Distal insertion of the clavicular portion of pectoralis major muscle: anatomical study.

PURPOSE: Several descriptions of the anatomy of the pectoralis major (PM) have been published. However, the precise description of its distal humeral insertion, which is involved in traumatic tears, remains controversial. The distal tendon is classically described as being made of two layers, one anterior (ALPM) and one posterior (PLPM), which regroup at their distal edge. The clavicular head (CH) participates in the ALPM according to most authors. However, others describe a more superficial termination in a close relationship with the deltoid humeral insertion. The objective of this anatomical work is to precisely describe the anatomy of the CH and its relationship with the rest of the distal PM tendon and the distal deltoid tendon. MATERIALS: Twenty-three fresh cadaveric specimens were dissected (41 shoulders). The entire PM as well as the deltoid were exposed. Several measurements were collected to establish the relationships between the distal tendon of the CH and the PM, the deltoid and the bony landmarks. RESULTS: In all cases, the CH muscular portion sits on the ALPM but does not participate in the connective structure of the PM distal tendon. The inferolateral part of its distal end gives a thin tendinous portion that inserts lower on the humerus in conjunction with the distal tendon of the deltoid. In 24.4%, this tendon was more difficult to isolate but was always observed. CONCLUSIONS: The distal tendon of the PM only comes from the muscle fibres of its sternal head. The CH fibres do not contribute to this tendon but appear to terminate in a separate tendon fusing with the humeral insertion of the deltoid: the deltopectoral tendon. This could explain the different patterns of tears observed in clinical practice.

Contrast enhancement early after renal malignancy cryoablation: imaging findings associated with benignity.

OBJECTIVES: Contrast enhancement by MRI done early after cryoablation for renal malignancies may suggest residual tumor (RT). However, we have observed MRI enhancement within 48 h of cryoablation in patients who had no contrast enhancement 6 weeks later. Our purpose was to identify features of 48-h contrast enhancement in patients without RT. METHODS: This single-center retrospective study included consecutive patients who underwent percutaneous cryoablation of renal malignancies in 2013-2020, exhibited cryoablation-zone MRI contrast enhancement 48 h later, and had available 6-week MRI scans. Persistent or growing CE at 6 weeks vs. 48 h was classified as RT. A washout index was calculated for each 48-h MRI, and its performance for predicting RT was assessed by receiver operating characteristic curve analysis. RESULTS: We included 60 patients with 72 cryoablation procedures and 83 cryoablation zones exhibiting 48-h contrast enhancement; mean age was 66 ± 17 years. Clear-cell renal cell carcinoma accounted for 95% of tumors. Of the 83 48-h enhancement zones, RT was observed in eight while 75 were benign. The 48-h enhancement was consistently visible at the arterial phase. Washout was significantly associated with RT (p < 0.001) and gradually increasing contrast enhancement with benignity (p < 0.009). A washout index below - 1.1 predicted RT with 88% sensitivity and 84% specificity. CONCLUSION: MRI contrast enhancement 48 h after cryoablation of renal malignancies was usually benign. Washout was associated with residual tumor, with a washout index value below - 1.1 exhibiting good performance in predicting residual tumor. These findings may help to guide decisions about repeat cryoablation. CLINICAL RELEVANCE STATEMENT: Magnetic resonance imaging contrast enhancement 48 h after cryoablation of renal malignancies rarely indicates residual tumor, which is characterized by washout with a washout index lower than - 1.1. KEY POINTS: • Contrast enhancement at the arterial phase of magnetic resonance imaging done 48 h after cryoablation of a renal malignancy is usually benign. • Residual tumor manifesting as contrast enhancement at the arterial phase is characterized by subsequent marked washout. • A washout index below - 1.1 has 88% sensitivity and 84% specificity for residual tumor.

Precocious puberty related to Leydig cell testicular tumor: the diagnostic imaging keys.

