Publications

BACKGROUND: The prevalence of unruptured intracranial aneurysms (UIA) in females who smoke cigarettes and the association between smoking and hypertension with purely incidental UIAs have been unexplored.

OBJECTIVE: To obtain the prevalence of UIA among females and to assess the relationship between smoking and hypertension with a diagnosis of incidental UIAs.

METHODS: A nested case-control study from a cohort of female patients aged between 30 and 60 yr with a brain magnetic resonance angiography (MRA) between 2016 and 2018. Incidental UIAs were compared to patients with normal MRAs. Smoking was characterized as never or former/current smokers. A logistic regression was used to evaluate the association between smoking, hypertension, or both, with a diagnosis of incidental UIAs.

RESULTS: A total of 1977 patients had a brain MRA between 2016 and 2018. From 1572 nonsmoker patients, we encountered 30 with an UIA (prevalence: 1.9%). There were 405 patients with a positive smoking history, and 77 patients harbored an UIA (prevalence: 19%). Of 64 aneurysm patients and 130 random controls eligible for the case control, aneurysm patients were more likely to have a positive smoking history and hypertension compared with healthy controls (60% vs 18%, P ≤ .001; 44% vs 14%, P ≤ .001). A multivariable analysis demonstrated a significant association between a smoking history, hypertension, or both factors with an incidental UIA (odds ratio [OR] 5.8 CI 1.22-11.70; OR 3.8 CI 2.31-14.78; OR 12.6 CI 4.38-36.26; respectively).

CONCLUSION: Females who smoke cigarettes have a higher prevalence of UIAs than the general population. Smoking confers a higher risk for having a silent UIA, aggravated by hypertension. This population is an ideal target for potential screening.

The diagnosis of coronavirus disease 2019 (COVID-19) is confirmed by reverse transcription polymerase chain reaction. The utility of chest radiography (CXR) remains an evolving topic of discussion. Current reports of CXR findings related to COVID-19 contain varied terminology as well as various assessments of its sensitivity and specificity. This can lead to a misunderstanding of CXR reports and makes comparison between examinations and research studies challenging. With this need for consistency, we propose language for standardized CXR reporting and severity assessment of persons under investigation for having COVID-19, patients with a confirmed diagnosis of COVID-19, and patients who may have radiographic findings typical or suggestive of COVID-19 when the diagnosis is not suspected clinically. We recommend contacting the referring providers to discuss the likelihood of viral infection when typical or indeterminate features of COVID-19 pneumonia on CXR are present as an incidental finding. In addition, we summarize the currently available literature related to the use of CXR for COVID-19 and discuss the evolving techniques of obtaining CXR in COVID-19-positive patients. The recently published expert consensus statement on reporting chest computed tomography findings related to COVID-19, endorsed by the Radiological Society of North American (RSNA), the Society of Thoracic Radiology (STR), and American College of Radiology (ACR), serves as the framework for our proposal.

OBJECTIVE: To evaluate the diagnostic accuracy of split-bolus single-scan computed tomography angiography (CTA) protocol for evaluation of acute mesenteric ischemia and alternate diagnoses.

MATERIALS AND METHODS: In this IRB-approved, HIPAA-compliant retrospective study, consecutive patients from 21 October 2016 to 6 May 2018 evaluated for mesenteric ischemia with split-bolus CTA (a single scan in concurrent arterial and portal venous phase) in a single tertiary academic institution were included. Intravenous contrast was administered on weight-based basis. Quantitative and qualitative assessments of superior mesenteric artery (SMA) and superior mesenteric vein (SMV) attenuation and patency were performed by two independent reviewers. CT imaging findings were correlated with clinical reference outcomes.

RESULTS: One hundred fifty-four patients (age 66.3 ± 14.1 years, BMI 27.3 ± 6, 86 (56%) female) were included. CTA studies were performed with a volumetric CT dose index of 15.9 ± 5.5 mSv and dose length product of 1042.9 ± 389.4 mGy cm. Average intravenous contrast volume administered was 164.3 ± 12.1 cc. SMA attenuation was 263.6 ± 92.4HU, SMV was 190 ± 50.2HU. Qualitative assessment of SMA and SMV showed good opacification in all patients. 17/154 (11%) patients were diagnosed on CT with mesenteric ischemia; in 6/154 (4%), CTA studies were indeterminate; in 131/154 (85%), CTA confidently ruled out mesenteric ischemia. Alternate diagnoses were made in 38/154 (25%) patients. Using composite clinical outcomes as a reference standard, sensitivity of split-bolus CTA protocol for diagnosis of mesenteric ischemia is 100% (95% CI 79-100%), and specificity is 99% (95% CI 96-100%).

