Regression of Endolymphatic Hydrops in Patient With Meniere's Disease Treated With Vestibular Neurectomy: A Case Report.

Vestibular neurectomy is an effective method eliminating vertigo attacks in patients suffering from disabling Meniere's disease with no clinical improvement despite conservative and intratympanic therapy. Magnetic resonance imaging allows in vivo evaluation of changes manifesting in the inner ear after treatment; however, downgrading of the endolymphatic hydrops after vestibular neurectomy had not been previously described in the literature. In the present article, a case of a patient with unilateral severe Meniere's disease treated with selective vestibular nerve section from middle fossa approach was described. Clinical symptoms and audiovestibular tests were evaluated before and 13 months after the surgery. Complete resolution of vertigo episodes and hearing preservation was achieved. Magnetic resonance imaging was performed before and after the surgery using a 3 Tesla scanner with dedicated protocol after intravenous administration of gadolinium contrast agent. In the follow-up examination, regression of the cochlear and vestibular endolymphatic hydrops was visualized, which may suggest processes occurring in the labyrinth as a result of the vestibular efferent fibers section.

Effectiveness and safety of CT-guided drainage of abdominal abscesses with small and extra-small-bore drains: a single-centre observational study.

Purpose: Computed tomography (CT)-guided percutaneous drainage is an established method for the treatment of abdominal abscesses. The purpose of this study is to evaluate the effectiveness and safety of drainage of abdominal abscesses with small-bore (6F and 9F) drains. Material and methods: The analysis of a prospectively maintained database included 135 consecutive patients from a single centre with abdominal or pelvic abscesses, who underwent CT-guided drainage. Procedures were performed using a one-step trocar technique with 6F (40 procedures) or 9F (95 procedures) catheters. Technical success was defined as insertion of the drain into the abscess cavity and aspiration of the fluid sample. Clinical success was defined as resolution of infection without surgical intervention or upsizing of the drain. Results: The mean size of abscesses was 77.0 ± 28.8 mm (32-220 mm). Thick fluid was aspirated from 129 collections; 6 collections contained thin fluid. Technical success was achieved in 100% of procedures. Clinical success was achieved in 94.8% of patients. Surgical drainage was necessary in 3.7% of patients and upsizing in 1.5% of patients. Complications of Clavien-Dindo grade III were noted in 2.2% of patients without grade IV or V adverse events. The mean radiation dose in terms of Dose Length Product was 617 ± 467 mGy x cm. The mean procedure time was 28.0 ± 11.3 min. Conclusions: CT-guided drainage of abdominal abscesses with small- and very small-bore drains is usually sufficient to obtain clinical success with a low complication rate in the case of thick fluid collections.

Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography.

Splenic artery aneurysm (SAAs) rupture is associated with a high mortality rate. Regular surveillance with imaging before and after intervention is crucial to guide best evidence treatment. The following study aimed to determine the efficacy of color Doppler ultrasound imaging (DUS) compared to digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) as a follow-up modality after selective coil embolization of true SAAs. We analyzed data from 20 patients, 15 females (48.1 ± 16.1 years) undergoing selective SAA coil embolization using detachable fibered embolization coils. Imaging using DUS, MRA, and DSA was performed 3 months after the initial embolization or the consequent re-embolization procedure. Primary clinical success, defined as Class I aneurysm occlusion, on 3-month follow-up was seen in 16 (80.0%) patients. DUS had a sensitivity of 94.4% and a specificity of 42.9% when compared to DSA and 92.3% and 30%, respectively, when compared to MRA in identifying Class I aneurysm occlusion. The positive predictive value (PPV) of DUS in identifying the need for re-embolization was 75.0%, while the NPV of DUS in these terms was 90.5%. DUS showed a high sensitivity in detecting aneurysm occlusion and clinical success, simultaneously exhibiting poor specificity. Still, with caution, this follow-up modality could be used for monitoring select low-risk patients after selective embolization of SAAs. DUS could provide a higher cost-to-benefit ratio, enabling more systematic post-procedural follow-up, as it is far more commonly used compared to MRA and non-invasive compared to DSA.

