds. However, PSV was not reliable with moderate NASCET stenoses. In such cases, complementary imaging should be used.

Moya-Moya Disease Revealed by a Non-lobar Intracerebral Hemorrhage in an Adult

Moya-Moya disease (MMD) is a rare cerebral vasculopathy affecting children and adults. It is a progressive steno-occlusive arterial disease generally discovered during the etiological assessment of an ischemic or hemorrhagic stroke. Its diagnosis is based essentially on imaging. Cerebral digital subtraction angiography (DSA) remains the gold standard. We report the case of a 42-year-old male patient admitted for the loss of consciousness with a Glasgow Coma Scale (GCS) of 12/15. A brain CT scan revealed a right capsulo-lenticular hematoma with ventricular flooding and hydrocephalus. Cerebral CT angiography showed features of Moya-Moya vasculopathy, which was confirmed by a cerebral catheter angiogram.

A novel system for evaluating collateralization of the external carotid artery after cerebral revascularization in moyamoya disease

OBJECTIVE

The objective of this retrospective study was to establish a novel system for evaluating collateralization of the external carotid artery in patients with moyamoya disease (MMD) following direct and indirect revascularization surgeries.

METHODS

The authors conducted a retrospective analysis of 456 patients diagnosed with MMD who underwent direct and indirect revascularization procedures at Beijing Tiantan Hospital, Capital Medical University, between January 2015 and May 2023. Using a newly proposed digital subtraction angiography (DSA)-based evaluation system, the authors assessed collateralization angiogenesis objectively and in a standardized manner.

RESULTS

The authors' findings indicated that there was no significant difference in collateralization angiogenesis between patients undergoing direct or indirect cerebral revascularization (p = 0.702). However, after cerebral revascularization, patients with ischemic MMD exhibited significantly higher collateralization angiogenesis compared with those with hemorrhagic MMD (p = 0.007). Children with MMD demonstrated higher angiogenesis levels than adults (p < 0.001), but subgroup analysis showed age-specific variations. In adults, collateralization angiogenesis was significantly greater in those with ischemic MMD (p = 0.006), whereas in children, no significant difference was noted between ischemic and hemorrhagic MMD (p = 0.962). Furthermore, regardless of MMD type, direct and indirect revascularization methods yielded similar collateralization angiogenesis (p = 0.962 and p = 0.963, respectively). Importantly, the Matsushima grading system revealed significant differences in angiogenesis in patients with ischemic MMD (p < 0.001).

CONCLUSIONS

The newly introduced DSA-based evaluation system offers an objective and standardized method for assessing collateralization angiogenesis in MMD. This study supports the efficacy of both direct and indirect revascularization surgical procedures and highlights distinct pathophysiological processes of ischemic and hemorrhagic disease subtypes. These findings contribute to a better understanding of surgical outcomes and aid in the selection of appropriate treatment strategies for patients with MMD.

A Case Report of Hemorrhagic Cavernoma Masquerading as a Thrombosed Aneurysm

Cavernous malformations are vascular lesions characterized by dilated blood vessels with minimal intervening brain parenchyma. Although often asymptomatic, they can present with seizures, headaches, or neurological deficits. Accurate diagnosis relies on magnetic resonance imaging, with characteristic features such as a "popcorn" appearance. We present a case of a 45-year-old male with chronic headaches and seizures who underwent an extensive work-up. Initial magnetic resonance imaging suggested a thrombosed aneurysm, with subsequent cerebral angiography being unremarkable, supporting the final diagnosis of a cavernous malformation. Conservative management, initiated for asymptomatic lesions, led to effective seizure control and improved quality of life. This case underscores diagnostic complexities in neuroradiology, emphasizing the need for careful consideration of differentials when faced with unexpected imaging results. Clinicians must remain vigilant for alternative explanations, recognizing the dynamic nature of optimal strategies in neurovascular medicine.

Feeding artery characteristics and enhancement patterns of hepatoblastoma patients treated with transarterial chemoembolization (TACE): Digital subtraction angiography evaluation

Hepatoblastoma is one of the most common primary malignant liver tumors in children. The incidence of hepatoblastoma has been increasing, reaching 1.2 per million children now. The transarterial chemoembolization (TACE) procedure is one of the most practical and effective treatment options besides surgery. Digital subtraction angiography (DSA) is performed as the first step of the TACE procedure. The aim of this study was to provide information about the feeding arteries and enhancement pattern of the hepatoblastoma that was assessed by DSA before the TACE procedure. A retrospective study was conducted among hepatoblastoma cases that had undergone DSA on the TACE procedure to obtain information on the vascularity of the tumor. A total of 26 hepatoblastoma cases who had DSA examination as a part of their first TACE procedure were included, consisting of 15 boys and 11 girls, aged between 1-15 years. All cases were stage III and IV according to the Pre-Treatment Extent of Tumor (PRETEXT) staging classification. All hepatoblastoma cases had multiple feeding arteries, most of which were branches of the right hepatic artery. The largest diameter of the feeding artery was 1.82 mm, and the smallest was 0.63 mm. Most cases (84.62%) had strong contrast absorption, and spread evenly, either at the edges or in the center of the tumor. DSA is believed to be an accurate procedure to provide a detailed description of the feeding artery; enhancement patterns of hepatoblastoma were influenced by an adequate TACE.

Diagnostic Value of Contrast-Enhanced Ultrasonography for Catheter-Related Right Brachiocephalic Vein and Superior Vena Cava Lesions in Patients Undergoing Hemodialysis-A Pilot Study

OBJECTIVES

To evaluate the diagnostic efficacy of contrast-enhanced ultrasonography (CEUS) for detecting catheter-related right brachiocephalic vein (RBV) and superior vena cava (SVC) obstructions in patients undergoing hemodialysis (HD).

METHODS

From June 1, 2021 to December 31, 2022, we enrolled 80 patients undergoing HD who had used or were using a central venous catheter as vascular access. We evaluated the diagnostic efficacy of conventional ultrasonography and CEUS for identifying RBV and SVC obstructions and compared them with that of digital subtraction angiography (DSA). In the stratified analysis, the SVC was divided into the upper and lower segments. In total, we analyzed 240 central venous segments, including the RBV.

RESULTS

Among the RBV and SVC visualized by DSA, conventional ultrasonography and CEUS could visualize 67.92 and 100% of the vein segments, respectively; however, the lengths and diameters of the RBV and SVC were smaller than those recorded with DSA (P < .001). The diagnostic efficacy of CEUS for detecting catheter-related central venous obstruction was better than that of conventional ultrasonography, with a higher sensitivity (83.95 vs 41.98%), specificity (89.94 vs 53.46%), accuracy (87.92 vs 49.58%), and F1 score (82.42 vs 49.64%). CEUS showed good agreement (κ = 0.732) with DSA. In the stratified analyses, CEUS also showed higher sensitivity (83.93, 83.33, and 84.62%, respectively) and better agreement with DSA (κ = 0.635, 0.655, and 0.673, respectively) than conventional ultrasonography for detecting the RBV and the upper and lower segments of the SVC.

CONCLUSIONS

CEUS had high sensitivity and specificity in diagnosing catheter-related RBV and SVC obstructions.

