Delayed Contrast-Enhanced MR Angiography for the Assessment of Internal Carotid Bulb Patency in the Context of Acute Ischemic Stroke: An Accuracy, Interrater, and Intrarater Agreement Study.

BACKGROUND AND PURPOSE: CTA has shown limited accuracy and reliability in distinguishing tandem occlusions and pseudo-occlusions on initial acute stroke imaging. The utility of early and delayed contrast-enhanced MRA in this setting is unknown. We aimed to assess the accuracy and reliability of early and delayed contrast-enhanced MRA for carotid bulb patency in patients with acute ischemic stroke. MATERIALS AND METHODS: We retrospectively reviewed patients who had ICA occlusion and underwent thrombectomy with preprocedural early and delayed contrast-enhanced MRA in a single comprehensive stroke center. During 2 sessions, 10 raters independently assessed 32 cases with early contrast-enhanced MRA (with an additional delayed contrast-enhanced MRA sequence during the second reading session). Their judgments were compared with DSA as a reference standard. Accuracy and interrater agreement were measured. Five raters undertook a third reading session to assess intrarater agreement. RESULTS: Accuracy for the assessment of carotid bulb patency with early contrast-enhanced MRA was limited (69%; 95% CI, 59%-79%), with moderate interrater agreement (κ = 0.42; 95% CI, 0.27-0.55). The second reading with an additional delayed contrast-enhanced MRA sequence improved both accuracy (82%; 95% CI, 73%-91%; P < .001) (raters corrected 43%-77% of incorrect diagnoses with early contrast-enhanced MRA alone; mean = 59%) and interrater agreement (κ = 0.56; 95% CI, 0.41-0.73; P = .07). Intrarater agreement was almost perfect, substantial, and moderate for 3, 1, and 1 raters. CONCLUSIONS: Early contrast-enhanced MRA has limited accuracy and repeatability for the evaluation of carotid bulb patency in acute ischemic stroke. The additional delayed contrast-enhanced MRA sequence may improve accuracy and reliability.

Blood Flow Mimicking Aneurysmal Wall Enhancement: A Diagnostic Pitfall of Vessel Wall MRI Using the Postcontrast 3D Turbo Spin-Echo MR Imaging Sequence.

Our aim was to compare the detectability of aneurysmal wall enhancement in unruptured intracranial aneurysms between conventional and motion-sensitized driven equilibrium-prepared postcontrast 3D T1-weighted TSE sequences (sampling perfection with applicationoptimized contrasts by using different flip angle evolution, SPACE). Twenty-two patients with 30 unruptured intracranial aneurysms were scanned at 3T. Aneurysmal wall enhancement was more significantly detected using conventional compared with motion-sensitized driven equilibrium-prepared SPACE sequences (10/30 versus 2/30, P < .0001). Contrast-to-noise ratio measurements did not differ between conventional and motion-sensitized driven equilibrium-prepared sequences (P = .51). Flowing blood can mimic aneurysmal wall enhancement using conventional SPACE sequences with potential implications for patient care.

Contrast-Enhanced and Time-of-Flight MRA at 3T Compared with DSA for the Follow-Up of Intracranial Aneurysms Treated with the WEB Device.

BACKGROUND AND PURPOSE: Imaging follow-up at 3T of intracranial aneurysms treated with the WEB Device has not been evaluated yet. Our aim was to assess the diagnostic accuracy of 3D-time-of-flight MRA and contrast-enhanced MRA at 3T against DSA, as the criterion standard, for the follow-up of aneurysms treated with the Woven EndoBridge (WEB) system. MATERIALS AND METHODS: From June 2011 to December 2014, patients treated with the WEB in our institution, then followed for ≥6 months after treatment by MRA at 3T (3D-TOF-MRA and contrast-enhanced MRA) and DSA within 48 hours were included. Aneurysm occlusion was assessed with a simplified 2-grade scale (adequate occlusion [total occlusion + neck remnant] versus aneurysm remnant). Interobserver and intermodality agreement was evaluated by calculating the linear weighted κ. MRA test characteristics and predictive values were calculated from a 2 × 2 contingency table, by using DSA data as the standard of reference. RESULTS: Twenty-six patients with 26 WEB-treated aneurysms were included. The interobserver reproducibility was good with DSA (κ = 0.71) and contrast-enhanced-MRA (κ = 0.65) compared with moderate with 3D-TOF-MRA (κ = 0.47). Intermodality agreement with DSA was fair with both contrast-enhanced MRA (κ = 0.36) and 3D-TOF-MRA (κ = 0.36) for the evaluation of total occlusion. For aneurysm remnant detection, the prevalence was low (15%), on the basis of DSA, and both MRA techniques showed low sensitivity (25%), high specificity (100%), very good positive predictive value (100%), and very good negative predictive value (88%). CONCLUSIONS: Despite acceptable interobserver reproducibility and predictive values, the low sensitivity of contrast-enhanced MRA and 3D-TOF-MRA for aneurysm remnant detection suggests that MRA is a useful screening procedure for WEB-treated aneurysms, but similar to stents and flow diverters, DSA remains the criterion standard for follow-up.

