Acute intracranial hypertension management in metastatic brain tumor: A French national survey

BackgroundBrain metastases occur in 15–30% of cancer patients and their frequency has increased over time. They can cause intracranial hypertension, even in the absence of hydrocephalus. Emergency surgical management of brain metastasis-related intracranial hypertension is not guided by specific recommendations.ObjectiveWe aimed to make a French national survey of emergency management of intracranial hypertension without hydrocephalus in the context of cerebral metastasis.MethodsA national online survey of French neurosurgeons from 16 centers was conducted, consisting of three clinical files, with multiple-choice questions on diagnostic and therapeutic management in different emergency situations.ResultsIn young patients without any previously known primary cancer, acute intracranial hypertension due to a seemingly metastatic single brain tumor indicated emergency surgery for all those interviewed; 61% aimed at complete resection; brain MRI was mandatory for 74%. When a primary cancer was known, 74% of respondents were more likely to propose surgery if an oncologist confirmed the possibility of adjuvant treatment; 27% were more likely to operate on an emergency basis when resection was scheduled after multi-disciplinary discussion, prior to acute degradation.ConclusionCurrently, there is no consensus on the emergency management of intracranial hypertension in metastatic brain tumor patients. In case of previously known primary cancer, a discussion with the oncology team seems necessary, even in emergency. Decision criteria emerge from our literature review, but require analysis in further studies.     

Threshold for lateral meniscal body extrusion on MRI in middle-aged and elderly patients with symptomatic knee osteoarthritis

PurposeTo determine the MRI-based threshold of lateral meniscal body extrusion (LMBE) that are associated with meniscal damage, cartilage damage and radiological knee osteoarthritis (OA).Materials and methodsA total of 142 patients (59 men and 83 women) with a mean age of 57.2 ± 7.9 (SD) years (range: 41–77 years) with symptomatic knee OA were included. Radiological assessment was performed using the Kellgren-Lawrence scoring system. Meniscus and cartilage damage were assessed using the whole-organ magnetic resonance imaging score. Meniscal extrusion was quantified on coronal sections of intermediate-weighted MRI sequences. Differences between medial and lateral compartments in meniscal extrusion and incidence of tibiofemoral OA-related structural changes were assessed using Wilcoxon signed rank test and Bowker test. Receiver operating characteristic curves and Youden index were used for determining thresholds for meniscal extrusion.ResultsA total of 142 knees were assessed. Meniscal body extrusion distances between medial and lateral compartments were significantly different in the entire sample, and in subjects with and without radiological knee OA (P < 0.05 for all). The incidence of structural changes between medial and lateral compartments were significantly different (P = 0.003 for meniscal damage; P = 0.001 for femoral cartilage damage). Three mm and 2 mm were determined to be the optimal thresholds for medial and lateral meniscal body extrusion, respectively.ConclusionMedial and lateral meniscal body extrusion were associated with the incidence of OA-related knee structural changes in symptomatic patients with knee OA. A threshold of 2 mm for LMBE with respect to meniscal damage, cartilage damage and radiological knee OA was determined.     

Percutaneous ablation of obscure hypovascular liver tumours in challenging locations using arterial CT-portography guidance

PurposeThe purpose of this study was to evaluate the feasibility, safety and efficacy of percutaneous ablation (PA) of obscure hypovascular liver tumors in challenging locations using arterial CT-portography (ACP) guidance.Materials and methodsA total of 26 patients with a total of 28 obscure, hypovascular malignant liver tumors were included. There were 18 men and 6 women with a mean age of 58 ± 14 (SD) years (range: 37–75 years). The tumors had a mean diameter of 14 ± 10 (SD) mm (range: 7–24 mm) and were intrahepatic cholangiocarcinoma (4/28; 14%), liver metastases from colon cancer (18/28; 64%), corticosurrenaloma (3/28; 11%) or liver metastases from breast cancer (3/28; 11%). All tumors were in challenging locations including subcapsular (14/28; 50%), liver dome (9/28; 32%) or perihilar (5/28; 18%) locations. A total of 28 PA (12 radiofrequency ablations, 11 microwave ablations and 5 irreversible electroporations) procedures were performed under ACP guidance.ResultsA total of 67 needles [mean: 2.5 ± 1.5 (SD); range: 1–5] were inserted under ACP guidance, with a 100% technical success rate for PA. Median total effective dose was 26.5 mSv (IQR: 19.1, 32.2 mSv). Two complications were encountered (pneumothorax; one abscess both with full recovery), yielding a complication rate of 7%. No significant change in mean creatinine clearance was observed (80.5 mL/min at baseline and 85.3 mL/min at day 7; P = 0.8). Post-treatment evaluation of the ablation zone was overestimated on ACP compared with conventional CT examination in 3/28 tumors (11%). After a median follow-up of 20 months (range: 12–35 months), local tumor progression was observed in 2/28 tumours (7%).ConclusionACP guidance is feasible and allows safe and effective PA of obscure hypo-attenuating liver tumors in challenging locations without damaging the renal function and with acceptable radiation exposure. Post-treatment assessment should be performed using conventional CT or MRI to avoid size overestimation of the ablation zone.     