Dural arteriovenous fistula with progressive dementia and parkinsonism: Two case reports and a literature review

RATIONALE

Dural arteriovenous fistulas (DAVFs) are rare cerebral abnormal arteriovenous anastomoses. It is uncommon for DAVFs with parkinsonism and dementia, so it is easily misdiagnosed. Neuroimaging examinations show that multifocal DAVFs are related to venous thrombosis and white matter changes, suggesting that cerebral circulatory disorders caused by venous hypertensive encephalopathy lead to dementia in patients. Digital subtraction angiography confirmed the diagnosis and subsequent treatment of DAVFs.

PATIENT CONCERNS

We report 2 cases, one caused by bilateral white matter lesions and the other caused by bilateral thalamus lesions. Their symptoms are all manifested as progressive dementia and parkinsonism.

DIAGNOSIS

They were diagnosed with dural arteriovenous fistulas by digital subtraction angiography.

OUTCOMES

The first patient developed progressive cognitive impairment, 6 months later, the patient developed bedridden, incontinence, and severe cognitive function.The second patient became increasingly bedridden 3 months after discharge and died of aspiration pneumonia.

LESSONS

There are few reports of progressive dementia and parkinsonism in DAVF patients, and neurologists should be vigilant to avoid misdiagnosing DAVF.

Pancreatic Ischemia-Reperfusion Injury Following Endovascular Treatment of Symptomatic Celiac and Superior Mesenteric Artery Stenosis

CLINICAL IMPACT

With endovascular therapy becoming the first-line treatment for symptomatic chronic mesenteric ischemia, acute pancreatitis within the context of abdominal ischemia-reperfusion injury may be seen more often in cross-sectional imaging following this kind of interventions and should therefore be kept in mind by the reading physician.

Pediatric anterior choroidal artery aneurysm successfully coiled after re-rupture

Pediatric cerebral aneurysms are rare, and pediatric anterior choroidal artery aneurysms are very rarely reported. A 14-month-old male with no personal or family history of connective tissue disorders or Moyamoya disease presented with a right temporal intracerebral hemorrhage with intraventricular extension. CTA was negative for vascular pathology, but digital subtraction angiography revealed an anterior choroidal artery aneurysm that was successfully coiled. This case underscores the importance of performing digital subtraction angiography in children presenting with intracerebral hemorrhage concerning for vascular pathology even if non-invasive vascular imaging is negative.

Shaken or Stirred? The Inconsistencies of Manual Contrast Media Dilution in Endovascular Interventions

MATERIALS AND METHODS

Phase I: Eleven radiological technologists were asked to fill a CM injector 3 times with 50% diluted CM (iopromide 300 mg I/mL). The dilution was injected (12 mL/s) through a Coriolis flowmeter, with CM concentration and total volume calculated. Interoperator, intraoperator, and intraprocedural variations were calculated as coefficients of variability. Contrast media dose reporting accuracy was determined. Phase II: The study was repeated after implementation of a standardized dilution protocol with 5 representative operators.

RESULTS

Phase I: The average injected concentration among 11 operators was 68% ± 16% CM (n = 33; range, 43%-98%), as compared with the target of 50% CM. The interoperator variability was 16%, the intraoperator variability was 6% ± 3%, and the intraprocedural variability was 23% ± 19% (range, 5%-67%). This led to overdelivery of CM compared with intended patient dose by 36% on average. Phase II: After standardization, injections averaged 55% ± 4% CM (n = 15; range, 49%-62%), with interoperator variability of 8%, intraoperator variability of 5% ± 1%, and intraprocedural variability of 1.6% ± 0.5% (range, 0.4%-3.7%).

CONCLUSIONS

Manual CM dilution can lead to substantial interoperator and intraoperator, as well as intraprocedural variability in injected concentration. This can result in underreporting of administered CM doses to patients. It is recommended that clinics assess their current standard of care regarding CM injections for endovascular interventions and evaluate potential corrective actions if appropriate.

Analysis of treatment cost differences in patients undergoing femoral versus radial access in outpatient diagnostic cerebral arteriograms

BACKGROUND

Outpatient diagnostic cerebral arteriograms are the most common procedure in neuroendovascular surgery, and the use of transradial access for these studies is growing. Although transradial access has been associated with lower hospital costs for elective diagnostic and interventional neuroendovascular procedures, no study has compared transfemoral access and transradial access costs for a homogenous population of patients undergoing outpatient diagnostic cerebral arteriogram.

METHODS

In this single-center retrospective study, the Value Driven Outcomes database was used to evaluate treatment costs for patients who underwent outpatient diagnostic cerebral arteriogram from January 2019 to December 2022. Propensity-score matching was performed to reduce confounders. Costs from each encounter were subcategorized into imaging, supplies, pharmacy, procedures, labs, and facility costs.

RESULTS

After matching, 337 patients each for transradial access and transfemoral access were available for analysis. A total of 118,992 cost data points were associated with all encounters. Overall, per-visit costs were 15.2% cheaper for patients who underwent transradial access versus transfemoral access (p < 0.001). Most of the cost difference was due to supplies (35.2% cost difference, p < 0.001) and procedure costs (9.3% cost difference, p < 0.001). No statistical differences were observed between the two approaches in imaging, pharmacy, labs, and facility costs (all p > 0.05).

CONCLUSIONS

Costs for outpatient diagnostic cerebral arteriogram were lower in patients who underwent transradial access versus transfemoral access because of supply and procedure costs. Understanding reasons for cost differences in common procedures is important for creating strategies to reduce overall healthcare costs. Additionally, addressing the cost differences of newer techniques may increase the likelihood that they are more readily implemented by hospitals and providers.

A Curious Case of Proptosis and Intracranial Calcifications Caused by a Vein of Galen Aneurysmal Malformation

Vein of Galen aneurysmal malformation (VGAM) is a rare, congenital, intracerebral arteriovenous malformation with a poor prognosis. This disorder commonly presents during the neonatal period and rarely in infancy and childhood. Reported here is a case of VGAM in a three-month-old female baby who presented with proptosis and intracranial calcifications, which are rare presentations of this rare entity. The diagnosis was confirmed by magnetic resonance imaging (MRI).

Pediatric Renovascular Hypertension: A Pediatric Interventional Radiologist's Perspective

Renovascular hypertension (RVH) contributes close to one-fourth of the secondary etiologies of hypertension in children and a delay in diagnosis can result in adverse clinical outcomes. RVH in children is clinically silent with elevations in blood pressure measurements sometimes as its sole manifestation. Only a high index of suspicion by the clinician can prompt its detection. Despite the availability of other imaging modalities like ultrasound, computed tomography, and magnetic resonance imaging, digital subtraction angiography is still considered the gold standard to make a diagnosis of RVH. Angioplasty is considered the treatment of choice in appropriately selected patients. In this article, we shall focus on the various imaging findings, and management of RVH in children, which requires a multidisciplinary approach with a special focus on the role of interventional radiology.

Endovascular Intervention for a Carotid-Cavernous Fistula: A Case Report

A carotid-cavernous fistula is a rare vascular anomaly involving abnormal communication between the carotid artery and the cavernous sinus. This condition leads to the shunting of arterial blood directly into the venous system, causing diverse clinical manifestations. The classification includes direct and indirect fistulas, with endovascular techniques emerging as a preferred treatment option. In this report, we present the case of a 58-year-old male who presented with progressive right-sided proptosis, headache, and visual disturbances. He exhibited right abducens nerve palsy, reduced visual acuity, and a dilated superior ophthalmic vein on imaging. A multidisciplinary team confirmed the diagnosis of a carotid-cavernous fistula and chose to pursue endovascular embolization. Catheter angiography revealed the fistula and balloon-assisted occlusion restored normal arterial flow. The patient's symptoms improved, and follow-up showed complete resolution of proptosis and enhanced visual acuity. Successful endovascular embolization underscores the significance of a multidisciplinary approach and showcases the positive outcomes achievable when diverse specialties converge for patient well-being.