Retrospective Analysis of Delayed Intraparenchymal Hemorrhage after Flow-Diverter Treatment: Presentation of a Retrospective Multicenter Trial.

BACKGROUND AND PURPOSE: Intracranial aneurysm treatment with flow diverters has shown satisfying results in terms of aneurysm occlusion, and while some cases of delayed intraparenchymal hemorrhage have been described, no systematic analysis of the risk factors affecting its occurrence has been conducted in a large series of patients. This retrospective analysis of delayed intraparenchymal hemorrhage after flow-diverter treatment is a multicenter, retrospective study using a large series of treated patients to analyze factors affecting the occurrence of delayed intraparenchymal hemorrhage. MATERIALS AND METHODS: Patients treated with flow diverters and presenting with delayed intraparenchymal hemorrhage were included from December 2007 to December 2014 in 7 participating centers in France. Patient and aneurysm characteristics were recorded as were characteristics of bleeding (size, lateralization, and time to bleed), treatment, and clinical outcome after 1, 3, and 6 months. RESULTS: Delayed intraparenchymal hemorrhage occurred in 11 patients between 1 and 21 days after the procedure. In 10 of these patients, hemorrhages were ipsilateral to the treated aneurysms. Five of the 11 underwent surgery, and 9 of the 11 had good clinical outcomes at 6 months (mRS ≤2). CONCLUSIONS: The pathogenesis of delayed intraparenchymal hemorrhage occurring after flow-diverter treatment remains unclear. The multidisciplinary management of delayed intraparenchymal hemorrhage yields a relatively low morbidity-mortality rate compared with the initial clinical presentation.

[Pitfalls for renogram interpretation in pediatric urology]. / Biais d'interprétation de la scintigraphie rénale chez l'enfant.

Renograms are currently used for functional assessment by pediatric urologists. The aim of the present work was to focus on the potential pitfalls concerning renography. Potential confounding factors are described in reference to concrete cases. The main types of pitfalls concern venous or urinary catheters and background area definition. Protocols and renogram interpretation are critiqued in a bibliographic review. We propose a technical update and original data on the potential pitfalls in renography interpretation. Multidisciplinary discussion between nuclear medicine, pediatrics and pediatric surgery departments is required before drawing conclusions.

WEB intrasaccular flow disruptor-prospective, multicenter experience in 83 patients with 85 aneurysms.

BACKGROUND AND PURPOSE: The safety and efficacy of WEB flow disruption have been analyzed in small, retrospective series. The object of this study was to evaluate the safety and efficacy of WEB flow disruption in a large, multicenter, prospectively collected population. MATERIALS AND METHODS: Data from all patients treated with the WEB-DL device between June 2011 and October 2013 in 11 French neurointerventional centers were prospectively collected and retrospectively analyzed. Complications occurring during and after treatment were analyzed as well as morbidity and mortality at 1 month. Aneurysm occlusion status at the last follow-up was analyzed. RESULTS: Eighty-three patients with 85 aneurysms were included in this series. Technical success was achieved in 77 patients with 79 aneurysms (92.9%). Periprocedural complications were observed in 9 patients (10.8%), leading to permanent neurologic deficits in 3 (3.9%). Morbidity and mortality at 1 month were 1.3% and 0.0%, respectively. Angiographic follow-up was performed for 65/79 aneurysms (82.3%) 3-24 months after treatment (mean, 5.3 months). Complete aneurysm occlusion was observed in 37/65 aneurysms (56.9%); neck remnant, in 23/65 (35.4%); and aneurysm remnant, in 5/65 (7.7%). CONCLUSIONS: In this large prospective series of patients, WEB flow disruption was a safe and efficient technique.

Anterior ischemic optic neuropathy complicating interferon alpha and ribavirin therapy in patients with chronic hepatitisC.

Ophthalmological complications with interferon therapy are rare, usually mild and reversible, and do not require the withdrawal of antiviral treatment. Anterior ischemic optic neuropathy is an uncommon complication of interferon treatment. From January 1998 to December 2007, three patients developed anterior ischemic optic neuropathy during antiviral treatment, with a favourable course after interferon was discontinued. Periodic Ophthalmological examinations, including visual acuity and fundus examinations should be performed before starting and during treatment, particularly in patients with vascular risk factors. Antiviral therapy should be stopped immediately if severe ophthalmologic complications occur.

Thyroid disorders during interferon alpha therapy in 625 patients with chronic hepatitis C: a prospective cohort study.

