Diagnostic performance of artificial intelligence in interpreting thyroid nodules on ultrasound images: a multicenter retrospective study.

Background: Thyroid nodules are commonly identified through ultrasound imaging, which plays a crucial role in the early detection of malignancy. The diagnostic accuracy, however, is significantly influenced by the expertise of radiologists, the quality of equipment, and image acquisition techniques. This variability underscores the critical need for computational tools that support diagnosis. Methods: This retrospective study evaluates an artificial intelligence (AI)-driven system for thyroid nodule assessment, integrating clinical practices from multiple prominent Thai medical centers. We included patients who underwent thyroid ultrasonography complemented by ultrasound-guided fine needle aspiration (FNA) between January 2015 and March 2021. Participants formed a consecutive series, enhancing the study's validity. A comparative analysis was conducted between the AI model's diagnostic performance and that of both an experienced radiologist and a third-year radiology resident, using a dataset of 600 ultrasound images from three distinguished Thai medical institutions, each verified with cytological findings. Results: The AI system demonstrated superior diagnostic performance, with an overall sensitivity of 80% [95% confidence interval (CI): 59.3-93.2%] and specificity of 71.4% (95% CI: 53.7-85.4%). At Siriraj Hospital, the AI achieved a sensitivity of 90.0% (95% CI: 55.5-99.8%), specificity of 100.0% (95% CI: 69.2-100%), positive prediction value (PPV) of 100.0%, negative prediction value (NPV) of 90.9%, and an overall accuracy of 95.0%, indicating the benefits of AI's extensive training across diverse datasets. The experienced radiologist's sensitivity was 40.0% (95% CI: 21.1-61.3%), while the specificity was 80.0% (95% CIs: 63.6-91.6%), respectively, showing that the AI significantly outperformed the radiologist in terms of sensitivity (P=0.043) while maintaining comparable specificity. The inter-observer variability analysis indicated a moderate agreement (K=0.53) between the radiologist and the resident, contrasting with fair agreement (K=0.37/0.33) when each was compared with the AI system. Notably, 95% CIs for these diagnostic indexes highlight the AI system's consistent performance across different settings. Conclusions: The findings advocate for the integration of AI into clinical settings to enhance the diagnostic accuracy of radiologists in assessing thyroid nodules. The AI system, designed as a supportive tool rather than a replacement, promises to revolutionize thyroid nodule diagnosis and management by providing a high level of diagnostic precision.

The Diagnostic Accuracy of Artificial Intelligence in Radiological Markers of Normal-Pressure Hydrocephalus (NPH) on Non-Contrast CT Scans of the Brain.

Diagnosing normal-pressure hydrocephalus (NPH) via non-contrast computed tomography (CT) brain scans is presently a formidable task due to the lack of universally agreed-upon standards for radiographic parameter measurement. A variety of radiological parameters, such as Evans' index, narrow sulci at high parietal convexity, Sylvian fissures' dilation, focally enlarged sulci, and more, are currently measured by radiologists. This study aimed to enhance NPH diagnosis by comparing the accuracy, sensitivity, specificity, and predictive values of radiological parameters, as evaluated by radiologists and AI methods, utilizing cerebrospinal fluid volumetry. Results revealed a sensitivity of 77.14% for radiologists and 99.05% for AI, with specificities of 98.21% and 57.14%, respectively, in diagnosing NPH. Radiologists demonstrated NPV, PPV, and an accuracy of 82.09%, 97.59%, and 88.02%, while AI reported 98.46%, 68.42%, and 77.42%, respectively. ROC curves exhibited an area under the curve of 0.954 for radiologists and 0.784 for AI, signifying the diagnostic index for NPH. In conclusion, although radiologists exhibited superior sensitivity, specificity, and accuracy in diagnosing NPH, AI served as an effective initial screening mechanism for potential NPH cases, potentially easing the radiologists' burden. Given the ongoing AI advancements, it is plausible that AI could eventually match or exceed radiologists' diagnostic prowess in identifying hydrocephalus.

Explainable Automated TI-RADS Evaluation of Thyroid Nodules.

