Interdisciplinary Diagnosis and Management of Cerebrospinal Fluid Leakage Due to a Meningeal Diverticulum: a Case Report

Cerebrospinal fluid leakage through meningeal diverticula represents a diagnostic and therapeutic challenge comparatively rarely encountered in the interdisciplinary management of spontaneous intracranial hypotension (SIH). Several false-positive CSF leakage signs may be observed during the imaging work-up of SIH. A 27-year-old female with orthostatic headache showing marked spinal epidural CSF collections and MRI signs of intracranial hypotension underwent a blind and CT-guided epidural blood patch (EBP) of a pathological T9/10 meningeal diverticulum (MD), detected by dynamic CT myelography (dCTM). After initial good imaging and symptomatic improvement, recurrent symptoms and a large left-sided subdural hematoma required neurosurgical MD ligation, with persisting clinical success. The following aspects of this brief report are remarkable: added value of dCTM to synchronously detect true CSF leakage and false-positive CSF leakage signs, near-complete resolution of spinal epidural CSF collections after CT fluoroscopy–guided EBP, interdisciplinary diagnosis, and definite management of CSF leakage through an anomalous MD

Radiation Dose and Fluoroscopy Time of Diagnostic Angiography in Patients with Spinal Dural Arteriovenous Fistula

PURPOSE Spinal dural arteriovenous fistulas (SDAVFs) represent the most common indication for a~spinal angiography. The diagnostic reference level (DRL) for this specific endovascular procedure is still to be determined. This single-center study provides detailed dosimetrics of diagnostic spinal angiography performed in patients with SDAVFs. METHODS Retrospective analysis of all diagnostic spinal angiographies between December 2011 and January 2021. Only patients with an SDAVF who had baseline magnetic resonance angiography (MRA), diagnostic digital subtraction angiography (DSA), treatment and follow-up at this institution were included. Dose area product (DAP, Gy cm2) and fluoroscopy time were compared between preoperative and postoperative angiographies, according to SDAVF locations (common versus uncommon), MRA results at baseline (positive versus negative) and DSA protocols (low-dose, mixed-dose, normal-dose). The 75th~percentile of the DAP distribution was used to define the local DRL. RESULTS A total of 62~spinal angiographies were performed in 25~patients with SDAVF. Preoperative angiographies (30/62, 48%) yielded a~significantly higher DAP and longer fluoroscopy time when compared to postoperative angiographies (32/62, 53%) (p 0.05). A~low-dose protocol yielded a~61% reduction of DAP. CONCLUSION The results of the present study suggest novel DRLs for spinal angiography in patients with SDAVF. Dedicated low-dose protocols enable radiation dose optimization in these procedures

Radiation dose and image quality of high-pitch emergency abdominal CT in obese patients using third-generation dual-source CT (DSCT)

In this third-generation dual-source CT (DSCT) study, we retrospectively investigated radiation dose and image quality of portal-venous high-pitch emergency CT in 60 patients (28 female, mean age 56 years) with a body mass index (BMI) (3) 30 kg/m(2). Patients were dichotomized in groups A (median BMI 31.5 kg/m(2);n = 33) and B (36.8 kg/m(2);n = 27). Volumetric CT dose index (CTDIvol), size-specific dose estimate (SSDE), dose length product (DLP) and effective dose (ED) were assessed. Contrast-to-noise ratio (CNR) and dose-independent figure-of-merit (FOM) CNR were calculated. Subjective image quality was assessed using a five-point scale. Mean values of CTDIvol, SSDE as well as normalized DLP and ED were 7.6 +/- 1.8 mGy, 8.0 +/- 1.8 mGy, 304 +/- 74 mGy * cm and 5.2 +/- 1.3 mSv for group A, and 12.6 +/- 3.7 mGy, 11.0 +/- 2.6 mGy, 521 +/- 157 mGy * cm and 8.9 +/- 2.7 mSv for group B (p 36.8 kg/m(2)

Radiation Dose and Fluoroscopy Time of Endovascular Treatment in Patients with Intracranial Lateral Dural Arteriovenous Fistulae