Angiographic Imaging of Prostatic Artery Origin in a Greek Population and Correlation With Technical and Clinical Aspects of Prostatic Artery Embolization

Background This study aimed, first, to angiographically investigate and analyze prostatic artery (PA) origin in a Greek male population with benign prostatic hyperplasia (BPH) treated with prostatic artery embolization (PAE) and, second, to correlate prostatic arterial anatomy with technical and clinical aspects of PAE. Methodology This was a retrospective study of BPH patients who underwent PAE in a single tertiary center in Greece from June 2019 to July 2022. For the first part of the study, PA was imaged with computed tomography angiography (CTA) before PAE and with digital subtraction angiography (DSA) during PAE in all patients. A widely accepted system for the classification of PA origin was applied. Type I, a common origin of PA and superior vesical artery (SVA) from the anterior division of internal iliac artery (IIA). Type II, PA originating from the anterior division of IIA, separate from, and inferior to SVA. Type III, the origin of PA from the obturator artery. Type IV, the origin of PA from the internal pudendal artery. Type V, rarer origins of PA. For the second part of the study, a subgroup of patients from the first part (treated with the same PAE protocol and free of vascular pathology that could have interfered with the technical success of PAE) was selected. In this subgroup, differences in PA origin were correlated with technical aspects (feasibility of catheterization of PA, fluoroscopy time (FT), dose area product (DAP)) and clinical outcomes of PAE. Results After the exclusion of four patients, 159 patients were included in the first part of the study. From a total of 355 PAs, 110 (31%) were compatible with type I, 58 (16.3%) type II, 45 (12.7%) type III, 110 (31%) type IV, and 32 (9%) type V. PA origin from an accessory internal pudendal artery was the most common among the rare origins of type V. Regarding the second part of the study (a subgroup of 101 patients selected to facilitate comparisons between the different types of PA origin), type I was associated with significantly more incidences of failed or difficult catheterization of the PA compared to all other types combined (27/64 vs. 18/138, p < 0.001). Types III, IV, and V showed a relatively low degree of technical difficulty. Patients with type I PA origin of at least one pelvic side (subgroup (I), n = 48) had significantly longer FT and DAP compared to the rest (subgroup (O), n = 53). Clinical success rates of PAE were slightly lower for the subgroup (I), although the difference was not statistically significant (75.8% vs. 83.8% at 18 months post-PAE, p = 0.137). No major complications were observed. Conclusions This is the first study of PA origin in Greece. It was demonstrated that types I and IV of PA origin were the most common and had the same prevalence. Type I showed significantly higher technical difficulty compared to the others, but had no significant impact on the clinical outcomes of PAE.

Segmental microbleeds: a radiological sign for cranial dural arteriovenous fistula

A 57-year-old man presented to the emergency department following a road traffic accident, having experienced a sudden ascending 'wave of emotion'. After the event, he developed an intense right-sided temporal headache and was thought to have a complex grief reaction resulting from a recent bereavement. Given persistent symptoms, a computed tomography (CT) scan of head was conducted at an outpatient transient ischaemic attack (TIA) clinic, which showed a possible right occipital infarct. Further magnetic resonance imaging (MRI) scanning revealed instead a segmental area of microbleeds in the posterior right temporal lobe, with occipital extension. Upon discussion at the neuroradiology multidisciplinary team meeting and subsequent digital subtraction angiography (DSA), a cranial dural arteriovenous fistula (DAVF) was confirmed. He underwent a successful embolisation, with his symptoms fully resolving 16 months later.

Conjoined Pathways: Unraveling the Coexistence of Developmental Venous Anomaly With Arteriovenous Malformation

Developmental venous anomalies (DVAs) are intracranial vascular malformations typically characterized by their benign nature, often obviating the need for radiological follow-up. These anomalies arise from variations in the standard drainage pattern. While previously deemed congenital, there has been ongoing debate about a developmental component contributing to their etiology. They frequently coexist with other cerebral venous malformations (CVM); however, their association with arteriovenous malformations (AVM) is exceedingly rare. Such mixed malformations pose a therapeutic challenge, necessitating meticulous consideration for appropriate treatment. We present a noteworthy case involving a patient with arteriovenous malformation along with dual developmental venous anomalies, one of which served as the draining vein for the AVM.

Spontaneous Rectus Sheath Hematoma

Rectus sheath hematoma (RSH) is one of the surgical emergencies that mimics peritonitis or other causes of acute abdominal pain. It is usually seen in old age, post-trauma, anticoagulation therapy pregnancy, chronic cough, and liver disease. Nevertheless, RSHs can be spontaneous without any underlying predisposing factors. Here, we present a 51-year-old female with sudden onset abdominal pain, abdominal distention, hypotension, and severe pallor. After initial resuscitation, the patient underwent radiological imaging. This suggested an RSH with active bleeding from the inferior epigastric artery or profunda femoris artery. The patient underwent digital subtraction angiography and angioembolization of the profunda femoris branch. After a few days, the patient continued deteriorating and succumbed to acute respiratory distress syndrome (ARDS).

Preoperative Transcatheter Arterial Embolization for Spontaneous Rupture of Huge Amebic Liver Abscess with Massive Intraperitoneal Hemorrhage

An 18-year-old male developed a huge liver abscess with severe anemia over the course of 2 weeks. Abdominal contrast enhanced computed tomography showed ruptured huge liver abscess in the right liver lobe with signs of active hemorrhage (contrast extravasation). Serology examination confirmed amoeba as the suspected pathogen of cause. Angiography was performed followed by transcatheter arterial embolization to localize and control the hemorrhage. Embolization using a combination of polyvinyl alcohol and gelfoam successfully controlled the active hemorrhage. Exploratory laparotomy was performed to evacuate and debride the huge abscess. Metronidazole was given and showed good results. Huge liver abscess size is a predictor of conservative management failure and requires a gradual step-up intervention. The purpose of this paper is to explain the importance of imaging in detecting liver abscess and active hemorrhage along with the role of interventional radiology in this case.

Effects of RIPC on the Metabolomical Profile during Lower Limb Digital Subtraction Angiography: A Randomized Controlled Trial

Remote ischemic preconditioning (RIPC) has demonstrated protective effects in patients with lower extremity arterial disease (LEAD) undergoing digital subtraction angiography (DSA) and/or percutaneous transluminal angioplasty (PTA). This study aimed to investigate the impact of RIPC on the metabolomical profile of LEAD patients undergoing these procedures and to elucidate its potential underlying mechanisms. A total of 100 LEAD patients were enrolled and randomly assigned to either the RIPC group (n = 46) or the sham group (n = 54). Blood samples were drawn before and 24 h after intervention. Targeted metabolomics analysis was performed using the AbsoluteIDQ p180 Kit, and changes in metabolite concentrations were compared between the groups. The RIPC group demonstrated significantly different dynamics in nine metabolites compared to the sham group, which generally showed a decrease in metabolite concentrations. The impacted metabolites included glutamate, taurine, the arginine-dimethyl-amide-to-arginine ratio, lysoPC a C24:0, lysoPC a C28:0, lysoPC a C26:1, PC aa C38:1, PC ae C30:2, and PC ae C44:3. RIPC exhibited a 'stabilization' effect, maintaining metabolite levels amidst ischemia-reperfusion injuries, suggesting its role in enhancing metabolic control. This may improve outcomes for LEAD patients. However, additional studies are needed to definitively establish causal relationships among these metabolic changes.