AIM: to report the prevalence, risk factors, management and long-term outcome of thyroid disorders caused by INFalpha in patients with chronic hepatitis C. PATIENTS AND METHODS: From January 1991 to December 2004, 625 patients with chronic hepatitis C underwent INFalpha therapy. TSH assay was normal and antithyroperoxidase antibodies (anti-TPO) was performed before onset antiviral treatment; then TSH was performed every 2 months in all patients during therapy, and every 3 months after treatment. RESULTS: 58 patients developed thyroid disorder (8.9%). Mean age was 50.6+/-13 years; sex ratio: 1 M/2 F; the anti-TPO antibodies were positive before onset antiviral treatment in 9 patients (13.8%). 26 patients developed hypothyroidism (44.8%), 9 patients developed hyperthyroidism (15.5%) and among them 3 cases of Grave's disease. Biphasic thyroiditis occurred in 21 patients (36.2%), anti-TPO increase during treatment in 2 patients (3.5%) without hypothyroidism. The dysthyroidism was more frequent in risk in female gender (p<0.05) and in the group with positive antiTPO antibodies before treatment (p<0.02). CONCLUSION: Female gender and positive antiTPO antibodies are the predictive factors of development of the thyroid dysfunction during INFalpha therapy.

[Hepatitis C and diabetes mellitus: effect of diabetes on the course of the liver disease]. / Hépatite virale C et diabète: influence du diabète sur l'évolution de l'hépatopathie.

UNLABELLED: The prevalence of diabetes mellitus is higher in chronic hepatitis C than in hepatitis B, even without cirrhosis. OBJECTIVE: To study the host, specific viral factors associated with diabetes mellitus and the influence of diabetes mellitus on the intensity of steatosis and the severity of fibrosis. MATERIAL AND METHODS: The following data were collected in a cohort of 1249 patients with chronic hepatitis C established between December 1991 and June 2004: age, gender, body mass index (BMI). None of the patients were under treatment for their liver disease. Serum transaminase level and hepatitis C serology with search for viral RNA, viral load and genotype were obtained. The Metavir score, iron overload using the Perls score (0-4) and steatosis class (0-3) were determined on liver biopsies. RESULTS: Mean patient age was 52.5+/-10 years (56% male). Mean BMI was 24.6+/-24 kg/m2. Forty-three patients (17.2%) presented diabetes mellitus. The mean duration of their diabetes was 8.9 years. Genotype 1 predominated (60.4%) and mean viral load was 7.7x10(6) eq.v/ml. Steatosis was present in 69.7% of the diabetic patients versus 17% of the non-diabetic patients. Grade 2 fibrosis (F2) was observed in 32.5% of diabetic patients versus 29% in non-diabetic patients and F3, F4 in 73% of the diabetic patients versus 57% of the non-diabetic patients. Comparison between diabetic and non-diabetic patients demonstrated an absence of statistically significant difference (at 5%) between the groups for gender, viral load and genotype. Diabetic persons were older (58.7 years against 51 years) and liver biopsy revealed steatosis and fibrosis (F3, F4) more often in diabetic patients (69.7% versus 49.5%). CONCLUSION: These findings suggest that steatosis could favor progression of fibrosis in diabetics with chronic hepatitis C.

[Primary hyperparathyroidism presenting as a brown tumor of the maxilla and hard palate. Apropos of a case]. / Hyperparathyroïdie primaire révélée par des tumeurs brunes des maxillaires et du palais osseux. A propos d'un cas.

Significant controversy persists in the classification of giant cell lesions of the maxillofacial skeleton. Multifocal giant cell lesions are strongly suggestive of hyperparathyroidism brown tumors. Maxillary localization is extremely rare. We report a case of primary hyperparathyroidism manifesting in the form of giant cell tumors of the maxilla, the hard palate and long bones. Biochemistry confirmed the diagnosis. Computed tomography localized the parathyroid tumor at the cervicothoracic junction in the retrosternal area. We discuss the clinical features of skeletal involvement in primary hyperparathyroidism and stress the need for ionized serum calcium assay in case of giant cell tumors of the cranial bones.

The tension-free transvaginal tape procedure in the treatment of female urinary stress incontinence: a French prospective multicentre study.