Purpose. Intracranial lateral dural arteriovenous fistula (LDAVF) represents a specific subtype of cerebrovascular fistulae, harboring a potentially life-threatening risk of brain hemorrhage. Fluoroscopically guided endovascular embolization is the therapeutic gold standard. We provide detailed dosimetry data to suggest novel diagnostic reference levels (DRL). Methods. Retrospective single-center study of LDAVFs treated between January 2014 and December 2019. Regarding dosimetry, the dose area product (DAP) and fluoroscopy time were analyzed for the following variables: Cognard scale grade, endovascular technique, angiographic outcome, and digital subtraction angiography (DSA) protocol. Results. A total of 70 patients (19 female, median age 65 years) were included. Total median values for DAP and fluoroscopy time were 325 Gy cm2 (25%/75% percentile: 245/414 Gy cm2) and 110 min (68/142min), respectively. Neither median DAP nor fluoroscopy time were significantly different when comparing low-grade with high-grade LDAVF (Cognard I + IIa versus IIb–V; p > 0.05, each). Transvenous coil embolization yielded the lowest dosimetry values, with significantly lower median values when compared to a combined transarterial/transvenous technique (DAP 290 Gy cm2 versus 388 Gy cm2, p = 0.031; fluoroscopy time 85 min versus 170 min, p = 0.016). A significant positive correlation was found between number of arterial feeders treated by liquid embolization and both DAP (rs = 0.367; p = 0.010) and fluoroscopy time (rs = 0.295; p = 0.040). Complete LDAVF occlusion was associated with transvenous coiling (p = 0.001). A low-dose DSA protocol yielded a 20% reduction of DAP (p = 0.021). Conclusion. This LDAVF study suggests several local DRLs which varied substantially dependent on the endovascular technique and DSA protocol

CT-Guided Drainage of Fluid Collections Following Liver Resection: Technical and Clinical Outcome of 143 Patients during a 14-Year Period

PURPOSE To retrospectively evaluate the technical and clinical outcome of patients with symptomatic postoperative fluid collections following liver resection treated with CT-guided drainage (CTD). METHODS 143 suitable patients were examined between 2004 and 2017. Technical success was defined as (a) sufficient drainage of the fluid collection and (b) the non-occurrence of peri-interventional complications requiring surgical treatment with minor or prolonged hospitalization. Clinical success was defined as (a) decreasing or normalization of specific blood parameters within 30 days after intervention and (b) no surgical revision in addition to intervention required. C-reactive protein (CRP), leukocytes and Total Serum Bilirubin (TSB) were assessed. Dose length product (DLP) for the intervention parts was determined. RESULTS Technical success was achieved in 99.5% of 189 performed interventions. Clinical success was reached in 74% for CRP, in 86.7% for Leukocytes and in 62.1% for TSB. The median of successful decrease was 6.0 days for CRP, 3.5 days for Leukocytes and 5.5 days for TSB. In 90.2%, no surgical revision was necessary. Total DLP was significantly lower in the second half of the observation period (median 536.0 mGy*cm between years 2011 and 2017 vs. median 745.5 mGy*cm between years 2004 and 2010). CONCLUSIONS Technical success rate of CTD was very high, and clinical success rate was fair to good. Reduction of the radiation dose reflects developments of CT technology and increased experience of the interventional radiologists

Intermittent quick-check CT fluoroscopy-guided percutaneous drainage placement in patients with infected renal and perirenal fluid collections: 11-year experience