A thyroid nodule, a common abnormal growth within the thyroid gland, is often identified through ultrasound imaging of the neck. These growths may be solid- or fluid-filled, and their treatment is influenced by factors such as size and location. The Thyroid Imaging Reporting and Data System (TI-RADS) is a classification method that categorizes thyroid nodules into risk levels based on features such as size, echogenicity, margin, shape, and calcification. It guides clinicians in deciding whether a biopsy or other further evaluation is needed. Machine learning (ML) can complement TI-RADS classification, thereby improving the detection of malignant tumors. When combined with expert rules (TI-RADS) and explanations, ML models may uncover elements that TI-RADS misses, especially when TI-RADS training data are scarce. In this paper, we present an automated system for classifying thyroid nodules according to TI-RADS and assessing malignancy effectively. We use ResNet-101 and DenseNet-201 models to classify thyroid nodules according to TI-RADS and malignancy. By analyzing the models' last layer using the Grad-CAM algorithm, we demonstrate that these models can identify risk areas and detect nodule features relevant to the TI-RADS score. By integrating Grad-CAM results with feature probability calculations, we provide a precise heat map, visualizing specific features within the nodule and potentially assisting doctors in their assessments. Our experiments show that the utilization of ResNet-101 and DenseNet-201 models, in conjunction with Grad-CAM visualization analysis, improves TI-RADS classification accuracy by up to 10%. This enhancement, achieved through iterative analysis and re-training, underscores the potential of machine learning in advancing thyroid nodule diagnosis, offering a promising direction for further exploration and clinical application.

Potential of Satellite Sign for Prediction of Hematoma Expansion in Small Spontaneous Hematoma within 7 Days' Follow-Up.

Background Hematoma expansion (HE) is the most important modifiable predictor that can change the clinical outcome of intracerebral hemorrhage (ICH) patients. The study aimed to investigate the potential of satellite sign for prediction of HE in spontaneous ICH patients who had follow-up non-contrast computed tomography (NCCT) within 7 days after the initial CT scan. Methods We retrospectively reviewed data and NCCT from 142 ICH patients who were treated at our hospital at Bangkok, Thailand. All included patients were treated conservatively, had baseline NCCT within 12 hours after symptom onset, and had follow-up NCCT within 168 hours after baseline NCCT. HE was initially estimated by two radiologists, and then by image analysis software. Association between satellite sign and HE was evaluated. Results HE occurred in 45 patients (31.7%). Patients with HE had significantly higher activated partial thromboplastin time ( p = 0.001) and baseline hematoma volume ( p = 0.001). The prevalence of satellite sign was 43.7%, and it was significantly independently associated with HE ( p = 0.021). The sensitivity, specificity, and accuracy of satellite sign for predicting HE was 57.8, 62.9, and 61.3%, respectively. From image analysis software, the cutoff of greater than 9% relative growth in hematoma volume on follow-up NCCT had the highest association with satellite sign ( p = 0.024), with a sensitivity of 55%, specificity of 64.6%, and accuracy of 60.5%. Conclusion Satellite sign, a new NCCT predictor, was found to be significantly associated with HE in Thai population. With different context of Thai population, HE was found in smaller baseline hematoma volume. Satellite sign was found more common in lobar hematoma. Further studies to validate satellite sign for predicting HE and to identify an optimal cutoff in Thai population that is correlated with clinical outcomes are warranted.

FLAIR vascular hyperintensity-DWI mismatch and DWI-FLAIR mismatch ASPECTS for prediction of good outcome after recanalization in anterior circulation stroke; multicenter observational study.

