Contemporary Clinical and Coronary Anatomic Risk Model for 30-Day Mortality After Percutaneous Coronary Intervention

Background: Percutaneous coronary intervention (PCI) procedures are increasing in clinical and anatomic complexity, likely increasing the calculated risk of mortality. There is need for a real-time risk prediction tool that includes clinical and coronary anatomic information that is integrated into the electronic medical record system. Methods: We assessed 70 503 PCIs performed in 73 Veterans Affairs hospitals from 2008 to 2019. We used regression and machine-learning strategies to develop a prediction model for 30-day mortality following PCI. We assessed model performance with and without inclusion of the Veterans Affairs SYNTAX score (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), an assessment of anatomic complexity. Finally, the discriminatory ability of the Veterans Affairs model was compared with the CathPCI mortality model. Results: The overall 30-day morality rate was 1.7%. The final model included 14 variables. Presentation status (salvage, emergent, urgent), ST-segment–elevation myocardial infarction, cardiogenic shock, age, congestive heart failure, prior valve disease, chronic kidney disease, chronic lung disease, atrial fibrillation, elevated international normalized ratio, and the Veterans Affairs SYNTAX score were all associated with increased risk of death, while increasing body mass index, hemoglobin level, and prior coronary artery bypass graft surgery were associated with lower risk of death. C-index for the development cohort was 0.93 (95% CI, 0.92–0.94) and for the 2019 validation cohort and the site validation cohort was 0.87 (95% CI, 0.83–0.92) and 0.86 (95% CI, 0.83–0.89), respectively. The positive likelihood ratio of predicting a mortality event in the top decile was 2.87% more accurate than the CathPCI mortality model. Inclusion of anatomic information in the model resulted in significant improvement in model performance (likelihood ratio test P <0.01). Conclusions: This contemporary risk model accurately predicts 30-day post-PCI mortality using a combination of clinical and anatomic variables. This can be immediately implemented into clinical practice to promote personalized informed consent discussions and appropriate preparation for high-risk PCI cases.

Comparative anatomy of dissected optic lobes, optic ventricles, midbrain tectum, collicular ventricles, and aqueduct: evolutionary modifications as potential explanation for non-tumoral aqueductal anomalies in humans

Purpose An extensive literature has postulated multiple etiologies for aqueductal stenosis. No publications were found, discussing that evolutionary modifications might explain aqueductal anomalies. This study’s objectives were to review the evolutionary modifications of vertebrates’ tectum structures that might explain human aqueduct anomalies. Undertaking vertebrate comparative study is currently not feasible in view of limitations in obtaining vertebrate material. Thus, vertebrate material collected, injected, dissected, and radiographed in the early 1970s was analyzed, focusing on the aqueduct and components of the midbrain tectum. Methods Photographs of brain dissections and radiographs of the cerebral ventricles and arteries of adult shark, frog, iguana, rabbit, cat, dog, and primate specimens, containing a barium-gelatin radiopaque compound, were analyzed focusing on the aqueduct, the optic ventricles, the quadrigeminal plate, and collicular ventricles. The anatomic information provided by the dissections and radiographs is not reproducible by any other radiopaque contrast currently available. Results Dissected and radiographed cerebral ventricular and arterial systems of the vertebrates demonstrated midbrain tectum changes, including relative size modifications of the mammalian components of the tectum, simultaneously with the enlargement of the occipital lobe. There is a transformation of pre-mammalian optic ventricles to what appear to be collicular ventricles in mammals, as the aqueduct and collicular ventricle form a continuous cavity. Conclusions The mammalian tectum undergoes an evolutionary cephalization process consisting of relative size changes of the midbrain tectum structures. This is associated with enlargement of the occipital lobe, as part of overall neocortical expansion. Potentially, aqueductal anomalies could be explained by evolutionary modifications.