Prospective assessment of reproducibility of three-dimensional ultrasound for fetal biometry

PurposeTo compare fetal ultrasound measurements performed by two observers with different levels of experience and evaluate the potential contribution of the use of three-dimensional (3D) ultrasound on repeatability, reproducibility and agreement of two-dimensional (2D) and 3D-derived measurements.Materials and methodsTwo observers (one senior and one junior) measured head circumference (HC), abdominal circumference (AC) and femur length (FL) in 33 fetuses (20 to 40 weeks of gestation). Each observer performed two series of 2D measurements and two series of 3D measurements (i.e., measurements derived from triplane volume processing). Measurements were converted into Z-scores according to gestational age. Variability between the different series of measurements was studied using Bland–Altmann plots and intra-class correlation coefficients (ICC).ResultsAgreement with the 2D measurements of the senior observer was higher in 3D than in 2D for the junior observer (systematic differences of −0.4, −0.2 and −0.8 Z-score vs. −0.1, −0.1 and −0.6 for HC, AC and FL on 2D and 3D datasets, respectively). The use of 3D ultrasound improved junior observer repeatability (ICC = 0.94, 0.88, 0.90 vs. 0.94, 0.94 and 0.96 for HC, AC and FL in 2D and 3D, respectively). The reproducibility was greater using the junior observer 3D datasets (ICC = 0.75, 0.60 and 0.45 vs. 0.79, 0.89 and 0.63 for HC, AC and FL, respectively).ConclusionThe use of 3D ultrasound improves the consistency of the measurements performed by a junior observer and increases the overall repeatability and reproducibility of measurements performed by observers with different levels of experience.     

Impact of ultra-low dose CT acquisition on semi-automated RECIST tool in the evaluation of malignant focal liver lesions

PurposeTo compare the evaluation of malignant focal liver lesions (FLLs) using a semi-automated RECIST tool with a standard and an ultra-low dose (ULD) computed tomography (CT) protocol.Materials and methodsThirty-four patients with malignant FLLs underwent two abdominal-pelvic CT examinations one using a standard protocol and one using an ULD protocol. There were 23 men and 11 women with a mean age 64.3 ± 14.4 (SD) years (range: 22–91 years). Dosimetric indicators were recorded, and effective dose was calculated for both examinations. Mean malignant FLL attenuation, image noise and contrast-to-noise-ratio (CNR) were compared. The largest malignant FLL per patient was evaluated using the semi-automated RECIST tool to determine longest axis length, longest orthogonal axis length, volume and World Health Organisation area.ResultsDosimetric values were significantly reduced by −56% with ULD compared to standard protocol. No differences in mean malignant FLL attenuation values were found between the two protocols. Image noise was significantly increased for all locations (P < 0.05) with ULD compared to standard protocol, and CNR was significantly reduced (P < 0.05). On the 34 malignant FLLs analyzed, six semi-automated shapes non-concordant with radiologist's visual impression were highlighted with the software, including one FLL (1/34; 3%) with standard CT acquisition only, three FLLs (3/34; 9%) with ULD CT acquisition only and two FLLs (2/34; 6%) with both CT acquisitions. After manual editing, the concordance of the values of the studied criteria between both acquisitions was good and no significant difference was reported.ConclusionSemi-automated RECIST tool demonstrates good performances using ULD CT protocol. It could be used in routine clinical practice with a ULD protocol for follow-up studies in patients with known malignant FLL.     