CONCLUSIONS: Split-bolus CTA has high sensitivity and specificity for diagnosis of acute mesenteric ischemia.

KEY POINTS: • Split-bolus CTA protocol for mesenteric ischemia has great diagnostic accuracy with lower radiation exposure and fewer images to interpret compared with standard multiphasic CTA.

OBJECTIVES: To evaluate the impact of patient positioning during CT-guided lung biopsy on patients' outcomes.

METHODS: In this retrospective, IRB-approved, HIPAA-compliant study, consecutive CT-guided lung biopsies performed on 5/1/2015-12/26/2017 were included. Correlation between incidence of pneumothorax, chest tube placement, pulmonary bleeding with patient, and procedure characteristics was evaluated. Lesion-trachea-table angle (LTTA) was defined as an angle between the lesion, trachea, and horizontal line parallel to the table. Lesion above trachea has a positive LTTA. Univariate and multivariate logistic regression analysis was performed.

RESULTS: A total of 423 biopsies in 409 patients (68 ± 11 years, 231/409, 56% female) were included in the study. Pneumothorax occurred in 83/423 (20%) biopsies with chest tube placed in 11/423 (3%) biopsies. Perilesional bleeding occurred in 194/423 (46%) biopsies and hemoptysis in 20/423 (5%) biopsies. Univariate analysis showed an association of pneumothorax with smaller lesions (p = 0.05), positive LTTA (p = 0.002), and lesions not attached to pleura (p = 0.026) with multivariate analysis showing lesion size and LTTA to be independent risk factors. Univariate analysis showed an association of increased pulmonary bleeding with smaller lesions (p < 0.001), no attachment to the pleura (p < 0.001), needle throw < 16 mm (p = 0.05), and a longer needle path (p < 0.001). Multivariate analysis showed lesion size, a longer needle path, and lesions not attached to the pleura to be independently associated with perilesional bleeding. Risk factors for hemoptysis were longer needle path (p = 0.002), no attachment to the pleura (p = 0.03), and female sex (p = 0.04).

CONCLUSIONS: Interventional radiologists can reduce the pneumothorax risk during the CT-guided biopsy by positioning the biopsy site below the trachea.

KEY POINTS: • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy results in lower rate of pneumothorax, as compared with the lesion above the trachea. • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy does not affect rate of procedure-associated pulmonary hemorrhage or hemoptysis.

INTRODUCTION: Risk stratification for acute pulmonary embolism (PE) incorporates metrics of right ventricle (RV) function. Significant RV dysfunction influences left ventricular (LV) function, though LV function metrics are not utilized for stratifying outcomes in patients with PE. Mitral annular plane systolic excursion (MAPSE) is a linear echocardiographic (TTE) measure that evaluates longitudinal LV function and may aid in risk stratification for acute PE.

METHODS: Using a single-center database of patients with PE from 2007 to 2014, MAPSE was calculated for all TTE's available with sufficient quality (n = 362). A MAPSE of ≥11 mm was used as a normal reference. Thirty-day adverse outcomes were defined as administration of vasopressor, fibrinolytic therapy, open embolectomy, or 30-day PE-related mortality. Odds ratios (OR) and adjusted OR (AOR) were calculated using logistic regression analysis. Tricuspid annular plane systolic excursion (TAPSE) measurements were incorporated to determine the additive benefit of MAPSE.

RESULTS: Compared with the reference MAPSE ≥ 11 mm and LVEF > 50%, patients with MAPSE < 11 mm and an LVEF > 50% had worse outcomes (AOR 2.94 [95% CI: 1.08-7.98], P = 0.035). Among patients with LVEF > 50%, the presence of both a MAPSE < 11 mm and TAPSE < 16 mm was associated with greater odds of adverse outcomes compared with isolated depressed TAPSE (AOR 10.75 [95% CI: 3.06-37.8], P < 0.01 vs AOR 1.68 [95% CI: 0.18-15.6], P = 0.65).

CONCLUSION: A depressed MAPSE, in patients with preserved LVEF, is associated with worse outcomes in patients with acute PE. The addition of MAPSE to TAPSE appears to have a greater prognostic value than either alone and may further aid in risk stratification, but for confirmation further prospective data are needed.

