Fully automated preoperative segmentation of temporal bone structures from clinical CT scans.

Middle- and inner-ear surgery is a vital treatment option in hearing loss, infections, and tumors of the lateral skull base. Segmentation of otologic structures from computed tomography (CT) has many potential applications for improving surgical planning but can be an arduous and time-consuming task. We propose an end-to-end solution for the automated segmentation of temporal bone CT using convolutional neural networks (CNN). Using 150 manually segmented CT scans, a comparison of 3 CNN models (AH-Net, U-Net, ResNet) was conducted to compare Dice coefficient, Hausdorff distance, and speed of segmentation of the inner ear, ossicles, facial nerve and sigmoid sinus. Using AH-Net, the Dice coefficient was 0.91 for the inner ear; 0.85 for the ossicles; 0.75 for the facial nerve; and 0.86 for the sigmoid sinus. The average Hausdorff distance was 0.25, 0.21, 0.24 and 0.45 mm, respectively. Blinded experts assessed the accuracy of both techniques, and there was no statistical difference between the ratings for the two methods (p = 0.93). Objective and subjective assessment confirm good correlation between automated segmentation of otologic structures and manual segmentation performed by a specialist. This end-to-end automated segmentation pipeline can help to advance the systematic application of augmented reality, simulation, and automation in otologic procedures.

Influence of Carotid Siphon Anatomy on Brain Aneurysm Presentation.

BACKGROUND AND PURPOSE: Intracranial aneurysm is a devastating disease of complex etiology that is not fully understood. The purpose of this study was to assess the implications of carotid siphon anatomy for the formation and development of intracranial aneurysms. MATERIALS AND METHODS: Between January 2007 and May 2015, lateral view digital subtraction angiographic images of 692 consecutive patients with intracranial aneurysms treated in our department of interventional neuroradiology were reviewed and had their angles measured. Data on the location, presentation, and size of the lesions were collected and evaluated by multivariate analysis in relation to the measured angles. RESULTS: Of 692 aneurysms, 225 (32.51%) ruptured and 467 (67.49%) unruptured, 218 (31.50%) were in the carotid siphon and 474 (68.50%) were distal to the siphon, and the mean aneurysm size was 7.99 ± 6.95 mm. Multivariate analysis showed an association between angles of >15.40° and rupture (P = .005), postsiphon location (P = .034), and aneurysm size of >1.001 mm (P = .015). Multivariate analysis also showed that every 1-year increase in patient age produced an increase of 1.002 mm in aneurysm size (P = .015). CONCLUSIONS: There was a significant independent direct relation of greater anterior knee angle with intracranial aneurysms located distal to the carotid siphon, larger aneurysms, and greater risk of rupture. These findings may be associated with the hemodynamic interactions of blood flow and the curvature of the carotid siphon.

Information Needs of Cancer Patients and Perception of Impact of the Disease, of Self-Efficacy, and Locus of Control.

The aim of our study was to investigate the relationship between information needs and cancer patients' perceptions of the impact of the disease, self-efficacy, and locus of control. Using a standardized questionnaire, we obtained data from patients who attended a series of lectures. The questionnaire included questions on their information needs, sources of information, satisfaction with information, and short questionnaires on self-efficacy, perception of the disease, and locus of control of reinforcement. Data was obtained from 185 patients. Our results showed that the sources of information that were most often used were physicians (84 %), print media (68 %), and the Internet (59 %); online fora (7.5 %), non-medical practitioners (9.7 %), and telephone-based counseling (8.6 %) were only used by a minority. Patients with a high perception of their own control over the disease more often used any source of information available to them and were more often interested in acquiring additional information. Higher self-efficacy was significantly associated with the need for information on all topics. Patients with a higher external locus of control significantly more often used sources of information and had significantly more need for additional information. By contrast, there were no associations with an internal locus of control. Neither external nor internal locus of control showed any associations with satisfaction with information. Information needs seem to be higher in patients with a high external locus of control and low self-efficacy. Physicians, other professionals, and institutions that provide information may take these relationships into consideration for tailoring their services to patients.

Treatment of severe chronic venous insufficiency with ultrasound-guided foam sclerotherapy: a two-year series in a single center in Brazil.

