Normalization of Peri-Arteriovenous Malformation Hemodynamics Prior to Direct Microsurgery: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Rudy J Rahme ◽  
Evelyn L Turcotte ◽  
Devi P Patra ◽  
Matthew E Welz ◽  
H Hunt Batjer ◽  
...  
Keyword(s):  
High Risk ◽  
Postoperative Hemorrhage ◽  
Endovascular Embolization ◽  
Vascular Lesions ◽  
Treatment Modalities ◽  
Multiple Treatment ◽  
Fluid Attenuated Inversion Recovery ◽  
Magnetic Resonance Imaging Mri ◽  
Vascular Steal ◽  
Complex Features

Abstract Arteriovenous malformations (AVMs) are highly complex vascular lesions characterized by abnormal connections between arteries and an intervening nidus. Definitive and safe treatment of AVMs may require the combination of multiple treatment modalities to address the various complex features of the AVM.1 Endovascular embolization can be used as an adjuvant to surgery in order to control deep feeders, reduce flow, and address high-risk features such as aneurysms. In addition, by progressively reducing the AVM flow, staged embolization can lead to normalization of peri-AVM hemodynamics and therefore may decrease the risk of postresection hemorrhage.2,3 In this operative video, we present a case of a 41-yr-old female who presented with progressively worsening left-sided hemiparesis. Magnetic resonance imaging (MRI) and angiography revealed a complex right fronto-parietal AVM with significant associated edema, likely due to the vascular steal phenomenon. The area of edema, which included the motor cortex, was thought to be at high risk for postoperative hemorrhage from normal perfusion pressure breakthrough. We therefore decided to proceed with staged presurgical embolization to gradually normalize the perilesional hemodynamics, and therefore possibly reduce the risk of postoperative morbidity. The patient underwent 3 embolization sessions at 6-wk intervals. An MRI after the last embolization showed near-complete resolution of the fluid-attenuated inversion-recovery (FLAIR) signal around the AVM. Microsurgical resection was performed on the day after the last embolization. The patient tolerated the procedure well and was discharged at her neurological baseline with mild contralateral hemiparesis, which has continued to improve at follow-up. Postoperative angiography showed complete resection of the AVM. The patient consented to the procedure as shown in this operative video and gave informed written consent for use of her images in publication.

Desmoid tumour of the distal forearm involving the distal radioulnar joint

2020 ◽  
Vol 13 (11) ◽  
pp. e237097
Author(s):  
Apoorv Sehgal ◽  
Pratyush Shahi ◽  
Avijeet Prasad ◽  
Manoj Bhagirathi Mallikarjunaswamy
Keyword(s):  
Distal Radioulnar Joint ◽  
Treatment Modalities ◽  
Desmoid Tumour ◽  
X Rays ◽  
Distal Forearm ◽  
Left Wrist ◽  
Radioulnar Joint ◽  
Magnetic Resonance Imaging Mri ◽  
Epidemiology Investigation

A 32-year-old woman presented with progressive pain and swelling of the left wrist for 6 months. Physical examination revealed a firm, tender, oval swelling over the left wrist. X-rays showed a pressure effect on the distal radius and ulna. Magnetic Resonance Imaging (MRI) revealed a well-defined, asymmetrical, dumbbell-shaped soft-tissue lesion involving the interosseous region of the distal forearm and extending until the distal radioulnar joint (DRUJ). Core needle biopsy confirmed the diagnosis of desmoid tumour. Marginal excision of the tumour was done. At the 2-year follow-up, the patient was doing well and had painless and improved left wrist motion. Desmoid tumour involving the DRUJ has not been previously reported. We, through this case, report new observation and discuss the epidemiology, investigation of choice, treatment modalities, and the need for a regular follow-up for appendicular desmoid tumours.

scholarly journals Juxtacortical susceptibility changes in progressive multifocal leukoencephalopathy at the gray–white matter junction correlates with iron-enriched macrophages