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients

PurposeThe purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures.Materials and methodsFrom July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (< 24 hours) and delayed (> 24 hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsA total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7 ± 12.7 [SD] years; age range: 32–88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and > 24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%).ConclusionThe rate of per-procedural and early (within 24 hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (> 24 hours).     

Single-source dual energy CT to assess myocardial extracellular volume fraction in aortic stenosis before transcatheter aortic valve implantation (TAVI)

PurposeTo assess myocardial extracellular volume fraction (ECV) measurement provided by a single-source dual-energy computed tomography (SSDE-CT) acquisition added at the end of a routine CT examination before transcatether aortic valve implantation (TAVI) compared to cardiac magnetic resonance imaging (MRI).Materials and methodsTwenty-one patients (10 men, 11 women; mean age, 86 ± 4.9 years [SD]; age range: 71–92 years) with severe aortic stenosis underwent standard pre-TAVI CT with additional cardiac SSDE-CT acquisition 7 minutes after intravenous administration of iodinated contrast material and myocardial MRI including pre- and post-contrast T1-maps. Myocardial ECV and standard deviation (σECV) were calculated in the 16-segments model. ECV provided by SSDE-CT was compared to ECV provided by MRI, which served as the reference. Analyses were performed on a per-segment basis and on a per-patient involving the mean value of the 16-segments.ResultsECV was slightly overestimated by SSDE-CT (29.9 ± 4.6 [SD] %; range: 20.9%–48.3%) compared to MRI (29.1 ± 3.9 [SD] %; range: 22.0%–50.7%) (P < 0.0001) with a bias and limits of agreement of +2.3% (95%CI: −16.1%– + 20.6%) and +2.5% (95%CI: −2.1%– + 7.1%) for per-segment and per-patient-analyses, respectively. Good (r = 0.81 for per-segment-analysis) to excellent (r = 0.97 for per-patient-analysis) linear relationships (both P < 0.0001) were obtained. The σECV was significantly higher at SSDE-CT (P < 0.0001). Additional radiation dose from CT was 1.89 ± 0.38 (SD) mSv (range: 1.48–2.47 mSv).ConclusionA single additional SSDE-CT acquisition added at the end of a standard pre-TAVI CT protocol can provide ECV measurement with good to excellent linear relationship with MRI.     

Radiomics for classification of bone mineral loss: A machine learning study

PurposeThe purpose of this study was to develop predictive models to classify osteoporosis, osteopenia and normal patients using radiomics and machine learning approaches.Materials and methodsA total of 147 patients were included in this retrospective single-center study. There were 12 men and 135 women with a mean age of 56.88 ± 10.6 (SD) years (range: 28–87 years). For each patient, seven regions including four lumbar and three femoral including trochanteric, intertrochanteric and neck were segmented on bone mineral densitometry images and 54 texture features were extracted from the regions. The performance of four feature selection methods, including classifier attribute evaluation (CLAE), one rule attribute evaluation (ORAE), gain ratio attribute evaluation (GRAE) and principal components analysis (PRCA) along with four classification methods, including random forest (RF), random committee (RC), K-nearest neighbor (KN) and logit-boost (LB) were evaluated. Four classification categories, including osteopenia vs. normal, osteoporosis vs. normal, osteopenia vs. osteoporosis and osteoporosis + osteopenia vs. osteoporosis were examined for the defined seven regions. The classification model performances were evaluated using the area under the receiver operator characteristic curve (AUC).ResultsThe AUC values ranged from 0.50 to 0.78. The combination of methods RF + CLAE, RF + ORAE and RC + ORAE yielded highest performance (AUC = 0.78) in discriminating between osteoporosis and normal state in the trochanteric region. The combinations of RF + PRCA and LB + PRCA had the highest performance (AUC = 0.76) in discriminating between osteoporosis and normal state in the neck region.ConclusionThe machine learning radiomic approach can be considered as a new method for bone mineral deficiency disease classification using bone mineral densitometry image features.     