Validation of exophthalmos magnetic resonance imaging measurements in patients with Graves' orbitopathy, compared to ophthalmometry results.

Purpose: Although assessment of the orbital structures using magnetic resonance imaging (MRI) is well described in the literature, there is no consensus as to which measurement method is the most useful in exophthalmos assessment. The aim of the study was to correlate 2 MRI methods of exophthalmos measurement with exophthalmometry results and to determine a proper technique of exophthalmos measurement. Material and methods: Fifty-four patients (108 orbits) with exophthalmos in the course of Graves' orbitopathy were enrolled in the study. Two measurements on axial T2W orbital MRI images were performed by 2 independent radiologists: the distance from the interzygomatic line to the anterior surface of the globe (AD) and the distance from the interzygomatic line to the posterior sclera (PD). Within 4 weeks, an exophthalmometry was performed by an ophthalmologist using a Hertel exophthalmometer. The inter-observer variation was assessed using the Pearson correlation coefficient. Values were presented as mean and standard deviation, and the differences in values were explored with Student's t-test. Results: The mean AD measured on MRI by the first observer was 20.6 ± 3 mm, and 20.6 ± 2.9 mm by the second observer. PD values were 2.9 ± 2.8 mm and 3.4 ± 2.8 mm, respectively. The mean exophthalmometry result was 21 ± 3.3 mm. The correlation was very high between observers for AD measurements (r = 0.98, p = 0.01) and high for PD measurements (r = 0.95, p = 0.01). AD measurements on MRI and exophthalmometry results were strongly correlated (r = 0.9, p = 0.01). Conclusions: The AD measurement has better reproducibility and is directly correlated with Hertel exophthalmometry. This method could be sufficient in routine practice.

Detailed insight into magnetic resonance assessment of Ménière's disease - description of methodology and imaging findings in a case series.

Purpose: The study aimed to describe the methodology and detailed interpretation of magnetic resonance imaging (MRI) in patients with Ménière's disease (MD). Material and methods: MRIs were performed on a 3T scanner. The three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequence 4 hours after a double dose of intravenous contrast was added to the standard MRI protocol in patients with clinically diagnosed MD. MRI findings of 7 patients with unilateral MD were analysed using 2 qualitative grading systems by Barath and Bernaerts. Results: In MRI, the following changes in the group of patients with MD were observed: lack of endolymphatic hydrops (cases #1 and #7), various grades of cochlear hydrops (cases #2 and #3), various grades of vestibular hydrops (cases #4, #5, and #6), endolymphatic hydrops herniation into the semi-circular canal (case #6), and more robust perilymphatic enhancement (case #7). Conclusions: In patients with MD, endolymphatic hydrops can be studied on MRI using 3D-FLAIR delayed post-contrast images. The qualitative grading system may be easily used in endolymphatic hydrops assessment. Recently described new radiological signs of MD such as increased perilymphatic enhancement of the cochlea and an extra low-grade VH may increase MD diagnosis sensitivity. MRI not only supports the clinical diagnosis of MD but also may help to understand its pathophysiology.

Correlation between magnetic resonance imaging classification of endolymphatic hydrops and clinical manifestations and audiovestibular test results in patients with definite Ménière's disease.

OBJECTIVES: The purpose was to evaluate magnetic resonance imaging (MRI) classification of endolymphatic hydrops with clinical features, audiological and vestibular tests in patients with definite unilateral Ménière's disease (MD). METHODS: Thirty-eight patients were enrolled in this study. The severity of the main clinical symptoms, audiovestibular tests, and MRI, performed 4 hours after intravenous injection of gadobutrol to visualize inner ear compartments, were evaluated. Endolymphatic space dilatation was assessed using Barath and Bernaerts grading systems, and the correlation between the grade of the hydrops and clinical features was evaluated. RESULTS: Using the Barath system, cochlear hydrops was visualized in 81.6% of affected ears, while vestibular was 63.2%. Sensitivity increased to 94.7% using Bernaerts' modification. Vestibular hydrops involving the utricle was present only among patients with cochlear and saccular endolymphatic space dilatation. There was a significant relationship between the hearing level and the vestibular hydrops degree in the Bernaerts scale. The grade of the hydrops correlated neither with the duration of MD nor with the severity of main clinical symptoms. Our study proved MRI to be a sensitive diagnostic tool in MD. The endolymphatic hydrops' grade correlates with the hearing level, which confirms endolymphatic space dilatation's role in hearing loss. CONCLUSIONS: In our study, two similar MRI grading systems were used; however, several differences were found compared to one another. The Bernaerts scale was more sensitive than the Barath scale, and several relationships between the radiological and clinical data were found. Therefore, several MRI evaluating scales and correlating them with the clinical features are needed. The increased perilymphatic enhancement of the cochlea and an extra low-grade vestibular hydrops distinguished in the Bernaerts scale may increase MD diagnosis sensitivity. Magnetic resonance findings in MD support the clinical diagnosis and may help to understand MD pathophysiology better. This study adds to the knowledge and diagnostics in MD for healthcare to improve patients' treatment.