DSA-Based 2D Perfusion Measurements in Delayed Cerebral Ischemia to Estimate the Clinical Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Technical Feasibility Study

(1) Background: To predict clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) and delayed cerebral ischemia (DCI) by assessment of the cerebral perfusion using a 2D perfusion angiography (2DPA) time-contrast agent (CA) concentration model. (2) Methods: Digital subtraction angiography (DSA) data sets of n = 26 subjects were acquired and post-processed focusing on changes in contrast density using a time-concentration model at three time points: (i) initial presentation with SAH (T0); (ii) vasospasm-associated acute clinical impairment (T1); and (iii) directly after endovascular treatment (T2) of SAH-associated large vessel vasospasm (LVV), which resulted in n = 78 data sets. Maximum slope (MS in SI/ms), time-to-peak (TTP in ms), and maximum amplitude of a CA bolus (dSI) were measured in brain parenchyma using regions of interest (ROIs). First, acquired parameters were standardized to the arterial input function (AIF) and then statistically analyzed as mean values. Additionally, data were clustered into two subsets consisting of patients with regredient or with stable/progredient symptoms (or Doppler signals) after endovascular treatment (n = 10 vs. n = 16). (3) Results: Perfusion parameters (MS, TTP, and dSI) differed significantly between T0 and T1 (p = 0.003 each). Significant changes between T1 and T2 were only detectable for MS (0.041 ± 0.016 vs. 0.059 ± 0.026; p = 0.011) in patients with regredient symptoms at T2 (0.04 ± 0.012 vs. 0.066 ± 0.031; p = 0.004). For dSI, there were significant differences between T0 and T2 (5095.8 ± 2541.9 vs. 3012.3 ± 968.3; p = 0.001), especially for those with stable symptoms at T2 (5685.4 ± 2967.2 vs. 3102.8 ± 1033.2; p = 0.02). Multiple linear regression analysis revealed that a) the difference in MS between T1 and T2 and b) patient's age (R = 0.6; R² = 0.34; p = 0.009) strongly predict the modified Rankin Scale (mRS) at discharge. (4) Conclusions: 2DPA allows the direct measurement of treatment effects in SAH associated DCI and may be used to predict outcomes in these critically ill patients.

Anterior inferior cerebellar artery occlusion accompanied by hemorheology-documented increased blood viscosity: a case report

Anterior inferior cerebellar artery (AICA) occlusion is a subtype of posterior circulation stroke. Confirmation of its angiomorphology and etiology is challenging because of the complex mechanisms underlying small-artery thrombogenesis. In addition to conventional factors, physicians frequently overlook hemorheological changes. In this case report, we describe right AICA occlusion in a 50-year-old man. He presented with an unsteady walk, tinnitus, dizziness, and left-sided peripheral facial palsy observed over 36 hours, accompanied by increased blood viscosity on hemorheological evaluation. Magnetic resonance imaging revealed acute infarction in the left cerebellar hemisphere and middle cerebellar peduncles. Magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) failed to detect AICA occlusion, which was later confirmed using digital subtraction angiography. Repeat routine blood examinations showed elevated erythrocyte and leukocyte counts and serum hemoglobin concentrations that persisted over many days. Hemorheological evaluation revealed increased whole blood viscosity at a low shear rate. AICA occlusion should thus be diagnosed based on its initial characteristic manifestations; notably, MRA and CTA may fail to detect arterial occlusion. The importance of hemorheological change as a factor of stroke is frequently neglected. We therefore report this case hoping to emphasize its relevance, especially in small-artery occlusion.

Evaluating a 3D deep learning pipeline for cerebral vessel and intracranial aneurysm segmentation from computed tomography angiography-digital subtraction angiography image pairs

OBJECTIVE

Computed tomography angiography (CTA) is the most widely used imaging modality for intracranial aneurysm (IA) management, yet it remains inferior to digital subtraction angiography (DSA) for IA detection, particularly of small IAs in the cavernous carotid region. The authors evaluated a deep learning pipeline for segmentation of vessels and IAs from CTA using coregistered, segmented DSA images as ground truth.

METHODS

Using 50 paired CTA-DSA images, the authors trained (n = 27), validated (n = 3), and tested (n = 20) a deep learning model (3D DeepMedic) for cerebrovasculature segmentation from CTA. A landmark-based coregistration algorithm was used for registration and upsampling of CTA images to paired DSA images. Segmented vessels from the DSA were used as the ground truth. Accuracy of the model for vessel segmentation was evaluated using conventional metrics (dice similarity coefficient [DSC]) and vessel segmentation-specific metrics, like connectivity-area-length (CAL). On the test cases (20 IAs), 3 expert raters attempted to detect and segment IAs. For each rater, the authors recorded the rate of IA detection, and for detected IAs, raters segmented and calculated important IA morphology parameters to quantify the differences in IA segmentation by raters to segmentations by DeepMedic. The agreement between raters, DeepMedic, and ground truth was assessed using Krippendorf's alpha.

RESULTS

In testing, the DeepMedic model yielded a CAL of 0.971 ± 0.007 and a DSC of 0.868 ± 0.008. The model prediction delineated all IAs and resulted in average error rates of < 10% for all IA morphometrics. Conversely, average IA detection accuracy by the raters was 0.653 (undetected IAs were present to a significantly greater degree on the ICA, likely due to those in the cavernous region, and were significantly smaller). Error rates for IA morphometrics in rater-segmented cases were significantly higher than in DeepMedic-segmented cases, particularly for neck (p = 0.003) and surface area (p = 0.04). For IA morphology, agreement between the raters was acceptable for most metrics, except for the undulation index (α = 0.36) and the nonsphericity index (α = 0.69). Agreement between DeepMedic and ground truth was consistently higher compared with that between expert raters and ground truth.

CONCLUSIONS

This CTA segmentation network (DeepMedic trained on DSA-segmented vessels) provides a high-fidelity solution for CTA vessel segmentation, particularly for vessels and IAs in the carotid cavernous region.

Accuracy of CT angiography for detecting ruptured intracranial aneurysms

Background

Digital subtraction angiography (DSA) is invasive, costly and unavailable in many South African hospitals; however, it remains the gold standard for imaging intracranial aneurysms. CT angiography (CTA) is a non-invasive and readily available screening tool prior to DSA.

Objectives

This study aimed to evaluate the diagnostic performance of CTA in detecting ruptured intracranial aneurysms using DSA as the reference standard and to determine the effect of aneurysm size and location on CTA sensitivity.

Method

A retrospective analysis of CTA and DSA data from reports of patients suspected to have aneurysmal subarachnoid haemorrhage (SAH) at Chris Hani Baragwanath Academic Hospital between January 2017 and June 2020.

Results

Conventional DSA detected aneurysms in 94 out of 115 patients; while of these, CTA detected 75 and missed 19. The CTA sensitivity, specificity and accuracy was 80%, 43% and 73%, respectively. The CTA sensitivity for aneurysms < 3 mm and 3 mm - 5 mm in size was 30% and 81.5%, respectively (p = 0.024). Sensitivity of CTA for posterior communicating artery (PComm) aneurysms was 56% and lower than other major anterior circulation locations (83% - 91%) (p = 0.045).