INTRODUCTION: Acute ischemic stroke is a medical emergency caused by decreased blood flow to the brain, leading cause of long-term disability. Recanalization, one of the most concerning difficulties linked with intracranial arterial occlusion, has been used to reduce mortality in ischemic stroke treatment. The mismatch concepts MR PWI-DWI or DWI-FLAIR can help identify patients for thrombolysis. PURPOSE: This paper introduces a novel method of predicting revascularization using the value of fluid-attenuated inversion recovery vascular hyperintensity FVH-DWI mismatch and DWI-FLAIR mismatch, which releases anterior circulation large vessel occlusion (LVO) after endovascular thrombectomy (EVT). Moreover, we present a new scoring system following anatomical region distributed for MCA territory called a DWI-FLAIR MISMATCH ASPECTS. RESULT: Statistical analysis was performed to predict revascularization and functional outcome with 110 patients with anterior circulation LVO treated with EVT. We found that FVH-DWI mismatch was present in 71 patients (89.9 %) with complete revascularization and present in 8 patients (10.1 %) with no/partial revascularization, which had no significant difference (p = 0.12), and there was no significant difference between good functional outcome and poor functional outcome. Moreover, in 76 patients with DWI-FLAIR mismatch ASPECTS of > 6 point-group, present FVH-DWI mismatch in 57 patients (83.8 %) with complete revascularization had a significant difference as compared to 11 patients (16.2 %) with absent FVH-DWI mismatch (p < 0.05). The clinical outcome in complete revascularization is better than no/partial revascularization, and complete revascularization is independently associated with good functional outcomes (p < 0.05). CONCLUSION: FVH-DWI mismatch paired with DWI-FLAIR mismatch ASPECTS > 6 points may be possible to predict revascularization in patients with anterior circulation LVO.

Improving GAN Learning Dynamics for Thyroid Nodule Segmentation.

Thyroid nodules are lesions requiring diagnosis and follow-up. Tools for detecting and segmenting nodules can help physicians with this diagnosis. Besides immediate diagnosis, automated tools can also enable tracking of the probability of malignancy over time. This paper demonstrates a new algorithm for segmenting thyroid nodules in ultrasound images. The algorithm combines traditional supervised semantic segmentation with unsupervised learning using GANs. The hybrid approach has the potential to upgrade the semantic segmentation model's performance, but GANs have the well-known problems of unstable learning and mode collapse. To stabilize the training of the GAN model, we introduce the concept of closed-loop control of the gain on the loss output of the discriminator. We find gain control leads to smoother generator training and avoids the mode collapse that typically occurs when the discriminator learns too quickly relative to the generator. We also find that the combination of the supervised and unsupervised learning styles encourages both low-level accuracy and high-level consistency. As a test of the concept of controlled hybrid supervised and unsupervised semantic segmentation, we introduce a new model named the StableSeg GAN. The model uses DeeplabV3+ as the generator, Resnet18 as the discriminator, and uses PID control to stabilize the GAN learning process. The performance of the new model in terms of IoU is better than DeeplabV3+, with mean IoU of 81.26% on a challenging test set. The results of our thyroid nodule segmentation experiments show that StableSeg GANs have flexibility to segment nodules more accurately than either comparable supervised segmentation models or uncontrolled GANs.

Artificial intelligence for localization of the acute ischemic stroke by non-contrast computed tomography.

A non-contrast cranial computer tomography (ncCT) is often employed for the diagnosis of the early stage of the ischemic stroke. However, the number of false negatives is high. More accurate results are obtained by an MRI. However, the MRI is not available in every hospital. Moreover, even if it is available in the clinic for the routine tests, emergency often does not have it. Therefore, this paper proposes an end-to-end framework for detection and segmentation of the brain infarct on the ncCT. The computer tomography perfusion (CTp) is used as the ground truth. The proposed ensemble model employs three deep convolution neural networks (CNNs) to process three end-to-end feature maps and a hand-craft features characterized by specific contra-lateral features. To improve the accuracy of the detected infarct area, the spatial dependencies between neighboring slices are employed at the postprocessing step. The numerical experiments have been performed on 18 ncCT-CTp paired stroke cases (804 image-pairs). The leave-one-out approach is applied for evaluating the proposed method. The model achieves 91.16% accuracy, 65.15% precision, 77.44% recall, 69.97% F1 score, and 0.4536 IoU.

Detection and Measurement of Intracranial Aneurysm Compared between Magnetic Resonance Intracranial Black Blood Vessel Imaging and Gold Standard Cerebral Digital Subtraction Angiography.