2021 ◽  
pp. 135245852199965
Author(s):  
Kedar R Mahajan ◽  
Moein Amin ◽  
Matthew Poturalski ◽  
Jonathan Lee ◽  
Danielle Herman ◽  
...  
Keyword(s):  
White Matter ◽  
Progressive Multifocal Leukoencephalopathy ◽  
Central Nervous System Lymphoma ◽  
Susceptibility Weighted Imaging ◽  
Resonance Imaging ◽  
Gradient Echo ◽  
Total N ◽  
Mri Brain ◽  
Fluid Attenuated Inversion Recovery ◽  
Magnetic Resonance Imaging Mri

Objective: Describe magnetic resonance imaging (MRI) susceptibility changes in progressive multifocal leukoencephalopathy (PML) and identify neuropathological correlates. Methods: PML cases and matched controls with primary central nervous system lymphoma (PCNSL) were retrospectively identified. MRI brain at 3 T and 7 T were reviewed. MRI-pathology correlations in fixed brain autopsy tissue were conducted in three subjects with confirmed PML. Results: With PML ( n = 26 total, n = 5 multiple sclerosis natalizumab-associated), juxtacortical changes on susceptibility-weighted imaging (SWI) or gradient echo (GRE) sequences were noted in 3/3 cases on 7 T MRI and 14/22 cases (63.6%) on 1.5 T or 8/22 (36.4%) 3 T MRI. Similar findings were only noted in 3/25 (12.0%) of PCNSL patients (odds ratio (OR) 12.83, 95% confidence interval (CI), 2.9–56.7, p < 0.001) on 1.5 or 3 T MRI. On susceptibility sequences available prior to diagnosis of PML, 7 (87.5%) had changes present on average 2.7 ± 1.8 months (mean ± SD) prior to diagnosis. Postmortem 7 T MRI showed SWI changes corresponded to areas of increased iron density along the gray–white matter (GM-WM) junction predominantly in macrophages. Conclusion: Susceptibility changes in PML along the GM-WM junction can precede noticeable fluid-attenuated inversion recovery (FLAIR) changes and correlates with iron accumulation in macrophages.

scholarly journals Exit Strategies in Natalizumab-Treated RRMS at High Risk of Progressive Multifocal Leukoencephalopathy: a Multicentre Comparison Study

2021 ◽  
Author(s):  
Aurora Zanghì ◽  
Antonio Gallo ◽  
Carlo Avolio ◽  
Rocco Capuano ◽  
Matteo Lucchini ◽  
...  
Keyword(s):  
High Risk ◽  
Progressive Multifocal Leukoencephalopathy ◽  
Safety Profile ◽  
Primary Study ◽  
Relapsing Remitting ◽  
Exit Strategies ◽  
Magnetic Resonance Imaging Mri ◽  
Anti Cd20 ◽  
Post Hoc ◽  
Relapsing Remitting Multiple Sclerosis

Abstract The main aim of the study is to evaluate the efficacy and safety profile of ocrelizumab (OCR), rituximab (RTX), and cladribine (CLA), employed as natalizumab (NTZ) exit strategies in relapsing–remitting multiple sclerosis (RRMS) patients at high-risk for progressive multifocal leukoencephalopathy (PML). This is a multicentre, retrospective, real-world study on consecutive RRMS patients from eleven tertiary Italian MS centres, who switched from NTZ to OCR, RTX, and CLA from January 1st, 2019, to December 31st, 2019. The primary study outcomes were the annualized relapse rate (ARR) and magnetic resonance imaging (MRI) outcome. Treatment effects were estimated by the inverse probability treatment weighting (IPTW), based on propensity-score (PS) approach. Additional endpoint included confirmed disability progression (CDP) as measured by Expanded Disability Status Scale and adverse events (AEs). Patients satisfying predefined inclusion and exclusion criteria were 120; 64 switched to OCR, 36 to RTX, and 20 to CLA. Patients from the 3 groups did not show differences for baseline characteristics, also after post hoc analysis. The IPTW PS-adjusted models revealed that patients on OCR had a lower risk for ARR than patients on CLA (ExpBOCR 0.485, CI 95% 0.264–0.893, p = 0.020). This result was confirmed also for 12-month MRI activity (ExpBOCR 0.248 CI 95% 0.065–0.948, p = 0.042). No differences were found in other pairwise comparisons (OCR vs RTX and RTX vs CLA) for the investigated outcomes. AEs were similar among the 3 groups. Anti-CD20 drugs were revealed to be effective and safe options as NTZ exit strategies. All investigated DMTs showed a good safety profile.