Conclusion

The CTA diagnostic efficiency was lower than previously reported, with even lower sensitivity for aneurysms < 3 mm and for those arising from the PComm. Thus, CTA should remain a screening tool prior to DSA in all local patients suspected to have aneurysmal SAH.

Contribution

Larger, prospective studies are required to accurately define the role of CTA in diagnosing intracranial aneurysms in a developing country with limited resources.

Towards quantitative digital subtraction perfusion angiography: An animal study

BACKGROUND

X-ray digital subtraction angiography (DSA) is the imaging modality for peri-procedural guidance and treatment evaluation in (neuro-) vascular interventions. Perfusion image construction from DSA, as a means of quantitatively depicting cerebral hemodynamics, has been shown feasible. However, the quantitative property of perfusion DSA has not been well studied.

PURPOSE

To comparatively study the independence of deconvolution-based perfusion DSA with respect to varying injection protocols, as well as its sensitivity to alterations in brain conditions.

METHODS

We developed a deconvolution-based algorithm to compute perfusion parametric images from DSA, including cerebral blood volume (CBV D S A $_{DSA}$ ), cerebral blood flow (CBF D S A $_{DSA}$ ), time to maximum (Tmax), and mean transit time (MTT D S A $_{DSA}$ ) and applied it to DSA sequences obtained from two swine models. We also extracted the time intensity curve (TIC)-derived parameters, that is, area under the curve (AUC), peak concentration of the curve, and the time to peak (TTP) from these sequences. Deconvolution-based parameters were quantitatively compared to TIC-derived parameters in terms of consistency upon variations in injection profile and time resolution of DSA, as well as sensitivity to alterations of cerebral condition.

RESULTS

Comparing to TIC-derived parameters, the standard deviation (SD) of deconvolution-based parameters (normalized with respect to the mean) are two to five times smaller, indicating that they are more consistent across different injection protocols and time resolutions. Upon ischemic stroke induced in a swine model, the sensitivities of deconvolution-based parameters are equal to, if not higher than, those of TIC-derived parameters.

CONCLUSIONS

In comparison to TIC-derived parameters, deconvolution-based perfusion imaging in DSA shows significantly higher quantitative reliability against variations in injection protocols across different time resolutions, and is sensitive to alterations in cerebral hemodynamics. The quantitative nature of perfusion angiography may allow for objective treatment assessment in neurovascular interventions.

A Case of Craniocervical Junction Arteriovenous Fistulas with a Brainstem Mass Lesion on Imaging: Case Report and Literature Review

Intracranial mass lesions occur within the cranial cavity, and their etiology is diverse. Although tumors and hemorrhagic diseases are the common causes, some rarer etiologies, such as vascular malformations, might also present with intracranial mass lesion manifestations. Such lesions are easily misdiagnosed due to the lack of manifestations of the primary disease. The treatment involves a detailed examination and differential diagnosis of the etiology and clinical manifestations. On 26 October 2022, a patient with craniocervical junction arteriovenous fistulas (CCJAVFs) was admitted to Nanjing Drum Tower Hospital. Imaging examinations showed a brainstem mass lesion, and the patient was initially diagnosed with a brainstem tumor. After a thorough preoperative discussion and a digital subtraction angiography (DSA) examination, the patient was diagnosed with CCJAVF. The patient was cured using interventional treatment, and an invasive craniotomy was not required. During diagnosis and treatment, the cause of the disease might not be apparent. Thus, a comprehensive preoperative examination is very important, and physicians need to conduct the diagnosis and differential diagnosis of the etiology based on the examination to administer precise treatment and reduce unnecessary operations.

Radiation Exposure Reduction by Digital Variance Angiography in Lower Limb Angiography: A Randomized Controlled Trial

BACKGROUND

digital variance angiography (DVA) provides higher image quality than digital subtraction angiography (DSA). This study investigates whether the quality reserve of DVA allows for radiation dose reduction during lower limb angiography (LLA), and compares the performance of two DVA algorithms.

METHODS

this prospective block-randomized controlled study enrolled 114 peripheral arterial disease patients undergoing LLA into normal dose (ND, 1.2 µGy/frame, n = 57) or low-dose (LD, 0.36 µGy/frame, n = 57) groups. DSA images were generated in both groups, DVA1 and DVA2 images were generated in the LD group. Total and DSA-related radiation dose area product (DAP) were analyzed. Image quality was assessed on a 5-grade Likert scale by six readers.

RESULTS

the total and DSA-related DAP were reduced by 38% and 61% in the LD group. The overall visual evaluation scores (median (IQR)) of LD-DSA (3.50 (1.17)) were significantly lower than the ND-DSA scores (3.83 (1.00), p < 0.001). There was no difference between ND-DSA and LD-DVA1 (3.83 (1.17)), but the LD-DVA2 scores were significantly higher (4.00 (0.83), p < 0.01). The difference between LD-DVA2 and LD-DVA1 was also significant (p < 0.001).

CONCLUSIONS

DVA significantly reduced the total and DSA-related radiation dose in LLA, without affecting the image quality. LD-DVA2 images outperformed LD-DVA1, therefore DVA2 might be especially beneficial in lower limb interventions.

A State-of-the-Art Review of Intra-Operative Imaging Modalities Used to Quality Assure Endovascular Aneurysm Repair

Endovascular aortic aneurysm repair (EVAR) is the preferred method for elective abdominal aortic aneurysm (AAA) repair. However, the success of this technique depends greatly on the technologies available. Intra-operative imaging is essential but can come with limitations. More complex interventions lead to longer operating times, fluoroscopy times, and greater contrast doses. A number of intra-operative imaging modalities to quality assure the success of EVAR have been developed. A systematic literature search was performed with separate searches conducted for each imaging modality in the study: computed tomography (CT), digital subtraction angiography (DSA), fusion, ultrasound, intra-operative positioning system (IOPS), and non-contrast imaging. CT was effective at detecting complications but commonly resulted in increased radiation and contrast dose. The effectiveness of DSA can be increased, and radiation exposure reduced, through the use of adjunctive technologies. We found that 2D-3D fusion was non-inferior to 3D-3D and led to reduced radiation and contrast dose. Non-contrast imaging occasionally led to higher doses of radiation. Ultrasound was particularly effective in the detection of type II endoleaks with reduced radiation and contrast use but was often operator dependent. Unfortunately, no papers made it past full text screening for IOPS. All of the imaging techniques discussed have advantages and disadvantages, and clinical context is relevant to guide imaging choice. Fusion and ultrasound in particular show promise for the future.

Clinical application of three-dimensional T1-weighted BrainVIEW in magnetic resonance imaging of cerebral venous thrombosis: a case report and literature review

To date, there is no clinical scoring system or laboratory indicator that can rule out cerebral venous thrombosis (CVT) or provide diagnostic proof for evaluating post-treatment thrombosis recanalization during follow-up. We therefore explored an imaging method for quantitative assessment of CVT and assessed thrombotic changes during follow-up. A patient presented with severe posterior occipital distension extending to the top of the forehead and an elevated plasma D-dimer (DD2) level. Computed tomography and pre-contrast-enhanced magnetic resonance imaging revealed only a small amount of cerebral hemorrhage. Three-dimensional (3D) T1-weighted (T1W) BrainVIEW pre-contrast-enhanced magnetic resonance scanning showed subacute thrombosis in the venous sinus, and the post-contrast-enhanced scan combined with volume rendering reconstruction showed cerebral thrombosis of the venous sinus and allowed for measurement of the thrombus volume. On days 30 and 60 of post-treatment follow-up, post-contrast-enhanced scans showed progressive reduction of the thrombus volume as well as recanalization and fibrotic flow voids in the chronic thrombosis. 3D T1W BrainVIEW was helpful to observe the size of the thrombi and the situation of venous sinus recanalization during the follow-up after clinical treatment of CVT. This technique can reflect the imaging manifestations of CVT throughout the whole process to guide clinical treatment decisions.