Background Magnetic resonance intracranial black blood vessel imaging (MR-IBBVI) is a new noninvasive method for evaluating intracranial vessel wall pathology. No previous studies have investigated the efficacy of MR-IBBVI to determine aneurysm size. We aimed to identify the precise diagnosis of MR-IBBVI for the detection and measurement of intracranial aneurysm compared with gold standard cerebral digital subtraction angiography (cDSA). Materials and Methods The retrospective study collected patients of precoiled or postcoiled intracranial aneurysm who were treated at our institute from January 2012 to June 2019 and who had MR-IBBVI, cDSA imaging, and/or three-dimensional time-of-flight sequence of magnetic resonance angiography. The sensitivity and specificity of aneurysm detection by MR-IBBVI and the accuracy of MR-IBBVI for measuring the aneurysm and vessel size were calculated. Results One hundred and twenty patients (61% female) with 132 aneurysms were included into this study. The mean aneurysm size was 5.3 mm (range: 2.2-22.6). Sensitivity and specificity of MR-IBBVI to detect a small aneurysm were 98.74 and 91.21%, respectively. No statistically significant results were observed between MR-IBBVI and DSA for aneurysm detection or any of the evaluated measurement parameters. Conclusion MR-IBBVI is an accurate and highly sensitive method to detect and evaluate the size of an intracranial aneurysm both before and after coiling.

Fate of Patients with Chronic Cerebrovascular Steno-occlusive Disease According to Change of Cerebral Perfusion, Cerebrovascular Reserved, and Incidence of Recurrent Ischemic Stroke.

OBJECTIVE: The objective is to demonstrate change of cerebral perfusion and cerebrovascular reserve (CVR) in treating patients with cerebrovascular steno-occlusive disease stratified by change of cerebral perfusion and CVR. METHODS: Retrospective review patients with radiographic proven major cerebrovascular steno-occlusive disease whom underwent cerebral perfusion imaging with vasoactive stimuli stress test in Siriraj Hospital and Bangkok General Hospital during 2010-2018. Medical records were also reviewed. Radiographic findings, cerebral perfusion parameters and signal change during the stress test were reviewed and used to categorize into three groups. RESULTS: There were 40 patients sent to radiology department for the evaluation of CVR. One patient had airway problem during the procedure and was excluded. Remaining 39 patients were included in this study (32 males and 7 females, mean age of 54.55 years). In 42 sites involved, 28 (66%) were internal carotid artery, 14 (33%) were middle cerebral arteries. Laterality is left side in 20 cases, right side in 14 cases, and bilateral in 5 cases. Poor CVR response (increased cerebral blood flow <10%) was found in 9 patients (2 severe stenoses and 7 total occlusions). The mean follow-up time was 28.9 months. Eight cases (20.5%) underwent surgical treatment; surgical bypasses and endovascular interventions. Only one patient had subsequential ischemic symptom at immediate postoperative vascular bypass surgery. The remaining patients had no report of progressive or recurrent neurological deficit symptom. CONCLUSION: Poor CVR response is more often found in higher degree of steno-occlusion. Even inconclusive predicting incidence of recurrent ischemic stroke, CVR that reflects the capacity of neuro-autoregulation.

Success Rate of Simple Coil Embolization in Wide-Neck Aneurysm with Aneurysmal Shoulder.

