Assessment of Reversibility of Transverse Venous Sinus Stenosis in Patients With Papilledema.

BACKGROUND: Bilateral transverse venous sinus stenosis (TVSS) or stenosis of a dominant venous sinus has been found to be very sensitive radiological findings in patients with intracranial hypertension (IH), yet there is still an ongoing debate whether they constitute reversible or permanent phenomena. Thus, the purpose of this study was to investigate the reversibility of TVSS in patients with IH, including conservatively treated patients with signs of IH as defined by the presence of papilledema. METHODS: This was a retrospective chart review of all patients diagnosed with IH between 2016 and 2022, assessed from 2 tertiary university-affiliated neuro-ophthalmology practices. Inclusion criteria were the presence of papilledema, as quantified by optical coherence tomography, and bilateral TVSS, which is considered typical of IH on neuroimaging. During follow-up, included patients must have had confirmation of papilledema resolution as well as subsequent neuroimaging after conservative treatment or cerebrospinal fluid flow diversion. Patients with dural sinus vein thrombosis or intrinsic stenosis from sinus trabeculations or significant arachnoid granulations were excluded from the study. Either CT venography or MRI/MR venography was reviewed by a fellowship-trained neuroradiologist, and the degree of stenosis was scored through the combined conduit score (CCS), as described by Farb et al. The primary outcome was to assess TVSS changes after resolution or improvement of papilledema. RESULTS: From 435 patients, we identified a subset of 10 who satisfied all inclusion criteria. Our cohort comprised entirely women with a median age of 29.5 years and a median BMI of 32.5 kg/m2. Treatment consisted of acetazolamide in 7 patients, of which 1 had additional topiramate and 2 underwent cerebrospinal fluid flow diversion. Furthermore, 6 patients demonstrated significant weight loss during follow-up. For the primary outcome, 5 of 10 patients exhibited no appreciable TVSS change, and 5 patients demonstrated significant improvement in TVSS, of which 4 received conservative treatment only. Papilledema resolution or improvement was statistically significantly associated with increasing average CCS, TVSS diameter, and grade. CONCLUSIONS: We were able to demonstrate that TVSS can be both irreversible and reversible in patients with resolved papilledema. The finding of TVSS reversibility from conservative treatment alone is novel and has important implications to optimize patient care. Future studies should work to identify factors associated with irreversible TVSS for subsequent targeted intervention and prevention.

The presence of pachymeningeal hyperintensity on non-contrast flair imaging in patients with spontaneous intracranial hypotension.

PURPOSE: Traditionally, in the work-up of patients for spontaneous intracranial hypotension, T1 post-contrast imaging is performed in order to assess for pachymeningeal enhancement. The aim of this study is to assess whether pachymeningeal hyperintensity can be identified on a non-contrast FLAIR sequence in these patients as a surrogate sign for pachymeningeal enhancement. METHODS: The patient cohort was identified from a prospectively maintained database of patients with a clinical diagnosis of intracranial hypotension. Patients who had both a post-contrast T1 sequence brain as well as non-contrast FLAR sequence of the brain were reviewed. Imaging was retrospectively reviewed by three independent neuroradiologists. Each study was assessed for the presence or absence of pachymeningeal hyperintensity on the FLAIR sequence. RESULTS: From January 2010 to July 2022, 177 patients were diagnosed with spontaneous intracranial hypotension. In total, 121 were excluded as post-contrast imaging was not performed during their work-up. Twenty-four were excluded as the FLAIR sequence was performed after administration of contrast. Six were excluded as there was no pachymeningeal thickening present on T1 post-contrast imaging, although there were other signs of intracranial hypotension. The study group therefore consisted of 26 patients. Pachymeningeal thickening was correctly identified on the non-contrast FLAIR sequence in all patients (100%). CONCLUSION: Where present, diffuse pachymeningeal hyperintensity can be accurately identified on a non-contrast FLAIR sequence in patients with spontaneous intracranial hypotension. This potentially obviates the need for gadolinium base contrast agents in the work-up of these patients.

Standardised aspiration first approach reduces materials used and cost of thrombectomy procedure in anterior circulation large vessel occlusion stoke.