Systematic Review of Morphometric Analysis of Anterior Cerebral Artery (ACA) Emphasizing on Its Clinical Implications

Thorough data of morphometric measurements of arteries forming Circle of Willis (CW) is crucial for radiological and neurosurgical interventions. This systematic review has been conducted with the objective to find an effective range of length and diameter of anterior cerebral artery (ACA) and to observe whether there is any change in the length and diameter of ACA depending on age or sex. Articles based on length and diameter of ACA via any mode of study like cadaveric or radiological were considered in this systematic review. A comprehensive literature search using databases Cochrane Library, PubMed, and Scopus for relevant articles was done. Research papers which answered the focused questions were selected for data analysis. It was observed that the range of length and diameter of ACA were 8.1 mm-21 mm and 0.5 Å-3.4 mm, respectively. In majority of the studies, length and diameter of ACA were more in the younger age group (>40 years); and the length of ACA was more in females whereas the diameter of ACA was more in males. These data will be applicable for better construction and decipherment of angiographic images. This will help in the proper and guided treatment of intracranial pathologies.

The Clinical Impact of Recent Methamphetamine Exposure in Aneurysmal Subarachnoid Patients

Background

Methamphetamines (MA) are a frequently used drug class with potent sympathomimetic properties that can affect cerebral vasculature. Conflicting reports in literature exist about the effect of exposure to MA on vasospasm risk and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to characterize the impact of recent MA use on the timing, severity and features of vasospasm in aneurysmal subarachnoid as well as neurological outcomes.

Methods

We retrospectively screened 441 consecutive patients admitted to a tertiary care hospital with a diagnosis of SAH who underwent at least one cerebral digital subtraction angiogram (DSA). Patients were excluded if no urinary toxicology screen was performed within 24 hours of admission, if there was a diagnosis of non-aneurysmal SAH, or if ictus was greater than 72 hours from hospital admission. Vasospasm characteristics were collected from DSA and transcranial doppler (TCD) studies and demographic as well as clinical outcome data was abstracted from the chart.

Results

129 patients were included and 24 tested positive for MA. Among the 312 excluded patients, 281 did not have a urinary toxicology screen and 31 had a non-aneurysmal pattern of SAH or ictus occurring greater than 72 hours from hospital admission. No significant differences were found in respect to patient age, sex, or admission Hunt and Hess Score or Modified Fisher Scale based on MA use. There was no difference in the severity of vasospasm or time to peak severity using either TCD or DSA criteria on multivariate analysis. Aneurysms were more likely to be in the anterior circulation for both groups, however the MA cohort experienced less vasospasm involving the anterior circulation and more isolated posterior circulation vasospasm. There was no difference in delayed cerebral ischemia (DCI) incidence, length of ICU stay, need for ventriculoperitoneal shunt placement, functional outcome at discharge or hospital mortality.

Interpretation

Recent MA use was not associated with worse vasospasm severity, time to vasospasm, or DCI in aSAH patients. Further investigations about localized MA effects in the posterior circulation and impact on long-term functional outcomes are warranted.

StemRad MD, An Exoskeleton-Based Radiation Protection System, Reduces Ergonomic Posture Risk Based on a Prospective Observational Study

OBJECTIVE

Poor ergonomic posture during interventional procedures might lead to increased physical discomfort and work-related musculoskeletal disorders. Adjunctive equipment such as lead aprons (LAs) has been shown to increase ergonomic posture risk (EPR). The objective of this study was to evaluate the effectiveness of StemRad MD (StemRad Ltd., Tel Aviv, Israel), a weightless exoskeleton-based radiation protective ensemble, in reducing EPR on the operator using wearable inertial measurement unit (IMU) sensors.

METHODS

A prospective, observational study was conducted at an academic hospital. Inertial measurement unit sensors were affixed to the upper back of 9 interventionalists to assess ergonomic risk posture during endovascular procedures while wearing a traditional LA or the StemRad MD radiation protection system. Total fluoroscopy time, procedure type, and ergonomic risk postures were recorded and analyzed.

RESULTS

Twenty-one cases were performed with StemRad MD and 30 with LAs. Mean procedure time for the StemRad MD procedures was 48.4±23.3 minutes (range: 24-106 min), and for LA procedures, it was 34.66±25.83 minutes (range: 6-100 min) (p=.060). The operators assumed low-risk ergonomic positions in 96.1% of StemRad MD cases and in 62.9% of LA cases (p=.001), and high-risk ergonomic positions in 0% and 6.2%, respectively (p=.80). Mean EPR score for StemRad MD was 1.16, and for the LA, it was 1.49 (p=.001).

CONCLUSIONS

StemRad MD significantly reduces the EPR to the torso compared with a LA-based radiation protection system.

CLINICAL IMPACT

Poor ergonomic posture during interventional procedures might leas to work-related musculoskeletal disorders for healthcare workers. StemRad MD, a weightless, exoskeleton-based radiation protection system was shown to significantly reduce ergonomic posture risk to the torso compared to conventional lead aprons. This might lead to reduced physical discomfort for procedure-based specialists.

Guiding atrial fibrillation ablation combined with left atrial appendage occlusion procedure by fluoroscopy with or without transesophageal echocardiography achieved comparable outcomes

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and can be treated with catheter ablation (CA) combined with left atrial appendage occlusion (LAAO). The study is designed to compare the safety and efficacy of guiding the combined procedure by digital subtraction angiography (DSA) with or without transesophageal echocardiography (TEE).

METHODS

From February 2019 to December 2020, 138 patients with nonvalvular AF who underwent CA combined with LAAO procedure were consecutively included, and two cohorts were built according to intraprocedural guidance (DSA or DSA with TEE). Periprocedural and follow-up outcomes were compared with investigate the feasibility and safety between the two cohorts.

RESULTS

71 patients and 67 patients were included in the DSA cohort and TEE cohort, respectively. Age and gender were comparable, despite the TEE cohort having a higher proportion of persistent AF (37 [55.2%] vs. 26 [36.6%]) and hemorrhage history (9 [13.4%] vs. 0). The procedure time of the DSA cohort was significantly reduced (95.7 ± 27.6 vs. 108.9 ± 30.3 min, p = .018), with a nonsignificant longer fluoroscopic time (15.2 ± 5.4 vs. 14.4 ± 7.1 min, p = .074). And the overall incidence of peri-procedural complications was similar between cohorts. After an average of 24 months of clinical follow-up, only three patients in the TEE cohort had ≤3 mm residual flow (p = .62). Kaplan-Meier estimates showed nonsignificant differences between the cohorts for freedom from atrial arrhythmia (log-rank p = .964) and major adverse cardiovascular events (log-rank p = .502).

CONCLUSIONS

Compared with DSA and TEE guidance, DSA-guided combined procedure could shorten the procedural time, while achieving similar periprocedural and long-term feasibility and safety.