BACKGROUND AND OBJECTIVE: Wide-necked intracranial aneurysm (WIA) is one of the challenging diseases for neuro-interventionist to treat by simple coiling technique. The purpose of this study is to identify the morphology associated with successful simple coil embolization in wide neck aneurysm patients. MATERIALS AND METHODS: Between January 2002 and August 2018, 102 patients with total 115 ruptured or unruptured WIA which received endovascular treatment were retrospective reviewed. Data were analyzed including demographics, aneurysm morphology, endovascular technique, angiographic outcome, complication, regrowth, and retreatment rate. RESULTS: The mean age of patients was 61.6 years with female predominant (72.5%). Ruptured WIA was diagnosed in 71 patients (61.7%). Majority of aneurysms were located in an anterior circulation which were 74 cases (64.3%), mainly paraclinoid aneurysm (30/115). Endovascular treatment was successful in 113 cases (98.3%) which can be mainly divided into simple coil embolization 50 cases (43.5%), balloon-assisted coil embolization 26 cases (22.6%), and stent-assisted coil embolization 32 cases (27.8%). Complete, subtotal, and incomplete occlusion of WIA was achieved in 32 cases (27.8%), 62 cases (53.9%), and 18 cases (15.7%), respectively. There was 9.6% complication occurred. Regrowth and retreatment were found 20% and 15.7%, respectively. CONCLUSION: WIA with two-sided aneurysmal shoulder or neck width <3.6 mm. are significantly associated with successful coil embolization using simple coiling technique.

Efficacy of Computed Tomography Perfusion - Alberta Stroke Program Early Computed Tomography Score for Identifying Patients with Anterior Circulation Acute Ischemic Stroke that Would Benefit from Endovascular Treatment.

BACKGROUND: The identification of criteria that improves the selection of ischemic stroke patients most suitable for mechanical thrombectomy (MT) will improve clinical outcomes. The aim of this study was to identify the computed tomography (CT) imaging parameter that best predicts patients who will benefit from endovascular treatment among patients with anterior circulation ischemic stroke. MATERIALS AND METHODS: This retrospective study was conducted in patients with acute middle cerebral artery (MCA) stroke with/without internal carotid artery occlusion who underwent successful MT at Siriraj Hospital from November 2009 to October 2016. Evaluated parameters were compared between those with and without a favorable outcome. RESULTS: Forty-four consecutive patients with acute MCA occlusion were included, and 61.4% had unfavorable clinical outcome. Regarding CT perfusion - Alberta stroke program early CT score (CTP-ASPECTS) at the 50% cut point, patients with favorable outcome had higher Cerebral blood volume-ASPECTS (CBV-ASPECTS) and mean transit time-ASPECTS (MTT-ASPECTS) than those with unfavorable outcome. For CTP-ASPECTS at the 75% cut point, patients with favorable outcome had higher CBV-ASPECTS, cerebral blood flow-ASPECTS, and MTT-ASPECTS than those with unfavorable outcome. CONCLUSIONS: CTP-ASPECTS at the 50% and 75% cut points of abnormality could not predict the clinical outcome of anterior ischemic stroke after thrombectomy. Of the ASPECTS evaluated in this study, MTT-ASPECTS at the 75% cut point was the most predictive parameter. Older age was associated with unfavorable outcome after thrombectomy.

Efficacy of Thrombus Density on Noninvasive Computed Tomography Neuroimaging for Predicting Thrombus Pathology and Patient Outcome after Mechanical Thrombectomy in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: The aim of this study was to investigate the efficacy of thrombus density on noninvasive computed tomography (CT) neuroimaging for predicting thrombus pathology and patient outcome after mechanical thrombectomy in acute ischemic stroke. MATERIALS AND METHODS: This retrospective chart and imaging review included patients that were treated by mechanical thrombectomy at Siriraj Hospital according to the American Heart Association/American Stroke Association guidelines for the early management of patients with acute ischemic stroke from March 2010 to February 2015 study period. Preintervention noncontrast CT (NCCT), CT angiography (CTA), and/or contrast-enhanced CT (CECT) images were interpreted using CT densitometry. Pathology results were classified as white, red, or mixed thrombi. The result of treatment was evaluated by the modified Rankin Scale at 90 days after treatment. RESULTS: From 97 included patients - 97 NCCT images, 48 CTA images, 48 CECT images, and 54 pathologic results of cerebral thrombi were included in the final analysis. Mean clot Hounsfield unit values on NCCT, CTA, and CECT were significantly different between red and white thrombus (P = 0.001 on NCCT, P = 0.03 on CTA, and P = 0.001 on CECT), and between red and mixed thrombus (P = 0.043 on NCCT and P = 0.002 on CTA). However, no significant difference was observed between white thrombus and mixed thrombus (P = 0.09 on NCCT, P = 1.00 on CTA, and P = 0.054 on CECT). There was no significant correlation between type of cerebral thrombus or clot density and the result of treatment. CONCLUSION: Thrombus density on CT was found to be a significant predictor of thrombus pathology; however, no significant association was observed between thrombus type or clot density and patient outcome after mechanical thrombectomy.