Imaging of Portal Gastroduodenopathy

Portal hypertension is characterized by elevated pressure in portal venous system due to portal resistance due to various causes. The etiologies are either pre-hepatic, hepatic, or post-hepatic. Elevated portal pressure results in varices at various sites some of which are difficult to identify on endoscopy alone. Other manifestations of elevated portal pressure include portal gastropathy, enteropathy, colopathy, gastric antral vascular ectasia, and ascites. Imaging plays an essential role in diagnosis and imaging of various manifestations of portal hypertension by determining the locations of varices and plan the management for same. Endoscopy helps in visualizing mucosal varices but newer imaging modalities give a panoramic extent of the disease in the entire gastrointestinal tract with great specificity and sensitivity. Initially, Barium study was used to determine esophageal or gastric varices, computed tomography provides detailed anatomic information which can be used to plan management. Due to advancement in imaging and interventional techniques, treatment for varices has seen advent of multiple minimally invasive interventional radiological techniques. A brief outlook on anatomical aspect of varices and various recent advances in management of the same has been provided. Overall knowledge of the various imaging manifestations of portal hypertension can be helpful to evaluate prognosis and plan proper management.

Early Experience With Virtual and Synchronized Augmented Reality Platform for Preoperative Planning and Intraoperative Navigation: A Case Series

BACKGROUND Virtual reality (VR) allows for presurgical planning. Intraoperatively, augmented reality (AR) enables integration of segmented anatomic information with neuronavigation into the microsurgical scene to provide guidance without workflow disruption. Combining VR and AR solutions may help guide microsurgical technique to improve safety, efficiency, and ergonomics. OBJECTIVE To describe a VR/AR platform that provides VR planning and intraoperative guidance via microscope ocular injection of a comprehensive AR overlay of patient-specific 360°/3D anatomic model aligned and synchronized with neuronavigation. METHODS Custom 360° models from preoperative imaging of 49 patients were utilized for preoperative planning using a VR-based surgical rehearsal platform. Each model was imported to SyncAR, the platform's intraoperative counterpart, which was coregistered with Medtronic StealthStation S8 and Zeiss or Leica microscope. The model was injected into the microscope oculars and referenced throughout by adjusting overlay opacity. For anatomic shifts or misalignment, the overlay was reregistered via manual realignment with known landmarks. RESULTS No SyncAR-related complications occurred. SyncAR contributed positively to the 3D understanding of patient-specific anatomy and ability to operate. Preoperative planning and intraoperative AR with 360° models allowed for more precise craniotomy planning and execution. SyncAR was useful for guiding dissection, identifying critical structures including hidden anatomy, understanding regional anatomy, and facilitating resection. Manual realignment was performed in 48/49 surgeries. Gross total resection was achieved in 34/40 surgeries. All aneurysm clipping and microvascular decompression procedures were completed without complications. CONCLUSION SyncAR combined with VR planning has potential to enhance surgical performance by providing critical information in a user-friendly, continuously available, heads-up display format.

PET/CT NEMA Body Phantom Image Reconstruction Study Using 2 mm Voxel Size for Improved Image Quality

Background PET/CT imaging is widely used in oncology and provides both metabolic and anatomic information. Because of the relatively poor spatial resolution of PET/CT imaging technique the detection of small lesions is limited. The low spatial resolution introduces the partial-volume effect (PVE) which negatively affects images both visually and quantitatively. The aim of our research was to investigate the effect of 4 mm and 2 mm voxel size on image quality and on detection of small spheres. MethodsWe used the NEMA body phantom with six fillable spheres. The spheres and background were filled with a solution of 18F-FDG, in ratio spheres vs background 2:1, 3:1, 4:1 and 8:1 In all images reconstructed with 2 mm and 4 mm voxel size the contrast recovery coefficient (CRC), contrast to noise ratio (CNR) in standardized uptake value (SUV) were evaluated.ResultsFor phantom spheres ≤ 13 mm, we found significant higher CRC, SUV and CNR using small-voxel reconstructions. CRC and SUV did not differ for large spheres (≥ 17 mm) using 2 mm and 4 mm voxel size. On the other hand, CNR for large spheres (≥ 17 mm) was significantly decreased in 2 mm voxel size images compared to the 4 mm.ConclusionAccording to our results, the reconstruction with 2 mm voxel size can improve precise lesion localization, image contrast, and image quality.