Renal pseudoaneurysm after holmium laser lithotripsy with flexible ureteroscopy: an unusual case report and literature review

Pseudoaneurysms of the renal arteries are caused by focal rupture or perforation of the arterial wall, resulting in local bleeding. Such pseudoaneurysms can be observed in conditions such as nodular polyarteritis, penetrating or closed renal injury, and medically induced injuries (such as renal puncture biopsy, percutaneous nephrostomy, or partial nephrectomy). Flexible ureteroscopy (FURS) is performed entirely through the urethra to prevent potentially severe kidney damage. Because of this, almost no renal parenchymal hemorrhage occurs after FURS laser lithotripsy. Only four cases had been documented in the literature as of December 2022. In this report, we describe a 53-year-old man with a history of recurrent kidney stones who underwent FURS laser lithotripsy for bilateral kidney stones. The procedure was smoothly performed, and no active bleeding occurred. However, the patient developed recurrent macroscopic hematuria after discharge from the hospital, and renal angiography revealed a pseudoaneurysm in the distal right kidney. The pseudoaneurysm was treated with selective arterial embolization. Serious complications of FURS surgery are rare, particularly the formation of pseudoaneurysms. We report the present case to bring this potential complication to the attention of urologists.

Comparison of image quality assessments between interventional radiographers and interventional radiologists using digital subtraction angiography

Purpose

The aim of our study was to compare the image quality assessments of vascular anatomy between interventional radiographers and interventional radiologists using digital subtraction angiography (DSA) runs acquired during an interventional radiology procedure.

Approach

Visual grading characteristics (VGC) analysis was used to assess image quality by comparing two groups of images, where one group consisted of procedures in which radiation dose was optimized (group A, n = 10 ) and one group where dose optimization was not performed (group B, n = 10 ). The radiation dose parameters were optimized based on theoretical and empirical evidence to achieve radiation dose reductions during uterine artery embolization procedures. The two observer groups comprised of interventional radiologists ( n = 4 ) and interventional radiographers ( n = 4 ). Each observer rated the image quality of 20 DSA runs using a five-point rating scale.

Results

The VGC analysis produced an area under the VGC curve (AUC VGC ) of 0.55 for interventional radiographers ( P = 0.61 ) and AUCVGC of 0.52 for interventional radiologists ( P = 0.83 ). The optimization of radiation dose parameters demonstrated a reduction in kerma-area product by 35% ( P = 0.026 , d = 0.5 ) and reference air kerma (Ka, r ) by 43% ( P = 0.042 , d = 0.5 ) between group A and group B.

Conclusions

VGC analysis indicated that the image quality assessments of interventional radiographers were comparable with interventional radiologists, where a reduction in radiation dose revealed no effect on both observer groups regarding their image quality assessment of vascular anatomy.

Poor inter-observer agreement in anatomical classifications of infrapopliteal arterial disease due to mandatory selection of only one target artery

BACKGROUND

Established anatomical classifications of infrapopliteal arterial lesion severity are based on assessment of only one target artery, not including all infrapopliteal arteries although multivessel revascularization is common.

PURPOSE

To investigate the reproducibility of one of these classifications and a new aggregated score.

MATERIAL AND METHODS

A total of 68 patients undergoing endovascular infrapopliteal revascularization at Sahlgrenska University Hospital during 2008-2016 were included. Preoperative magnetic resonance angiographies (MRA) and digital subtraction angiographies (DSA) were evaluated by three blinded observers in random order, using the infrapopliteal TransAtlantic Inter-Society Consensus (TASC) II classification. An aggregated score, the Infrapopliteal Total Atherosclerotic Burden (I-TAB) score, including all infrapopliteal arteries, was constructed and used for comparison.

RESULTS

Inter-observer agreement on lesion severity for each evaluated artery was good; Krippendorff's α for MRA 0.64-0.79 and DSA 0.66-0.84. Inter-observer agreement on TASC II grade, based on the selected target artery as stipulated, was poor; Krippendorff's α 0.14 (95% confidence interval [CI]=-0.05 to 0.30) for MRA and 0.48 (95% CI=0.33-0.61) for DSA. Inter-observer agreement for the new I-TAB score was good; Krippendorff's α 0.76 (95% CI=0.70-0.81) for MRA and 0.79 (95% CI=0.74-0.84) for DSA.

CONCLUSION

Reproducible assessment of infrapopliteal lesion severity can be achieved for separate arteries with both MRA and DSA using the TASC II definitions. However, poor inter-observer agreement in selecting the target artery results in low reproducibility of the overall infrapopliteal TASC II grade. An aggregated score, such as I-TAB, results in less variability and may provide a more robust evaluation tool of atherosclerotic disease severity.

Transcatheter arterial embolization of the common hepatic artery for pseudoaneurysm after a laparoscopic-assisted pancreaticoduodenectomy: A case report

Common hepatic artery pseudoaneurysm is a rare and potentially life-threatening complication after pancreaticoduodenectomy, and the possible cause is unclear. We report a case of intraperitoneal hemorrhage after pancreaticoduodenectomy who was discharged after embolization under digital subtraction angiography. We conside that this complication may be related to iatrogenic injury.

Diagnostic performance of dynamic 3D magnetic resonance angiography in daily practice for the detection of intracranial arteriovenous shunts in patients with non-traumatic intracranial hemorrhage

Introduction

Identification of treatable causes of intracranial hemorrhage (ICH) such as intracranial arteriovenous shunt is crucial to prevent recurrence. However, diagnostic approaches vary considerably across centers, partly because of limited knowledge of the diagnostic performance of first-line vascular imaging techniques. We assessed the diagnostic performance of dynamic three-dimensional magnetic resonance angiography (dynamic 3D MRA) in daily practice to detect intracranial arteriovenous shunts in ICH patients against subsequent digital subtraction angiography (DSA) as reference standard.

Methods

We reviewed all adult patients who underwent first-line dynamic 3D MRA and subsequent DSA for non-traumatic ICH between January 2016 and September 2021 in a tertiary center. Sensitivity, specificity, accuracy, positive and negative predictive values of dynamic 3D MRA for the detection of intracranial arteriovenous shunt were calculated with DSA as reference standard.

Results

Among 104 included patients, 29 (27.9%) had a DSA-confirmed arteriovenous shunt [19 pial arteriovenous malformations, 10 dural arteriovenous fistulae; median onset-to-DSA: 17 (IQR: 3-88) days]. The sensitivity and specificity of dynamic 3D MRA [median onset-to-dynamic 3D MRA: 14 (3-101) h] for the detection of intracranial arteriovenous shunt were 66% (95% CI: 48-83) and 91% (95% CI: 84-97), respectively. The corresponding accuracy, positive and negative predictive values were 84% (95% CI: 77-91), 73% (95% CI: 56-90), and 87% (95% CI: 80-95), respectively.

Conclusion

This study suggests that although first-line evaluation with dynamic 3D MRA may be helpful for the detection of intracranial arteriovenous shunts in patients with ICH, additional vascular imaging work-up should not be withheld if dynamic 3D MRA is negative. Comparative prospective studies are needed to determine the best imaging strategy to diagnose arteriovenous shunts after non-traumatic ICH.

Diagnostic yield of cerebral angiography for intracranial hemorrhage in young patients: A single-center retrospective analysis

BACKGROUND

Intracranial hemorrhage (ICH) secondary to hypertension (HTN) classically occurs in the basal ganglia, cerebellum, or pons. Vascular lesions such as aneurysms or arteriovenous malformations (AVMs) are more common in younger patients. We investigated the utility of diagnostic subtraction angiography (DSA) in young hypertensive patients with non-lobar ICH.