A large number of cerebral microbleeds in CADASIL patients presenting with recurrent seizures: a case report.

BACKGROUND: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary arteriopathy associated with the NOTCH3 gene. Clinical manifestations include strokes, transient ischaemic events, psychiatric disturbances, dementia, and migraines. We report a case of a Thai man with a severe CADASIL phenotype who presented with recurrent seizures and acute ischaemic stroke and classic vascular risk factors. CASE PRESENTATION: A 50-year-old man with a history of mood disorder and progressive cognitive decline for 20 years as well as well-controlled diabetes mellitus and hypertension presented with recurrent generalized seizures and acute right-sided weakness. An MRI of the brain showed acute infarction of the left pons, a large number of cerebral microbleeds throughout the brain and white matter abnormalities without classic anterior temporal lobe lesions. Molecular genetic testing identified a homozygous pathologic variant, c.1672C > T (p. Arg558Cys), in the NOTCH3 gene. The diagnosis of CADASIL was confirmed. His clinical symptoms deteriorated, and he died of tracheobronchitis with secretion obstruction. CONCLUSION: This case raises awareness of an uncommon cause of acute ischaemic stroke in patients with classic vascular risk factors and emphasizes the need for a complete evaluation in cases with unexpected clinical presentation or unexpected diagnostic study results.

Favorable Outcome of Endovascular Treatment for Intracranial Aneurysms: A Single-Center Study in Thailand.

PURPOSE: The purpose of this study is to collect the information on patients with intracranial aneurysm (IA) receiving endovascular management in Siriraj Hospital, Mahidol University, Thailand. MATERIALS AND METHODS: We retrospectively reviewed data from patients with IA who underwent endovascular treatment from January 1997 through July 2013. We collected patients' demographic data including age, sex, clinical presentations, and aneurysmal profiles, as well as endovascular treatment technique, complications, angiographic results, and regrowth rate. Treatment results included success rate, clinical findings during follow-up, and regrowth rate. RESULTS: We reviewed data from 497 patients with 636 aneurysms (female:male ratio, 1.9:1; age range, 15-90 years; mean age, 59.18 years) and 69% presented with rupture. One hundred and twenty patients with 127 aneurysms received endovascular treatment. The most common location for endovascular treatment was the posterior communicating artery (15.8%), and endovascular techniques were used most often for posterior circulation and paraclinoid aneurysms. The success rate was approximately 99.2% with a 16.5% regrowth rate and no rebleeding. Regrowth rate did not correlate with immediate postoperative angiographic findings. We encountered 23 complications (18.1%); most commonly, intra-procedural rupture (7/23). Good outcomes occurred in approximately 95.9% of the patients. CONCLUSIONS: The success rate for endovascular treatment was >90%. Regrowth rate and clinical outcomes were within standard limits. Posterior circulation and paraclinoid aneurysms were our main targets. We tended to use fewer devices and simpler techniques to secure ruptured IA; however, the regrowth rate was similar to that using device-assisted techniques in other studies. We found no significant factors affecting regrowth rate, including immediate posttreatment angiographic results.

The Effectiveness of Dural Venous Sinus Sacrifice as a Treatment of Aggressive Type Cranial Dural Arteriovenous Fistulas.