Cribriform adenocarcinoma of minor salivary glands presented as a nasopharyngeal tumor: A case report highlighting the significance of cytology.

Cribriform adenocarcinoma of minor salivary gland (CAMSG) is a rare malignancy presenting cytologic features resembling papillary thyroid carcinoma, localized in the oral cavity and oropharynx. Although cervical lymph node (LN) metastasis is a frequent manifestation of CMSG, there are few publications evaluating its cytology. The aim of this report was to present a CAMSG in an unusual location in the light of cytologic features, thereby enriching the spectrum of fine-needle aspiration biopsy (FNAB) differential diagnosis. We report a case of a 76-year-old woman presenting an enlarged submandibular LN on physical examination. Computed tomography revealed a submucosal lesion situated predominantly in the nasopharynx. FNAB and subsequently an open biopsy of submandibular LN were conducted. In cytologic smear cribriform, dense clusters of monomorphic round-oval tumor cells with scant cytoplasm were observed. Histologically, the tumor was composed of oval, overlapping cells with bright nuclear chromatin and nuclear grooves forming cribriform, papillary, and solid structures. Immunohistochemistry panel revealed the following: TTF-1 (-), thyroglobulin (-), S100 (+), p63 (+), Gal-3 (+), and CK19 (+) focally. The diagnosis of CAMSG should be considered when dealing with nasopharyngeal mass. Commonly, nodal metastases are observed in this tumor; therefore, appropriate evaluation of cytologic smear is crucial for patient management.

Changes in endolymphatic hydrops after vestibular neurectomy observed in magnetic resonance imaging - A pilot study.

OBJECTIVES: The aim was to evaluate endolymphatic hydrops in patients with Ménière's disease before and after vestibular neurectomy to verify if the endolymphatic space dilatation, observed in magnetic resonance imaging, regressed within several months after surgery. METHODS: Magnetic resonance imaging was performed after intravenous gadolinium injection in four patients with unilateral definite Ménière's disease before and eight months after vestibular neurectomy. Clinical symptoms, audiovestibular tests, and endolymphatic hydrops in magnetic resonance imaging were evaluated. RESULTS: Endolymphatic hydrops was visualized in preoperative magnetic resonance imaging in three out of four analyzed patients. In the remaining one, an asymmetrical contrast enhancement in the affected ear was found. After the vestibular neurectomy, all four patients presented a complete resolution of vertigo episodes and improved functional level. Significant postoperative hearing deterioration was found in two patients. In the follow-up magnetic resonance imaging, no reduction of the endolymphatic hydrops was visualized. A reduction of asymmetrical contrast enhancement in one patient was found. CONCLUSIONS: Magnetic resonance imaging of the inner ear is a helpful diagnostic tool for Menière's disease. Vestibular neurectomy is an effective treatment for intractable vertigo; however, there is no endolymphatic hydrops regression evidence within several months after the surgery. Therefore, further studies with a long follow-up period and repeated magnetic resonance imaging are needed to assess the vestibular neurectomy's impact on endolymphatic hydrops. Nevertheless, magnetic resonance imaging supports the clinical diagnosis of Ménière's disease and may help understand its pathophysiology.