OBJECTIVES: To portray the initial experience at a public health center of the Federal District of Brazil in the treatment of chronic venous insufficiency with ultrasound-guided foam sclerotherapy in patients in advanced stages of the disease. METHOD: Eighty-seven reports of patients in C5 and C6 stages, according to CEAP classification, were evaluated for clinical improvements, ulcer-healing rates, and complications of ultrasound-guided foam sclerotherapy. McNemar test was used for statistical analysis with the level of significance set at 5% (P-value, 0.05). RESULTS: The results showed high rates of ulcer healing (85%) and significant improvement of symptoms after treatment, such as pain, heaviness, fatigue, burning, paresthesia, and itching (P < 0.0001). CONCLUSIONS: An outpatient, low-cost and high-resolution technique, without the need for hospitalization and use of the operating room showed to be a safe and effective alternative for the treatment of varicose disease associated with severe chronic venous insufficiency.

Histopathologic evaluation of arterial wall response to 5 neurovascular mechanical thrombectomy devices in a swine model.

BACKGROUND AND PURPOSE: Five commercial devices are available for mechanical thrombectomy in acute ischemic stroke. This study evaluated and compared the resultant arterial damage from these devices. MATERIALS AND METHODS: Wall damage after 4 wall-contact devices (the Merci retriever, Catch thromboembolectomy system, and Solitaire FR revascularization devices of 4 and 6 mm) and 1 aspiration device (the Penumbra System) was evaluated in the superficial femoral arteries of 20 male swine. Each device was tested with and without intraluminal clot. Twenty control vessels were not subjected to any intervention. Acute histopathologic changes were evaluated. RESULTS: In the device samples, endothelial denudation (72.8 ± 29.4% versus 0.9 ± 1.9%, P < .0001), medial layer edema (52 ± 35.9% versus 18.1 ± 27.8%, P = .004), and mural thrombus (5.3 ± 14.2% versus 0%, P = .05) were found to a greater extent compared with the control samples. The aspiration device provoked more intimal layer (100 ± 79.1% versus 58.8 ± 48.9%, P = .27) and medial layer (75 ± 35.4% versus 46.3 ± 34.8%, P = .13) edema than the wall-contact devices. CONCLUSIONS: All devices caused vascular injuries extending into the medial layer. The aspiration device was associated with more intimal and medial layer edema, compared with the wall-contact devices except for the Catch thromboembolectomy system.

Carotid artery stenting in patients with symptomatic carotid stenosis: a single-center series.

OBJECTIVES: Carotid angioplasty with stenting (CAS) in patients with carotid stenosis (CS) has become more restricted in France especially since the disclosure of such studies as EVA-3S and Stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy (SPACE). This report is of a series of CS cases contraindicated for endarterectomy that underwent CAS at a French center of interventional neuroradiology. PATIENTS AND METHODS: Fifty-five patients with symptomatic CS more than 60% consecutively submitted to CAS between September 2008 and February 2011. The primary endpoint was either death or stroke within 30 days of the procedure; a secondary goal was to identify any possible factors that might have influenced the success and outcome of the intervention. RESULTS: The overall periprocedural stroke/death rate at 30 days was 5.4% (three out of 55 patients), with three non-disabling strokes and no deaths. Twenty-seven patients (49.1%) were treated with a cerebral protection device (CPD). Stent placement was achieved in all cases. Open- and closed-cell stents were implanted in 40 (72.7%) and 15 procedures (27.3%), respectively. Neither the use of a CPD, the carotid stent cell design nor any anatomical or technical factors were associated with a lower risk of stroke or death within 30 days of CAS. CONCLUSION: CAS in symptomatic patients with CS contraindicated for endarterectomy in this selected French series proved feasible and safe, with acceptable levels of morbidity. Use of a CPD, type of stent (open- or closed-cell), and anatomical and technical factors had no influence on the success of the procedure or the outcome within 30 days of the operation.

Initial experience of intracranial aneurysm embolization using the balloon remodeling technique with Scepter C, a new double-lumen balloon.

The balloon remodeling technique (BRT) was designed for endovascular treatment of wide-necked intracranial aneurysms. To date, the balloon catheters available have had a single lumen and suitable guidewires ranging from 0.010 to 0.012 inches. We describe the first case of aneurysm embolization using the BRT with the new double-lumen balloon catheter, Scepter C(®), navigable on a 0.014-inch wire, and discuss the benefit of such a device.

Endovascular treatment of tentorial dural arteriovenous fistulae.