METHODS

A retrospective review (2013-2022) identified young (18-60 years) patients who underwent DSA for ICH. HTN history, ICH location, presence/absence of subarachnoid hemorrhage (SAH), and computed tomography angiography (CTA) findings were collected. The main outcome was DSA-positivity, defined as presence of an AVM, aneurysm, Moyamoya disease, reversible cerebral vasoconstriction syndrome, or dural arteriovenous fistula on DSA.

RESULTS

Two hundred sixty patients were included, and the DSA-positivity rate was 19%.DSA-positivity was lower in hypertensive patients with ICHs in the cerebellum, pons, or basal ganglia compared to the rest of the patient sample (9% vs 26%, p = 0.0002, Fisher's exact test). We developed the ICH-Angio score (0-5 points) based on CTA findings, ICH location, HTN history, and presence of SAH to predict risk of underlying vascular lesions. DSA-positivity was lower in those with a score of 0 (0/62; 0%) compared to a score of 1 (5/52; 10%), 2 (17/48; 35%), 3 (10/20; 50%), 4 (5/6; 83%), or 5 (3/3; 100%).

CONCLUSION

The ICH-Angio score was able to non-invasively rule out an underlying vascular etiology for ICH in up to one-third of patients. HTN, ICH location, CTA findings, and associated SAH can identify patients at low risk for harboring underlying vascular lesions.

Digital Subtraction Angiography-Guided Percutaneous Kyphoplasty in Treatment of Multi-Segmental Osteoporotic Vertebral Compression Fracture: A retrospective single-Center study

Purpose

This study aimed to explore the effectiveness and safety of digital subtractionangiography (DSA)-guided percutaneous kyphoplasty (PKP) in treating multi-segmental osteoporotic vertebral compression fracture (OVCF).

Methods

We retrospectively reviewed 68 patients with multi-segmental OVCF who had unilateral PKP surgeries using DSA and C arm guiding at our hospital between October 2016 and June 2020 and were followed for at least two years. All patients were divided into two groups: DSA guidance (n = 31) and C-arm guidance (n=37). In addition, we collected the clinical and radiological evaluation results during postoperative and last follow-up periods.

Results

Our findings revealed that the DSA guidance group required lesser time for channel establishment and surgery than the C-arm guidance group at P < 0.05. The incidences of bone cement leakage, fluoroscopy times, and radiation dose of the DSA guidance group were significantly lesser than the C-arm guidance group (P < 0.05). Compared to the C-arm guidance group, the deviation of puncture in the DSA guidance group was significantly lower, the puncture angle in the DSA guidance group was significantly larger, and better bone cement distribution was obtained (P < 0.05). Compared to preoperative data, the VAS score, median vertebral height, and Cobb angle were significantly improved one day after surgery and the final follow-up in both groups (P < 0.05). However, the VAS score, the median vertebral height, average length of stay, and Cobb angle were not significantly different between the two groups (P > 0.05).

Conclusion

DSA-guided PKP in treating multi-segmental OVCF can shorten the operation time, improve puncture accuracy, reduce the times and dose of fluoroscopy, reduce the leakage of bone cement, and achieve better cement distribution.

Treatment of abdominal aortic pseudoaneurysm caused by brucellosis with endovascular aneurysm repair

Peripheral vascular disease caused by brucellosis is rarely seen around the world; thus, it is easily ignored by patients and doctors, leading to a lack of corresponding screening and delayed comprehensive treatment. Currently, there is no standard or guideline for diagnosing and treating peripheral arterial disease caused by brucellosis. From June 2021 to December 2022, four cases of abdominal aortic pseudoaneurysm caused by brucellosis disease were treated with endovascular aneurysm repair This study reported treatment results as follows and reviewed the incidence, treatment, and prognosis of abdominal aortic pseudoaneurysm caused by brucellosis.

Use of PETRA-MRA to assess intracranial arterial stenosis: Comparison with TOF-MRA, CTA, and DSA

Background and purpose

Non-invasive and accurate assessment of intracranial arterial stenosis (ICAS) is important for the evaluation of intracranial atherosclerotic disease. This study aimed to evaluate the performance of 3D pointwise encoding time reduction magnetic resonance angiography (PETRA-MRA) and compare its performance with that of 3D time-of-flight (TOF) MRA and computed tomography angiography (CTA), using digital subtraction angiography (DSA) as the reference standard in measuring the degree of stenosis and lesion length.

Materials and methods

This single-center, prospective study included a total of 52 patients (mean age 57 ± 11 years, 27 men, 25 women) with 90 intracranial arterial stenoses who underwent PETRA-MRA, TOF-MRA, CTA, and DSA within 1 month. The degree of stenosis and lesion length were measured independently by two radiologists on these four datasets. The degree of stenosis was classified according to DSA measurement. Severe stenosis was defined as a single lesion with >70% diameter stenosis. The smaller artery stenosis referred to the stenosis, which occurred at the anterior cerebral artery, middle cerebral artery, and posterior cerebral artery, except for the first segment of them. The continuous variables were compared using paired t-test or Wilcoxon signed rank test. The intraclass correlation coefficients (ICCs) were used to assess the agreement between MRAs/CTA and DSA as well as inter-reader variabilities. The ICC value >0.80 indicated excellent agreement. The agreement of data was assessed further by Bland-Altman analysis and Spearman's correlation coefficients. When the difference between MRAs/CTA and DSA was statistically significant in the degree of stenosis, the measurement of MRAs/CTA was larger than that of DSA, which referred to the overestimation of MRAs/CTA for the degree of stenosis.

Results

The four imaging methods exhibited excellent inter-reader agreement [intraclass correlation coefficients (ICCs) > 0.80]. PETRA-MRA was more consistent with DSA than with TOF-MRA and CTA in measuring the degree of stenosis (ICC = 0.94 vs. 0.79 and 0.89) and lesion length (ICC = 0.99 vs. 0.97 and 0.73). PETRA-MRA obtained the highest specificity and positive predictive value (PPV) than TOF-MRA and CTA for detecting stenosis of >50% and stenosis of >75%. TOF-MRA and CTA overestimated considerably the degree of stenosis compared with DSA (63.0% ± 15.8% and 61.0% ± 18.6% vs. 54.0% ± 18.6%, P < 0.01, respectively), whereas PETRA-MRA did not overestimate (P = 0.13). The degree of stenosis acquired on PETRA-MRA was also more consistent with that on DSA than with that on TOF-MRA and CTA in severe stenosis (ICC = 0.78 vs. 0.30 and 0.57) and smaller artery stenosis (ICC = 0.95 vs. 0.70 and 0.80). In anterior artery circulation stenosis, PETRA-MRA also achieved a little bigger ICC than TOF-MRA and CTA in measuring the degree of stenosis (0.93 vs. 0.78 and 0.88). In posterior artery circulation stenosis, PETRA-MRA had a bigger ICC than TOF-MRA (0.94 vs. 0.71) and a comparable ICC to CTA (0.94 vs. 0.91) in measuring the degree of stenosis.

Conclusion

PETRA-MRA is more accurate than TOF-MRA and CTA for the evaluation of intracranial stenosis and lesion length when using DSA as a reference standard. PETRA-MRA is a promising non-invasive tool for ICAS assessment.