Reliability of Endolymphatic Hydrops Qualitative Assessment in Magnetic Resonance Imaging.

The study aimed to compare the consistency of MRI interpretation of endolymphatic hydrops qualitative assessment of inner ear structures performed by independent observers. MRI with a delayed post-contrast 3D-FLAIR sequence was performed to visualize EH in patients suspected of having or diagnosed with MD. The scans were analyzed independently by three observers. In total, 220 ears were evaluated and, of these, 75 had definite MD, five probable MD, 67 with other Menieriform symptoms, and 73 were asymptomatic. Significant differences in cochlear endolymphatic hydrops (CoEH) grading between all observers were observed. On the Barath scale of vestibular endolymphatic hydrops (VEH), differences were found between the radiologists and otorhinolaryngologist in grading. No differences were noted in VEH on the Bernaerts scale and increased perilymphatic enhancement. Our study showed that evaluation of vestibular endolymphatic hydrops is repeatable between observers and easy to learn. It proved that Bernaerts' modification increased the sensitivity of EH diagnosis. Both parameters, CoEH and VEH, may serve as a differentiation method of EH from normal ears. The distinction between normal and hydropic ears is much easier to perform than EH grading. Therefore, it may be used to diagnose MD rather than EH staging.

Spinal Epidural Venous Plexus Enlargement as a Cause of Neurologic Symptoms: Vascular Anatomy and MRI Findings.

Pathology of the spinal venous system, unlike that of the spinal arterial system, is rarely considered as a possible cause of clinical symptoms. As the imaging features of the spinal venous anatomy and its diseases are not well-known, related pathologies may be overlooked or misdiagnosed. The major noninvasive technique enabling optimal visualization of spinal venous plexuses is magnetic resonance imaging (MRI). We report MRI findings from three cases of spinal venous plexus engorgement of different etiologies that resulted in neurologic symptoms, including radiculopathy and/or back pain. These cases are discussed in the context of the relevant anatomic and pathophysiologic background.

Magnetic resonance imaging of the inner ear in the diagnostics of Ménière's disease.

Ménière's disease is characterized by sudden episodes of vertigo accompanied by tinnitus and/or feeling of fullness in the ear as well as fluctuating sensorineural hearing loss. Despite numerous studies, the etiology of this disease remains unknown. However, the enlargement of the inner ear's endolymphatic spaces, referred to as endolymphatic hydrops, is considered the underlying condition. Thanks to recent advances in magnetic resonance (MR) technology, it is now possible to obtain in vivo imaging of endolymphatic hydrops in patients presenting with Ménière's disease symptoms. Visualization of the inner ear fluid compartments is achieved after gadolinium contrast is administered into the tympanic cavity or via the intravenous route. Evaluation of endolymphatic hydrops is possible as the contrast agent selectively penetrates the perilymph, and endolymph is visualized as contrast defects. The currently used radiological hydrops grading systems include qualitative, semi-quantitative, and volumetric scales. The methods are subject to ongoing modifications to increase their sensitivity and specificity. Numerous studies describe correlations between clinical symptoms and audiological and otoneurological examination results with the endolymphatic hydrops grade. MRI is also applicable in patients' diagnostics with an incomplete or atypical course of the Ménière's disease. In the course of the treatment, follow-up MRI scans enable assessing individual treatment modalities' efficacy in terms of the severity of lesions and the further course of the disease within the inner ear.

Selective occlusion of splenic artery aneurysms with the coil packing technique: the impact of packing density on aneurysm reperfusion correlated between contrast-enhanced MR angiography and digital subtraction angiography.

