Objective To identify geometric indices of abdominal aortic aneurysms (AAAs) on computed tomography that are associated with higher risk of rupture. Methods This retrospective case-control, ...institutional review board-approved study involved 63 cases with ruptured or symptomatic AAA and 94 controls with asymptomatic AAA. Three-dimensional models were generated from computed tomography segmentation and used for the calculation of 27 geometric indices. On the basis of the results of univariate analysis and multivariable sequential logistic regression analyses with a forward stepwise model selection based on likelihood ratios, a traditional model based on gender and maximal diameter (Dmax) was compared with a model that also incorporated geometric indices while adjusting for gender and Dmax. Receiver operating characteristic (ROC) curves were calculated for these two models to evaluate their classification accuracy. Results Univariate analysis revealed that gender ( P = .024), Dmax ( P = .001), and 14 other geometric indices were associated with AAA rupture at P < .05. In the multivariable analysis, adjusting for gender and Dmax, the AAA with a higher bulge location ( P = .020) and lower mean averaged area ( P = .005) were associated with AAA rupture. With these two geometric indices, the area under the ROC curve showed an improvement from 0.67 (95% confidence interval, 0.58-0.77) to 0.75 (95% confidence interval, 0.67-0.83; P < .001). Our predictive model showed comparable sensitivity (64% vs 60%) and specificity (79% vs 77%) with current treatment criteria based on gender and diameter at the point optimizing the Youden index (sensitivity + specificity − 1) on the ROC curve. Conclusions Two geometric indices derived from AAA three-dimensional modeling were independently associated with AAA rupture. The addition of these indices in a predictive model based on current treatment criteria modestly improved the accuracy to detect aneurysm rupture.
Objectives
Abdominal aortic aneurysm (AAA) rupture has a high mortality rate. Although the diagnosis of a ruptured AAA is usually straightforward, detection of impending rupture signs can be more ...challenging. Early diagnosis of impending AAA rupture can be lifesaving. Furthermore, differentiating between impending and complete rupture has important repercussions on patient management and prognosis. The purpose of this article is to classify and illustrate the entire spectrum of AAA rupture signs and to review current treatment options for ruptured AAAs.
Methods
Using medical illustrations supplemented with computed tomography (CT), this essay showcases the various signs of impending rupture and ruptured AAAs. Endovascular aneurysm repair (EVAR) and open surgical repair are also discussed as treatment options for ruptured AAAs.
Results
CT imaging findings of ruptured AAAs can be categorised according to location: intramural, luminal, and extraluminal. Intramural signs generally indicate impending AAA rupture, whereas luminal and extraluminal signs imply complete rupture. EVAR has emerged as an alternative and possibly less morbid method to treat ruptured AAAs.
Conclusions
AAA rupture occurs at the end of a continuum of growth and wall weakening. This review describes the CT imaging findings that may help identify impending rupture prior to complete rupture.
Teaching Points
AAA rupture occurs at the end of a continuum of growth and wall weakening.
Intramural imaging findings indicate impending AAA rupture.
Luminal and extraluminal imaging findings imply complete AAA rupture.
Some imaging findings are not specific to AAA ruptures and can be seen in other pathologies.
EVAR has emerged as an alternative and possibly less morbid method of treating ruptured AAAs.
Intraventricular rupture of a colloid cyst is a rare phenomenon and has been proposed as a mechanism for sudden death in patients with colloid cysts. Imaging of a colloid cyst during rupture has been ...described in only one other instance. The authors report a highly unusual case of a 53-year-old man who presented with acute onset headaches and imaging findings of hydrocephalus caused by a colloid cyst originating from the septum pellucidum and superior surface of the roof of the third ventricle. Interestingly, the colloid cyst revealed imaging signs of intraventricular rupture characterized by a tail-like drainage of cystic contents into the occipital horn of the lateral ventricle. The patient was surgically treated with a craniotomy and transcallosal approach to the colloid cyst, where it was noted that the cyst wall was spontaneously open. This rare case highlights unique imaging findings of a rare event in an infrequent pathology confirmed with intraoperative microscopy. The authors further document the process of cyst rupture and speculate on its pathomechanisms.