BACKGROUND: We report the challenging case of a 6-year-old boy with precocious puberty related to histologically proven Leydig cell tumor. CASE PRESENTATION: Multiparametric ultrasound and magnetic resonance imaging (MRI) was performed. Interesting findings were scarcely or never reported in children and differed from adults Leydig cell tumors s such as the hyperechogenic halo surrounding the lesion and the dominant central vascularization using ultrasensitive Doppler. MRI revealed an enlarged testicle with strong enhancement of a tumor, a tumor apparent diffusion coefficient (ADC) of 600 × 10-3 mm2/s and a lower ADC value of the non-tumor parenchyma compared to the contralateral testis (ADC = 800 × 10-3 mm2/s vs 1100 × 10-3 mm2/s), attributed to the spermatogenesis induced by hormonal impregnation. CONCLUSION: We illustrate multiparametric US and MRI findings of a pediatric Leydig cell tumor, including the imaging changes attributed to local hormone secretion, which may be helpful in similar cases.

Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus.

PURPOSE: Mechanical thrombectomies (MT) in patients with large vessel occlusion (LVO) related to calcified cerebral embolus (CCE) have been reported, through small case series, being associated with low reperfusion rate and worse outcome, compared to regular MT. The purpose of the MASC (Mechanical Thrombectomy in Acute Ischemic Stroke Related to Calcified Cerebral Embolus) study was to evaluate the incidence of CCEs treated by MT and the effectiveness of MT in this indication. METHODS: The MASC study is a retrospective multicentric (n = 37) national study gathering the cases of adult patients who underwent MT for acute ischemic stroke with LVO related to a CCE in France from January 2015 to November 2019. Reperfusion rate (mTICI ≥ 2B), complication rate and 90-day mRS were systematically collected. We then conducted a systematic review by searching for articles in PubMed, Cochrane Library, Embase and Google Scholar from January 2015 to March 2020. A meta-analysis was performed to estimate clinical outcome at 90 days, reperfusion rate and complications. RESULTS: We gathered data from 35 patients. Reperfusion was obtained in 57% of the cases. Good clinical outcome was observed in 28% of the patients. The meta-analysis retrieved 136 patients. Reperfusion and good clinical outcome were obtained in 50% and 29% of the cases, respectively. CONCLUSION: The MASC study found worse angiographic and clinical outcomes compared to regular thrombectomies. Individual patient-based meta-analysis including the MASC findings shows a 50% reperfusion rate and a 29% of good clinical outcome.

Clinical Characteristics, Angioarchitecture and Management of Tectum Mesencephali Arteriovenous Malformations : A Retrospective Case Series.

PURPOSE: Tectum mesencephali arteriovenous malformations (TM-AVMs) are rare lesions deeply located close to eloquent structures making them challenging to treat. We aimed to present clinical presentation, angiographic features and treatment strategies of TM-AVMs through a single center retrospective case series. METHODS: A TM-AVMs is defined as a nidus located in the parenchyma or on the pia mater of the posterior midbrain. Records of consecutive patients admitted with TM-AVMs over a 21-year period were retrospectively analyzed. Vascular anatomy of the region is also reviewed. RESULTS: In this study 13 patients (1.63% of the complete cohort; 10 males), mean age 48 years, were included. All patients presented with intracranial hemorrhage and two patients (15%) died after an early recurrent bleeding. Mean size of the TM-AVMs was 10.1 ± 5 mm. Multiple arterial feeders were noted in every cases. Of the patients 11 underwent an exclusion treatment, 8 via embolization (6 via arterial access and 2 via venous access) and 4 via stereotactic radiosurgery (SRS) (1 patient received both). Overall success treatment rate was 7/11 patients (64% overall; 63% in the embolization group, 25% in the SRS group). Two hemorrhagic events led to a worsened outcome, one during embolization and one several years after SRS. All other patients remained clinically stable or improved. CONCLUSION: The TM-AVMs are rare but stereotypic lesions found in a hemorrhagic context. Multiple arterial feeders are always present. Endovascular treatment seems to be an effective technique with relatively low morbidity; SRS had a low success rate but was only use in a limited number of patients.

Visual lung damage CT score at hospital admission of COVID-19 patients and 30-day mortality.

