Spontaneous haemothorax caused by a ruptured pulmonary arterio-venous malformation: A manifestation of hereditary haemorrhagic telangiectasia in pregnancy.

We report our experience of managing a massive haemothorax caused by a ruptured, previously unknown, pulmonary arteriovenous malformation (pAVM) at 34 + 5 weeks of gestation, which proved to be a manifestation of hereditary haemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. The patient underwent an emergency caesarean section under general anaesthesia after placement of a chest tube and gave birth to a healthy infant. A postoperative thoracic computed tomography angiography highlighted the presence of the large pAVM. Transcatheter embolization was performed right after the delivery. Subsequent patient's anamnesis, family history and genetic analysis finally revealed the presence of the syndrome. The aim of our report is to create awareness of this serious condition with potential life-threatening complications, especially in pregnancy. Simple criteria have been published and allow to easily consider HHT and the presence of potential AVM during anamnesis, ideally even before pregnancy.

Haemothorax in a Pregnant Woman Secondary to Rupture of a Pulmonary Arteriovenous Malformation.

Pulmonary arteriovenous malformations (PAVMs) are abnormal communications between the arteries and veins of the pulmonary vasculature leading to a right-to-left shunt. We report the case of a pregnant patient who presented with chest pain revealing a haemothorax secondary to the rupture of an arteriovenous malformation. The diagnosis was made during arteriography after simultaneous performance of an urgent caesarean section and thoracic drainage. LEARNING POINTS: The rupture of a pulmonary arteriovenous malformation in a pregnant patient is a serious and potentially life-threatening event, especially if it is not diagnosed quickly.It is crucial to use whatever imaging test is available whether ionizing or non-ionizing, as no thoracic imaging has been shown to adversely affect the fetus beyond embryogenesis.It is important for emergency doctors to consider this life-threatening condition in the differential diagnosis of atypical chest pain in pregnant women.

Non-Neurological Complications after Mechanical Thrombectomy for Acute Ischemic Stroke: A Retrospective Single-Center Study.

Introduction: The global burden of stroke is high and mechanical thrombectomy is the cornerstone of the treatment. Incidences of acute non-neurological-complications are poorly described. Improve knowledge about these complications may allow to better prevent, detect and/or manage them. The aim is to identify risk markers of death or poor evolution. Method: We conducted a retrospective single-center study to analyzed the incidence of non-neurologicalcomplications after mechanical thrombectomy in acute ischemic stroke. Patients who had experienced a stroke and undergone thrombectomy were identified using a registry in which we prospectively collected data from each patient admitted to our hospital with a diagnosis of stroke. Quantitative and qualitative variables were analyses. The association between studied variables and hospital death was assessed using simple logistic regression models. Result: 361 patients were reviewed but 16 were excluded due to a lack of medical information. Between 2012 and 2019, 345 patients were included. The median admission NIHSS score was 15. Seven percent of the patients died in the ICU. The following independent risk markers of death in the ICU were identified by logistic regression: respiratory complication, hypotension, infectious complication, and hyperglycemia. Conclusion: In this large retrospective study of stroke, respiratory complications and pulmonary infections represented the most important non-neurological adverse events encountered in the ICU and associated with a risk of death.

Periprocedural safety and technical outcomes of the new Silk Vista Baby flow diverter for the treatment of intracranial aneurysms: results from a multicenter experience.

PURPOSE: The aim of our study was to assess the technical success and the safety of this new low-profile flow diverter Silk Vista Baby (SVB) by evaluating the intraprocedural and periprocedural complication rate. MATERIAL/METHODS: Clinical, procedural, and angiographic data were analyzed. RESULTS: 41 consecutive patients (28 women; age average 50.5 years) with 43 aneurysms were treated with SVB. Aneurysm sizes were classified by their maximum diameter, with an average size of 9.5 mm (range 2-30 mm). Thirty-four cases were unruptured. five aneurysms previously ruptured, had recurrence after the initial coiling. There were two ruptured cases. Aneurysms' locations were: M1 segment (five cases), M2 segment (three cases), M3 segment (one case), middle cerebral artery (MCA) bifurcation (six cases), carotid-T (two cases), anterior communicating artery/A1/A2 (11 cases), pericallosal artery (four cases), supraclinoid ICA (two cases), PCom (one case), V4 segment (three cases), PCA (three cases), SCA (one case), and PICA (one case). We had five intraprocedural complications which resolved without clinical consequences and three events postprocedural events. Initial occlusion rates were: eight aneurysms (18.6%) were completely occluded, five aneurysms (11.6%) showed near-complete occlusion, four cases (9.3%) showed incomplete filling, and 26 cases (60.4%) showed persisting filling. The mRS score at discharge from the hospital did not change from the admission mRS score. CONCLUSION: Our study demonstrated that the use of the new low-profile flow diverter, SVB device, for the treatment of intracranial aneurysms is feasible and technically safe.