OBJECTIVE: To evaluate the effectiveness of dural venous sinus sacrifice as a treatment of aggressive type cranial dural arteriovenous fistulas (dAVFs) in terms of both clinical outcome and angiographic outcome. MATERIALS AND METHODS: One hundred and twenty-eight patients with 163 aggressive type cranial dAVFs who were treated with dural sinus sacrifice were retrospectively reviewed. Clinical and angiographic outcomes were analyzed. Procedural complications were also recorded. Only 103 patients (80.5%) who had been following up for at least 90 days were analyzed for clinical outcome. RESULTS: There were 53 males and 75 females with age ranging from 20 years to 93 years (mean age 55.44 years). The overall angiographic cure rate of dural venous sinus sacrifice as a part of the treatment of aggressive dAVFs was 81.6%. Considering clinical outcome (average duration of follow-up was 2 years and 6 months), 75 patients (72.8%) had clinical improvement and 21 (20.4%) were clinically stable. Worsening of the presenting symptoms was observed in 7 patients (6.8%). Procedural complications were found in 5 patients (3.9%). CONCLUSION: Dural venous sinus sacrifice is a safe and effective treatment strategy with high angiographic cure rate, good clinical outcome, and low incidence of procedural-related complication.

Computerized Tomographic Angiography for Detection of Cerebral Vasospasm after Ruptured Intracranial Aneurysm.

OBJECTIVE: Digital subtraction angiography (DSA) is the gold standard to diagnose cerebral vasospasm but it is usually not available due to lack of expertise and proper equipment. The present study aimed to compare the diagnostic accuracy of brain computerized tomographic angiography (CTA) in detecting cerebral vasospasm after intracranial aneurysmal rupture. MATERIAL AND METHOD: Between January 2011 and October 2014, 20 patients who were suspected of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) were prospectively enrolled. All patients underwent brain CTA andDSA within 24 hours after clinical onset ofvasospasm. Separate reviewers independently reviewed the CTA and DSA. RESULTS: Twenty patients were enrolled, including 7 males and 13 females. The patient characteristics did not have any relationship to the incidence of cerebral vasospasm. The CTA finding of vasospasm was well correlated to the DSA finding (Kappa 0.793). Diagnostic accuracy and false negative of the CTA were 90% and 5%, respectively. Sensitivity of the CTA was 94% and specificity was 100%. Positive predictive value ofthe CTA was 100% and negative predictive value was 66%. The vessels that showed the most correlation between the CTA and DSA findings were left A1 (Kappa 0.684) and left A2 (Kappa 0.663) segments of anterior cerebral artery, and left M1 (Kappa 0.503) segment of middle cerebral artery. Both CTA and DSA can detect mild vasospasm (< 50% luminal stenosis) located proximal to the circle of Willis. CONCLUSION: Compared to the DSA, the CTA can be used for detecting cerebral vasospasm in patients with ruptured intracranial aneurysms with high sensitivity, specificity, and diagnostic accuracy.

Comparative outcomes for sclerotherapy of head and neck venous vascular malformation between alcohol and bleomycin.

OBJECTIVE: To assess and compare the effectiveness of the two sclerosing agents (95% alcohol and Bleomycin) for the treatment of head and neck venous malformation (VM). MATERIAL AND METHOD: The authors retrospectively reviewed our experience in treating VM of the head and neck region using two sclerosing agents, 95% alcohol (November 2001 to June 2008) and bleomycin (July 2008 to July 2010). Patients' demography (age, sex), lesion number location, type (focal/extensive), and characteristic features (cystic/tubular/mixed) were recorded. The treatment outcome was determined by decrease in size of VM in photographs taken at one month and at final clinical follow-up. These were analyzed by two radiologists using visual rating scale (worst or not improved, <50%, 50-75%, >75% of size reduction). One-way Anova test (p < 0.1) was used to show the differences in treatment effectiveness of the two sclerosing agents at short- and long-term intervals. RESULTS: Thirty-three patients, age ranged from 11 to 62 years (mean 25.1 years), with 27 female and six male patients were included in this study. The majority of patients were less than 16 years (17 patients, 51%). The 43 lesions were categorized as 28 VMs were focal (65.1%), 15 (34.9%) diffuse, and30 (69.7%) were of the mixed type. Sixteen lesions were treated with 95% alcohol, 23 lesions with bleomycin, and four lesions with a combination of the two sclerosants. The range of number of procedures was 1 to 16 (mean 3.76 procedures per patient) for alcohol, and 1 to 5 (mean 2.27 procedures per patient) for bleomycin. The cumulative dose ofsclerosant used was 101 ml for alcohol and 32.11 mg for bleomycin. Total follow-up at 1-month and at final was 43/43.(100%) and 35/43 (81.4%) respectively. Mean follow-up interval was 14.7 months. Differences in size reduction after treatment by different sclerosing agents were found. At more than 1-year follow-up, those treated with bleomycin gained graded 3 (> 75%) size reduction more than treated by 95% alcohol. No VM treated with 95% alcohol obtained grade 3 of size reduction at 1-year follow-up. Multiple regression analysis showed VM's favorable character for bleomycin treatment by decreasing mixed, cystic, and tubular Pediatrics had relatively more benefit with bleomycin treatment. CONCLUSION: Sclerotherapy using either alcohol or bleomycin is an effective treatment for VMs. Different treatment outcomes were significant at long-term with group of VM those treated with bleomycin but not at short-term (p < 0.1).