Tentorial dural arteriovenous fistula (DAVF) is a rare vascular disease, which accounts for less than 4% of all cases of intracranial DAVF. Because of the high risk of intracranial hemorrhage, patients with tentorial DAVF need aggressive treatment. Management approaches are still controversial, and endovascular treatment has emerged as an effective alternative. In the current work, we describe our experience with the endovascular approach in the treatment of these deep and complex DAVF of the tentorium. Eight patients were treated between January 2006 and July 2009. Six patients (75%) presented with intracranial hemorrhage related to the DAVF rupture. Four patients (50%) had subarachnoid bleeding and two had intraparenchymal hematoma. Endovascular treatment was performed via the transarterial route alone in five cases (62.5%), by the transvenous approach in two cases (25.0%) and in a combined procedure using both arterial and venous routes in one patient (12.5%). Complete obliteration of the fistula was achieved in all cases. The outcome at 15 months was favorable (modified Rankin scale 0-3) in seven (87.5%) patients. Complete cure of the lesion was confirmed in these cases. This paper reports on the effectiveness of endovascular treatment in tentorial DAVF management. The choice of the venous versus the arterial approach is determined by regarding different anatomical dispositions.

Preoperative onyx embolization of meningiomas fed by the ophthalmic artery: a case series.

Embolization of head and neck hypervascular tumors is a well-established therapeutic technique. Preoperative embolization reduces intraoperative blood loss, shortens the length of surgery, and decreases surgical morbility and mortality. This study assesses the safety and efficacy of preoperative embolization of meningiomas fed by the OPH by using Onyx liquid embolic agent.

Endovascular transvenous embolization combined with direct punction of the sinus pericranii. A case report.

SUMMARY: Sinus Pericranii is a rare venous anomaly in which the communication between the intra- and extracranial venous system is constituted by a network of thin-walled veins that form a varix on the external table of the skull. This varix is continuous with the pericranial veins of the scalp. We describe a 31-year-old woman with frontal sinus pericranii treated using an original endovascular technique by transvenous approach combined with direct punction.

Nidal embolization of brain arteriovenous malformations using Onyx in 94 patients.

BACKGROUND AND PURPOSE: To report our experience in the treatment of brain arteriovenous malformations (BAVMs) using Onyx (ev3, Irvine, Calif). PATIENTS AND METHODS: From January 1999 to October 2004, 94 patients with BAVMs were treated endovascularly in our department. They were 51 (54%) men and 43 (46%) women with a mean age of 32 years. A total of 210 endovascular procedures were performed with Onyx as the sole embolic agent in 88 procedures; Onyx and n-butyl cyanoacrylate (n-BCA) were used in combination in 50 procedures, and n-BCA alone was used in 72 procedures. RESULTS: The course of endovascular treatment was completed in 53 patients. In 26 patients (49%, 26/53) an angiographic cure was achieved using embolization as the sole therapeutic technique. Seven (13%, 7/53) patients underwent a surgical resection of the residual BAVM nidus, 20 (38%, 20/53) patients underwent radiosurgical treatment after nidal size reduction <2 cm was accomplished by endovascular treatment. Further endovascular treatment was planned in 33 patients, whereas in 5 patients, the continuation of embolization was aborted due to difficult nidus catheterization. Procedure-related permanent neurologic deficits were observed in 8 (8.5%, 8/94) patients. There were 3 procedure-related deaths. CONCLUSION: Onyx is suitable for brain BAVM embolizations and allows obtaining higher rates of anatomic cures compared with those obtained previously with other embolic agents.

Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement.

OBJECTIVE: To compare physician and patient impressions and interphysician diagnostic agreement between live teledermatology and in-person examinations. DESIGN: Paired video and in-person examinations with different dermatologists. SETTING: An urban Veterans Affairs dermatology clinic. PATIENTS: One hundred thirty-nine patients. MAIN OUTCOME MEASURES: Satisfaction questionnaires and interphysician diagnostic agreement. RESULTS: Patient and physician satisfaction was high. Agreement between video and in-person diagnoses was 80%. CONCLUSIONS: Physicians and patients were satisfied with teledermatology examinations. Diagnostic agreement between in-person and video dermatologists was high.

[Vascular stroke of the brain stem. Study of 21 cases]. / Acidente vascular de tronco encefálico. Estudo de 21 casos.

A prospective study was designed to follow patients with syndromes of brain stem during 12 months (in 1991-1992). The aim was to correlate clinical and radiologic findings and comparing them with the classical descriptions of brain stem syndromes. Twenty one consecutive patients were admitted at the Hospital de Base do Distrito Federal. The diagnosis and the follow up were carried out by neurological examination and neuroradiologic images: CT (100%), angiography (24%, 5) and MRI (5%, 1). Hypertension and old age were the most important risk factors and hemorrhage at pons with extension to midbrain was the most frequent finding. Coma at admission was associated to a poor outcome. The outcome was defined by the Glasgow Outcome Scale: 28% rated 5, 24% rated 4, 5% rated 3, 28% rated 2 and 14% rated 1. Our results show that the clinical presentation of ischemic strokes and hemorrhages of the brain stem very frequently follow a mixed pattern, which do not conciliate with the classical of these syndromes.