Endovascular treatment of intracranial aneurysms with the Woven EndoBridge device: mid term and long term results.

PURPOSE: To evaluate the clinical and anatomical results of treatment of intracranial aneurysms (IA) with the Woven EndoBridge (WEB) device, with emphasis on mid term and long term follow-up. METHODS: Between November 2010 and November 2015, we retrospectively identified, in our prospectively maintained database, all patients treated by WEB device placement for an IA at three institutions. Clinical charts, procedural data, and angiographic results were reviewed. RESULTS: 48 patients with 49 IAs were identified. There were 35 women and 13 men with a mean age of 57 years (range 35-76 years). All IA were wide necked. Mean aneurysm size was 8.6 mm. There were 44 unruptured IA and 5 ruptured IA. During endovascular treatment (EVT), adjunctive devices were used in 22.4% of procedures. A good clinical outcome (modified Rankin Scale score ≤2) was achieved in 44/48 patients (92%). There was no mortality. Mean follow-up was 25 months (range 3-72 months; median 24 months). Between mid term and long term follow-up, occlusion was stable in 19/23 IA (82.6%), improved in 2/23 IA (8.7%), and worsened in 2/23 IA (8.7%). Retreatment was performed in 8/49 IA (16.3%). At the latest available follow-up, there were 34/47 (72.3%) complete occlusions and 13/47 (27.7%) neck remnants. CONCLUSIONS: Our study suggests that EVT of IA with the WEB device provides adequate and stable long term occlusion.

Mechanical endovascular thrombectomy for acute ischemic stroke: a retrospective multicenter study in Belgium.

Clinical trials have shown a beneficial effect of mechanical thrombectomy in acute ischemic stroke patients treated within six up to even 12 h after symptom onset. This treatment was already performed in selected hospitals in Belgium before completion of the randomized controlled trials. Outcome data on these procedures in Belgium have not been published. We performed a retrospective multicenter study of all patients with acute ischemic stroke treated with mechanical endovascular therapy in four hospitals in Belgium. Clinical outcomes, as measured by the modified Rankin Scale (mRS), site of arterial occlusion, reperfusion and the association between these variables were studied. The study included 80 patients: 65 patients with an occlusion in the anterior circulation and 15 with an occlusion in the posterior circulation. Good functional outcome (GFO) rates, defined as mRS 0-2 at 90 days, were 42 % in all patients, 44 % in anterior circulation stroke and 34 % in posterior circulation stroke. Reperfusion was achieved in 78 % of patients; more (100 %) in patients with posterior compared to patients with anterior circulation stroke (72 %; p = 0.02). The rate of GFO was greater in patients with reperfusion versus patients in whom reperfusion was not achieved (adjusted OR 8.2, 95 % CI 2.0-34.2). Symptomatic intracerebral hemorrhage was documented in 5 % of all patients. Endovascular treatment with mechanical devices for acute ischemic stroke in Belgium results in GFO and reperfusion rates similar to recently published results in the endovascular-treated arms of randomized clinical trials. Rates of symptomatic intracranial hemorrhage are low and comparable to other cohort studies and clinical trials.

Stent-assisted coiling of unruptured intracranial aneurysms: long-term follow-up in 164 patients with 183 aneurysms.