scholarly journals Clinical and Pathological Evidence of Anti-GD2 Immunotherapy Induced Differentiation in Relapsed/Refractory High-Risk Neuroblastoma

Cancers ◽  
2021 ◽  
Vol 13 (6) ◽  
pp. 1264
Author(s):  
Jaume Mora ◽  
Alicia Castañeda ◽  
Maria Cecilia Colombo ◽  
Maite Gorostegui ◽  
Fernando Gomez ◽  
...  
Keyword(s):  
High Risk ◽  
Fdg Pet ◽  
Current Therapy ◽  
Bone Lesions ◽  
Functional Magnetic Resonance ◽  
Positron Emission ◽  
Apparent Diffusion ◽  
Neuroblastic Tumors ◽  
Direct Cell ◽  
Magnetic Resonance Imaging Mri

Background: Neuroblastic tumors (NBTs) originate from a block in the process of differentiation. Histologically, NBTs are classified in neuroblastoma (NB), ganglioneuroblastoma (GNB), and ganglioneuroma (GN). Current therapy for high-risk (HR) NB includes chemotherapy, surgery, radiotherapy, and anti-GD2 monoclonal antibodies (mAbs). Anti-GD2 mAbs induce immunological cytoxicity but also direct cell death. Methods: We report on patients treated with naxitamab for chemorefractory NB showing lesions with long periods of stable disease. Target lesions with persisting 123I-Metaiodobenzylguanidine (MIBG) uptake after 4 cycles of immunotherapy were further evaluated by functional Magnetic Resonance Imaging (MRI) and/or Fluorodeoxyglucose (FDG)-positron emission tomography (PET). MIBG avid lesions that became non-restrictive on MRI (apparent diffusion coefficient (ADC) > 1) and/or FDG-PET negative (SUV < 2) were biopsied. Results: Twenty-seven relapse/refractory (R/R) HR-NB patients were enrolled on protocol Ymabs 201. Two (7.5%) of the 27 showed persistent bone lesions on MIBG, ADC high, and/or FDG-PET negative. Forty-four R/R HR-NB patients received chemo-immunotherapy. Twelve (27%) of the 44 developed persistent MIBG+ but FDG-PET- and/or high ADC lesions. Twelve (86%) of the 14 cases identified were successfully biopsied producing 16 evaluable samples. Histology showed ganglioneuroma maturing subtype in 6 (37.5%); ganglioneuroma mature subtype with no neuroblastic component in 4 (25%); differentiating NB with no Schwannian stroma in 5 (31%); and undifferentiated NB without Schwannian stroma in one (6%). Overall, 10 (62.5%) of the 16 specimens were histopathologically fully mature NBTs. Conclusions: Our results disclose an undescribed mechanism of action for naxitamab and highlight the limitations of conventional imaging in the evaluation of anti-GD2 immunotherapy clinical efficacy for HR-NB.

scholarly journals Integrating Systemic Therapies into the Multimodality Treatment of Resectable Colorectal Liver Metastases

2018 ◽  
Vol 2018 ◽  
pp. 1-4 ◽  
Author(s):  
Omar Abdel-Rahman ◽  
Winson Y. Cheung
Keyword(s):  
Liver Metastases ◽  
Management Strategy ◽  
Multimodality Treatment ◽  
Treatment Modalities ◽  
Considerable Proportion ◽  
Optimal Management ◽  
Related Factors ◽  
Multiple Treatment ◽  
Current Review ◽  
Systemic Therapies

Colorectal carcinoma (CRC) is one of the most common cancers worldwide. A considerable proportion of CRC patients may present with metastatic disease either at upfront presentation (synchronous with the primary) or following diagnosis and treatment of the primary tumor (metachronous). Management of CRC liver metastases is a challenging endeavor which frequently necessitates proper assessment of patient- and disease-related factors. There is an opportunity within the management of CRC liver metastases to incorporate multiple treatment modalities (including surgery, other locoregional treatments, and systemic therapy). The current review aims to provide an updated overview on the optimal management strategy for CRC patients with liver metastases with a specific focus on the integration of systemic and/or locoregional treatments among patients with resectable or potentially resectable disease.