PURPOSE: The aim of this study is to compare the volume of equipment and equipment costs in a cohort of consecutive patients with anterior circulation large vessel occlusion treated with a standardised aspiration first approach to those treated with a stent retriever first approach. METHODS: The equipment used in each case was recorded from a prospectively maintained equipment log. We then compared the volume of equipment used in each group. The cost of this equipment was calculated for each group based on local prices. Estimated equipment costs were then compared. RESULTS: Our patient cohort consisted of 127 consecutive patients who were treated with a non-standardised stent retriever first technique (group A), 127 consecutive patients who underwent a new standardised aspiration first technique (group B), and 126 consecutive patients reflecting more recent practise where an aspiration first approach has been an established practise in our department (group C).Standardised aspiration first approach results in reduced equipment usage in thrombectomy procedures. The total equipment cost per case in the stent retriever first group (group A) was significantly higher at €4726.4 ($4818.3) versus €3093.1 ($3153.2) in the aspiration first group (group B), a reduction of 34.6% and €2798.5 ($2852.9) in the current practise group (group C), a reduction of 40.8%. There was no statistically significant difference in cost between groups B and C (p = 0.57). CONCLUSION: The standardised aspiration first technique utilised a reduced volume of equipment and confers a 40.8% reduced cost per procedure compared to a stent retriever first approach.

Is CT thorax, abdomen and pelvis a useful test in patients with weight loss?

INTRODUCTION: Unintentional weight loss is an important clinical problem. The role of CT is not firmly established in the workup of these patients. The aim of this study is to determine the diagnostic yield of CT Thorax, Abdomen and Pelvis (CT TAP) in patients with unexplained weight loss and to determine whether clinical or laboratory variables are associated with positive CT findings. METHODS: A retrospective review was performed of CT TAP examinations over 12 months with weight loss as an indication. Patients' electronic records and radiology reports were reviewed. Clinical and laboratory variables were assessed for correlation with positive findings on CT. RESULTS: 461 CT TAP studies with weight loss as the primary indication were identified. 124 were excluded; 82 due to a recent history of malignancy, 41 because CT TAP was used for staging of a new malignancy and one study was incomplete. This left 337 eligible examinations. 217 studies had findings of no clinical relevance, 50 studies were normal, 40 studies identified a possible cause of weight loss and 30 studies identified a definite cause. Of the 40 where a possible cause was identified, further work up led to a diagnosis which explained the weight loss in 13 patients. The diagnostic yield of CT TAP was 12.8%. Age, abdominal symptoms, degree of weight loss, anaemia, tumour markers and LDH did not significantly correlate with positive findings on CT. CONCLUSION: CT TAP is a helpful investigation in patients with unexplained weight loss with a diagnostic yield of 12.8%.

Improving endovascular access to the target vessel for thrombus aspiration -Use of the wedge device to overcome anatomic hurdles.

BACKGROUND AND PURPOSE: Aspiration is a successful technique used in thrombectomy for acute stroke. It is contingent upon the appropriate position of the aspiration catheter, so that it is in contact with the thrombus. However, navigating the craniocervical vasculature is challenging is some patients. The wedge microcatheter (MicroVention®) is designed to reduce the gap between the microcatheter and the SofiaPlus 6F catheter for ease of advancement. The purpose of this study is to describe our initial experience with the wedge microcatheter. MATERIALS AND METHODS: A retrospective review of 38 consecutive patients in whom the wedge microcatheter was used during thrombectomy was performed to determine whether the wedge microcatheter was successful in delivering the Sofia catheter to the desired location. RESULTS: We have found this device to be successful in delivering the aspiration catheter to the correct position in 97% (N = 37) of cases. It was used predominantly to pass the origin of branching vessels and also to navigate the tortuous cavernous and petrous segments of the ICA. CONCLUSION: The wedge microcatheter is a successful tool in delivering the aspiration catheter to the desired vessel for revascularisation.

Derivation of a Clinical Score for Prediction of Recurrence Following Evacuation of Chronic Subdural Hematoma: A Retrospective Cohort Study at a National Referral Centre.

BACKGROUND: Chronic subdural hematoma (cSDH) is a common pathology, and recurrence is a common complication, which may be predicted by certain patient and radiologic factors. Empiric radiologic surveillance has been shown to convey no benefit. METHODS: A retrospective review of a prospectively collated database was performed. Preoperative and postoperative noncontrast computed tomography scans were reviewed. Radiologic appearance, preoperative hematoma volume, patient age, presence of bilateral hematomas, maximal hematoma thickness, and therapeutic coagulopathy were assessed as predictors. Receiver operating characteristic curve analysis, logistic regression, and LASSO regression were used to select potential predictors. A multivariate model was then fitted, and a score was derived. RESULTS: A total of 142 patients were included. Maximal hematoma thickness >12 mm (P = 0.02) and age >65 years (P = 0.01) were found to correlate with the likelihood of recurrence. Bilateral hematomas and a hyperdense or mixed density appearance were also identified on LASSO regression. Bilateral hematomas (P = 0.19), hyperdense or mixed density (P = 0.66), maximum thickness >12 mm (P = 0.01), and age >65 years (P = 0.02) were included in the multivariate model. A 6-point score was derived. A score of >3 had a sensitivity of 89% (95% confidence interval [CI] 78%-97%) and specificity of 26% (95% CI, 17%-34%) for predicting recurrence, with recurrence significantly more likely in patients with a score of 4-6 versus those with a score of 0-3 (P = 0.02). CONCLUSIONS: Certain radiologic findings may predict the recurrence of cSDH following evacuation. The score derived may be useful in identifying patients who might benefit from routine postoperative surveillance imaging.

