Aortic Intramural Hematoma due to Intercostal Artery Aneurysms

Background Intercostal artery aneurysms (ICA) are rare vascular disease. A rupture of ICA is a possible mechanism of intramural aortic hematoma (IH). We report a case with IH and ICAs without clear etiology. Case presentation: A 64-year-old man was admitted to our emergency room with a sudden onset of acute diffused abdominal and chest pain, radiating to the back. Without previous traumatic insult, a computed tomographic angiography scan (CTA) revealed an IH beginning inferior to the left subclavian artery extending to the level of the celiac trunk. Follow-up CTA demonstrated a stable maximal IH thickness diameter of 11 mm, maximal aortic diameter of 40 mm, a new left hemorrhagic pleural effusion, and a focal contrast enhancement at T9 level. Due to these findings, thoracic endovascular aortic repair (TEVAR) was performed. During follow up, T9 focal enhancement continues to grow and an additional one developed. Selective angiography was performed demonstrating a connection to the costal artery and the aortic lumen, confirming ICA. Successful embolization with micro coils was performed. During follow up, additional 2 ICAs developed and treated with embolization. CTA three months later showed a complete resolution of the IH and obliteration of all treated ICAs. Infectious, inflammatory and connective tissue disease investigations were undertaken without a clear etiology. Conclusions: This is a case of IH and ICAs, in the absence of a clear etiology which were successfully treated by endovascular procedures TEVAR and coil embolization. It is not clear whether the hematoma was the source of the ICA or the other way round. Lack of ICAs in the initial CTA might be due to the pressure exerted by the hematoma or that they were too small to be detected but continued to grow on follow up. Rupture of these micro-aneurysms is a possible mechanism of intramural aortic hematoma.

Comparison of the Effectiveness of Carotid Artery Endarterectomy and Carotid Endarterectomy + Patch Plasty in Preventing Restenosis and Stroke in Carotid Artery Occlusions.

BackgroundCarotid artery stenosis is one of the most important causes of stroke, and atherosclerosis plays a role in one third of all strokes. It has been reported in some studies that the patency rate of carotid endarterectomies performed with patplasty is better than standard surgical treatment. In this retrospective study, we investigated vascular patency rates and strokes due to postoperative restenosis in patients who underwent classical carotid endarterctomy and patch plasty endarterctomy due to carotid artery stenosis.We investigated 126 patients diagnosed with carotid artery occlusion between January 2015 and January 2021. We retrospectively analyzed and compared 44 patients who were operated on using carotid endarterectomy (CAE) with patch technique and 82 patients who underwent only carotid endarterectomy in terms of risk factors, restenosis and stroke. Color Doppler Ultrasonography (CDUS) and Computed Tomographic Angiography (CTA) were used in the diagnosis of carotid artery occlusions and the evaluation of restenosis.Results:The characteristics of the risk factors of the patients were examined and recorded. PTFE graft was used as a patch in patients. There were no significant complications during or after the operation. Restenosis and stroke were investigated at the 10th day, third month, sixth month, and first year after discharge, and mostly by imaging with CDUS. Restenosis was detected in one patient in the study group and in thirteen patients in the control group. Stroke was detected in none of the patients in the study group and in four patients in the control group.Conclusion: In our clinic, patch-based CAE is preferred to primary CAE due to its successful results and very low risk of restenosis. We think that CAE with the patch is a much more effective method in protecting patients from neurological pathologies.

Multimodality Imaging in the Diagnosis of Prosthetic Valve Endocarditis: A Brief Review

Infective endocarditis is a common and treatable condition that carries a high mortality rate. Currently the workup of infective endocarditis relies on the integration of clinical, microbiological and echocardiographic data through the use of the modified Duke criteria (MDC). However, in cases of prosthetic valve endocarditis (PVE) echocardiography can be normal or non-diagnostic in a high proportion of cases leading to decreased sensitivity for the MDC. Evolving multimodality imaging techniques including leukocyte scintigraphy (white blood cell imaging), 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), multidetector computed tomographic angiography (MDCTA), and cardiac magnetic resonance imaging (CMRI) may each augment the standard workup of PVE and increase diagnostic accuracy. While further studies are necessary to clarify the ideal role for each of these imaging techniques, nevertheless, these modalities hold promise in determining the diagnosis, prognosis, and care of PVE. We start by presenting a clinical vignette, then evidence supporting various modality strategies, balanced by limitations, and review of formal guidelines, when available. The article ends with the authors' summary of future directions and case conclusion.

Association of Bleb Formation With Peri-aneurysmal Contact in Unruptured Intracranial Aneurysms

The mechanism of bleb formation in unruptured intracranial aneurysms (UIAs) remains unclear. This study aimed to investigate the association between peri-aneurysmal contact (PAC) and bleb formation. Forty-five aneurysms were classified depending on the presence of blebs and PAC using computed tomographic angiography and magnetic resonance imaging. Aneurysmal hemodynamics were assessed using computational fluid dynamics. The independent variables associated with bleb formation were statistically assessed. Fourteen aneurysms (31.1%) had blebs, all of which were located at the site of PAC (group A). Thirty-one aneurysms (68.9%) had no bleb, of which 13 had a PAC (group B) and 18 had no PAC (group C). PAC was the only independent variable associated with bleb formation (p < 0.05). Aneurysmal volumes were significantly higher in group A, followed by groups B and C in series. Aneurysmal wall shear stress (WSS) tended to be lowest in group A, followed by groups B and C in series. The maximum WSS at the blebs was only 17% of the maximum WSS at the aneurysmal domes. This study demonstrated that bleb formation in UIAs was associated with the establishment of PAC during their growth, which may have more detrimental effects on bleb formation than hemodynamics.

