Abstract WP65: Clinical and Radiographic Characterization of Cerebral Hyperdensities on Post-thrombectomy Conventional Non-contrast Ct Brain: Differentiating Between Contrast Staining and Post-thrombectomy Hemorrhage

Background: Post-interventional cerebral hyperdensities (PCHD) are present 31.2 to 87.5% of the time on post-thrombectomy (PT) CT. It can be difficult for radiologists to differentiate if PCHD represents intracerebral hemorrhage (ICH) or contrast staining using conventional CT. The ability to accurately determine the etiology of PCHD may be important for a patient’s outcome.

Methods: We retrospectively investigated clinical risk factors, imaging findings, and interventional technique of patients who had a thrombectomy from 2011-2017 (n=238) at a Comprehensive Stroke Center. 112 patients with anterior circulation infarcts and immediate PT CTs as well as either a PT MRI or follow-up CT within 48 hours were included. Two experienced neuroradiologists interpreted all imaging. Baseline demographics and imaging characteristics were collected. The presence of ICH was determined by dephasing on gradient echo or by its persistence > 2 days on repeat CT. Chi-square and Fisher’s exact tests were used for statistical significance, and logistic regression to determine risk estimates.

Results: 84% of patients had PCHD, of which 56% had ICH. Patients had similar demographics (ICH: median age 69, 47.5% female; non-ICH: median age 71, 42.5% female). Higher pre-thrombectomy ASPECTS score (OR 0.62, p < 0.05) decreased the risk of ICH, and higher Hounsfield units (HU) of PCHD both on immediate (OR 1.04, p < 0.05) and intermediate (OR 1.1, p < 0.0005) PT CT increased the risk of ICH. PCHDs in the deep grey matter (OR 2.84, p < 0.05) and demonstrating a confluent pattern (OR 3.9 p < 0.05) increased the likelihood of ICH. 10% increase risk of ICH was seen for every HU increase in density on PT CT at 24 or 48 hours. A 50% decrease in ICH was observed for each unit increase of the pre-thrombectomy ASPECTS score. ROC revealed the optimal cut-off for predicted probability as 0.64, sensitivity 70.2% and specificity 69.2%. The AUC for the predicted model was 0.84 (95%CI= (0.75- 0.92, p <0.0001).

Conclusion: Several imaging characteristics of PCHDs and ASPECTS score can help differentiate between the PT ICH and contrast staining. Application of these variables to patients in the immediate PT period may change clinical management.

Metastatic meningioma: Case report of a WHO grade I meningioma with liver metastases and review of the literature

Meningioma represents the most frequently diagnosed primary brain tumor, accounting for over one-third of central nervous system neoplasms. The majority of tumors are categorized as benign. However, albeit rarely, meningiomas may metastasize to distant sites. We describe a 78-year-old man with a history of recurrent World Health Organization grade I meningioma managed who presented for evaluation of weakness and urinary retention. A computed tomography scan obtained in the emergency department revealed multiple scattered low-density liver lesions. Subsequent magnetic resonance imaging showed a 5.5-centimeter heterogeneous enhancing mass with 2 smaller enhancing lesions suspicious for a primary or secondary malignant neoplasm. Microscopic examination of a tissue sample obtained via liver biopsy demonstrated a metastatic spindle cell neoplasm with histologic features compatible with a diagnosis of World Health Organization grade I transitional meningioma. The patient was referred to hematology/oncology for systemic therapy.

Low rates of osteoporosis treatment after hospitalization for hip fracture in Hawaii

We evaluated osteoporosis treatment and DEXA utilization rates of patients who were admitted for hip fracture in a single healthcare system in Hawaii from 2015 to 2016. We found that osteoporosis treatment and DEXA utilization rates were low, highlighting a critical gap in osteoporosis care after admission for hip fracture.

INTRODUCTION

The objective of this study was to evaluate osteoporosis care after an admission for hip fracture at three community hospitals within a single healthcare system in Hawaii.

METHODS

A retrospective chart review was conducted (n = 428) of patients ≥ 50 years and hospitalized for hip fractures between January 1, 2015, and May 31, 2016, at three major hospitals within Hawaii Pacific Health, a large healthcare system in Hawaii. Basic demographics were collected, and medications prescribed were quantified and described within 1 year of hip fracture. Logistic regression was used to evaluate the association between collected variables and the odds of osteoporosis treatment.

RESULTS

Only 115 (26.9%) patients were prescribed a medication for osteoporosis as a secondary prevention within a year of hospitalization for hip fracture. DEXA scans were performed in 137 (32.0%) patients. Most of the treated patients were prescribed oral bisphosphonates. Treatment facility, female gender, and higher BMI were found to be predictive factors for osteoporosis treatment.

CONCLUSION

The use of osteoporosis medication for secondary prevention after admission for hip fracture in Hawaii is low. Efforts need to be made to improve treatment rates, especially among males.