PURPOSE: The aim was to evaluate the relationship between coil packing densities after splenic artery aneurysm (SAA) treatment using detachable microcoils and rates of SAA reperfusion and to suggest a post-treatment surveillance protocol using contrast-enhanced MRA. MATERIALS AND METHODS: Evaluated were 16 patients (4 men; mean age 46.7), who underwent true SAA embolization using detachable microcoils (Concerto, Medtronic). SAAs were treated by selective coil packing (CP) or stent-assisted coil exclusion (SAC). Contrast-enhanced magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA) were performed at 3 months post-procedure and correlated. RESULTS: Primary CP was used in 13 patients, while SAC was used in three patients. On follow-up, complete aneurysm occlusion was seen in seven patients (43.8%). Sac reperfusion occurred in nine patients (56.2%) and was demonstrated in all CE-MRA and six DSA studies. Mean aneurysm packing density was 20.10 ± 8.05% for the CP group and 32.90 ± 11.95% for the SAC group (p = 0.038). There was a significant difference in the incidence of aneurysm sac reperfusion on CE-MRA study between CP and SAC (9 vs. 0). No sac reperfusion was seen in aneurysms with packing densities ≥ 29%, irrespective of either embolization method. CONCLUSION: Favorable midterm results for coil packing of SAAs seem to depend on the coil packing density with a coil volume approximately a quarter of the aneurysm volume being most effective. Follow-up should involve the use of CE-MRA as this modality has been shown to be superior over DSA in detecting aneurysm reperfusion and coil compaction. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Promoting False-Lumen Thrombosis after Thoracic Endovascular Aneurysm Repair in Type B Aortic Dissection by Selectively Excluding False-Lumen Distal Entry Tears.

PURPOSE: To evaluate the efficacy and clinical outcomes of ancillary endovascular procedures in promoting false-lumen (FL) thrombosis (FLT) and preventing aortic expansion in patients after thoracic endografting for type B dissections. MATERIALS AND METHODS: This retrospective review included 15 patients (12 men and 3 women; mean age, 59.6 y). Mean aortic diameter at the time of ancillary treatment was 47.4 mm. Different techniques were used as single procedures or sequentially: covered stent occlusion of detached visceral artery entry tears, occlusion of single entry tears with vascular plugs, or aortic endograft occlusion of multiple FL entry tears. FL embolization with ethylene vinyl alcohol copolymer was performed when selective occlusion was considered insufficient to close distal entry tears. Apart from endovascular aneurysm repair, all procedures were performed percutaneously under local anesthesia. If FL diameter increase persisted after 6-month follow-up computed tomographic (CT) angiography, another intervention was planned; otherwise, yearly follow-up was performed. RESULTS: Mean clinical follow-up duration was 43.8 months (range, 8 d to 86.8 mo), with no in-hospital mortality. Estimated overall survival rates were 93.3%, 86.6%, and 77% at 12, 24, and 48 months, respectively. Three late deaths occurred, one of which was dissection-related at 40 months. Eight surviving patients (53%) had total FLT and 3 had partial FLT with stable aortic diameter on follow-up CT angiography. FL diameter increased in one patient, requiring further intervention. CONCLUSIONS: Selective exclusion of new distal entry tears remaining after thoracic endovascular aneurysm repair can stabilize abdominal aortic expansion and promote FLT.

Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx.

INTRODUCTION: Type 2 endoleaks (T2E) occur in 10 to 20% of patients after endovascular abdominal aortic aneurysm repair (EVAR) and remain a significant clinical issue. AIM: To evaluate the efficacy and clinical outcomes of transarterial treatment of persistent type II endoleaks after EVAR using the liquid embolic Onyx. MATERIAL AND METHODS: From February 2012 to August 2015 transarterial T2E embolization was attempted in 22 patients (21 men, median age: 73, range: 62-88 years). Indications for treatment included an increase in the diameter of the aneurysm sac above 5 mm and a persistent endoleak observed for more than 6 months. Mean time from EVAR to endoleak treatment was 43 months (range: 2-125 months). RESULTS: Primary technical success was achieved in 17 (77.3%) patients and secondary technical success in 81.8%, with 0% in-hospital mortality. The mean procedure time was 95 ±48 min, with an average fluoroscopy time of 54 ±25 min. The mean amount of Onyx used was 7.5 ±6.6 ml. Clinical success was seen in 17/21 patients with follow-up imaging (80.9%). Mean follow-up time was 17 months (range: 3-38 months). CONCLUSIONS: Onyx has been shown to effectively stabilize previous aneurysm growth as a result of the T2E in the majority of our patients. Transarterial embolization of T2E can be significantly improved as compared to previously reported results by using liquid embolic polymers such as Onyx.