Is intervertebral cement leakage a risk factor for new adjacent vertebral collapse?

This retrospective study evaluated the relationship between intervertebral cement leakage and new adjacent vertebral fracture and describes the different characteristics of cement leakage. Increased risk of new adjacent vertebral fracture (NF) has been reported to be a complication of cement leakage in vertebroplasty. In our observation, an incidental intervertebral cement leakage may occur during vertebroplasty but is commonly asymptomatic. The study focused on osteoporotic collapse patients who had percutaneous vertebroplasty (PV) between 2005 and 2007. We divided patients into leakage and non-leakage groups and compared the incidence of NF. Leakage characteristics were divided into three types: Type I intervertebral-extradiscal leakage, Type II intradiscal leakage and Type III combined leakage. Visual analog scale for pain and the Karnofsky Performance Status at 24 h, three months, six months and one year were compared between groups and types of leakages. Among 148 PVs (102 patients) there were 30 leakages (20.27%) and 21(14.19%) NFs. The incidence of NF did not significantly differ between leakage and non-leakage groups (P<0.05). Type II was the most common type of leakage (15/30). Reduction of average pain and improvement of Karnofsky Performance Status score did not differ between groups (P< 0.05). Type II had decreased pain score < type I and III at 24 h (P < 0.01), three months and six months (P < 0.1) but not at one year (P<0.10). Type II also had decreased pain score < non-leakage group only at 24 h (P<0.05). Intervertebral cement leakage is not an increased risk for NF, influenced outcomes of pain relief or improvement of physical function. Intradiscal leakage (Type II) is the most common characteristic of cement leakage and probably related to delayed pain relief.

Complications in vertebroplasty.

BACKGROUND: Vertebroplasty is one of the minimally invasive surgery that benefit in pain relief from the osteoporotic or malignancy related vertebral compression fractures. However, many literatures reported both asymptomatic and serious complications. The aim of the present study was to summarize, collect data and report the complication ofvertebroplastyfrom our experience at a single institute. MATERIAL AND METHOD: Three hundred and twenty five vertebroplasty procedures from 236 patients performed in our institute were retrospectively reviewed. Data of diagnosis, age at the time of procedure were collected. All complications found were reviewed in detail. RESULTS: Commonly performed procedures were at thoracolumbar junction (51.4%). Osteoporosis was the most common cause of fracture. The present study found 88 (27%) complications with 26 (8%) symptomatic patients. Most common complication was cement leakage, which intervertebral disc was the most common site (42.9). Spinal canal leakage was found in 14 cases (20%). Four out of 14 cases had neurological complications and need further managements. Two cases had neurologic complications from needle injury.Adjacent level collapse found in 13 patients (4%) and remote segment collapse occurred in 5 patients (1.5%). Three had progressive kyphosis required later surgical treatment. One asymptomatic cement pulmonary embolism was found in the present study. CONCLUSION: The complications of vertebroplasty were mostly asymptomatic, but serious complication such as neurologic injury could occur. Vertebroplasty could be considered a quite safe treatment for osteoporotic vertebral fracture. Meticulous technique should be executed during the procedure to avoid the leakage complication.