To compare automated measurements of maximal diameter (D
) of abdominal aortic aneurysm (AAA) orthogonal to luminal or outer wall envelope centerline for endovascular repair (EVAR) follow-up.
...Eighty-three consecutive patients with AAA treated by EVAR who had at least 1 computed tomography (CT) scan before and 2 CT scans after EVAR with at least 5 months' interval were included. Three-dimensional reconstruction of the AAA was achieved with dedicated segmentation software. Performances of automated calculation algorithms of D
perpendicular to lumen or outer wall envelope centerlines were then compared to manual measurement of D
on double-oblique multiplanar reconstruction (gold standard). Accuracy of automated D
measurements at baseline, follow-up, and progression over time was evaluated by calculation of mean error, Bland-Altman plot, and regression models.
Disagreement in D
measurements between outer wall envelope algorithm and manual method was insignificant (mean error: baseline, -0.07 ± 1.66 mm, P = .7; first follow-up, 0.24 ± 1.69 mm, P = .2; last follow-up, -0.41 ± 2.74 mm, P = .17); whereas significant discrepancies were found between the luminal algorithm and the manual method (mean error: baseline, -1.24 ± 2.01 mm, P < .01; first follow-up, -1.49 ± 3.30 mm, P < .01; last follow-up, -1.78 ± 3.60 mm, P < .01). D
progression results were more accurate with AAA outer wall envelope algorithm compared to luminal method (P = .2).
AAA outer wall envelope segmentation is recommended to enable automated calculation of D
perpendicular to its centerline during EVAR follow-up.
Purpose
To assess the impact of contrast injection and stent-graft implantation on feasibility, accuracy, and reproducibility of abdominal aortic aneurysm (AAA) volume and maximal diameter (D-max) ...measurements using segmentation software.
Materials and methods
CT images of 80 subjects presenting AAA were divided into four equal groups: with or without contrast enhancement, and with or without stent-graft implantation. Semiautomated software was used to segment the aortic wall, once by an expert and twice by three readers. Volume and D-max reproducibility was estimated by intraclass correlation coefficients (ICC), and accuracy was estimated between the expert and the readers by mean relative errors.
Results
All segmentations were technically successful. The mean AAA volume was 167.0 ± 82.8 mL and the mean D-max 55.0 ± 10.6 mm. Inter- and intraobserver ICCs for volume and D-max measurements were greater than 0.99. Mean relative errors between readers varied between −1.8 ± 4.6 and 0.0 ± 3.6 mL. Mean relative errors in volume and D-max measurements between readers showed no significant difference between the four groups (
P
≥ 0.2).
Conclusion
The feasibility, accuracy, and reproducibility of AAA volume and D-max measurements using segmentation software were not affected by the absence of contrast injection or the presence of stent-graft.
Key points
•
AAA volumetry by semiautomated segmentation is accurate on CT following endovascular repair
.
•
AAA volumetry by semiautomated segmentation is accurate on unenhanced CT
.
•
Standardization of the segmentation technique maximizes the reproducibility of volume measurements
.
Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute ...respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening.
POCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion.
Among 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 95%CI:0.60-0.94. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were <1 and ≥16, respectively. The rate of patients with an unfavorable outcome was 0/95 (0%95%CI:0-3.9) for low-risk patients (score = 0), 4/184 (2.17%95%CI:0.8-5.5) for intermediate-risk patients (score 1-15) and 4/17 (23.5%95%CI:11.4-42.4) for high-risk patients (score ≥16). In confirmed COVID-19 patients (n = 58), the AUC of L-POCUS was 0.97 95%CI:0.92-1.00.
L-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19.
IntroductionIn the context of the COVID-19 pandemic, early identification of patients who are likely to get worse is a major concern. Severity mainly depends on the development of acute respiratory ...distress syndrome (ARDS) with a predominance of subpleural lesions. Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may be appropriate for examining patients with COVID-19. We suggest that L-POCUS performed during the initial examination may identify patients with COVID-19 who are at a high risk of complicated treatment or unfavourable evolution.Methods and analysisPoint-of-care ultrasonography for risk stratification of non-critical COVID-19 patients on admission is a prospective, multicentre study. Adult patients visiting the emergency department (ED) of participating centres for suspected or confirmed COVID-19 are assessed for inclusion. Included patients have L-POCUS performed within 48 hours following ED admission. The severity of lung damage is assessed using the L-POCUS score based on 36 points for ARDS. Apart from the L-POCUS score assessment, patients are treated as recommended by the WHO. For hospitalised patients, a second L-POCUS is performed at day 5±3. A follow-up is carried out on day 14, and the patient’s status according to the Ordinal Scale for Clinical Improvement for COVID-19 from the WHO is recorded.The primary outcome is the rate of patients requiring intubation or who are dead from any cause during the 14 days following inclusion. We will determine the area under the ROC curve of L-POCUS.Ethics and disseminationThe protocol has been approved by the French and Belgian Ethics Committees and is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The study is funding by a grant from the French Health Ministry, and its findings will be disseminated in peer-reviewed journals and at scientific conferences.Trial registration numberNCT04338100.
Background Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an ...acute respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening. Methods POCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion. Results Among 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 95%CI:0.60–0.94. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were <1 and ≥16, respectively. The rate of patients with an unfavorable outcome was 0/95 (0%95%CI:0–3.9) for low-risk patients (score = 0), 4/184 (2.17%95%CI:0.8–5.5) for intermediate-risk patients (score 1–15) and 4/17 (23.5%95%CI:11.4–42.4) for high-risk patients (score ≥16). In confirmed COVID-19 patients (n = 58), the AUC of L-POCUS was 0.97 95%CI:0.92–1.00. Conclusion L-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19.
Sustained response off treatment (SROT) after thrombopoietin receptor agonist (TPO-RA) discontinuation has been reported in immune thrombocytopenia (ITP). This prospective multicenter interventional ...study enrolled adults with persistent or chronic primary ITP and complete response (CR) on TPO-RAs. The primary end point was the proportion of patients achieving SROT (platelet count >30 × 109/L and no bleeding) at week 24 (W24) with no other ITP-specific medications. Secondary end points included the proportion of sustained CR off-treatment (SCROT, platelet count >100 × 109/L and no bleeding) and SROT at W52, bleeding events, and pattern of response to a new course of TPO-RAs. We included 48 patients with a median age of 58.5 years; 30 of 48 had chronic ITP at TPO-RA initiation. In the intention-to-treat analysis, 27 of 48 achieved SROT, 15 of 48 achieved SCROT at W24; 25 of 48 achieved SROT, and 14 of 48 achieved SCROT at W52. No severe bleeding episode occurred in patients who relapsed. Among patients rechallenged with TPO-RA, 11 of 12 achieved CR. We found no significant clinical predictors of SROT at W24. Single-cell RNA sequencing revealed enrichment of a tumor necrosis factor α signaling via NF-κB signature in CD8+ T cells of patients with no sustained response after TPO-RA discontinuation, which was further confirmed by a significant overexpression of CD69 on CD8+ T cells at baseline in these patients as compared with those achieving SCROT/SROT. Our results strongly support a strategy based on progressive tapering and discontinuation of TPO-RAs for patients with chronic ITP who achieved a stable CR on treatment. This trial was registered at www.clinicaltrials.gov as #NCT03119974.
Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute ...respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening. POCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion. Among 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 95%CI:0.60-0.94. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were <1 and greater than or equal to16, respectively. The rate of patients with an unfavorable outcome was 0/95 (0%95%CI:0-3.9) for low-risk patients (score = 0), 4/184 (2.17%95%CI:0.8-5.5) for intermediate-risk patients (score 1-15) and 4/17 (23.5%95%CI:11.4-42.4) for high-risk patients (score greater than or equal to16). In confirmed COVID-19 patients (n = 58), the AUC of L-POCUS was 0.97 95%CI:0.92-1.00. L-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19.
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