Abstract TP35: Estimation of Red Blood Cells in the Thrombus Using MRI. A Phantom Study with Predetermined Thrombus Components

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ana Paula Narata ◽  
Isabelle Filipiak ◽  
Richard Bibi ◽  
Jean Philippe Cottier ◽  
Kevin Janot
Keyword(s):  
Red Blood Cells ◽  
Blood Cells ◽  
Spin Echo ◽  
In Vitro Study ◽  
Fibrin Clot ◽  
Fluid Attenuated Inversion Recovery ◽  
Magnetic Resonance Imaging Mri ◽  
C 50 ◽  
D 20

Background and Purpose: Better understanding about thrombus composition seems necessary, as treatment of acute ischemic stroke (AIS) is focus on clot chemical dissolution and mechanical extraction. We propose to evaluate whether magnetic resonance imaging (MRI) can differentiate white from red clots and estimate red blood cells percentage (RBC%) using clots with predetermined components and an index based on MRI signal intensity (SI). Material and Methods: 5 clots (A=100% fibrin, B=80% RBC, C=50% RBC, D=20% RBC, E=unknown) were fixed in gelatin-manganese solution and studied by: high-resolution 3D T1-weighted (T1MPR), T2-weighted turbo spin echo (T2TSE), T2-weighted gradient echo (T2GE), susceptibility weighted (SWI), fluid-attenuated inversion recovery (FLAIR) and diffusion weighted imaging (DWI) with apparent diffusion coefficient (ADC). SI index was calculated with clot SI and gelatin SI. Statistical analysis compared RBC-clots to fibrin-clot SI index and the correlation of RBC% and SI index in each MRI sequence. Results: Each red clot was different from clot A except clot D in FLAIR. Correlation between clots SI index and RBC concentration were found in T1MPR (r=-0.84), SWI (r=-0.79), T2GE (r=-0.72) and FLAIR (r=0.80). Linear regression resolution provided an indirect RBC estimation for clot E: 47.3 % in T1MPR, SWI 41.5%, T2GE 45.1% and FLAIR 50.9%. Histological analysis confirmed clot E composition. Conclusion: This in vitro study suggests that MRI can differentiate white from red clots except clots with low RBC% in FLAIR and also provide approximate RBC%.

scholarly journals Current and Future Directions of Breast MRI

2021 ◽  
Vol 10 (23) ◽  
pp. 5668
Author(s):  
Margaret Houser ◽  
David Barreto ◽  
Anita Mehta ◽  
Rachel F. Brem
Keyword(s):  
Breast Cancer ◽  
High Risk ◽  
Digital Breast Tomosynthesis ◽  
Breast Mri ◽  
Preoperative Assessment ◽  
Average Risk ◽  
Dense Breast Tissue ◽  
Increased Risk ◽  
High Risk Populations ◽  
Magnetic Resonance Imaging Mri

Magnetic resonance imaging (MRI) is the most sensitive exam for detecting breast cancer. The American College of Radiology recommends women with 20% or greater lifetime risk of developing breast cancer be screened annually with MRI. However, other high-risk populations would also benefit. Hartmann et al. reported women with atypical hyperplasia have nearly a 30% incidence of breast cancer at 25-year follow-up. Women with dense breast tissue have up to a 4-fold increased risk of breast cancer when compared to average-risk women; their cancers are more likely to be mammographically occult. Because multiple cohorts of women are at high risk for developing breast cancer, there has been a movement to develop an abbreviated MRI (abMRI) protocol to expand the availability of MRI screening. Studies on abMRI effectiveness have been promising, with Weinstein et al. demonstrating a cancer detection rate of 27.4/1000 in women with dense breasts after a negative digital breast tomosynthesis. Breast MRI is also used to evaluate the extent of disease as part of preoperative assessment in women with newly diagnosed breast cancer, and to assess a patient’s response to neoadjuvant chemotherapy. This paper aims to explore the current uses of MRI and propose future indications and directions.