PURPOSE: Stent-assisted coiling (SAC) is increasingly used to treat complex unruptured intracranial aneurysms (UIA) including wide-necked and fusiform IA. However, few data are available over the long-term results of this technique. We report our 9-year-experience of SAC of UIA. METHODS: A retrospective review of our prospectively maintained database identified all patients treated by SAC for an UIA in 2 institutions. The clinical charts, procedural data and angiographic results were reviewed. RESULTS: Between 2004 and 2012, we identified 164 patients with 183 UIA. There were 115 women and 49 men with a mean age of 46 years. Embolization was successful in all patients. Procedural morbidity and mortality rates were 2.2% and 0% respectively. Immediate anatomical outcome included 54 complete occlusion (29.5%), 43 neck remnants (23.5%) and 86 incomplete occlusions (47%). Imaging follow-up was available in 137 patients (mean=26 months, range 3 to 99 months) and it showed 104 complete occlusions (75.9%), 23 neck remnants (16.8%) and 10 incomplete occlusions (7.3%). At follow-up, only 3 patients developed a significant intrastent stenosis, one of which was induced by radiosurgery. One of these patients had a symptomatic thrombo-embolic complication 3 years after stent placement. CONCLUSION: SAC of complex UIA is effective and associated with low complication rates. Even if immediate anatomical results are relatively unsatisfying, mid- and long-term follow-up show a major improvement with a high rate of adequate occlusion that is stable over time. Moreover, the long-term clinical and angiographic tolerance of intracranial stents is excellent.

Endovascular treatment of proximal superior middle cerebral artery aneurysms.

INTRODUCTION: Aneurysms superiorly located on the proximal segment of the middle cerebral artery (PMCAA) are rare and challenging to treat. No information is available regarding their management by endovascular approach. The aim of this study was to report our experience with endovascular treatment (EVT) of PMCAA. METHODS: A retrospective review of our prospectively maintained database identified all PMCAA treated in our institution. The clinical charts, procedural data, and angiographic results were reviewed. RESULTS: From April 2004 to December 2011, 17 patients were identified including six who presented with subarachnoid hemorrhage (SAH) and 11 with an unruptured PMCAA. All aneurysms were small (<6 mm) and had a branch arising from the neck or the sac, and 15/17 were wide-necked. All patients were successfully treated by balloon-assisted coiling (n = 10), stent-assisted coiling (n = 5), and coiling (n = 2). No technical or clinical complication occurred. Fifteen patients showed an excellent clinical outcome, and two kept a slight or a significant deficit that were both SAH-related. Immediate anatomical outcome includes nine complete occlusions and eight neck remnants. Imaging follow-up in 11 patients (mean = 21, range, 6 to 60 months) showed stable or improved results in all cases. CONCLUSION: Our study is the first reported series of patients with PMCAA treated by selective embolization. It suggests that EVT is a safe and effective alternative to surgery for the management of PMCAA. Balloon- or stent-assisted coiling are needed in most cases because of PMCAA morphological characteristics.

MR imaging of iron phagocytosis in intraluminal thrombi of abdominal aortic aneurysms in humans.

PURPOSE: To prospectively determine if superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging could help visualize leukocyte phagocytic activities in human abdominal aortic aneurysms (AAAs). MATERIALS AND METHODS: This study was approved by the institutional ethics committee; all patients gave informed consent. Preoperative MR imaging data, including unenhanced and SPIO-enhanced T1-, T2*-, and T2-weighted transverse images of the entire AAA, obtained 1 hour after contrast enhancement from 15 patients (mean age, 72.7 years +/- 8.2; range, 60-83 years), 10 men (mean age, 73.5 years +/- 7.9; range, 60-83 years) and five women (mean age, 71.2 years +/- 9.4; range 60-82), were retrospectively evaluated. Morphologic appearance and semiquantitative and contrast-to-noise ratio (CNR) analyses of the thrombi were performed. Thrombi were analyzed semiquantitatively at microscopy after staining with hematoxylin-eosin, CD68, and CD66b. Levels of promatrix metalloproteinase (pro-MMP)-2 and pro-MMP-9, MMP-2 and MMP-9, and their mRNA located in the thrombus were assessed by using zymography and quantitative reverse transcriptase polymerase chain reaction analysis. Nonparametric statistics of the Spearman rank correlation were calculated to evaluate correlations between the aneurysm thrombus signal level decrease after SPIO and the levels of CD68(+), CD66b(+) cells, pro-MMP-2 and pro-MMP-9, MMP-2 and MMP-9, and MMP-9 mRNA. RESULTS: The pre-SPIO CNRs in the luminal sublayer of the thrombus and the deeper thrombus were -10.20 +/- 12.69 and -5.68 +/-10.38, respectively. After SPIO, the CNRs decreased to -21.34 +/-13.07 (P < .001) and -12.44 +/- 14.56, respectively (P < .012). There was a significant linear correlation between the thrombus signal level decrease and the levels of CD68(+) and CD66b(+) cells, pro-MMP-9, and MMP-9 mRNA (P < .05). CONCLUSION: MR imaging allows in vivo demonstration of SPIO uptake at the luminal interface of the thrombus. This uptake is correlated to the abundance of leukocytes. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09090657/-/DC1.