Awake spinal anesthesia facilitates spine surgery in poor surgical candidates: A case series

BackgroundAnnually, hundreds of thousands of patients undergo surgery for degenerative spine disease (DSD). This represents only a fraction of patients that present for surgical consideration. Procedures are often avoided due to comorbidities that make patients poor candidates for general anesthesia (GA) and its associated risks. With increasing interest in awake surgery under spinal anesthesia (SA), the authors have observed that SA may facilitate spine surgery in patients with relative contraindications to GA. With this in mind, the authors set out to summarize the outcomes of a series of highly comorbid patients who received surgery under SA.MethodsCase logs of a single surgeon were reviewed, and patients undergoing spine surgery under SA were identified. Within this group, patients were identified with relative contraindications to GA, such as advanced age and medical comorbidities. For these patients, for whom surgery was facilitated by SA, the medical records were consulted to report demographic information and patient outcomes.ResultsTen highly comorbid patients were identified who received lumbar spine surgery for DSD under SA. Comorbidities included octogenarian status, obesity, and chronic health conditions such as heart disease. The cohort had a mean age of 75.5 and a mean American Society of Anesthesiologists Physical Status (ASA-PS) score of 3.1. The patients were predicted to have a 2.74-fold increase of serious complications compared to the average patient. There were no adverse events.ConclusionFor patients with symptomatic, refractory DSD and relative contraindications to GA, SA may facilitate safe surgical intervention with excellent outcomes.     

Prognostic factors for progression-free survival of the filum terminale ependymomas in adults

ObjectiveTo define the prognostic factors for progression and to determine the impact of the histological grading (according to the World Health Organization) on the progression-free survival (PFS) of filum terminale ependymomas.MethodsA retrospective chart review of 38 patients with ependymoma of the filum terminale was performed, focusing on demographic data, preoperative symptoms, tumor size, quality of resection, presence of a tumor capsule, and histological grade.ResultsGross total resection (GTR) was achieved in 30 patients (78.9%). Histopathological analysis found 21 (55.3%) myxopapillary grade I ependymoma (MPE), 16 (42.1%) ependymoma grade II (EGII), and 1 (2.6%) ependymoma grade III. There was no significant difference between the mean ± SD volume of MPE (5840.5 ± 5244.2 mm³) and the one of EGII (7220.3 ± 6305.9 mm³, p = 0.5). The mean ± SD follow-up was 54.1 ± 38.4 months. At last follow-up, 30 (78.9%) patients were free of progression. In multivariate analysis, subtotal resection (p = 0.015) and infiltrative tumor (p = 0.03) were significantly associated with progression. The PFS was significantly higher in patients with encapsulated tumor than in patients with infiltrative tumor (log-rank p = 0.01) and in patients who had a GTR in comparison with those who had an incomplete resection (log-rank p = 0.05). There was no difference in PFS between patient with MPE and EGII (p = 0.1).ConclusionThe progression of ependymoma of the filum terminale highly depends on the quality of resection, and whether the tumor is encapsulated. Except for anaplastic grade, histopathological type does not influence progression.     

Aortitis and periaortitis: The puzzling spectrum of inflammatory aortic diseases

Aortitis and periaortitis are inflammatory diseases of the aorta and its main branches; they differ in the extension of inflammation, which is confined to the aortic wall in aortitis, and spreads to the periaortic space in periaortitis. Aortitis is classified as non-infectious or infectious. Non-infectious aortitis represents a common feature of large-vessel vasculitides but can also be isolated or associated with other rheumatologic conditions. Periaortitis can be idiopathic or secondary to a wide array of etiologies such as drugs, infections, malignancies, and other proliferative diseases. Notably, both aortitis and periaortitis may arise in the context of IgG4-related disease, a recently characterised fibro-inflammatory systemic disease. Prompt recognition, correct diagnosis and appropriate treatment are essential in order to avoid life-threatening complications.     

Intra-osseous cerebrospinal fluid shunts–Overview of past and present clinical and experimental evidence

In the history of hydrocephalus treatment, a variety of diversion sites have been explored to ensure an adequate alternative when the peritoneum was not a feasible option. An interesting choice was the elimination of excessive cerebrospinal fluid (CSF) in the skeletal system. The purpose of this review was to evaluate all shunting systems that have been implemented in bone structures and to determine their therapeutic potential. All articles pertaining to bone derivations were selected from PubMed, Medline, EBSCO and Scopus, using relevant search terms. The search revealed 6 types of osseous shunts that have been used throughout history: vertebral, diploic, ventriculomastoid, ventriculoiliac, ventriculosternal and ventriculohumeral. Some of them are purely of historical significance, but data from more recent clinical and experimental studies have rendered this type of receptacle a potential site for diverting CSF. Having knowledge of all the alternatives used in cases of refractory hydrocephalus is vital for choosing the appropriate surgical intervention.     