A Novel End-to-End Deep Learning Solution for Automatic Coronary Artery Segmentation from CCTA: Algorithm Development and Validation Study (Preprint)

BACKGROUND Coronary computed tomographic angiography (CCTA) plays a vital role in the diagnosis of cardiovascular diseases, among which automatic Coronary Artery Segmentation (CAS) serves as one of the most challenging tasks. To computationally assist the task, this paper proposes a novel DL solution. OBJECTIVE This study introduces an end-to-end novel deep learning-based (DL) solution for automatic CAS. METHODS Inspired by the Di-Vnet network, a fully automatic multistage DL solution is proposed. The new solution aims to preserve the integrity of blood vessels in terms of both their shape details and continuity. The solution is developed using 338 CCTA cases, among which 133 cases (33865 axial images) have their groundtruth cardiac masks pre-annotated and 205 cases (53365 axial images) have their groundtruth coronary artery (CA) masks pre-annotated. DSC and 95% HD scores are used to measure the solution’s accuracy in CAS. RESULTS The proposed solution attains (90.29±1.38) % in its DSC and (2.11±0.24) mm in its 95% HD respectively, which consumes 0.112 seconds per image and 30 seconds per case on average. CONCLUSIONS The proposed solution attains (90.29±1.38) % in its DSC and (2.11±0.24) mm in its 95% HD respectively, which consumes 0.112 seconds per image and 30 seconds per case on average.

596 Multidisciplinary in-depth investigation in a young athlete suffering from syncope caused by myocardial bridge

Aims Laboratory medicine along with genetic investigations are taking on an increasingly important role in monitoring athlete’s health conditions. Acute or intense exercise can lead to metabolic imbalances, muscle injuries, or can point up cardiovascular disorders. Methods and results This study aimed to monitor the health status of a basketball player, through an integrated approach including biochemical and genetic investigations and advanced imaging techniques, to shed light on the causes of recurrent syncope he experienced during exercise. Biochemical analyses showed that the athlete had abnormal iron, ferritin, and bilirubin levels. Coronary computed tomographic angiography highlighted the presence of an intramyocardial bridge, suggesting this may be the cause of the observed syncopes. The athlete was excluded from competitive activity. To understand if this cardiac malformation could be caused by an inherited genetic condition, both array-CGH and whole exome sequencing were performed. Array-CGH showed two intronic deletions involving MACROD2 and COMMD10 genes, which could be related to the congenital heart defect; the whole exome sequencing highlighted the genotype compatible with the Gilbert syndrome. However, no clear pathogenic mutations related to the patient’s cardiological phenotype were detected, even after applying machine learning methods. Conclusions This case highlights the importance and the need to provide exhaustive personalized diagnostic work-up for the athletes to cover the cause of their malaise, safeguarding their health. This multidisciplinary approach can be useful to create ad personam training and treatments, thus avoiding the appearance of diseases and injuries which, if underestimated, can become irreversible disorders and sometimes can lead to the death of the athlete.

Impact of Several Factors on the Diagnostic Interpretability of Coronary Computed Tomographic Angiography Using a 256-Detector Row CT Scanner

Purpose: To explore the impact of patient-related, vessel-related, image quality-related and cardiovascular risk factors on CCTA interpretability using 256-detector row Computed Tomography (CT). Methods: One hundred ten patients who underwent CCTA and Invasive Coronary Angiography (ICA) were consecutively retrospectively enrolled from January 2018 to October 2018. Using ICA as the reference standard, ≥50% diameter stenosis was defined as the cut-off criterion to detect the diagnostic performance of CCTA. Diagnostic reproducibility was investigated by calculating the interrater reproducibility of CCTA. Multiple logistic regression models were performed to evaluate the impact of 14 objective factors. Results: A total of 1019 segments were evaluated. The per-segment sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CCTA were 76.8%, 93.7%, 91.2%, 67.8% and 95.9%, respectively. The per-segment diagnostic reproducibility was 0.44 for CCTA. Regarding accuracy, a negative association was found for stenosis severity, calcium load and hyperlipidaemia. Regarding sensitivity, calcium load and diabetes mellitus (DM) were positively related. Regarding specificity, a negative correlation was observed between stenosis severity and calcium load. Regarding interrater reproducibility, stenosis severity and calcium load were negatively associated, whereas male sex and the signal-to-noise ratio (SNR) were positively related (all p<0.05). Conclusion: Per-segment 256-detector row CCTA performance was optimal in stenosis-free or occluded segments. Heavier calcium load was associated with poorer CCTA interpretability. On the one hand, our findings confirmed the rule-out value of CCTA; on the other hand, they suggested improvements in calcium subtractions and deep learning-based tools to improve CCTA diagnostic interpretability.