Role of routine post-operative CT brain following evacuation of extradural haematoma in children: a single-centre experience.

PURPOSE: Extradural haematoma (EDH) is a serious neurosurgical emergency in children, which confers significant morbidity and mortality rates. The objective of this study was to retrospectively evaluate the role of post-operative imaging in children with EDH who were managed surgically in a national paediatric neurosurgical unit over a 9-year period (January 2008 to December 2016). METHODS: A retrospective case review of paediatric patients who underwent surgical evacuation of extradural haematoma between January 2008 and December 2016 was performed. This included demographic and clinical details, indications for post-operative imaging and outcomes. RESULTS: Seventy patients underwent surgical management of EDH during this time period, with a male preponderance (69%) and a mean age of 8 years. The commonest location of haematoma in this cohort was in the parietal region (n = 24), with a mean maximum thickness of 25.9 mm and mean volume of 57 ml. Post-operative imaging was performed in 84% of patients. However, only one patient had a change in the course of their post-operative management as a result of post-operative imaging findings. CONCLUSIONS: Post-operative imaging in asymptomatic paediatric patients after evacuation of EDH could therefore be avoided as a routine investigation.

Breast screening in symptomatic women over 35 years of age: improvements in service efficiency.

INTRODUCTION: The rationalization of cancer services in Ireland saw all women with symptomatic breast problems referred to one of the eight regional cancer centers. A pilot triaging system was introduced in St Vincent's University Hospital to streamline these services. Women over 35 years who do not meet urgent referral criteria are referred for a mammogram prior to a clinic appointment ("image first"). The aim of this study was to retrospectively determine the recall rates, biopsy rates, and rate of breast cancer identification within this cohort of patients. This was compared to a screening population of patients. METHODS: Patients triaged into the "image first" group within a one-year period were identified. Results of the initial mammogram, further imaging and subsequent biopsies were recorded. Data relating to number of recalls, number of patients biopsied and number of cancers identified within the Merrion Unit of the National Breastcheck Screening Program was obtained for comparison. RESULTS: One thousand six hundred eighty-eight referrals were triaged as "image first" over this period. 185 (11%) of patients required a biopsy of an identified lesion. Breast cancer was diagnosed in 65 patients (3.9%). During the same study period, of the 42,099 women who were screened for breast cancer, 496 (1.8%) underwent biopsy and 267 (0.63%) were diagnosed with breast cancer. CONCLUSION: Image first patients, who represent a cohort of "symptomatic" non-urgent women, have a greater rate of breast cancer detection than an asymptomatic screening population. This may have an impact on the appropriate triaging of symptomatic women in a national cancer center.

Medical device patents-a review of contemporary global trends with an Irish comparison.

INTRODUCTION: Trends in medical technology patents provide an objective comparison of research and development between countries and over time. An analysis of these trends can benchmark innovation within Ireland in a worldwide context. By identifying and examining leading countries, domestic educational, infrastructural, regulatory and fiscal planning may be optimised. MATERIALS AND METHODS: Published data filing and granting reports from the two major patent offices (United States Patent and Trademark Office (USPTO) and European Patent Office (EPO)) were analysed. RESULTS: USPTO statistics demonstrated an 83.1% decrease in the overall number of medical device patents filed over the 10-year period, from 2005 (n = 1092) to 2015 (n = 185). Conversely, there was a 166% increase in the number of medical device patents granted over the same period. EPO applications in the field of medical technology represented the single largest industry category. The proportion of patents granted of Irish origin have increased from 0.7 (n = 22) to 0.9% (n = 73) over 10 years. Switzerland ranks first for medical device patents granted per head of population by the EPO, with Ireland ranking 5th. Ireland's medical device patents have increased dramatically per head of population, from 4.1 per million in 2012, to 15.3 in 2016. Israel has the highest number of USPTO patents granted per head of population, with Ireland ranking 5th. CONCLUSIONS: Ireland demonstrates high levels of medical technology patent filing per head of population, reflecting the importance of this industry. However, both Switzerland and Israel demonstrate dominance amongst smaller nations, and serving as benchmarks for national planning.