Interventional oncology at the time of COVID-19 pandemic: Problems and solutions

The COVID-19 pandemic has deeply impacted the activity of interventional oncology in hospitals and cancer centers. In this review based on official recommendations of different international societies, but also on local solutions found in different expert large-volume centers, we discuss the changes that need to be done for the organization, safety, and patient management in interventional oncology. A literature review of potential solutions in a context of scarce anesthesiologic resources, limited staff and limited access to hospital beds are proposed and discussed based on the literature data.     

Comparison of conventional magnetic resonance imaging and diffusion-weighted imaging in the differentiation of bone plasmacytoma from bone metastasis in the extremities

PurposeTo compare conventional magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) in the differentiation of bone plasmacytoma from bone metastasis in the extremities.Materials and methodsA total of 65 patients with 27 bone plasmacytomas (11 men; mean age, 63.6 ± 8.2 [SD] years) and 38 patients with bone metastases (20 men; mean age, 64.1 ± 11.5 [SD] years) were retrospectively included. Plasmacytomas and metastases were compared for size, peritumoral edema, signal intensity (SI), SI pattern, apparent diffusion coefficient (ADC) values and standard deviation (SD) of ADC. Receiver operating characteristic analysis with area under the curve (AUC) was used to calculate sensitivity, specificity, and accuracy of MRI and DWI for the diagnosis of plasmacytoma according to a defined cut-off value.ResultsOn conventional MRI, plasmacytomas showed less peritumoral edema (22% vs. 71%; P < 0.001), were more often hyperintense on T1-weighted image (48% vs. 18%; P = 0.022) and more homogeneous on T2-weighted image (78% vs. 26%; P < 0.001) and contrast-enhanced T1-weighted images (70% vs. 25%; P = 0.001) than bone metastases. Mean ADC value and SD of ADC were significantly lower in bone plasmacytomas (760.1 ± 196.9 [SD] μm²/s and 161.5 ± 62.7 [SD], respectively) than in bone metastases (1214.2 ± 382.6 [SD] μm²/s and 277.0 ± 110.3 [SD], respectively) (P < 0.001). Using an ADC value ≤ 908.3 μm²/s, DWI yielded 88% sensitivity and 78% specificity for the diagnosis of plasmacytoma. ADC value yielded best area under the curve (AUC = 0.913), followed by SD of ADC (AUC = 0.814) and homogeneity on T2-weighted images (AUC = 0.757). The combination of conventional MRI and DWI (AUC = 0.894) showed improved diagnostic performance over conventional MRI alone (AUC= 0.843) for discriminating between plasmacytoma and metastasis.ConclusionConventional MRI in combination with DWI can be useful to discriminate between bone plasmacytoma and bone metastasis in the extremities.     

Prenatal neurosurgical counseling for conditions affecting the fetal nervous system

ObjectiveThe aim of this study was to share a single center's experience of prenatal neurosurgical counseling and explore pregnant women's experiences with counseling.Material and methodsThis retrospective study analyzed data for 81 women who received prenatal counseling in a single institution (same senior pediatric neurosurgeon) over a 6-year period. Additionally, a retrospective questionnaire study was conducted with 33 women who chose to continue their pregnancy, to assess the strengths and weaknesses of counseling and analyze the reasons for their decision.ResultsSpinal dysraphism was the most frequent condition leading to prenatal counseling, followed by conditions affecting the cerebrospinal fluid. 57.6% of the women did not follow the French national recommendations on folic acid supplementation in the periconceptional period, and 38.3% underwent termination of pregnancy (TOP). One-third of the 33 women who answered our questionnaire changed their mind about TOP after counseling, and 50% reported that the information provided influenced their decision.ConclusionPrenatal neurosurgical counseling is nowadays an important part of a pediatric neurosurgeon's practice. It provides specific information to the woman to decide whether to continue the pregnancy. Urological concerns are frequent among the malformations encountered. Hence, we conclude that these women should be offered the possibility of seeing a urologist. Areas for improvement include greater awareness regarding folic acid supplementation and improved psychological care. The advantage for a woman of consulting a neurosurgeon consists in receiving information that is as accurate as possible about the level of disability of the future child and about surgery and follow-up.     

