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

Technischer und klinischer Erfolg der primären perkutanen Stentrevaskularisierung bei Patienten mit atherosklerotischer akuter mesenterialer Ischämie

Hintergrund: Patienten mit akuter mesenterialer Ischämie (AMI) haben häufig schwere Komorbiditäten und ein signifikantes Operationsrisiko. Entsprechend ist die perioperative Morbidität bei diesen Patienten sehr hoch. Zielsetzung: Im Rahmen dieser Studie wurde untersucht, inwieweit die primäre perkutane Stentrevaskularisierung (PPSR) bei Patienten mit atherosklerotischer AMI machbar ist und welchen Einfluss diese Technik auf das klinische Outcome hat. Material und Methoden: Retrospektive Analyse von 19 Patienten (7 weiblich, 12 männlich; medianes Alter, 69 Jahre) mit atherosklerotischer AMI und PPSR. Klinische Charakteristika einschließlich dem Charlson Comorbidity Index adjusted by age (CCIa) und der Symptomdauer, technischer und klinischer Erfolg der PPSR, klinischer Verlauf, 30-Tages Mortalität, und Follow-up wurden evaluiert und mit rein operativen Literaturdaten verglichen. Die Intervention wurde als technisch erfolgreich gewertet bei einer residuellen Stenose von weniger als 30% im Diameter. Klinischer Erfolg lag vor, falls sich die akuten Symptome und/oder das erhöhte Serumlaktat nach alleiniger PPSR zurückbildeten. Ergebnisse: Die meisten Patienten hatten schwere Komorbiditäten (CCIa > 4 bei 17 von 19 Patienten, 89%). Die mediane Symptomdauer betrug 50 Stunden. Der technische und klinische Erfolg der PPSR lag bei 95% (21 von 22 Arterien) bzw. 53% (10 von 19 Patienten). Bei sieben Patienten wurde eine anschließende Laparatomie durchgeführt mit konsekutiver Darmresektion bei vier Patienten. Die 30-Tages Mortalität betrug 42% (8 von 19 Patienten). Schlussfolgerung: In unserer Studienpopulation von Patienten mit atherosklerotischer AMI, schweren Komorbiditäten, einer langen Symptomdauer und einem signifikanten Operationsrisiko war die PPSR technisch machbar und das klinische Outcome akzeptabel

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 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

Endovascular treatment of basilar tip aneurysms in the era of endosaccular flow disruption: a comparative study

PURPOSE This study aims to compare endosaccular flow disruptor (EFD) for treatment of basilar tip aneurysm (BTA) with coiling in terms of safety and efficacy. METHODS We retrospectively reviewed patients treated with an EFD for BTAs at our institution between 2013 and 2019 to standard coiling from the same period (control group). Patient demographics, aneurysm characteristics, procedural data, complications and clinical and angiographic outcome were compared between groups. RESULTS Twenty-three (56%) patients were treated with an EFD and eighteen (44%) patients were treated with coiling. Average aneurysm size was 8~mm in the EFD group and 6.9~mm in the coiling group, respectively (P = 0.2). Average fluoroscopy time, treatment DAP and air kerma were 33~min, 76 Gycm2 and 1.7~Gy in the EFD group and 81~min, 152 Gycm2 and 3.8~Gy in the coiling group, respectively (P < 0.001). In the EFD group, clinically relevant thromboembolic complications occurred in one patient (4%) vs. in 5 patients (28%) in the coiling group (P = 0.07). In each group, 4 patients had an unfavourable outcome at discharge (P = 0.7). Adequate occlusion rates were 96% in the EFD group and 100% and coiling group. Six (26%) patients were prescribed long-term antiplatelet therapy in the EFD group vs. eleven (61%) patients in the coiling group (P = 0.02). CONCLUSION Both treatment concepts provided similar technical success and safety. However, procedure time, radiation exposure and a need for long-term antiaggregation were lower with EFD

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)

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

Outcome of primary percutaneous stent-revascularization in patients with atherosclerotic acute mesenteric ischemia

Background: Patients with acute mesenteric ischemia (AMI) often exhibit severe co-morbidities and significant surgical risks, leading to high perioperative morbidity. Purpose: To investigate the feasibility of primary percutaneous stent-revascularization (PPSR) in atherosclerotic AMI and its impact on patients' outcome. Material and Methods: Retrospective analysis of 19 consecutive patients (7 women, 12 men;median age, 69 years) with AMI caused by atherosclerotic, non-embolic stenoses/occlusions of the splanchnic arteries and PPSR. Alternative minimally invasive techniques were excluded. Clinical characteristics including the Charlson Comorbidity Index adjusted by age (CCIa) and symptom duration, technical and clinical success of PPSR, clinical course, 30-day mortality, and follow-up were evaluated and compared to literature data for surgical approaches. Technical success was defined as residual stenosis of 4 in 17 of 19 patients, 89%). Median symptom duration was 50 h. Technical and clinical success rates of PPSR were 95% (21 of 22 arteries) and 53% (10 of 19 patients). Seven patients underwent subsequent laparotomy with bowel resection in four cases. Thirty-day mortality was 42% (8 of 19 patients). Conclusion: In our study population of patients with atherosclerotic AMI, severe co-morbidities, prolonged acute symptoms, and significant perioperative risks PPSR of splanchnic stenoses were technically feasible and the clinical outcome was acceptable

Safety and efficacy of the Derivo Embolization Device for the treatment of unruptured intracranial aneurysms: a multicentric study

Background The Derivo Embolization Device (DED) is a novel flow diverter stent that provides increased x-ray visibility, an improved delivery system, and potentially reduced thrombogenicity. The objective of this study was to evaluate the early safety and efficacy of the second-generation DED. Methods We retrospectively analyzed all patients with unruptured intracranial aneurysms (UIAs) treated with the DED between November 2015 and December 2017 in three German tertiary care centers. Procedural details, complications, and morbidity within 30 days after treatment, as well as the aneurysm occlusion rates after 6 months (O'Kelly-Marotta scale, OKM), were evaluated. Results Implantation of the DED was attempted in 42 patients with 42 aneurysms. All procedures were technically successful. Multiple DEDs were used in three aneurysms (7.2%) and adjunctive coiling in 11 (26.2%). Procedure-related complications occurred in four cases (9.5%) including three thromboembolic events and one aneurysm perforation. The morbidity rate was 2.4% and there was no mortality. One patient suffered an ischemic stroke with persistent aphasia at 30-day follow-up due to a thromboembolic infarct (modified Rankin Scale score 1). Among 33 patients (78.6%) available for angiographic follow-up, complete (OKM D) and favorable (OKM C+D) aneurysm occlusion was obtained in 72.7% (24/33) and 87.9% (29/33), respectively. Conclusions Endovascular treatment of UIAs with the DED is associated with high procedural safety and adequate occlusion rates. Examinations at 1- and 2-year follow-up will provide data on the long-term safety and angiographic outcomes of this device