Epidemiological considerations in the role of dendritic/Langerhans cells in human cancer.

The roles of dendritic or Langerhans cells in human neoplasia have been studied in animal models and human subjects for some years. Much has already been learned concerning the operative immunological processes, relationships with other components of the reticuloendothelial system, and correlations with genetics and the aging process. Unfortunately, the present requirement for microscopic examination of human tissues to assay these cells greatly limits the types of study which can be under-taken and their scope. Investigations must presently be limited to human cancers occurring in readily accessible sites such as the uterine cervix, urinary bladder and skin. In the future, it is anticipated that new experimental approaches can be developed which permit the measurement of DC/LC activity levels without the need for biopsy specimens, thus greatly enhancing research possibilities in the important arena of biomedical investigation.

A muscarinic receptor different from the M1, M2, M3 and M4 subtypes mediates the contraction of the rabbit iris sphincter.

In order to analyse the subtype of muscarinic receptors involved in the methacholine-induced contraction of the rabbit iris sphincter we have determined equilibrium dissociation constants (KB) of various antagonists in the sphincter muscle. The values were compared with those observed at M1 (rabbit vas deferens), M2 (heteroreceptors in rat iris) and M3 receptors (guinea-pig ileum), or at the muscarinic receptors in the guinea-pig uterus. The methacholine-induced contraction of the uterus from immature guinea-pigs was competitively antagonized by pirenzepine (6.64, -log KB), 4-DAMP (8.39), hexahydrodifenidol (HHD; 7.00 for the (R)- and 5.40 for the (S)-enantiomer), p-fluoro-hexahydrosiladifenidol (p-F-HHSiD; 6.25) and valethamate bromide (8.04). The affinity of the antagonists is consistent with the presence of an M2 receptor. The -log KB values of the antagonists in the rabbit iris sphincter (6.43, p-F-HHSiD; 6.22, AQ-RA 741; 7.23 and 5.34, (R)- and (S)-trihexyphenidyl) were lower than, or within the lowest range of, estimates in the other experimental models, irrespective of the subtype selectivity of the antagonist. This excludes the presence of an M1, M2, M3 or M4 receptor in this smooth muscle. The affinity of UH-AH 37 in the iris was intermediate between that for M1 or M3, and M2 receptors. The low affinity of AQ-RA 741 and the low enantiomeric ratio of trihexyphenidyl (THP) in the iris (77.6) would be compatible with a presumed M5 receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

A community laboratory for studies on low-risk cancer agents.

This paper presents the concepts underlying the establishment of a community epidemiological laboratory that could serve the diverse needs of investigators worldwide who are involved in a variety of studies on low-risk lung cancer agents. The desiderata for selecting a specific geographically defined community are suggested together with a discussion of practical applications.

Disseminated intravascular coagulopathy and adult respiratory distress syndrome: life-threatening complications of hysteroscopy.

A 23-year-old, healthy woman underwent hysteroscopy during which Hyskon solution was injected into the uterine cavity. Soon afterward she developed a bleeding coagulopathy followed by acute respiratory insufficiency and pulmonary edema, necessitating endotracheal intubation and artificial ventilation with positive end-expiratory pressure. This rare complication of hysteroscopy was most probably due to the injection of Hyskon solution.

Arthrolysis of the elbow. 13 cases of posttraumatic stiffness.

On an average 5 years after arthrolysis for posttraumatic stiffness of 13 elbows, motion was good in eight, fair in three, and poor in two. The poor cases were reoperated on with unsatisfactory results.

Predictors of rehabilitation outcome among patients with SCI.

Because rehabilitation medicine has undergone major changes with respect to patient management and case mix since 1980, it is important to determine whether the factors predictive of rehabilitation outcomes also have changed over time.

[Metroplasty in congenital uterine malformations].

44 women with congenital uterine malformations, aged 22-39, underwent metroplasty during a 19-year period. They constituted 7.3% of all patients with such malformations diagnosed during that period. Indications were a high rate of spontaneous abortions (78.3%), and low rates for term deliveries (9.3%) and live children (11.8%) among 163 pregnancies. The operations were tailored to the uterine malformations; some were by the abdominal route and others involved hysteroscopic resection of a uterine septum (13 cases). After metroplasty, in 52 pregnancies the abortion rate was reduced to 26.9%, and term deliveries increased to 59.6% and neonatal survival to 69.2% (for all 3, p less than 10(-8)). It is concluded that a poor obstetric history is an indication to search for uterine malformations, and that if found, there is a clear indication for metroplasty. The surgeon must know the types of malformations and should be well acquainted with the different operative techniques.