First intention vertebroplasty in fractures within an ankylosed thoracolumbar spinal segment

PurposeTo evaluate the outcome of percutaneous vertebral cementoplasty (PVC) as the first-line treatment for traumatic thoracolumbar fractures within an ankylosed spinal segment.Materials and methodsThirty-one patients (15 men, 16 women; mean age: 79.2 ± 11 [SD] years; age range: 66–95 years) with thoracolumbar fractures within an ankylosed spine segment without neurological impairment treated with PVC were retrospectively evaluated. All patients were controlled at six weeks and one year after PVC. Ankylosing conditions, fractures sites and types, radiological consolidation, spinal complications were assessed. Anterior/posterior vertebral height ratios were measured before and after PVC. Postoperative pain relief and treatment success (radiological fracture consolidation) rates were considered.ResultsThe 31 patients had a total of 39 fractures (19 stable [49%], 20 unstable [51%]) treated with PVC. Primary success rate of PVC (initial fracture consolidation without complication) was 61% (19/31). Seven patients (7/31; 23%) exhibited new fractures, and the secondary success rate of PVC (global fracture consolidation one year after repeat PVC) was 87% (34/39). Global consolidation rates of unstable fractures were 85% (17/20) of treated levels. Pain score was null in 84% patients (26/31) one year after PVC. There were no significant differences between pre-PVC (0.62 ± 0.18 [SD]; range: 0.22–0.88) and post-PVC (0.60 ± 0.18 [SD]; range: 0.35–0.88) vertebral height ratios (P = 0.94).ConclusionPVC conveys a high overall success rate and effectively controls pain in patients with vertebral fractures within ankylosed spine segments.     

Effects of a projector-based hybrid virtual reality on pain in young children with burn injuries during hydrotherapy sessions: A within-subject randomized crossover trial

AimThe aim of this study was to examine the effect of a water-friendly Projector-Based Hybrid Virtual Reality (VR) dome environment combined with standard pharmacological treatment on pain in young children undergoing burn wound care in hydrotherapy.MethodsThis study was a prospective, within-subject crossover trial of 38 children aged 6 months to 7 years old (mean age = 1.8 years old). Each hydrotherapy procedure was divided into two equivalent wound care segments (No hybrid VR during one segment vs. Hybrid VR during the other segment, treatment order was randomized). Pain was measured using the 0–10 FLACC (Face, Legs, Activity, Cry Consolability scale) and the 0–10 NRS-obs (Numerical Rating Scale-obs).ResultsProjector-Based Hybrid VR significantly reduced procedural pain levels measured by the FLACC (p = 0.026) and significantly increased patients' comfort levels (p = 0.002). Patients' pain levels rated by the nurses using the NRS-obs were non-significant between both groups (p = 0.135). No side effects were reported.ConclusionProjector-Based Hybrid VR helped in reducing the pain related to hydrotherapy procedures in young children with burn wound injuries. This is the first study using virtual reality distraction with young children, and our findings are especially important because a large percentage of pediatric burn patients are very young. Additional research and development are recommended.Trial registrationClinicalTrials.gov, NCT02986464, registered on June 12, 2016.     

Automatic coronary artery calcium scoring from unenhanced-ECG-gated CT using deep learning

PurposeThe purpose of this study was to develop and evaluate an algorithm that can automatically estimate the amount of coronary artery calcium (CAC) from unenhanced electrocardiography (ECG)-gated computed tomography (CT) cardiac volume acquisitions by using convolutional neural networks (CNN).Materials and methodsThe method used a set of five CNN with three-dimensional (3D) U-Net architecture trained on a database of 783 CT examinations to detect and segment coronary artery calcifications in a 3D volume. The Agatston score, the conventional CAC scoring, was then computed slice by slice from the resulting segmentation mask and compared to the ground truth manually estimated by radiologists. The quality of the estimation was assessed with the concordance index (C-index) on CAC risk category on a separate testing set of 98 independent CT examinations.ResultsThe final model yielded a C-index of 0.951 on the testing set. The remaining errors of the method were mainly observed on small-size and/or low-density calcifications, or calcifications located near the mitral valve or ring.ConclusionThe deep learning-based method proposed here to compute automatically the CAC score from unenhanced-ECG-gated cardiac CT is fast, robust and yields accuracy similar to those of other artificial intelligence methods, which could improve workflow efficiency, eliminating the time spent on manually selecting coronary calcifications to compute the Agatston score.     