A rare variant of persistent trigeminal artery: cavernous carotid-cerebellar artery anastomosis--a case report and a systematic review.

We report a very rare anomalous anatomic variant of the cavernous internal carotid artery supplying directly the posterior inferior cerebellar artery, with no basilar artery opacification. A systematic review as well as a description of other variants of trigeminal-cerebellar anastomosis is given.

Free-breathing accelerated gadolinium-enhanced MR Angiography in the Diagnosis of Renovascular Disease.

OBJECTIVE: The purpose of this study was to assess the feasibility and accuracy of accelerated free-breathing and breath-hold gadolinium-enhanced MR angiography of the main renal arteries compared with digital subtraction angiography. MATERIALS AND METHODS: Renal MR angiograms and catheter angiograms of 47 patients (19 men, 28 women; mean age, 68.1 +/- 15.1 years; range, 28-86 years) were reviewed. Thirty-one of the patients underwent free-breathing and 16 underwent breath-hold MR angiography with the same accelerated multiphase imaging protocol. Images were analyzed for examination quality, percentage narrowing of the main renal artery, and visibility of the branches. Diagnostic values of MR angiography were calculated with catheter angiography as the standard of reference. RESULTS: Sixty-five arteries, 24 of which (37%) had > 49% narrowing, were evaluated in the free-breathing group, and 37 arteries, six of which (16%) had > 49% narrowing, were evaluated in the breath-hold group. Comparison with digital subtraction angiography showed 100% (24/24) sensitivity and 95% (39/41) specificity for > 49% renal artery stenosis and 88% sensitivity (15/17) and 100% (48/48) specificity for > 74% renal artery stenosis in the free-breathing group. In the breath-hold group, sensitivity was 100% (6/6) and specificity 97% (30/31) for > 49% renal artery stenosis, and sensitivity was 100% (5/5) and specificity 100% (32/32) for > 74% renal artery stenosis. None of the examinations was nondiagnostic for the main renal arteries, but a smaller number of visible arterial tree subdivisions were found in the free-breathing group (average, 3.64 per patient) than in the breath-hold group (average, 5.87 per patient) (p = 0.035). CONCLUSION: Like breath-hold examinations, accelerated free-breathing MR angiographic examinations are feasible and accurate in evaluation of the main renal arteries.

Quadruple-phase MDCT of the liver in patients with suspected hepatocellular carcinoma: effect of contrast material flow rate.

OBJECTIVE: The purposes of this study were to evaluate the effect of contrast material flow rate (3 mL/sec vs 5 mL/sec) on the detection and visualization of hepatocellular carcinoma (HCC) with MDCT and the safety profile of iodixanol at different injection rates. SUBJECTS AND METHODS: In a prospective, randomized multicenter trial, 97 patients (83 men and 14 women, with a mean age of 64 years) suspected of having HCC underwent quadruple-phase (double arterial, portal venous, delayed phase) 4-16-MDCT. Patients were randomized to receive iodixanol, 320 mg I/mL (1.5 mL/kg body weight), at a flow rate of 3 mL/sec (48 patients) or 5 mL/sec (49 patients). Qualitative (lesion detection, image quality) and quantitative (liver and aortic enhancement, tumor-liver contrast) analyses and safety assessment were performed. RESULTS: Overall, 145 HCCs were detected in the 5 mL/sec group and 100 HCCs in the 3 mL/sec group (p < 0.05). More lesions equal to or less than 1 cm were detected at 5 mL/sec (33 vs 16 lesions). The late arterial phase showed significantly more lesions than the early, arterial phase (133 vs 100 and 96 vs 67 lesions, respectively, p < 0.0001). Hyperattenuating HCCs were better visualized in the late arterial phase at 5 mL/sec (excellent visualization: 54% vs 27%). Using a flow of 5 mL/sec did not increase the rate of patient discomfort or contrast media-related adverse events. Most discomfort in both groups was of mild intensity and there was no severe discomfort. CONCLUSION: For detection of HCC with MDCT, a higher flow rate of 5 mL/sec is recommended. Visualization of hyperattenuating HCC is improved with no greater discomfort or adverse events.