OBJECTIVE. The purpose of this study was to develop a motion insensitive clinical dynamic contrast-enhanced MRI (DCE-MRI) protocol to assess the response of pleural tumors in clinical trials. MATERIALS AND METHODS. Thirty-two patients with pleura-based lesions were administered contrast material and imaged with gradient-recalled echo DCE-MRI sequence variants: either a traditional cartesian k-space acquisition (FLASH), a time-resolved imaging with stochastic trajectories acquisition (TWIST), or a radial stack-of-stars acquisition (radial) sequence in addition to other standard-of-care imaging sequences. Each image acquisition's sensitivity to motion was evaluated by comparing the motion of the thoracic border in 3D throughout the acquisition. One-way ANOVA was used to compare the image quality between different acquisitions. The 95% CIs were calculated for mean thoracic border displacement. The effects of motion on kinetic parameter estimation were explored with simulations according to clinically acquired data. RESULTS. Radial was the most motion-robust sequence with subvoxel mean displacement in the superior-inferior direction (0.4 ± 1.2 [SD] mm). FLASH showed intermediate displacement (4.6 ± 2.0 mm), whereas TWIST was most sensitive to motion (6.4 ± 3.4 mm). Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the images acquired with the radial sequence were on par or better than the FLASH and TWIST sequences when reconstructed with an improved density compensation algorithm. Simulations showed that motion on scans showing pleural-based lesions can lead to markedly inaccurate kinetic parameter estimation and inappropriate kinetic model convergence within a nested model analysis. CONCLUSION. A practical radial k-space trajectory sequence that provides motion-insensitive pharmacokinetic parameters was incorporated as part of the DCE-MRI protocol of pleural tumors. Validation and usefulness in clinical trials assessing response to therapy is needed.

BACKGROUND: The optimal management of Chiari I malformation during pregnancy remains uncertain. Labor contractions, which increase intracranial pressure, and neuraxial anesthesia both carry the theoretical risk of brainstem herniation given the altered CSF dynamics inherent to the condition. Mode of delivery and planned anesthesia, therefore, require forethought to avoid potentially life-threatening complications. Since the assumed potential risks are significant, we seek to systematically review published literature regarding Chiari I malformation in pregnancy and, therefore, to establish a best practice recommendation based on available evidence.

METHODS: The English-language literature was systematically reviewed from 1991 to 2018 according to PRISMA guidelines to assess all pregnancies reported in patients with Chiari I malformation. After analysis, a total of 34 patients and 35 deliveries were included in this investigation. Additionally, a single case from our institutional experience is presented for illustrative purposes but not included in the statistical analysis.

RESULTS: No instances of brain herniation during pregnancy in patients with Chiari I malformation were reported. Cesarean deliveries (51%) and vaginal deliveries (49%) under neuraxial blockade and general anesthesia were both reported as safe and suitable modes of delivery. Across all publications, only one patient experienced a worsening of neurologic symptoms, which was only later discovered to be the result of a previously undiagnosed Chiari I malformation. Several patients underwent decompressive suboccipital craniectomy to treat the Chiari I malformation during the preconception period (31%), during pregnancy (3%), and after birth (6%). Specific data regarding maternal management were not reported for a large number (21) of these patients (60%). Aside from one abortion in our own institutional experience, there was no report of any therapeutic abortion or of adverse fetal outcome.

CONCLUSIONS: Although devastating maternal complications are frequently feared, very few adverse outcomes have ever been reported in pregnant patients with a Chiari I malformation. The available evidence is, however, rather limited. Based on our survey of available data, we recommend vaginal delivery under neuraxial blockade for truly asymptomatic patients. Furthermore, based on our own experience and physiological conceptual considerations, we recommend limiting maternal Valsalva efforts either via Cesarean delivery under regional or general anesthesia or by choosing assisted vaginal delivery under neuraxial blockade. There is no compelling reason to offer suboccipital decompression for Chiari I malformation during pregnancy. For patients with significant neurologic symptoms prior to conception, decompression prior to pregnancy should be considered.