OBJECTIVE: To evaluate in a prospective multicentre study (five centres) the preliminary results regarding efficacy and morbidity of the new tension-free transvaginal tape (TVT) technique in the treatment of urinary stress incontinence (USI) in women. METHODS: From November 1996 to May 1999, 52 women of mean age 64 (range 37--91) years underwent the TVT procedure to treat isolated grade 2 or 3 USI (44 cases) or grade 1 or 2 USI associated with uterine or rectal prolapse surgery (8 cases). Twenty-nine patients (55.8%) presented recurrent USI (1--4 previous procedures). Clinical data showed urethrovesical junction hypermobility in 35 cases (67.3%), isolated intrinsic sphincter deficiency (ISD) in 17 cases (32.6%) and pelvic organ prolapse in 8 cases. Urodynamics confirmed ISD in 27 cases (51.9%) with a mean urethral closure pressure of 18.5 (range 7--25) cm H(2)O. All data were collected by surgeons on a questionnaire. RESULTS: The surgical procedure was performed under spinal cord anaesthesia in 82.7% of patients (local anaesthesia 11.5%) with a mean operation time of 30 (range 20--60) min for TVT implantation. Six bladder injuries (11.5%) were identified and the needle was repositioned. Mean hospital stay was 2.5 (range 1-7) days in the group who underwent TVT alone. Mean follow-up of continence was 15.2 (range 6--36) months: 83% of patients were dry and 17% were improved. Nine patients (17.3%) required self-catheterization for 2--10 days postoperatively. No recurrence of USI, defect healing or tape rejection were reported. CONCLUSION: TVT is a new technique for the surgical treatment of USI which is useful for recurrent cases. The advantages are simplicity, low morbidity, reproducibility and reduced operative time. These early results indicate the technique is effective in correcting incontinence and is locally well tolerated. But these are preliminary data and the long-term outcome on USI and the urethra is needed.

[Acute involuntary intoxication with gamma-hydroxybutyric acid]. / Intoxication aiguë involontaire à l'acide gamma-hydroxybutyrique (gamma-OH).

Dangerous misuse of anaesthetic drugs is illustrated in a case of gamma-hydroxybutyrate (gamma-OH) poisoning. A 36-year-old patient, coming from USA ingested approximately 200 mL of a liquid. He presented a non reactive coma (Glasgow coma scale at 3), abnormal movements, hypotension and bradycardia. Outcome was favorable with symptomatic treatment including tracheal intubation and ventilation. The patient was discharged 24 hours later. This case was a typical gamma OH poisoning. Its consumption is current in the United States for body-builders. Poisoning was involuntary, due to a dilution mistake. Toxicological analysis assessed this diagnostic. Such poisoning is exceptional in France.

[Measurement of carbon monoxide in expired breath in prehospital management of carbon monoxide intoxication]. / Intérêt du dosage du monoxyde de carbone dans l'air expiré au cours de la prise en charge préhospitalière des intoxications oxycarbonées.

INTRODUCTION: Carbon monoxide detectors are currently used by the French prehospital medical teams. These detectors can also be used to measure expired breath carbon monoxide concentration. The interest of this measurement has never been studied. OBJECTIVE: To evaluate interest of expired breath carbon monoxide concentration measurement in the management of prehospital carbon monoxide intoxication. STUDY DESIGN: Patients with carbon monoxide poisoning were included during 1998. PATIENTS AND METHODS: Four levels of clinical severity: no symptom, minor, medium or severe intoxication were defined. Carbon monoxide concentration were measured in the expired breath (COHbe) at the place of the intoxication and in blood samples collected at the place of the intoxication (COHbs) and at the hospital (COHbh). RESULTS: 209 patients were included, 144 had no symptom (55%), the value of COHbe was 11.6 +/- 7.5% (mean +/- DS) and the value of COHbh was 4.9 +/- 3.3%. 91 patients had minor intoxication (35%), the value of COHbe was 16.4 +/- 7.9% and the value of COHbh was 7.1 +/- 4.5%, 21 patients had sever or medium intoxication (8%) the value of COHbe was 26.4 +/- 17.7% and the the value of COHbh was 12.8 +/- 9.3%. Results for COHbh were obtained for only three patients. Relationship between symptoms and expired breath carbon monoxide and relationship between symptoms and carbon monoxide blood concentration on arrival at the hospital were significant (p < 0.05). CONCLUSION: Measurement of expired carbon monoxide concentration, easy and quick to perform is correlated with clinical severity in carbon monoxide poisoning.

[Acute verapamil poisoning. A proposal of a strategy for therapeutic management]. / Intoxication aiguë par le vérapamil. Proposition d'une stratégie de prise en charge thérapeutique.

Verapamil poisonings are rare, but are associated with a high proportion of deaths. The authors present a case of acute poisoning by verapamil associated with collapsus and a high degree of heart block. They propose a strategy for therapeutic management based on the study of calcium-channel blocker mechanisms of toxicity.

[Spondylodiscitis in subacute bacterial endocarditis. Apropos of a case]. / Spondylodiscite oslérienne. A propos d'un cas.

Occurring of spondylodiscitis as first manifestation of bacterial endocarditis in an uncommon condition. About fifty cases are reported in the literature. Such association makes imperious the regular examination of the heart of patients with spondylodiscitis and spine radiography when a vertebral pain is found to be present in patients with bacterial endocarditis. An additional case is her by reported.