scholarly journals Nongalenic arteriovenous fistulas: history of treatment and technology

2006 ◽  
Vol 20 (6) ◽  
pp. 1-8 ◽  
Author(s):  
Kristen Upchurch ◽  
Lei Feng ◽  
Gary R. Duckwiler ◽  
John G. Frazee ◽  
Neil A. Martin ◽  
...  
Keyword(s):  
Open Surgery ◽  
Interventional Neuroradiology ◽  
Endovascular Embolization ◽  
High Flow ◽  
Vascular Lesions ◽  
Arteriovenous Fistulas ◽  
The Past ◽  
Technological Developments ◽  
History Of ◽  
Endovascular Technology

✓ Nongalenic cerebral arteriovenous fistulas (AVFs) are uncommon, high-flow vascular lesions first treated by Walter Dandy and his colleagues by using open surgery with ligation of the feeding artery. Due to advances in endovascular technology over the past four decades that make possible the control of high flow in AVFs, treatment has evolved from the sole option of surgery to include the alternative or adjunct option of endovascular embolization. The authors of this review discuss the history of nongalenic AVF treatment, including techniques of both surgery and interventional neuroradiology and the technological developments underlying them.

Intraoperative Spinal Angiography during Microsurgical Occlusion of Spinal Dural Arteriovenous Fistula within the Hybrid Operation Room

2021 ◽  
Author(s):  
Jenny Christine Kienzler ◽  
Salome Schoepf ◽  
Serge Marbacher ◽  
Michael Diepers ◽  
Luca Remonda ◽  
...  
Keyword(s):  
Arteriovenous Fistula ◽  
Prone Position ◽  
Popliteal Artery ◽  
Dural Arteriovenous Fistula ◽  
Endovascular Embolization ◽  
Treatment Modalities ◽  
Safe Procedure ◽  
Spinal Dural Arteriovenous Fistula ◽  
Segmental Artery ◽  
Small Branch

Abstract Background Spinal dural arteriovenous fistula (SDAVF) is a rare cause of progressive myelopathy in predominantly middle-aged men. Treatment modalities include surgical obliteration and endovascular embolization. In surgically treated cases, failure of obliteration is reported in up to 5%. The aim of this technical note is to present a safe procedure with complete SDAVF occlusion, verified by intraoperative digital subtraction angiography (DSA). Methods We describe four patients with progressive leg weakness who underwent surgical obliteration of SDAVF with spinal intraoperative DSA in the prone position after cannulation of the popliteal artery. All surgeries took place in our hybrid operating room (OR) and were accompanied by electrophysiologic monitoring. Surgeries and cannulation of the popliteal artery were performed in the prone position. Ultrasound was used to guide the popliteal artery puncture. A 5-Fr sheath was inserted and the fistula was displayed using a 5-Fr spinal catheter. Spinal intraoperative DSA was performed prior to and after temporary clipping of the fistula point as well after the final SDAVF occlusion. Results The main feeder of the SDAVF fistula in the first patient arose from the right T11 segmental artery, which also supplied the artery of Adamkiewicz. The second patient initially underwent endovascular treatment and deteriorated 5 months later due to recanalization of the SDAVF via a small branch of the T12 segmental artery. The third and fourth cases were primarily scheduled for surgical occlusion. Access through the popliteal artery for spinal intraoperative DSA proved to be beneficial and safe in the hybrid OR setting, allowing the sheath to be left in place during the procedure. During exposure and after temporary and permanent occlusion of the fistulous point, intraoperative indocyanine green (ICG) video angiography was also performed. In one case, the addition of intraoperative DSA showed failure of fistula occlusion, which was not visible with ICG angiography, leading to repositioning of the clip. Complete fistula occlusion was documented in all cases. Conclusion Spinal intraoperative DSA in the prone position is a feasible and safe intervention for rapid localization and confirmation of surgical SDAVF occlusion.

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