Flood Syndrome: Spontaneous Umbilical Hernia Rupture Leaking Ascitic Fluid-A Case Report

INTRODUCTION

We report a rare case of Flood syndrome, which is a spontaneous rupture of an umbilical hernia.

CASE PRESENTATION

A 42-year-old man with decompensated hepatitis C and alcoholic cirrhosis complicated by ascites and esophageal varices presented with 1 day of ascitic fluid drainage after rupture of a preexisting umbilical hernia associated with diffuse abdominal pain and tenderness. A pigtail drain was placed in the right upper abdominal quadrant to decrease fluid drainage from the abdominal wall defect, allowing it to heal naturally.

DISCUSSION

The spontaneous rupture of an umbilical hernia in our patient highlights a rare complication with high mortality rates and stresses the challenge of treatment that falls in the area between medical and surgical management.

Pemphigus vulgaris with tense bullae

We report a case of a 51-year-old woman with a history of type II diabetes mellitus and dyslipidemia presenting with pain, swelling, and crusting of the lips. One year after onset of mucosal lesions, she developed an abdominal eruption with several tense vesicles and bullae on an erythematous base. The hematoxylin and eosin stain sample was consistent with a diagnosis of pemphigus vulgaris. The tense bullae of our patient highlight a rare phenotype of pemphigus vulgaris, which fits the mucocutaneous type because of involvement of the oral mucosa, with the exception of the findings of tense bullae.

Anomalous left coronary artery arising from the pulmonary artery

A 24-year-old female presented to her general practitioner with shortness of breath. She was referred for an echocardiogram, which demonstrated features suggestive of a right coronary artery fistula, and referred to our institute. We performed a contrast-enhanced, prospectively triggered cardiac CT angiogram, which demonstrated the primary and secondary features of anomalous left coronary artery arising from the pulmonary artery (ALCAPA), also known as the Bland-White-Garland syndrome, a rare congenital abnormality of the origin of the left main coronary artery.

Expanding the diversity of mycobacteriophages: insights into genome architecture and evolution

Mycobacteriophages are viruses that infect mycobacterial hosts such as Mycobacterium smegmatis and Mycobacterium tuberculosis. All mycobacteriophages characterized to date are dsDNA tailed phages, and have either siphoviral or myoviral morphotypes. However, their genetic diversity is considerable, and although sixty-two genomes have been sequenced and comparatively analyzed, these likely represent only a small portion of the diversity of the mycobacteriophage population at large. Here we report the isolation, sequencing and comparative genomic analysis of 18 new mycobacteriophages isolated from geographically distinct locations within the United States. Although no clear correlation between location and genome type can be discerned, these genomes expand our knowledge of mycobacteriophage diversity and enhance our understanding of the roles of mobile elements in viral evolution. Expansion of the number of mycobacteriophages grouped within Cluster A provides insights into the basis of immune specificity in these temperate phages, and we also describe a novel example of apparent immunity theft. The isolation and genomic analysis of bacteriophages by freshman college students provides an example of an authentic research experience for novice scientists.

Breast MRI in the evaluation of locally recurrent or new breast cancer in the postoperative patient: correlation of morphology and enhancement features with the BI-RADS category

BACKGROUND

While breast magnetic resonance imaging (MRI) is a highly sensitive test for detecting breast carcinoma, its specificity is lower, and several methods have been described on how to optimize specificity.

PURPOSE

To compare the specificity and sensitivity of the BI-RADS category with the Fischer score in breast MRI for diagnosing cancer in women previously treated for breast cancer.

MATERIAL AND METHODS

Women referred for evaluation of possible local recurrence or new breast cancer underwent breast MRI examination. Morphologic and kinetic enhancement characteristics were evaluated. BI-RADS category and Fischer score were assigned for each enhancing lesion and compared using a chi-square test. Sensitivity, specificity,and positive predictive values for 27 morphologic and enhancement characteristics were calculated. Pathologic diagnosis was obtained in all patients with enhancing lesions who had ultrasound or mammographic correlation. In those without correlate, 6-, 12-, and 24-month follow-up breast MRIs were obtained. Interobserver kappa correlation was determined for each variable studied.

RESULTS

34 benign and 32 malignant lesions were identified in 26 of 30 patients. BIRADS category yielded a specificity of 77.1% and a sensitivity of 81.8%. Fischer score had a lower specificity and sensitivity (62.9% and 72.7%, respectively) (P<0.0001). Of the 27 variables studied, >100% enhancement was more sensitive than BI-RADS for malignant lesions. Specificity was highest for rim enhancement (97.1%), but sensitivity was low (24.2%). Interobserver kappa correlation was good for all 27 characteristics(k=0.84), and highest for BI-RADS assessment (k=0.91).

CONCLUSION

BI-RADS category in breast MRI had the highest combination of specificity and sensitivity, and the highest interobserver correlation. Fischer score and other morphologic and enhancement features lack sensitivity or specificity and do not have high positive predictive values when analyzed as single independent variables.