Arterial endofibrosis in endurance athletes: Prospective comparison of the diagnostic accuracy of intra-arterial digital subtraction angiography and computed tomography angiography

PurposeTo prospectively compare the diagnostic capabilities of computed tomography angiography (CTA) to those of digital subtraction angiography (DSA) in endurance athletes with suspicion of arterial endofibrosis.Materials and methodsForty-five athletes (39 men, 6 women; median age: 30 years, interquartile range: 23–42 years) prospectively underwent DSA and CTA without (n = 5) or with (n = 40) electrocardiogram gating. DSA was interpreted by a single expert (experience of 15 years). CTA was independently interpreted by three other readers (experience of 5–8 years). Readers assessed the presence and degree of stenoses on iliac and femoral arteries and the overall diagnosis (negative, uncertain, positive) of endofibrosis at the limb level. Sensitivities and specificities of DSA and CTA were estimated at the limb level using histological findings and long-term follow-up as reference, and compared using the McNemar test.ResultsFor diagnosing and quantifying stenoses, concordance between DSA and CTA was moderate-to-good for common and external iliac arteries, moderate for lateral circumflex arteries and poor-to-moderate for the other branches of the deep femoral artery. It was good for all readers for the overall diagnosis of endofibrosis. After long-term follow-up (median, 95 months; interquartile range: 7–109 months), DSA sensitivity and specificity were respectively 88.6% (39/44; 95% confidence interval [CI]: 76–95%) and 75% (24/32; 95% CI: 57.9–86.7%); CTA sensitivity and specificity were respectively 88.6% (39/44; 95% CI: 76–95%; P > 0.99) and 84.4% (27/32; 95% CI: 68.2–93.1%; P = 0.51), 86.3% (38/44; 95% CI: 73.3–93.6%; P > 0.99) and 75% (24/32; 95% CI: 57.9–86.7%; P > 0.99), and 84.1% (37/44; 95% CI: 70.6–92.1%; P = 0.68) and 75% (24/32; 95% CI: 57.9–86.7%; P > 0.99) for the three readers.ConclusionCTA shows performances similar to those of DSA in predicting the long-term diagnosis of endofibrosis in endurance athletes with suggestive symptoms.     

Prediction of overall survival in patients with hepatocellular carcinoma treated with Y-90 radioembolization by imaging response criteria

PurposeTo evaluate the potential of imaging criteria in predicting overall survival of patients with hepatocellular carcinoma (HCC) after a first transcatheter arterial yttrium-90 radioembolization (TARE)Materials and methodsFrom October 2013 to July 2017, 37 patients with HCC were retrospectively included. There were 34 men and 3 women with a mean age of 60.5 ± 10.2 (SD) years (range: 32.7–78.9 years). Twenty-five patients (68%) were Barcelona Clinic Liver Cancer (BCLC) C and 12 (32%) were BCLC B. Twenty-four primary index tumors (65%) were > 5 cm. Three radiologists evaluated tumor response on pre- and 4–7 months post-TARE magnetic resonance imaging or computed tomography examinations, using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, modified RECIST (mRECIST), European Association for Study of the Liver (EASL), volumetric RECIST (vRECIST), quantitative EASL (qEASL) and the Liver Imaging Reporting and Data System treatment response algorithm. Kaplan–Meier survival curves were used to compare responders and non-responders for each criterion. Univariate and multivariate Cox proportional hazard ratio (HR) analysis were used to identify covariates associated with overall survival. Fleiss kappa test was used to assess interobserver agreement.ResultsAt multivariate analysis, RECIST 1.1 (HR: 0.26; 95% confidence interval [95% CI]: 0.09–0.75; P = 0.01), mRECIST (HR: 0.22; 95% CI: 0.08–0.59; P = 0.003), EASL (HR: 0.22; 95% CI: 0.07–0.63; P = 0.005), and qEASL (HR: 0.30; 95% CI: 0.12–0.80; P = 0.02) showed a significant difference in overall survival between responders and nonresponders. RECIST 1.1 had the highest interobserver reproducibility.ConclusionRECIST and mRECIST seem to be the best compromise between reproducibility and ability to predict overall survival in patients with HCC treated with TARE.