OBJECTIVES: Chest CT has been widely used to screen and to evaluate the severity of COVID-19 disease in the early stages of infection without severe acute respiratory syndrome, but no prospective data are available to study the relationship between extent of lung damage and short-term mortality. The objective was to evaluate association between standardized simple visual lung damage CT score (vldCTs) at admission, which does not require any software, and 30-day mortality. METHODS: In a single-center prospective cohort of COVID-19 patients included during 4 weeks, the presence and extent of ground glass opacities(GGO), consolidation opacities, or both of them were visually assessed in each of the 5 lung lobes (score from 0 to 4 per lobe depending on the percentage and out of 20 per patient = vldCTs) after the first chest CT performed to detect COVID-19 pneumonia. RESULTS: Among 210 confirmed COVID-19 patients, the number of survivors and non-survivors was 162 (77%) and 48 (23%), respectively at 30 days. vldCTs was significantly higher in non-survivors, and the AUC of vldCTs to distinguish survivors and non-survivors was 0.72 (95%CI 0.628-0.807, p < 0.001); the best cut-off vldCTs value was 7. During follow-up, significant differences in discharges and 30-day mortality were observed between patients with vldCTs ≥ 7 versus vldCTs < 7: (98 [85.2%] vs 49 [51.6%]; p < 0.001 and 36 [37.9%] vs 12 [12.4%]; p < 0.001, respectively. The 30-day mortality increased if vldCTs ≥ 7 (HR, 3.16 (1.50-6.43); p = 0.001), independent of age, respiratory rate and oxygen saturation levels, and comorbidities at admission. CONCLUSIONS: By using chest CT in COVID-19 patients, extensive lung damage can be visually assessed with a score related to 30-day mortality independent of conventional risk factors of the disease. KEY POINTS: • In non-selected COVID-19 patients included prospectively during 4 weeks, the extent of ground glass opacities(GGO) and consolidation opacities evaluated by a simple visual score was related to 30-day mortality independent of age, respiratory rate, oxygen saturation levels, comorbidities, and hs-troponin I level at admission. • This severity score should be incorporated into risk stratification algorithms and in structured chest CT reports requiring a standardized reading by radiologists in case of COVID-19.

AI-driven quantification, staging and outcome prediction of COVID-19 pneumonia.

Coronavirus disease 2019 (COVID-19) emerged in 2019 and disseminated around the world rapidly. Computed tomography (CT) imaging has been proven to be an important tool for screening, disease quantification and staging. The latter is of extreme importance for organizational anticipation (availability of intensive care unit beds, patient management planning) as well as to accelerate drug development through rapid, reproducible and quantified assessment of treatment response. Even if currently there are no specific guidelines for the staging of the patients, CT together with some clinical and biological biomarkers are used. In this study, we collected a multi-center cohort and we investigated the use of medical imaging and artificial intelligence for disease quantification, staging and outcome prediction. Our approach relies on automatic deep learning-based disease quantification using an ensemble of architectures, and a data-driven consensus for the staging and outcome prediction of the patients fusing imaging biomarkers with clinical and biological attributes. Highly promising results on multiple external/independent evaluation cohorts as well as comparisons with expert human readers demonstrate the potentials of our approach.

Middle meningeal artery embolization reduces the post-operative recurrence rate of at-risk chronic subdural hematoma.

BACKGROUND: Embolization of the middle meningeal artery (MMA) has emerged as a potential treatment of chronic subdural hematomas (CSDHs). OBJECTIVE: To evaluate the impact on recurrence rate of postsurgical embolization of CSDH in patients with a higher than average risk of recurrence. METHODS: A monocentric retrospective study was performed on retrospectively collected data. From March 2018 to December 2019, embolization of the MMA was proposed as an adjunct postoperative treatment after burr-hole surgery in patients operated for a recurrent CSDH or a CSDH with an independent recurrence risk factor, including antiplatelet therapy, full anticoagulation therapy, coagulation disorder, hepatopathy, or chronic alcoholism. Patients who had undergone postoperative embolization were compared with a historic group of patients operated between March 2016 and March 2018, selected based on the same inclusion criteria. RESULTS: During the study period, 89 patients (with 74 unilateral and 15 bilateral CSDHs) were included and underwent an embolization procedure, leading to 91 out of a total of 104 MMA being embolized (88%). These were compared with 174 patients (138 unilateral and 36 bilateral CSDH) in the historic control group. One major procedure-related adverse event was registered. Four of the 89 patients (4%) required surgery for a CSDH recurrence in the embolization group, significantly less than the 24 of 174 patients (14%) in the control group (OR=0.28, 95% CI 0.07 to 0.86, p=0.02). CONCLUSIONS: Postsurgical embolization of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence.