Safety and Efficacy of Percutaneous Morton Neuroma Cryoneurolysis Under Ultrasound Guidance.

PURPOSE: To assess the technical success, safety and early efficacy of Morton neuroma (MN) cryoneurolysis. MATERIALS AND METHODS: Retrospective review of 54 consecutive patients with MN treated with cryoneurolysis after failure of conservative treatment, from September 2022 to June 2023. Outcomes measurements included technical success (defined a successful ultrasound-guided placement of the cryoprobe), procedural safety according to Cirse classification and change in 6 months post-procedure by pain numeric rating scale (pNRS). RESULTS: A total of 59 MN were treated during 55 procedures. Mean procedure duration was 47 min, all patients were discharged 2 h after the intervention. Technical success was 98.1%. No Cirse grade 3, 4 or 5 complication was reported. Three grade 2 complication occurred, including two chilblain-type lesions and one bone insufficiency fracture. At 6 months post-procedure, pNRS score was significantly decreased (2.7 ± 2.2 vs 7.1 ± 1.1) (p < 0.0001), with a mean score decrease of 4.1points. Thirty-two patients (60.4%) reported a complete pain relief, 15 (28.3%) a partial pain relief and 6 (11.3%) no pain relief, or increased pain. CONCLUSION: Cryoneurolysis seems to be safe for the treatment of Morton neuroma. Six-month pain relief is promising and needs to be confirmed at long term.

Prostate Artery Embolization: Challenges, Tips, Tricks, and Perspectives.

Prostatic artery embolization (PAE) consists of blocking the arteries supplying the prostate to treat benign prostate hypertrophia (BPH). Its effectiveness on both urinary symptoms and flowmetric parameters has now been amply demonstrated by around a hundred studies, including several randomized trials. The main advantage of this procedure is the very low rate of urinary and sexual sequelae, including ejaculatory, with an excellent tolerance profile. The arterial anatomy is a key element for the realization of PAE. Its knowledge makes it possible to anticipate obstacles and prevent potential complications related to nontarget embolization. Nontarget embolization can occur with a small intraprostatic shunt or reflux and has no consequences except some local inflammation symptoms that resolve in a couple of days. Nevertheless, some situations with large arterial shunts arising from the prostatic artery must be recognized (accessory rectal, bladder, or pudendal branches), and must imperatively be protected before embolization, at the risk of exposing oneself to otherwise ischemic complications that are more severe, such as bladder necrosis and skin or mucosal necrosis. This article offers a step-by-step review of the various anatomical and technical key points to ensure technical and clinical success, while avoiding the occurrence of adverse events.

Cardiac Intravoxel Incoherent Motion Diffusion-Weighted Magnetic Resonance Imaging With T1 Mapping to Assess Myocardial Perfusion and Fibrosis in Systemic Sclerosis: Association With Cardiac Events From a Prospective Cohort Study.

OBJECTIVE: Myocardial involvement may occur during systemic sclerosis (SSc) and can lead to impaired myocardial contraction and/or arrhythmia. Cardiac magnetic resonance imaging (MRI) is used for noninvasive characterization of the myocardium. The aim of this study was to evaluate the utility of cardiac MRI with intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) and longitudinal relaxation time (T1) sequence mapping for assessment of myocardial microvascular and interstitium impairment in SSc. METHODS: In this single-center prospective cohort study, 40 consecutive patients with SSc and 20 healthy controls were assessed by cardiac MRI with IVIM DWI and T1 mapping sequences on a 3T scanning system. Images were analyzed independently by 2 assessors, and Bland-Altman plots were used to assess interreader concordance and reproducibility. Characteristics of the patients were compared according to quartiles of T1 and perfusion fraction (f-coefficient) values, using exact Cochran-Ermitage trend tests for qualitative variables and analysis of variance for quantitative variables. Kaplan-Meier cardiac events-free survival curves were plotted and compared with a log-rank test for trend. RESULTS: T1 values were higher in SSc patients than in healthy controls, and were higher in the diffuse cutaneous SSc (dcSSc) subset (P = 0.02). Higher T1 values were associated with the immunologic pattern seen in patients with the dcSSc form (P = 0.0001), a higher modified Rodnan skin thickness score (MRSS) (P = 0.003), and a higher frequency of interstitial lung disease (P = 0.03). Moreover, higher T1 values were correlated with higher MRSS scores (r = +0.32, P = 0.04) and reduced forced vital capacity (r = -0.34, P = 0.048), and tended to be correlated with reduced total lung capacity (r = -0.30, P = 0.07). Lower f-coefficient values, as a measure of decreased tissue perfusion, were associated with less frequent use of vasodilators (P = 0.02 for angiotensin-converting enzyme inhibitors and P = 0.06 for calcium-channel blockers) and more frequent use of glucocorticoids (P = 0.02). The f-coefficients were inversely correlated with the T1 values (r = -0.31, P = 0.02). Furthermore, higher T1 values were associated with higher incidence of cardiac events (log-rank test for trend P = 0.03). CONCLUSION: Increased T1 values, potentially suggesting microscopic fibrosis, were observed more frequently in patients with dcSSc, and higher T1 values were associated with interstitial lung disease and more frequent cardiac events during follow-up. The results of this study show that cardiac MRI with T1 mapping sequences and IVIM DWI may be useful in assessing myocardial involvement in patients with SSc.

Cardiac sarcoidosis: Diagnosis, therapeutic management and prognostic factors.

BACKGROUND: Cardiac sarcoidosis (CS) is a severe localization, observed mostly in cardiology departments. Despite appropriate cardiological treatment, CS is a potentially life-threatening condition, and accounts for 13-85% of sarcoidosis-related deaths. AIMS: This retrospective study aimed to give an overview of CS in a non-cardiac unit, to analyse the effect of first-line immunosuppressive treatment on outcome and survival and to evaluate factors associated with relapses. METHODS: From 534 cases of sarcoidosis, we selected 59 patients with CS according to "2006 international criteria". We performed an in-depth analysis regarding symptoms, physical signs and cardiac investigation results. Patients were followed for a median period of 60 months. RESULTS: The median age at cardiac signs was 42 years. Echocardiography abnormalities, isotopic defects and abnormal magnetic resonance imaging findings were observed in 81%, 84% and 92% of patients, respectively. First-line treatment included steroids alone in 24 patients and steroids plus immunosuppressive therapy in 35 patients. Forty-seven (80%) patients recovered; 12 stabilized or worsened. The recovery rate was 75% in the steroids alone group versus 83% in the steroids plus immunosuppressive therapy group. Five (9%) patients died during follow-up, with two deaths attributed to CS. The overall 1- and 5-year survival rates were 98% and 92%, respectively. CONCLUSION: Our series of patients with CS who received steroids alone or combined with immunosuppressive therapy had a good prognosis, with an overall 5-year survival rate of 92%. The recovery rate was 85%, with no significant difference between patients treated with steroids alone or plus immunosuppressive therapy.

Cardiac involvement in granulomatosis with polyangiitis: a magnetic resonance imaging study of 31 consecutive patients.

Objectives: Specific cardiac involvement in granulomatosis with polyangiitis (GPA) is probably underestimated since many of these conditions are subclinical. The objective of this study was to assess the prevalence and patterns of cardiac abnormalities detected by cardiac MRI (CMRI) in patients with GPA. Methods: Thirty-one consecutive patients with newly diagnosed or relapsing GPA underwent CMRI to assess morphological, functional, perfusion at rest and delayed enhancement abnormalities. Results: At least one abnormality was observed on CMRI for 19 of 31 patients (61%). Four patients (13%) had an impaired left ventricle ejection fraction (LVEF). LV regional wall motion abnormalities were found in 11 patients (35%). Late gadolinium enhancement (LGE) was detected in 10 of 31 patients (32%). LGE was mostly nodular ( n = 9). Myocardial early contrast enhancement was detected in 5 of the 31 patients (16%), which was systematically associated with LGE in the same territory. CMRI detected pericarditis in eight patients (26%). GPA with <18 months duration was associated with a higher LVEF ( P = 0.03), fewer CMRI abnormalities ( P = 0.04) and less LV hypokinesia ( P = 0.04) than GPA with a longer duration. Patients with recent-onset GPA had a higher LVEF ( P = 0.01) and less LV hypokinesia ( P = 0.006) than patients experiencing a relapse ( P = 0.02). Conclusion: CMR is an accurate technique for detecting heart involvement in GPA. This unique non-invasive technique may provide information with important clinical implications for the accurate early assessment of cardiac lesions in GPA patients and for detecting cumulative, irreversible damage. It may also have prognostic implications.

Comparative assessment of image quality for coronary CT angiography with iobitridol and two contrast agents with higher iodine concentrations: iopromide and iomeprol. A multicentre randomized double-blind trial.

OBJECTIVES: To demonstrate non-inferiority of iobitridol 350 for coronary CT angiography (CTA) compared to higher iodine content contrast media regarding rate of patients evaluable for the presence of coronary artery stenoses. METHODS: In this multicentre trial, 452 patients were randomized to receive iobitridol 350, iopromide 370 or iomeprol 400 and underwent coronary CTA using CT systems with 64-detector rows or more. Two core lab readers assessed 18 coronary segments per patient regarding image quality (score 0 = non diagnostic to 4 = excellent quality), vascular attenuation, signal and contrast to noise ratio (SNR, CNR). Patients were considered evaluable if no segment had a score of 0. RESULTS: Per-patient, the rate of fully evaluable CT scans was 92.1, 95.4 and 94.6 % for iobitridol, iopromide and iomeprol, respectively. Non-inferiority of iobitridol over the best comparator was demonstrated with a 95 % CI of the difference of [-8.8 to 2.1], with a pre-specified non-inferiority margin of -10 %. Although average attenuation increased with higher iodine concentrations, average SNR and CNR did not differ between groups. CONCLUSIONS: With current CT technology, iobitridol 350 mg iodine/ml is not inferior to contrast media with higher iodine concentrations in terms of image quality for coronary stenosis assessment. KEY POINTS: • Iodine concentration is an important parameter for image quality in coronary CTA. • Contrast enhancement must be balanced against the amount of iodine injected. • Iobitridol 350 is non-inferior compared to CM with higher iodine concentrations. • Higher attenuation with higher iodine concentrations, but no SNR or CNR differences.

Portal hypertension in patients with cirrhosis: indirect assessment of hepatic venous pressure gradient by measuring azygos flow with 2D-cine phase-contrast magnetic resonance imaging.

OBJECTIVES: To measure azygos, portal and aortic flow by two-dimensional cine phase-contrast magnetic resonance imaging (2D-cine PC MRI), and to compare the MRI values to hepatic venous pressure gradient (HVPG) measurements, in patients with cirrhosis. METHODS: Sixty-nine patients with cirrhosis were prospectively included. All patients underwent HVPG measurements, upper gastrointestinal endoscopy and 2D-cine PC MRI measurements of azygos, portal and aortic blood flow. Univariate and multivariate regression analyses were used to evaluate the correlation between the blood flow and HVPG. The performance of 2D-cine PC MRI to diagnose severe portal hypertension (HVPG ≥ 16 mmHg) was determined by receiver operating characteristic curve (ROC) analysis, and area under the curves (AUC) were compared. RESULTS: Azygos and aortic flow values were associated with HVPG in univariate linear regression model. Azygos flow (p < 10(-3)), aortic flow (p = 0.001), age (p = 0.001) and presence of varices (p < 10(-3)) were independently associated with HVPG. Azygos flow (AUC = 0.96 (95 % CI [0.91-1.00]) had significantly higher AUC than aortic (AUC = 0.64 (95 % CI [0.51-0.77]) or portal blood flow (AUC = 0.40 (95 % CI [0.25-0.54]). CONCLUSIONS: 2D-cine PC MRI is a promising technique to evaluate significant portal hypertension in patients with cirrhosis. KEY POINTS: • Noninvasive HVPG assessment can be performed with MRI azygos flow. • Azygos MRI flow is an easy-to-measure marker to detect significant portal hypertension. • MRI flow is more specific that varice grade to detect portal hypertension.

Impact of cardiac magnetic resonance imaging on eosinophilic granulomatosis with polyangiitis outcomes: A long-term retrospective study on 42 patients.

OBJECTIVE: To determine the diagnostic and prognostic significance of cardiac magnetic resonance imaging (CMRI) in a cohort of patients with eosinophilic granulomatosis with polyangiitis (EGPA). METHODS: We conducted a monocentric retrospective study including 42 EGPA patients who had consecutively undergone CMRI at diagnosis or during follow-up, independently of signs of cardiac involvement. RESULTS: Forty-two patients (male 59.5%, mean age at diagnosis 46.5 years) were included. ANCA was positive in 26.2%, and median EGPA duration before the 1st CMRI screening was 5 months. Seventeen (40.5%) were diagnosed with cardiomyopathy, independently of CMRI findings. CMRI showed myocardial late gadolinium enhancement (LGE) in 82.4% patients with cardiomyopathy vs. 44% without cardiomyopathy (P=0.024). Using LGE as the sole criterion, CMRI sensitivity and specificity for diagnosing cardiomyopathy were 82.4% and 56%, respectively. Among the 15 patients with cardiomyopathy who underwent additional CMRI during follow-up, CMRI-detected cardiac lesions had improved in 7 patients, while those of 8 patients worsened or stabilized despite treatment. These latter patients presented with significantly more cardiac events during follow-up (P=0.026). No differences were found between non-cardiomyopathic patients with or without CMRI anomalies concerning EGPA cardiac manifestations and outcomes. CONCLUSION: The diagnostic significance of myocardial LGE in EGPA patients remains uncertain and should not be the only criterion for cardiomyopathy diagnosis. For patients with no other signs of cardiomyopathy, CMRI-detected anomalies do not seem to adversely affect prognosis or outcome. For patients with cardiomyopathy, CMRI reassessment seems promising in detecting patients with a less favorable cardiac outcome.

Complications of peripherally inserted central catheters in adults with cystic fibrosis or bronchiectasis.

BACKGROUND: Peripherally inserted central catheters (PICCs) are increasingly used in patients with cystic fibrosis (CF) or with non-CF bronchiectasis, but little data exist on catheter-related complications in this setting. METHODS: Prospective follow-up of consecutive PICCs inserted for intravenous (IV) antibiotics in adults with CF or with non-CF bronchiectasis at Cochin Hospital (Paris, France). RESULTS: Between March 2009 and December 2011, 182 PICCs were prescribed in 117 adults (67 CF and 50 non-CF patients). Ultrasound-guided placement of catheter was successful in 174/182 (95.6%) procedures; no insertion complication occurred. The mean ± SD catheter dwell time was 15 ± 9 days. No catheter-associated bloodstream infection occurred; main complications were symptomatic upper limb deep vein thrombosis (2%), catheter obstruction (18%) and persistent pain after catheter insertion (18%). Patients' satisfaction was high and PICC could be used to perform antibiotic courses in most patients. CONCLUSIONS: PICCs were generally safe for performing IV antibiotic courses in patients with CF or non-CF bronchiectasis, but prolonged pain and/or catheter obstruction occurred in approximately 20% of cases.

Value of 18-F-FDG PET/CT and CT in the Diagnosis of Indeterminate Adrenal Masses.

The purpose of this paper was to study the value of 18-FDG PET/CT and reassess the value of CT for the characterization of indeterminate adrenal masses. 66 patients with 67 indeterminate adrenal masses were included in our study. CT/MRI images and 18F-FDG PET/CT data were evaluated blindly for tumor morphology, enhancement features, apparent diffusion coefficient values, maximum standardized uptake values, and adrenal-to-liver maxSUV ratio. The study population comprised pathologically confirmed 16 adenomas, 19 metastases, and 32 adrenocortical carcinomas. Macroscopic fat was observed in 62.5% of the atypical adenomas at CT but not in malignant masses. On 18F-FDG PET/CT, SUVmax and adrenal-to-liver maxSUV ratio were significantly lower in adenomas than in malignant tumors. An SUVmax value of less than 3.7 or an adrenal-to-liver maxSUV ratio of less than 1.29 is highly predictive of benignity.

Lung and heart-lung transplantation for systemic sclerosis patients. A monocentric experience of 13 patients, review of the literature and position paper of a multidisciplinary Working Group.

Systemic sclerosis per se should not be considered as an a priori contraindication for a pre-transplantation assessment in patients with advanced interstitial lung disease and/or pulmonary hypertension. For lung or heart-lung transplantation, a multidisciplinary approach, adapting the pre-transplant assessment to systemic sclerosis and optimizing systemic sclerosis patient management before, during and after surgery should improved the short- and long-term prognosis. Indications and contraindications for transplantation have to be adapted to the specificities of systemic sclerosis. A special focus on the digestive tract involvement and its thorough evaluation are mandatory before transplantation in systemic sclerosis. As the esophagus is almost always involved, isolated gastro-oesophageal reflux disease, pH metry and/or manometry abnormalities should not be a systematic per se contraindication for pre-transplantation assessment. Corticosteroids may be harmful in systemic sclerosis as they are associated with acute renal crisis. A low dose corticosteroids protocol for immunosuppression is therefore advisable in systemic sclerosis.

Severe mitral stenosis as the first manifestation of systemic lupus erythematosus in a 20-year-old woman: the value of magnetic resonance imaging in the diagnosis of Libman-Sacks endocarditis.

We report a case of severe mitral stenosis caused by Libman-Sacks endocarditis, as an initial manifestation of systemic lupus erythematosus (SLE) in a 20-year-old woman. Cardiac magnetic resonance imaging (MRI) demonstrated a thickening of the mitral valve with basal endocardial thickening exhibiting defect on first-pass perfusion short-axis acquisition and delayed enhancement in keeping with extensive fibrous endocarditis. The patient underwent successful mechanical mitral valve replacement. This case illustrates that MRI is useful in diagnosing this recognised but uncommon cardiac complication of SLE and excluding differential diagnosis such as valve tumour and infective endocarditis with perivalvular abscesses.

Churg-Strauss syndrome cardiac involvement evaluated by cardiac magnetic resonance imaging and positron-emission tomography: a prospective study on 20 patients.

OBJECTIVE: Churg-Strauss syndrome (CSS) cardiac involvement is associated with a poor prognosis. Recently cardiac MRI (CMRI) has emerged as a promising technique to detect early CSS cardiac involvement. However, CMRI-detected myocardial delayed enhancement (MDE) could correspond to fibrosis or inflammation. Fluoro-2-deoxyglucose PET (FDG-PET) was previously used in other systemic diseases to distinguish between them. To determine whether the CMRI-MDE detected in CSS patients reflected fibrosis or myocardial inflammation, patients in CSS remission underwent FDG-PET. METHODS: Twenty consecutive CSS patients in remission (BVAS = 0) were recruited. Fourteen patients [eight men, six women; mean (S.D.) age 49 (9) years; mean disease duration 3.5 (2.9) years] with CMRI-detected MDE, and six patients [four men, two women; mean (S.D.) age 44 (15) years; mean disease duration 3.5 (5.3) years] with normal CMRI underwent FDG-PET. Segments with MDE on CMRI were analysed on FDG-PET images, with myocardial FDG hypofixation defining fibrosis and hyperfixation corresponding inflammation. RESULTS: Among the 14 patients with MDE on CMRI, FDG-PET showed 10 had hypofixation, 2 had hyperfixation and 2 had normal scans. CSS duration at the time of CMRI was shorter for patients with myocardial inflammation than in those with fibrosis. The six patients with normal CMRI had normal FDG-PET images. CONCLUSION: For CSS patients in remission, CMRI detected subclinical active myocardial lesions and could be recommended to assess cardiac involvement. However, because CMRI-detected MDE can reflect fibrosis or inflammation, FDG-PET might help to distinguish between the two.

Benefit of an early and systematic imaging procedure after cardiac arrest: insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry.

AIMS: Identification of the cause of out-of-hospital cardiac arrest (OHCA) is of paramount importance. We investigated the ability of our imaging strategy to provide an early etiological diagnosis of OHCA and the influence of this strategy on ICU survival. METHODS: Retrospective review of a prospectively acquired ICU database (01/2000-12/2010) including all OHCA patients without obvious extracardiac cause, for which an early diagnosis research was conducted (coronary angiography and/or brain and chest CT scan) within 24h after resuscitation. These procedures could be performed separately or be combined, according to a decision algorithm. RESULTS: Of the 1274 patients admitted after OHCA during this 10-year period, the imaging strategy was applied in 896 patients. Patients who benefited from coronary angiography and/or CT scan were admitted to our ICU after a median delay of 180 [130-220]min after resuscitation. Seven hundred and forty-five coronary angiographies were performed, of which 452 (61%) identified at least one significant coronary lesion deemed responsible for the OHCA. CT-scan was performed in 355 patients and provided a diagnosis in 72 patients (20%), mainly stroke (n=38) and pulmonary embolism (n=19). Overall, this strategy allowed early diagnosis in 524 patients (59%). ICU survival was significantly higher for patients with a diagnosis identified by coronary angiography as compared with CT-scan (43% vs 10%, p<0.001). CONCLUSION: The use of an early diagnosis protocol with immediate coronary angiography and/or CT scan provided the etiology of nearly two thirds of OHCA cases. In this large retrospective database, coronary angiography yielded a better diagnostic value than brain and/or chest CT-scan.

CT antegrade colonography to assess proctectomy and temporary diverting ileostomy complications before early ileostomy takedown in patients with low rectal endometriosis.

OBJECTIVE: The purpose of this study is to describe an imaging method based on a CT technique, CT antegrade colonography, for the evaluation of low anastomosis and to evaluate the value of CT antegrade colonography before early ileostomy closure after proctectomy in low rectal endometriosis. MATERIALS AND METHODS: One hundred ninety-five patients referred for low rectal endometriosis underwent proctectomy and were eligible for early ileostomy closure. All patients underwent standard antegrade fluoroscopy (n=77) or CT antegrade colonography (n=118) 8 days after surgery. The negative predictive values, positive predictive values, sensitivity, specificity, and likelihood ratio of standard antegrade fluoroscopy and CT antegrade colonography in detecting anastomotic leakage and abscesses were assessed. The reference standard for positive and negative examinations was based on clinical follow-up, imaging, surgical, or interventional procedure findings. RESULTS: Negative and positive predictive values for detecting anastomotic leakage were 100% (95% CI, 96.8-100%) and 100% (95% CI, 39.8-100%), respectively, for CT antegrade colonography and 98.6% (95% CI, 92.4-100%) and 100% (95% CI, 54.1-100%), respectively, for standard antegrade fluoroscopy. The negative and positive predictive values for detecting abscess were 100% (95% CI, 96.8-100%) and 100% (95% CI, 47.8-100%), respectively, for CT antegrade colonography and 97.3% (95% CI, 90.8-99.7%) and 100% (95% CI, 2.5-100%), respectively, for standard antegrade fluoroscopy. CONCLUSION: CT antegrade colonography may play a major role in the evaluation of low anastomosis protected by an ileostomy after proctectomy in low rectal endometriosis, leading to the development of a new strategy with early restoration of the intestinal continuity.