Evaluation of semiautomated internal carotid artery stenosis quantification from 3-dimensional contrast-enhanced magnetic resonance angiograms

Rationale and Objectives: The performance of a semiautomatic technique for internal carotid artery (ICA) stenosis quantification of the internal carotid artery in contrast-enhanced magnetic resonance angiography was evaluated. Materials and Methods: The degree of stenosis of 52 ICAs was quantified by measuring the cross-sectional area along the center lumen line. This was performed both by 3 independent observers and the semiautomated method. The degree of stenosis was defined as the amount of cross-sectional lumen reduction. Results: Agreement between the method and observers was good (weighted-kappa, kappa(w) = 0.89). Reproducibility of measurements of the semiautomated technique was better (kappa(w) = 0.97) than that of the observers (kappa(w) = 0.76), and the evaluated technique was considerably less time-consuming. Conclusions: Because the user interaction is limited, this technique can be used to replace an expert observer in 3-dimensional stenosis quantification of the ICA at CE-MRA in clinical practice

Iatrogenic Subtotal Stenosis of the Right Subclavian Artery Treated With Percutaneous Transluminal Angioplasty

This report describes a rare vascular complication of surgical placement of a marking clip and a possible approach to problem solving. A 55-year-old patient presented with loss of sensation in the fingers and loss of peripheral pulsations in the right arm 4 days after right upper lobectomy for a pT2N1 moderately differentiated adenocarcinoma of the lung. Duplex examination and computed tomography were performed the same day and showed a subtotal stenosis of the right subclavian artery, which was caused by the surgical placement of a metal clip to mark the surgical boundary. Selective angiography was subsequently performed. Percutaneous transluminal angioplasty (PTA) successfully dilated the stenosis and pushed the clip off. Flow in the right subclavian artery (RSA) was completely restored as were neurology and peripheral pulses. In conclusion, arterial stenosis by a surgical (marking) clip may be feasibly treated with PTA

Predictive factors for sustained pain after (sub)acute osteoporotic vertebral fractures:Combined results from the VERTOS II and VERTOS IV trial

PURPOSE: Osteoporotic vertebral compression fractures are treated conservatively or in selected cases with percutaneous vertebroplasty (PV). The purpose of this retrospective analysis is to determine predictive factors for a high visual analogue scale (VAS) pain score after conservative, sham or PV and is based on previously published randomized trials. METHODS: The VERTOS II compared conservative versus PV, and VERTOS IV compared sham versus PV treatment. The conservative group received pain medication. The sham and PV group received subcutaneous lidocaine/bupivacaine. In addition, the PV group received cementation, which was simulated in the sham group. Nineteen different predictors of high (≥ 5) versus low ( 8, long-term baseline pain, mild/severe Genant and new fractures. CONCLUSIONS: Statistically significant more patients had a high pain score at 12 months in the sham and conservative group when compared with the PV group. Five predictors were identified for sustained high local back pain, regardless of the received treatment. Patients with moderate fracture deformity were less likely to have high pain scores at 12 months if they received PV than if they had sham or conservative therapy. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00270-022-03170-7

A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke

The value of administering intravenous alteplase before endovascular treatment (EVT) for acute ischemic stroke has not been studied extensively, particularly in non-Asian populations. METHODS We performed an open-label, multicenter, randomized trial in Europe involving patients with stroke who presented directly to a hospital that was capable of providing EVT and who were eligible for intravenous alteplase and EVT. Patients were randomly assigned in a 1:1 ratio to receive EVT alone or intravenous alteplase followed by EVT (the standard of care). The primary end point was functional outcome on the modified Rankin scale (range, 0 [no disability] to 6 [death]) at 90 days. We assessed the superiority of EVT alone over alteplase plus EVT, as well as noninferiority by a margin of 0.8 for the lower boundary of the 95% confidence interval for the odds ratio of the two trial groups. Death from any cause and symptomatic intracerebral hemorrhage were the main safety end points. RESULTS The analysis included 539 patients. The median score on the modified Rankin scale at 90 days was 3 (interquartile range, 2 to 5) with EVT alone and 2 (interquartile range, 2 to 5) with alteplase plus EVT. The adjusted common odds ratio was 0.84 (95% confidence interval [CI], 0.62 to 1.15; P=0.28), which showed neither superiority nor noninferiority of EVT alone. Mortality was 20.5% with EVT alone and 15.8% with alteplase plus EVT (adjusted odds ratio, 1.39; 95% CI, 0.84 to 2.30). Symptomatic intracerebral hemorrhage occurred in 5.9% and 5.3% of the patients in the respective groups (adjusted odds ratio, 1.30; 95% CI, 0.60 to 2.81). CONCLUSIONS In a randomized trial involving European patients, EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke. The incidence of symptomatic intracerebral hemorrhage was similar in the two groups

Overestimation of carotid artery stenosis with magnetic resonance angiography compared with digital subtraction angiography

BACKGROUND AND PURPOSE: Three-dimensional time-of-flight (3D TOF) magnetic resonance angiography (MRA) is generally considered to overestimate the degree of stenosis in the internal carotid artery (ICA) in comparison with the reference standard intraarterial digital subtraction angiography (DSA). We evaluated whether the degree of stenosis was more accurately assessed with 3D TOF MRA if corresponding projections on MRA and DSA were compared instead of comparison of maximal stenosis at MRA with maximal stenosis at DSA. METHODS: From February 1997 to December 1999, we included 186 symptomatic and 17 asymptomatic consecutive patients suspected of having carotid artery stenosis on the basis of clinical presentation and screening with duplex ultrasound scan examination. All patients subsequently underwent DSA and MRA imaging. From each ICA, 12 maximum intensity projections with 3D TOF MRA and two or three projections with DSA were obtained. First, we compared the maximal stenosis at MRA with the maximal stenosis at DSA. Subsequently, we used the stenosis at MRA measured on the projection corresponding with the DSA projection that showed the maximal stenosis. For both strategies, the mean differences in stenosis and sensitivity and specificity for assessment of severe stenosis (70% to 99%) were calculated and compared. RESULTS: The MRA and DSA images of 354 ICAs could be compared. The sensitivity and specificity of MRA with the projection that showed the maximal stenosis were 92.6% (95% CI, 85.3% to 97.0%) and 82.7% (95% CI, 78.1% to 87.3%), respectively. The sensitivity and specificity with the MRA projection, corresponding with the DSA projection showing the maximal stenosis, were 88.3% (95% CI, 81.8% to 94.8%) and 89.6% (95% CI, 85.9% to 93.3%), respectively. The mean difference between maximal stenosis at MRA and DSA was 7.5% (95% CI, 5.2% to 9.9%). The mean difference between stenosis at MRA and DSA in corresponding projections was 0.4% (95% CI, -2.0% to 2.7%). CONCLUSION: If corresponding MRA and intraarterial DSA projections are compared, 3D TOF MRA does not overestimate carotid stenosi

Carotid artery stenosis: accuracy of contrast-enhanced MR angiography for diagnosis

PURPOSE: To assess accuracy of contrast material-enhanced magnetic resonance (MR) angiography as compared with three-dimensional (3D) time-of-flight (TOF) MR angiography and reference digital subtraction angiography (DSA) in diagnosis of carotid artery stenosis. MATERIALS AND METHODS: Enhanced and 3D TOF MR angiography and DSA were performed in 51 consecutive patients suspected of having carotid artery stenosis at duplex ultrasonography. Stenoses were measured by two independent observers blinded to clinical information and other test results. Pearson correlation coefficients were used, and kappa for interobserver variabilities was estimated. Sensitivity and specificity of enhanced and 3D TOF MR angiography were calculated and compared with those of DSA. RESULTS: Pearson correlation coefficients were 0.94 (P <.01) for enhanced angiography versus DSA, 0.92 (P <.01) for 3D TOF angiography versus DSA, and 0.93 (P <.01) for enhanced versus 3D TOF angiography for observer 1 and 0.94 (P <.01), 0.95 (P <.01), and 0.94 (P <.01), respectively, for observer 2. kappa statistics were 0.81 for enhanced angiography, 0.79 for 3D TOF angiography, and 0.78 for DSA. Stenosis measurements of observer 1 at enhanced MR angiography, with inclusion of carotid arteries on the symptomatic side only, compared with those of DSA yielded a sensitivity of 90% (95% CI: 68%, 99%) and a specificity of 77% (95% CI: 55%, 92%). 3D TOF angiography yielded a sensitivity of 86% (95% CI: 67%, 97%) and a specificity of 73% (95% CI: 50%, 89%) compared with those of DSA. For observer 2, sensitivity and specificity for enhanced angiography were 91% (95% CI: 70%, 99%) and 76% (95% CI: 52%, 91%), respectively, and 90% (95% CI: 68%, 99%) and 77% (95% CI: 51%, 92%), respectively, for 3D TOF angiography. CONCLUSION: Accuracy of enhanced MR angiography in diagnosis of severe stenosis is similar to that of 3D TOF MR angiograph

Percutaneous vertebroplasty is no risk factor for new vertebral fractures and protects against further height loss (VERTOS IV)

Background: Percutaneous vertebroplasty (PV) is an alternative option to treat pain after an osteoporotic vertebral compression fracture (OVCF). Controversy exists as to whether PV increases the risk of new OVCFs or prevents further vertebral height loss in treated levels. We assessed both during 1-year follow-up in patients with acute OVCF randomised to PV or a sham procedure. Mehods: VERTOS IV is a prospective, multicentre, randomised controlled trial comparing PV with sham therapy in 180 patients. NewOVCFs and further vertebral height loss were assessed at 3, 6, and 12 months. Results: After a median follow-up of 12 months (interquartile range (IQR) = 12-12) 31 new fractures were reported in 15 patients from the PV group and 28 new fractures in 19 patients from the sham group. The occurrence of new vertebral fractures did not significantly differ between the groups (χ2(1) = 0.83, p = 0.36, OR = .71, 95%CI = 0.33-1.50). There was no higher fracture risk of adjacent versus distant vertebrae. After sham procedure, further height loss of treated vertebrae occurred more frequently (7 patients (8%) in the PV group and 39 (45%) in the sham group (χ2(1) = 28.85, p < 0.001, OR = 9.84, 95%CI = 4.08-23.73)) and was more severe (p < .001) than after PV. Conclusions: The risk of further vertebral height loss is significantly lower after PV compared to a sham intervention, i.e. PV protectsagainst progressive vertebral height loss. In addition, PV does not increase the risk of new adjacent and distant OVCFs

Predictive factors for sustained pain after (sub)acute osteoporotic vertebral fractures: Combined results from the VERTOS II and VERTOS IV trial

Purpose Osteoporotic vertebral compression fractures are treated conservatively or in selected cases with percutaneous vertebroplasty (PV). The purpose of this retrospective analysis is to determine predictive factors for a high visual analogue scale (VAS) pain score after conservative, sham or PV and is based on previously published randomized trials. Methods The VERTOS II compared conservative versus PV, and VERTOS IV compared sham versus PV treatment. The conservative group received pain medication. The sham and PV group received subcutaneous lidocaine/bupivacaine. In addition, the PV group received cementation, which was simulated in the sham group. Nineteen different predictors of high (>= 5) versus low (= 5 at the 12-month, compared to 40.1% in the conservative or sham group, with a significant difference (chi(2)(1) = 15.26, p = 5 after 12 months follow-up), namely: female, baseline VAS > 8, long-term baseline pain, mild/severe Genant and new fractures. Conclusions Statistically significant more patients had a high pain score at 12 months in the sham and conservative group when compared with the PV group. Five predictors were identified for sustained high local back pain, regardless of the received treatment. Patients with moderate fracture deformity were less likely to have high pain scores at 12 months if they received PV than if they had sham or conservative therapy