Molecularly matched targeted therapy: a promising approach for refractory metastatic melanoma

BACKGROUND

Only a fraction of patients with metastatic melanoma derive durable benefit from approved treatments. The clinical impact of personalized medicine strategies for melanoma, apart from BRAF, NRAS, or CKIT targeting, has rarely been reported.

MATERIALS AND METHODS

By means of the Group of Cutaneous Oncology of the French Society of Dermatology, we retrospectively included all patients with advanced melanoma aged 18 years and older for whom molecular testing identified one or more actionable molecular alterations and who accordingly received molecularly matched therapy. We excluded patients with only BRAF, NRAS, or CKIT alterations and patients who received molecularly matched therapy for less than 15 days.

RESULTS

We included 26 patients with a median follow-up of 8 months (1-54), a median age of 63 years (24-89), and a sex ratio of 2.7. These patients had been heavily pretreated, and 64% had elevated LDH levels. The disease control rate was 38%, with 4 cases of partial response (overall response rate: 15%) and 6 of stable disease for at least 6 months. The median duration of treatment was 3.1 months (0.9-13.5). Among patients with disease control, the median duration of control was 6.6 months (2.6-13.5) and 3 cases were ongoing at the end of the study. Patients with controlled disease had GNA11, MAP2K1, FYCO1-RAF1, HRAS, ATM, CCND1, MDM2/CDK4, and CDKN2A/NRAS alterations.

CONCLUSIONS

High-throughput sequencing followed by matched targeted therapy is a promising approach for patients with advanced melanoma refractory to approved treatments.

The Value of Aortic Volume and Intraluminal Thrombus Quantification for Predicting Aortic Events after Endovascular Thoracic Aneurysm Repair

Objectives: To assess the ability of the aortic aneurysm volume (AAV), aneurysmal lumen volume (ALV), and aneurysmal thrombus volume (ATV) to predict the need for aortic reintervention when using the maximal aortic diameter as a reference. Methods: This monocentric retrospective study included 31 consecutive patients who underwent successful thoracic endovascular aortic repair (TEVAR) to treat an atheromatous thoracic aortic aneurysm. All patients underwent clinical and computed tomography angiography (CTA) for 3 years after TEVAR. The patients were categorized into group 0 if no aortic reintervention was required during the follow-up period and categorized into group 1 if they experienced a type I or III endoleak or aneurysm diameter increase requiring intervention. The maximum aneurysm sac diameter and the AAV, ALV, and ATV were calculated using CTA images obtained preoperatively (T0) and at 6-12 months (T1), 24 months (T2), and 36 months (T3) postoperatively, and their changes over time were analyzed. Correlations between diameter and changes in AAV, ALV, and ATV were assessed, and the association between diameter and volume changes and reintervetion was examined. The cutoff values for predicting the need for reintervention was determined using a receiver operating characteristic (ROC) curve. The accuracy of volume change versus diameter change for predicting the need for reintervention was analyzed. Results: There were no significant differences in terms of the mean aneurysm diameter or AAV, ALV or ATV between the groups at preoperative CTA or after one year of follow-up imaging. The mean ATV was higher in group 1 than in group 0 at 2 years (187.6 ± 86.3 mL vs. 114.7 ± 64.7 mL; p = 0.057) and after 3 years (195.0 ± 86.7 mL vs. 82.1 ± 39.9 mL; p = 0.013). The maximal diameter was greater in group 1 than in group 0 at 3 years (67.3 ± 9.5 mm vs. 55.3 ± 12.6 mm; p = 0.044). The rate of AAV change between T0 and T1 was significantly higher in group 1 (7 ± 4.5%) than in group 0 (-6 ± 6.8%; p < 0.001). The rate of ATV change between T1-T3 was significantly higher in group 1 than in group 0 (34 ± 40.9% vs. -13 ± 14.4% (p = 0.041)); similar results were observed for the rate of ATV change between T2 and T3 (27 ± 50.1% for group 1 vs. -8 ± 49.5% in group 0 (p < 0.001)). According to our multivariate analysis, the annual growth rate for AAV between T0 and T1 was the only independent factor that was significantly associated with aortic reintervention (area under the curve (AUC) = 0.84, OR = 1.57, p = 0.025; optimal cutoff +0.4%). An increase in the annual growth rate of the ATV between T0 and T3 was independently associated with the need for aortic reintervention (area under the curve (AUC) = 0.90, OR = 1.11, p = 0.0347; optimal cutoff +10.1%). Conclusions: Aortic volume analysis can predict the need for aortic reintervention more accurately and earlier than maximal aortic diameter.

Left Ventricular Trabeculations at Cardiac MRI: Reference Ranges and Association with Cardiovascular Risk Factors in UK Biobank

Background The extent of left ventricular (LV) trabeculation and its relationship with cardiovascular (CV) risk factors is unclear. Purpose To apply automated segmentation to UK Biobank cardiac MRI scans to (a) assess the association between individual characteristics and CV risk factors and trabeculated LV mass (LVM) and (b) establish normal reference ranges in a selected group of healthy UK Biobank participants. Materials and Methods In this cross-sectional secondary analysis, prospectively collected data from the UK Biobank (2006 to 2010) were retrospectively analyzed. Automated segmentation of trabeculations was performed using a deep learning algorithm. After excluding individuals with known CV diseases, White adults without CV risk factors (reference group) and those with preexisting CV risk factors (hypertension, hyperlipidemia, diabetes mellitus, or smoking) (exposed group) were compared. Multivariable regression models, adjusted for potential confounders (age, sex, and height), were fitted to evaluate the associations between individual characteristics and CV risk factors and trabeculated LVM. Results Of 43 038 participants (mean age, 64 years ± 8 [SD]; 22 360 women), 28 672 individuals (mean age, 66 years ± 7; 14 918 men) were included in the exposed group, and 7384 individuals (mean age, 60 years ± 7; 4729 women) were included in the reference group. Higher body mass index (BMI) (β = 0.66 [95% CI: 0.63, 0.68]; P < .001), hypertension (β = 0.42 [95% CI: 0.36, 0.48]; P < .001), and higher physical activity level (β = 0.15 [95% CI: 0.12, 0.17]; P < .001) were associated with higher trabeculated LVM. In the reference group, the median trabeculated LVM was 6.3 g (IQR, 4.7-8.5 g) for men and 4.6 g (IQR, 3.4-6.0 g) for women. Median trabeculated LVM decreased with age for men from 6.5 g (IQR, 4.8-8.7 g) at age 45-50 years to 5.9 g (IQR, 4.3-7.8 g) at age 71-80 years (P = .03). Conclusion Higher trabeculated LVM was observed with hypertension, higher BMI, and higher physical activity level. Age- and sex-specific reference ranges of trabeculated LVM in a healthy middle-aged White population were established. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Kawel-Boehm in this issue.

Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BACKGROUND

COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes.

MATERIAL AND METHODS

An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.

RESULTS

Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.

CONCLUSIONS

These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) Is Associated With Good Anatomical Results on the Distal Thoracoabdominal Aorta at 2 Years

PURPOSE

The aim of this comparative study was to evaluate the increased aortic diameter of the distal aorta after implementing the STABILISE technique in complicated type B aortic dissection (AD).

DESIGN

This is a comparative monocentric retrospective study.

MATERIALS AND METHODS

All patients who underwent an STABILISE procedure for complicated AD between 2018 and 2020 were included and compared with a historic cohort treated with thoracic endovascular aortic repair (TEVAR) alone. Aortic diameters were measured at 6 different levels on the thoracic and abdominal aorta. The primary end point was an increased aortic diameter at 1 and 2 years. The exclusion criterion was the absence of a computed tomography (CT) scan at 1 or 2 years.

RESULTS

A total of 55 patients were included: 24 in the TEVAR group and 31 in the STABILISE group. At the level of the stent graft, there was a decrease in aortic diameters in both groups without significant differences. At the level of the distal aorta, there was an increase in aortic diameters in both groups without significant differences. There were significantly more patients in the TEVAR group with an unfavorable increase in aortic diameter >5 mm of the distal aorta at 2 years than in the STABILISE group: 8 (33%) vs 1 (3%) (p=0.01). For chronic ADs, a significantly greater increase in aortic diameters of the distal aorta was observed in the STABILISE group.

CONCLUSIONS

The STABILISE technique is technically feasible and potentially leads to decreased longer re-intervention rates; indeed, more patients had an unfavorable increase in aortic diameter in the TEVAR group than in the STABILISE group at 2 years. The high rate of long-term distal aortic aneurysm progression and reintervention after TEVAR alone suggests that this option is not sufficient to definitively treat these complex patients.

CLINICAL IMPACT

This article reported the results of stent assisted balloon induced intimal disruption and relamination (STABILISE) with a follow-up at 2 years. This is the first comparative study between STABILISE, which has emerged as a new technique inducing aortic remodeling and therefore better long-term outcome, and the standard technique TEVAR alone. STABILISE technique is associated with good results on the distal aorta at 2 years with a rate of patient with unfavorable aortic diameter evolution greater in TEVAR group compared to STABILISE group and could improve the long-term results on the distal aorta by inducing extensive aortic remodeling.

Late Post-Dissection Dynamic Intermittent Malperfusion of the Aortic Arch in Association with a Rare Heterogenous LOX Gene Variation

Late ischaemic consequences of type A aortic dissection are rare. We present a 6-year late complication of type A aortic dissection treated by Bentall surgery in a 41-year-old patient. The patient presented with several episodes of lipothymia associated with hypertensive attacks with anisotension, cervicalgia, hemicranial headache, abdominal pain and lower limb slipping initially on exertion and later at rest. On dynamic examination, we diagnosed an intermittent dynamic occlusion of the aortic arch and rare LOX gene variation, which is considered to be associated with aneurysm or dissection of the ascending aorta in young patients. Surgical treatment by replacement of the ascending aorta and the aortic arch with reimplantation of the brachiocephalic trunk (BcTr) allowed the symptoms to resolve.

The impact of a history of status epilepticus for epilepsy surgery outcome

OBJECTIVE

Patients with focal drug resistant epilepsy are excellent candidates for epilepsy surgery. Status epilepticus (SE) and seizure clusters (SC), described in a subset of patients, have both been associated with extended epileptogenic cerebral networks within one or both hemispheres. In this retrospective study, we were interested to determine if a history of SE or SC is associated with a worse surgical outcome.

METHODS

Data of 244 patients operated between 2000 to 2018 were reviewed, with a follow-up of at least 2 years. Patients with a previous history of SE or SC were compared to operated patients without these conditions (control group, CG).

RESULTS

We identified 27 (11%) and 38 (15.5%) patients with history of SE or SC, respectively. No difference in post-operative outcome was found for SE and SC patients. Compared to the control group, patients with a history of SE were diagnosed and operated significantly at earlier age(p = 0.01), and after a shorter duration of the disease (p = 0.027), but with a similar age of onset.

SIGNIFICANCE

A history of SE or SC was not associated with a worse post-operative prognosis. Earlier referral of SE patients for surgery suggests a heightened awareness regarding serious complications of recurrent SE by the referring neurologist or neuropediatrician. While the danger of SE is evident, policies to underline the impact for SC or very frequent seizures might be an efficient approach to accelerate patient referral also for this patient group.

Diffusion weighted imaging changes in extra-abdominal desmoid tumor after cryotherapy

Desmoid tumors (DT) are rare benign tumors with a local invasion potential and recurrence. It is characterized on histology by an abnormal fibroblastic proliferation in a collagenous stroma, in variable proportions leading to heterogeneity of the lesion signal on magnetic resonance imaging (MRI). Current guidelines propose watchful waiting but in case of progression or symptoms, cryotherapy may be a therapeutic option in its extra-abdominal form. Tumor recurrence is mostly detected based on post-contrast magnetic resonance imaging (MRI). Although DWI sequence is the key-sequence for tumor detection in oncologic imaging, there are very few data in literature on diffusion weighted imaging (DWI) in DT generally and even fewer on DT after cryotherapy. DWI changes after cryotherapy may be confusing and suspicious of residual tumor or tumor recurrence when displaying low ADC values; thus knowledge of possible DWI patterns after cryotherapy of DT seem paramount. We found that the early changes of DT after cryotherapy are hyperintensity on DWI sequence with low ADC values (<1.00 × 10^-3mm²/s), without corresponding enhancement and a later decrease in signal of the treated lesion on DWI. The freezing-thawing cycles of cryotherapy turn DT into gelatinous necrosis with a slow resorption rate, as reported in the only few studies referring of changes of DWI signals after cryotherapy, which are on renal and prostate models. Hyperintensity on DWI with low ADC values may be seen in early MRI follow-up after cryotherapy of extra-abdominal DT, corresponding with tumor necrosis changes and should not be mistaken with recurrence.KEY MESSAGESMagnetic resonance imaging is the modality of choice for desmoid tumor (DT) follow-up, mainly based on contrast uptake which make data on diffusion weighted imaging (DWI) very rare.Cryotherapy is an accepted therapeutic option for DT that will lead to tumor necrosis.Hyperintensity on DWI with low apparent diffusion coefficient values is a possible expected early pattern on DWI after cryotherapy of DT.

Probing artificial intelligence in neurosurgical training: ChatGPT takes a neurosurgical residents written exam

Introduction

Artificial Intelligence tools are being introduced in almost every field of human life, including medical sciences and medical education, among scepticism and enthusiasm.

Research question

to assess how a generative language tool (Generative Pretrained Transformer 3.5, ChatGPT) performs at both generating questions and answering a neurosurgical residents' written exam. Namely, to assess how ChatGPT generates questions, how it answers human-generated questions, how residents answer AI-generated questions and how AI answers its self-generated question.

Materials and methods

50 questions were included in the written exam, 46 questions were generated by humans (senior staff members) and 4 were generated by ChatGPT. 11 participants took the exam (ChatGPT and 10 residents). Questions were both open-ended and multiple-choice.8 questions were not submitted to ChatGPT since they contained images or schematic drawings to interpret.

Results

formulating requests to ChatGPT required an iterative process to precise both questions and answers. Chat GPT scored among the lowest ranks (9/11) among all the participants). There was no difference in response rate for residents' between human-generated vs AI-generated questions that could have been attributed to less clarity of the question. ChatGPT answered correctly to all its self-generated questions.

Discussion and conclusions

AI is a promising and powerful tool for medical education and for specific medical purposes, which need to be further determined. To request AI to generate logical and sound questions, that request must be formulated as precise as possible, framing the content, the type of question and its correct answers.

Acute mesenteric ischemia: which predictive factors of delayed diagnosis at emergency unit?

PURPOSE

Acute mesenteric ischemia (AMI) is frequently diagnosed late, leading to a poor prognosis. Our aims were to identify predictive factors of delayed diagnosis and to analyze the outcomes of patients with AMI admitted in emergency units.

METHODS

All the patients with AMI (2015-2020), in two Emergency units, were retrospectively included. Two groups were defined according to the time of diagnosis between the arrival at emergency unit and the CT scan: ≤ 6 h (early), > 6 h (delayed).

RESULTS

119 patients (mean age = 71 ± 7 years) were included. The patients with a delayed diagnosis (n = 33, 28%) were significantly associated with atypical presentation, including lower rates of abdominal pain (73 vs 89%, p = 0.003), abdominal tenderness (33 vs 43%, p = 0.03), and plasma lactate (4 ± 2 vs 6 ± 7 mmol/l, p = 0.03) when compared with early diagnosis. After multivariate analysis, the absence of abdominal pain was the only independent predictive factor of delayed diagnosis (Odd Ratio = 0.17; 95% CI = 0.03-0.88, p = 0.03). Patients with delayed diagnosis tended to be associated to lower rates of revascularization (9 vs 17%, p = 0.4), higher rates of major surgical morbidity (90 vs 57%, p = 0.1), longer length of stay (16 ± 23 vs 13 ± 15 days, p = 0.4) and, at the end of follow-up, higher rate of short small bowel syndrome (18 vs 7%, p = 0.095).

CONCLUSION

AMI is a challenge for emergency physicians. History of patient, physical exam, biological data are not sufficient to diagnose AMI. New biomarkers, and awareness of emergency physicians should improve and accelerate the diagnosis of AMI.

Radiomics model to classify mammary masses using breast DCE-MRI compared to the BI-RADS classification performance

BACKGROUND

Recent advanced in radiomics analysis could help to identify breast cancer among benign mammary masses. The aim was to create a radiomics signature using breast DCE-MRI extracted features to classify tumors and to compare the performances with the BI-RADS classification.

MATERIAL AND METHODS

From September 2017 to December 2019 images, exams and records from consecutive patients with mammary masses on breast DCE-MRI and available histology from one center were retrospectively reviewed (79 patients, 97 masses). Exclusion criterion was malignant uncertainty. The tumors were split in a train-set (70%) and a test-set (30%). From 14 kinetics maps, 89 radiomics features were extracted, for a total of 1246 features per tumor. Feature selection was made using Boruta algorithm, to train a random forest algorithm on the train-set. BI-RADS classification was recorded from two radiologists.

RESULTS

Seventy-seven patients were analyzed with 94 tumors, (71 malignant, 23 benign). Over 1246 features, 17 were selected from eight kinetic maps. On the test-set, the model reaches an AUC = 0.94 95 CI [0.85-1.00] and a specificity of 33% 95 CI [10-70]. There were 43/94 (46%) lesions BI-RADS4 (4a = 12/94 (13%); 4b = 9/94 (10%); and 4c = 22/94 (23%)). The BI-RADS score reached an AUC = 0.84 95 CI [0.73-0.95] and a specificity of 17% 95 CI [3-56]. There was no significant difference between the ROC curves for the model or the BI-RADS score (p = 0.19).

CONCLUSION

A radiomics signature from features extracted using breast DCE-MRI can reach an AUC of 0.94 on a test-set and could provide as good results as BI-RADS to classify mammary masses.

Feasibility of Non-Invasive Coronary Artery Disease Screening with Coronary CT Angiography before Transcatheter Aortic Valve Implantation

Coronary artery disease (CAD) screening is usually performed before transcatheter aortic valve implantation (TAVI) by invasive coronary angiography (ICA). Computed coronary tomography angiography (CCTA) has shown good diagnostic performance for CAD screening in patients with a low probability of CAD and is systematically performed before TAVI. CCTA could be an efficient alternative to ICA for CAD screening before TAVI. We sought to investigate the diagnostic performance of CCTA in a population of unselected patients without known CAD who were candidates for TAVI. All consecutive patients referred to our center for TAVI without known CAD were enrolled. All patients underwent CCTA and ICA, which were considered the gold standard. A statistical analysis of the diagnostic performance per patient and per artery was performed. 307 consecutive patients were enrolled. CCTA was non-analyzable in 25 patients (8.9%). In the per-patient analysis, CCTA had a sensitivity of 89.6%, a specificity of 90.2%, a positive predictive value of 65.15%, and a negative predictive value of 97.7%. Only five patients were classified as false negatives on the CCTA. Despite some limitations of the study, CCTA seems reliable for CAD screening in patients without known CAD who are candidates for TAVI. By using CCTA, ICA could be avoided in patients with a CAD-RADS score ≤ 2, which represents 74.8% of patients.

Prognostic value of cardiovascular magnetic resonance T1 mapping and extracellular volume fraction in nonischemic dilated cardiomyopathy

BACKGROUND

Heart failure- (HF) and arrhythmia-related complications are the main causes of morbidity and mortality in patients with nonischemic dilated cardiomyopathy (NIDCM). Cardiovascular magnetic resonance (CMR) imaging is a noninvasive tool for risk stratification based on fibrosis assessment. Diffuse interstitial fibrosis in NIDCM may be a limitation for fibrosis assessment through late gadolinium enhancement (LGE), which might be overcome through quantitative T1 and extracellular volume (ECV) assessment. T1 and ECV prognostic value for arrhythmia-related events remain poorly investigated. We asked whether T1 and ECV have a prognostic value in NIDCM patients.

METHODS

This prospective multicenter study analyzed 225 patients with NIDCM confirmed by CMR who were followed up for 2 years. CMR evaluation included LGE, native T1 mapping and ECV values. The primary endpoint was the occurrence of a major adverse cardiovascular event (MACE) which was divided in two groups: HF-related events and arrhythmia-related events. Optimal cutoffs for prediction of MACE occurrence were calculated for all CMR quantitative values.

RESULTS

Fifty-eight patients (26%) developed a MACE during follow-up, 42 patients (19%) with HF-related events and 16 patients (7%) arrhythmia-related events. T1 Z-score (p = 0.008) and global ECV (p = 0.001) were associated with HF-related events occurrence, in addition to left ventricular ejection fraction (p < 0.001). ECV > 32.1% (optimal cutoff) remained the only CMR independent predictor of HF-related events occurrence (HR 2.15 [1.14-4.07], p = 0.018). In the arrhythmia-related events group, patients had increased native T1 Z-score and ECV values, with both T1 Z-score > 4.2 and ECV > 30.5% (optimal cutoffs) being independent predictors of arrhythmia-related events occurrence (respectively, HR 2.86 [1.06-7.68], p = 0.037 and HR 2.72 [1.01-7.36], p = 0.049).

CONCLUSIONS

ECV was the sole independent predictive factor for both HF- and arrhythmia-related events in NIDCM patients. Native T1 was also an independent predictor in arrhythmia-related events occurrence. The addition of ECV and more importantly native T1 in the decision-making algorithm may improve arrhythmia risk stratification in NIDCM patients. Trial registration NCT02352129. Registered 2nd February 2015-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02352129.

Simultaneous multi-slice T1 mapping using MOLLI with blipped CAIPIRINHA bSSFP

BACKGROUND

This study evaluates the possibility for replacing conventional 3 slices, 3 breath-holds MOLLI cardiac T1 mapping with single breath-hold 3 simultaneous multi-slice (SMS3) T1 mapping using blipped-CAIPIRINHA SMS-bSSFP MOLLI sequence. As a major drawback, SMS-bSSFP presents unique artefacts arising from side-lobe slice excitations that are explained by imperfect RF modulation rendering and bSSFP low flip angle enhancement. Amplitude-only RF modulation (AM) is proposed to reduce these artefacts in SMS-MOLLI compared to conventional Wong multi-band RF modulation (WM).

MATERIALS AND METHODS

Phantoms and ten healthy volunteers were imaged at 1.5 T using a modified blipped-CAIPIRINHA SMS-bSSFP MOLLI sequence with 3 simultaneous slices. WM-SMS3 and AM-SMS3 were compared to conventional single-slice (SMS1) MOLLI. First, SNR degradation and T1 accuracy were measured in phantoms. Second, artefacts from side-lobe excitations were evaluated in a phantom designed to reproduce fat presence near the heart. Third, the occurrence of these artefacts was observed in volunteers, and their impact on T1 quantification was compared between WM-SMS3 and AM-SMS3 with conventional MOLLI as a reference.

RESULTS

In the phantom, larger slice gaps and slice thicknesses yielded higher SNR. There was no significant difference of T1 values between conventional MOLLI and SMS3-MOLLI (both WM and AM). Positive banding artefacts were identified from fat neighbouring the targeted FOV due to side-lobe excitations from WM and the unique bSSFP signal profile. AM RF pulses reduced these artefacts by 38%. In healthy volunteers, AM-SMS3-MOLLI showed similar artefact reduction compared to WM-SMS3-MOLLI (3 ± 2 vs 5 ± 3 corrupted LV segments out of 16). In-vivo native T1 values obtained from conventional MOLLI and AM-SMS3-MOLLI were equivalent in LV myocardium (SMS1-T1 = 935.5 ± 36.1 ms; AM-SMS3-T1 = 933.8 ± 50.2 ms; P = 0.436) and LV blood pool (SMS1-T1 = 1475.4 ± 35.9 ms; AM-SMS3-T1 = 1452.5 ± 70.3 ms; P = 0.515). Identically, no differences were found between SMS1 and SMS3 postcontrast T1 values in the myocardium (SMS1-T1 = 556.0 ± 19.7 ms; SMS3-T1 = 521.3 ± 28.1 ms; P = 0.626) and the blood (SMS1-T1 = 478 ± 65.1 ms; AM-SMS3-T1 = 447.8 ± 81.5; P = 0.085).

CONCLUSIONS

Compared to WM RF modulation, AM SMS-bSSFP MOLLI was able to reduce side-lobe artefacts considerably, providing promising results to image the three levels of the heart in a single breath hold. However, few artefacts remained even using AM-SMS-bSSFP due to residual RF imperfections. The proposed blipped-CAIPIRINHA MOLLI T1 mapping sequence provides accurate in vivo T1 quantification in line with those obtained with a single slice acquisition.

Endovascular therapies for hepatic artery stenosis post liver transplantation

PURPOSE

To evaluate primary patency at 12 months after endovascular therapies in hepatic artery stenosis.

METHODS

A retrospective review of all endovascular interventions for hepatic artery stenosis (HAS) after liver transplantation that occurred between June 2013 and November 2020 was performed at a single institution in France. Follow up occurred from 1 month to 4 years (median 15 months). The treatment consisted of dilation with a balloon or stent. We analyzed short-term (technical success and complications) and long-term outcomes (liver function, arterial patency, graft survival at 12 months (GS), and reintervention). We also compared percutaneous balloon angioplasty (PBA) with stent placement. PBA alone was used if < 30% residual stenosis of the hepatic artery was achieved. Stenting was performed if there was greater than 30% residual stenosis and in the case of complications (dissection or rupture).

RESULTS

A total of 18 stenoses were suspected on the basis of routine surveillance duplex ultrasound imaging (peak systolic velocity > 200 cm/s, systolic accelerating time > 10 ms and resistive index < 0.5), all of which were confirmed by angio CT, but only 17 were confirmed by angiography. Seventeen patients were included (14 males, mean age 57 years; and three females, mean age 58 years). Interventions were performed in 17 cases (95%) with PBA only (5/17), stent only (5/17) or both (4/17). Immediate technical success was 100%. Major complications occurred in 1 of 17 cases (5.8%), consisting of target vessel dissection. The analysis of the three (groups PBA only, stent only or both) showed the same procedural success (100%), GS (100%) and normal liver function after the procedures but different rates of complications (20% vs. 0% vs. 0%), arterial patency at 12 months (60% vs. 80% vs. 85%) (p = 0.4), early stenosis (40% vs. 80% vs. 0%) or late stenosis (60% vs. 20% vs. 100%) and requirement for reintervention (40% vs. 20% vs. 14%) (p = 0.56).

CONCLUSION

This study suggests that PBA, stent, or both procedures show the same primary patency at 12 months. It is probably not a definitive answer, but these treatments are safe and effective for extending graft survival in the context of graft shortages.

Angio Cone-Beam CT (Angio-CBCT) and 3D Road-Mapping for the Detection of Spinal Cord Vascularization in Patients Requiring Treatment for a Thoracic Aortic Lesion: A Feasibility Study

BACKGROUND

Spinal cord ischemia is a major complication of treatment for descending thoracic aorta (DTA) disease. Our objectives were (1) to describe the value of angiographic cone-beam CT (angio-CBCT) and 3D road-mapping to visualize the Adamkiewicz artery (AA) and its feeding artery and (2) to evaluate the impact of AA localization on the patient surgical strategy.

METHODS

Between 2018 and 2020, all patients referred to our institution for a surgical DTA disorder underwent a dedicated AA evaluation by angio-CBCT. If the AA feeding artery was not depicted on angio-CBCT, selective artery catheterization was performed, guided by 3D road-mapping. Intervention modifications, based on AA location and one month of neurologic follow-up after surgery, were recorded.

RESULTS

Twenty-one patients were enrolled. AA was assessable in 100% of patients and in 15 (71%) with angio-CBCT alone. Among them, 10 patients needed 3D road-mapping-guided DSA angiography to visualize the AA feeding artery. The amount of contrast media, irradiation dose, and intervention length were not significantly different whether the AA was assessable or not by angio-CBCT. AA feeding artery localization led to surgical sketch modification for 11 patients.

CONCLUSIONS

Angio-CBCT is an efficient method for AA localization in the surgical planning of DTA disorders.

Endovascular Management of Vascular Complications in Ehlers-Danlos Syndrome Type IV

(1) Background: The vascular type of Ehlers-Danlos syndrome (vEDS) is a rare genetic connective tissue disorder caused by pathogenic variants in the COL3A1 gene that result in arterial and organ fragility and premature death. We present five cases of vEDS that highlight the diagnosis and treatment challenges encountered by clinicians with these patients. (2) Case presentations: we present the cases of five patients with vascular complications of vEDS who were successfully managed using endovascular interventions or hybrid techniques at our institution from 2005 to 2022. (3) Conclusions: These data emphasize that a multidisciplinary approach is needed for vEDS patients and that when endovascular or hybrid treatment is performed in a timely manner by a skilled team of interventional radiologists, good results can be achieved. Our report also demonstrates that the prognosis of vEDS patients has improved over the past 20 years with a new prevention program including celiprolol therapy, physical activity adaptation and limitation, and scheduled monitoring by expert clinicians.

Diaphragm dysfunction after severe COVID-19: An ultrasound study

Background

SARS-CoV-2 infection can impair diaphragm function at the acute phase but the frequency of diaphragm dysfunction after recovery from COVID-19 remains unknown.