PURPOSEWe aimed to evaluate technical and clinical success and safety of computed tomography fluoroscopy (CTF)-guided percutaneous pigtail drainage (PPD) placement in patients with infected renal and perirenal fluid collections.METHODSThis retrospective analysis comprised 44 patients (52.27% men; age, 57.1±18.5 years) undergoing low-milliampere (10–20 mA) CTF-guided PPD placement in 61 sessions under local anesthesia from August 2005 to November 2016. Infected fluid collections (n=71) included infected renal cysts (12.68%), renal and perirenal abscesses due to comorbidities (23.94%), or fluid collections after renal surgery or urological intervention (63.38%). Technical success was defined as PPD placement with consecutive fluid aspiration, clinical success as normalization or marked improvement of clinical symptoms (e.g., flank pain, fever) and inflammatory parameters (leukocyte count, C-reactive protein) after minimally invasive combination therapy (intravenous broad-spectrum antibiotics and drainage). Complications were classified according to the CIRSE classification.RESULTSOverall, 73 single lumen PPD (7.5–12 F) were utilized (1 PPD per session, 69.86%; 2 PPD per session, 15.07%). In 4 cases, PPD could not be inserted into the fluid collection (4.11%) or could not be aspirated (1.37%), yielding overall 94.5% primary technical success. Mean duration of functioning PPD before removal was 10.9 days. Adverse events within 30 days comprised PPD failure (2.27%) or secondary dislocation (Grade 3, 11.36%) and one death (Grade 6, unrelated to intervention, 2.27%). Additional invasive measures after primary CTF-guided PPD were required in 5 patients (nephrectomy 6.82%, partial nephrectomy 2.27%, surgical drainage 2.27%). Thus, clinical success using only minimally invasive measures was achieved in 39 of 44 patients (88.64%).CONCLUSIONGiven a minor proportion of patients requiring surgical revision, combined antibiotics and CTF-guided PPD of infected renal and perirenal fluid collections provides an excellent technical and clinical outcome

Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement after Pancreatic Surgery: Technical and Clinical Outcome in 133 Consecutive Patients during a 14-Year Period

(1) Purpose: To retrospectively assess the technical and clinical outcome of patients with symptomatic postoperative fluid collections after pancreatic surgery, treated with CT-guided drainage (CTD). (2) Methods: 133 eligible patients between 2004 and 2017 were included. We defined technical success as the sufficient drainage of the fluid collection(s) and the absence of peri-interventional complications (minor or major according to SIR criteria). Per definition, clinical success was characterized by normalization of specific blood parameters within 30 days after the intervention or a decrease by at least 50% without requiring additional surgical revision. C-reactive protein (CRP), Leukocytes, Interleukin-6, and Dose length product (DLP) for parts of the intervention were determined. (3) Results: 97.0% of 167 interventions were technically successful. Clinical success was achieved in 87.5% of CRP, in 78.4% of Leukocytes, and in 87.5% of Interleukin-6 assessments. The median of successful decrease was 6 days for CRP, 5 days for Leukocytes, and 2 days for Interleukin-6. No surgical revision was necessary in 93.2%. DLP was significantly lower in the second half of the observation period (total DLP: median 621.5 mGy*cm between 2011–2017 vs. median 944.5 mGy*cm between 2004–2010). (4) Conclusions: Technical success rate of CTD was very high and the clinical success rate was fair to good. Given an elderly and multimorbid patient cohort, CTD can have a temporizing effect in the postoperative period after pancreatic surgery. Reducing the radiation dose over time might reflect developments in CT technology and increased experience of interventional radiologists

Incidental CT Findings in the Elderly with Low-Energy Falls: Prevalence and Implications

Background: Computed tomography (CT) is commonly used in trauma care, with increasing implementation during the emergency work-up of elderly patients with low-energy falls (LEF). The prevalence of incidental findings (IFs) resulting from CT imaging and requiring down-stream actions in this patient cohort is unknown. We have investigated the prevalence and urgency of IFs from emergency CT examinations in these patients. Methods: A total of 2871 patients with LEF and emergency CT examinations were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of IFs;the secondary endpoint was their urgency. Results: The median age was 82 years (64.2% were women). IFs were identified in 73.9% of patients, with an average of 1.6 IFs per patient. Of all IFs, 16.4% were classified as urgent or relevant, predominantly in the abdomen, chest and neck. Increasing age was associated with the prevalence of an IF (odds ratio: 1.053, 95% confidence interval: 1.042-1.064). Significantly more IFs were found in female patients (75.2% vs. 71.5%). Conclusion: IFs resulting from CT examinations of the elderly are frequent, but in more than 8 out of 10, they are harmless or currently asymptomatic. For the benefit of an accurate diagnosis of traumatic lesions, concerns about IFs with respect to disease burden, further work-up and resource utilisation might be disregarded