OBJECTIVE. The purpose of this study was to investigate the causes and rates of 30-day readmission after transjugular intrahepatic portosystemic shunt (TIPS) at a single liver transplant center. MATERIALS AND METHODS. We reviewed 165 TIPS procedures performed between 2003 and 2013. After excluding patients who died during the index admission (n = 16), any readmission within 30 days of discharge was identified, and cause of readmission was determined. Causes were categorized as planned or unplanned and interventional radiology (IR)-related or IR-unrelated. Unplanned readmissions were independently categorized as preventable or unpreventable by two interventional radiologists. Discrepant opinions were resolved by consensus. Factors predictive of 30-day readmission were identified by univariate and multivariate analysis. RESULTS. The reviewed TIPS procedures were performed in 165 patients (mean age ± SD, 56 ± 11 years; 69% male, 31% female). TIPS were placed for ascites or hydrothorax in 82 patients (50%) and variceal bleeding in 83 patients (50%). The 30-day readmission rate was 21% (31/149). The most common causes for readmissions were ascites or hydrothorax (23%, 7/31) and hepatic encephalopathy (23%, 7/31). All 30-day readmissions were unplanned; 17 (55%) of them were potentially preventable. Of the 17 potentially preventable readmissions, five (29%) were IR-related and 12 (71%) were IR-unrelated. In IR-related readmissions, all patients presented with a recurrence of symptoms (rebleeding or ascites) and were found to have TIPS stenosis or occlusion. Mortality rates were similar between patients who were and were not readmitted (p = 0.23). On multivariate analysis, spontaneous bacterial peritonitis during the index admission was the only variable associated with 30-day readmission (odds ratio = 4.81, p = 0.02). CONCLUSION. Over half of 30-day readmissions after TIPS could have been prevented by early outpatient follow-up and intraprocedural technique to optimize stent landing zones.

Patients with acute pulmonary embolism (PE) can present with various clinical manifestations including syncope. The mechanism of syncope in PE is not fully elucidated and data of right ventricular (RV) function in patients has been limited. We retrospectively identified 477 consecutive patients hospitalized with acute PE diagnosed with a computed tomogram (CT) who also had a transthoracic echocardiogram (TTE) 24 h prior to or 48 h after diagnosis. Parameters of RV strain on CT, TTE, electrocardiogram (ECG), and clinical characteristics and adverse outcomes were collected. Patients with all three studies available for assessment were included (n = 369) and those with syncope (n = 34) were compared to patients without syncope (n = 335). Patients with syncope were more likely to demonstrate RV strain on all three modes of assessment compared to those without syncope [17 (50%) vs. 67 (20%); p = 0.001], and those patients were more likely to receive advanced therapies [9 (53%) vs. 15 (22%); p = 0.02]. PE-related mortality was highest among those presenting with high-risk PE and syncope (36%, OR 20.1, 95% CI 5.3-81.1; p < 0.001) and was low in patients with syncope without criteria for high-risk PE (3%, OR 1.2, 95% CI 0.2-10.0; p < 0.001). In conclusion, acute PE patients with syncope are more likely to demonstrate multimodality evidence of RV strain and to receive advanced therapies. Syncope was only associated with increased PE-related mortality in patients presenting with a high-risk PE. Syncope alone without evidence of RV strain is associated with low short-term adverse events and is similar to those without syncope.

Purpose: The aim of this study was to determine whether moderate hyperthermic doses, routinely encountered in the periablational zone during thermal ablation, activate tumor cells sufficiently to secrete pro-tumorigenic factors that can induce increased proliferation.Material and methods: R3230 rat mammary tumor cells and human cancer cell lines, MCF7 breast adenocarcinoma, HepG2 and Huh7 HCC, and HT-29 and SW480 colon adenocarcinoma, were heated in to 45 ± 1 °C or 43 ± 1 °C in vitro for 5-10 min and incubated thereafter at 37 °C for 1.5, 3 or 8 hr (n = 3 trials each; total N = 135). mRNA expression profiles of cytokines implicated in RF-induced tumorigenesis including IL-6, TNFα, STAT3, HGF, and VEGF, were evaluated by relative quantitative real-time PCR. HSP70 was used as control. c-Met and STAT3 levels were assessed by Western blot. Finally, naïve cancer cells were incubated with medium from R3230 and human cancer cells that were subjected to 43-45 °C for 5 or 10 min and incubated for 3 or 8 h at 37 °C in an xCELLigence or incuCyte detection system.Results: Cell-line-specific dose and time-dependent elevations of at least a doubling in HSP70, IL-6, TNFα, STAT3, and HGF gene expression were observed in R3230 and human cancer cells subjected to moderate hyperthermia. R3230 and several human cell lines showed increased phosphorylation of STAT3 3 h post-heating and increased c-Met following heating. Medium of cancer cells subject to moderate hyperthermia induced statistically significant accelerated cell growth of all cell lines compared to non-heated media (p < 0.01, all comparisons).Conclusion: Heat-damaged human tumor cells by themselves can induce proliferation of tumor by releasing pro-tumorigenic factors.