Materials and methods

This study was carried out on patients reporting persistent respiratory symptoms 3–4 months after severe COVID-19 pneumonia. The included patients were selected from a medical consultation designed to screen for recovery after acute infection. Respiratory function was assessed by a pulmonary function test, and diaphragm function was studied by ultrasonography.

Results

In total, 132 patients (85M, 47W) were recruited from the medical consultation. During the acute phase of the infection, the severity of the clinical status led to ICU admission for 58 patients (44%). Diaphragm dysfunction (DD) was detected by ultrasonography in 13 patients, two of whom suffered from hemidiaphragm paralysis. Patients with DD had more frequently muscle pain complaints and had a higher frequency of prior cardiothoracic or upper abdominal surgery than patients with normal diaphragm function. Pulmonary function testing revealed a significant decrease in lung volumes and DLCO and the dyspnea scores (mMRC and Borg10 scores) were significantly increased in patients with DD. Improvement in respiratory function was recorded in seven out of nine patients assessed 6 months after the first ultrasound examination.

Conclusion

Assessment of diaphragm function by ultrasonography after severe COVID-19 pneumonia revealed signs of dysfunction in 10% of our population. In some cases, ultrasound examination probably discovered an un-recognized pre-existing DD. COVID-19 nonetheless contributed to impairment of diaphragm function. Prolonged respiratory physiotherapy led to improvement in respiratory function in most patients.

Clinical trial registration

[www.cnil.fr], identifier [#PADS20-207].

Automatic Deep-Learning Segmentation of Epicardial Adipose Tissue from Low-Dose Chest CT and Prognosis Impact on COVID-19

Background: To develop a deep-learning (DL) pipeline that allowed an automated segmentation of epicardial adipose tissue (EAT) from low-dose computed tomography (LDCT) and investigate the link between EAT and COVID-19 clinical outcomes. Methods: This monocentric retrospective study included 353 patients: 95 for training, 20 for testing, and 238 for prognosis evaluation. EAT segmentation was obtained after thresholding on a manually segmented pericardial volume. The model was evaluated with Dice coefficient (DSC), inter-and intraobserver reproducibility, and clinical measures. Uni-and multi-variate analyzes were conducted to assess the prognosis value of the EAT volume, EAT extent, and lung lesion extent on clinical outcomes, including hospitalization, oxygen therapy, intensive care unit admission and death. Results: The mean DSC for EAT volumes was 0.85 ± 0.05. For EAT volume, the mean absolute error was 11.7 ± 8.1 cm3 with a non-significant bias of −4.0 ± 13.9 cm3 and a correlation of 0.963 with the manual measures (p < 0.01). The multivariate model providing the higher AUC to predict adverse outcome include both EAT extent and lung lesion extent (AUC = 0.805). Conclusions: A DL algorithm was developed and evaluated to obtain reproducible and precise EAT segmentation on LDCT. EAT extent in association with lung lesion extent was associated with adverse clinical outcomes with an AUC = 0.805.

Value and prognostic impact of a deep learning segmentation model of COVID-19 lung lesions on low-dose chest CT

Objectives

1) To develop a deep learning (DL) pipeline allowing quantification of COVID-19 pulmonary lesions on low-dose computed tomography (LDCT). 2) To assess the prognostic value of DL-driven lesion quantification.

Methods

This monocentric retrospective study included training and test datasets taken from 144 and 30 patients, respectively. The reference was the manual segmentation of 3 labels: normal lung, ground-glass opacity(GGO) and consolidation(Cons). Model performance was evaluated with technical metrics, disease volume and extent. Intra- and interobserver agreement were recorded. The prognostic value of DL-driven disease extent was assessed in 1621 distinct patients using C-statistics. The end point was a combined outcome defined as death, hospitalization>10 days, intensive care unit hospitalization or oxygen therapy.

Results

The Dice coefficients for lesion (GGO+Cons) segmentations were 0.75±0.08, exceeding the values for human interobserver (0.70±0.08; 0.70±0.10) and intraobserver measures (0.72±0.09). DL-driven lesion quantification had a stronger correlation with the reference than inter- or intraobserver measures. After stepwise selection and adjustment for clinical characteristics, quantification significantly increased the prognostic accuracy of the model (0.82 vs. 0.90; p<0.0001).

Conclusions

A DL-driven model can provide reproducible and accurate segmentation of COVID-19 lesions on LDCT. Automatic lesion quantification has independent prognostic value for the identification of high-risk patients.