Using 3D computed tomography in the anatomical description of the eye and the vestibulocochlear organ of a blue-and-yellow macaw (Ara ararauna Linnaeus, 1758) and of a toucan (Ramphastos toco Statius Muller, 1776)

The aim of this study was to evaluate the use of Computed Tomography to study the anatomy of the eye and the vestibulocochlear organ of the wild birds. For this purpose, formaldehyde-embalmed specimens of a toucan and of a blue-and-yellow macaw were submitted to a whole-body scan by a 64 slice-Multidetector CT yielding 0,7mm-thick transversally oriented images. These were reconstructed by specific software that produced additional images in dorsal, transversal, and sagittal planes, as well as three-dimensional images, which were obtained by two techniques: Maximum Intensity Projection and Volume Rendering. Our study found that the eye bulbs in the orbit occupy a proportionally large space in the skull, highlighting the important role that vision plays in these animals. CT provided gross anatomic information about the size and shape of the eye, such as lenses and scleral rings of these birds. Regarding the vestibulocochlear organ, CT was less likely to identify the inner ear structures, especially the ones of the membranous labyrinth. The bony semicircular canals were clearly seen and in the middle ear, thecolumellawas identified. Our results demonstrate that the vestibulocochlear organ of birds is less complex than that of mammals, although, as expected, the semicircular canals are very well developed, being adapted to the accurate balance present in these animals.CT can be used as a good technique to evaluate eye and ear structures on these birds, and can be useful to study them in vivofor pathological conditions or for comparisons between different species.

Analisis Variasi Slice Thickness Terhadap Informasi Anatomi Potongan Axial Pada Pemeriksaan MSCT Cervical Pada Kasus Trauma

Background: One step to create a good image is by doing slice thickness reconstruction. Slice thickness is thick slices or pieces of the object checked out. The examination procedure of MSCT in case of Cervical trauma in Radiology Installation RSUD Tugurejo Semarang using slice thickness 3 mm. This contrasts with Seeram (2016), which explained that the examination of adult MSCT Cervical Spine using slice thickness between 1-2 mm. This research aims to know the difference of anatomic information resulted by 5 slice thickness variation in MSCT Cervical Spine and to find out which slice thickness can provide optimum anatomic information.Methods: The type of this research is quantitative with an experimental approach. Data is performed by reconstructing the 5 images of MSCT cervical of trauma patients using 5 slice thickness variation which is 1 mm, 1.5 mm, 2 mm, 2.5 mm and 3 mm. The final images are evaluated by two Respondents to see the differences in anatomic information and then analyzed by using a different test (Friedman Test) from the SPSS version 24.0.Results: The results showed there is a significant difference in anatomic information on the corpus, lamina, spinous process, transverse process and fragment fracture between variations in slice thickness of 1 mm, 1.5 mm, 2 mm, 2.5 mm, and 3 mm on the MSCT Cervical examination with a significance value of 0,000 or p 0.05.Conclusion: The most optimal slice thickness to provide anatomic information on the cervical MSCT examination is 1 mm slice thickness with a mean rank value of 3.64.

Comprehensive review of evaluation and management of cardiac paragangliomas

Cardiac paraganglioma (PGL) is a rare neuroendocrine tumour causing significant morbidity primarily due to norepinephrine secretion potentially causing severe hypertension, palpitations, lethal tachyarrhythmias, stroke and syncope. Cardiologists are faced with two clinical scenarios. The first is the elevated norepinephrine, whose actions must be properly counteracted by adrenoceptor blockade to avoid catastrophic consequences. The second is to evaluate the precise location of a cardiac PGL and its spread since compression of cardiovascular structures may result in ischaemia, angina, non-noradrenergic-induced arrhythmia, cardiac dysfunction or failure. Thus, appropriate assessment of elevated norepinephrine by its metabolite normetanephrine is a gold biochemical standard at present. Furthermore, dedicated cardiac CT, MRI and transthoracic echocardiogram are necessary for the precise anatomic information of cardiac PGL. Moreover, a cardiologist needs to be aware of advanced functional imaging using 68Ga-DOTA(0)-Tyr(3)-octreotide positron emission tomography/CT, which offers the best cardiac PGL-specific diagnostic accuracy and helps to stage and rule out metastasis, determining the next therapeutic strategies. Patients should also undergo genetic testing, especially for mutations in genes encoding succinate dehydrogenase enzyme subunits that are most commonly present as a genetic cause of these tumours. Curative surgical resection after appropriate α-adrenoceptor and β-adrenoceptor blockade in norepinephrine-secreting tumours is the primary therapeutic strategy. Therefore, appropriate and up-to-date knowledge about early diagnosis and management of cardiac PGLs is paramount for optimal outcomes in patients where a cardiologist is an essential team member of a multidisciplinary team in its management.