Journal articles on the topic 'Nodule Feeding Vessel CT'

This is a case of septic pulmonary embolism in a patient presented with a right foot ulcer as foci of infection. A Septic Pulmonary embolism is a thromboembolic event in which case an infected thrombus from an infectious focus; distal to the lung vasculature travels through the lung and results in occlusive, inflammatory and infectious insult to the lung. Clinically it may present as mild respiratory symptoms such as cough, fever or more severe symptoms such as shortness of breath (SOB), hemoptysis, pleuritic chest pain or difficulty breathing1; on computed tomography (CT) imaging, cavitary or non-cavitary peripheral nodules with or without feeding vessel, consolidation and Pleural effusion are prominent findings.2 In this case report, we present a rare case of septic pulmonary emboli from a foci of soft tissue infection.

Bullous lung disease in pediatric patients is a rare case. The etiology of lung bullae is cigarette smoking history, pulmonary sarcoidosis, alpha 1-antitrypsin deficiency and many more. One of the treatments for lung bulla is surgical approach. We present a case of 4-year-old girl with lung bulla due to septic pulmonary embolism. Primarily the patient was admitted with a decrease in consciousness, fever, cough and dyspnea. A CT scan revealed bilateral bullae, multiple nodules in various size, mostly with internal cavities and feeding vessel sign suggestive of a septic pulmonary embolism accompanied by a pneumothorax. We did thoracotomy, wedge resection and pleurodesis, the outcome was clinical improvement and no postoperative complication occurred. Thoracotomy, wedge resection and pleurodesis can be considered as a treatment for lung bulla in pediatric population, so this case report may provide guidance on management of these cases for clinicians.

In this paper, we describe a recognition method of lung nodule shadows in X-ray CT images using 3-dimensional nodule and blood vessel models. From these 3D object models, artificial CT images are generated as templates. The templates are then applied to input images which comprise of suspicious shadows. If any parameters of the suspicious shadow matches a nodule template rather than any blood vessel template, then it is determined to be abnormal. Otherwise, it is determined to be normal. By applying our new method to the actual lung CT images of 38 patients, the false positive ratio is reduced to 4.31 [shadow/patient] with the sensitivity exceeding 95%.

Background Liver dynamic computed tomography (CT) is an established method for pre- and post-interventional evaluation of hepatocellular carcinoma. To date only the liver parenchyma and perfusion information of dynamic CT has been evaluated widely. Purpose To evaluate the vascular information contained in dynamic CT datasets. Material and Methods Dynamic CT performed one day after transarterial chemoembolization (60 mL of contrast medium, 6 mL/s, 40 s scan duration) were retrospectively evaluated. Conventional slice and angiographic maximum-intensity-projection reconstructions were calculated on a multi-modality post-processing platform. Datasets were evaluated for viable tumor, anatomy of the vasculature, and potential tumor-feeding vessels. The results were compared to digital subtraction angiography images. Results In total, 94 treated hepatocellular carcinoma nodules were evaluated (62 dynamic CT scans, 46 patients [34 men; mean age = 69 years]). Forty-six partially viable tumors were diagnosed after transarterial chemoembolization. In all of these, tumor-feeding vessels were found in dynamic CT. Seventeen suspected extra-hepatic tumor feeders were reported, of which 14 had not been found during previous transarterial chemoembolization. Conclusion Dynamic CT is useful in post-interventional imaging of hepatocellular carcinoma after transarterial chemoembolization due to its ability to detect residual viable tumor parts and to show previously unknown intra- and extra-hepatic tumor-feeding vessels.

A new computer-aided detection (CAD) scheme for detecting lung nodules is proposed in this paper. Firstly, the lung region is segmented from the CT data using adaptive threshold algorithm etc; Secondly, building active contour model to segment and remove lung vessel accurately in the lung region; Next, suspicious nodules are detected and omitted renal vessel is filtered using a selective shape filter; Finally, nodule features are extracted and rule-based classifier is used to distinguish true or false positive nodules. Experiment results indicate that this scheme can help radiologist improve the diagnosis efficiency.

For solving the segmentation problem of vessel attachment nodule, a new adaptive bandwidth chosen method based on EM is proposed and apply it into Mean-shift algorithm to segment vessel attachment nodule. This method has some advantages such as time low complexity and correct bandwidth when comparing it to the method of bandwidth chosen based on statistical analysis rule or optimized rule, Imposing the vertical orientation vectors of vessel’s gradient submitting to normal distribution and the vertical orientation vectors of nodule’s gradient submitting to uniform distribution, modeling the nodule connected vessel, and estimating model parameter by EM, extract bandwidth parameter in Mean-shift based on the weight of uniform distribution. The proposed method was tested on synthetic data set and the clinical chest CT volumes, and all the results were correct. The results revealed that the proposed method is successful in segmentation lung vessel attachment nodule.

Objective. To evaluate the application of CT postprocessing reconstruction technique in differential diagnosis of benign and malignant solitary pulmonary nodules and analysis of risk factors. Methods. A total of 150 solitary pulmonary nodules (SPN) patients admitted to our hospital from January 2020 to January 2022 were selected and divided into the benign SPN group ( n = 64 ) and the malignant SPN group ( n = 86 ) according to pathological results. All subjects underwent CT plain scan and CT postprocessing reconstruction, and the general information of the subjects was collected. The diagnostic value of CT plain scan and CT postprocessing reconstruction techniques for benign and malignant SPN was compared; and the CT signs of benign and malignant SPN were compared, and the risk factors of malignant SPN were analyzed. Results. The pathological results of this study showed that there were 64 cases with benign SPN and 86 cases with malignant SPN. The sensitivity, specificity, accuracy, positive predictive rate, and negative predictive rate of CT postprocessing reconstruction technology in diagnosing malignant SPN were 73.44%, 89.53%, 82.67%, 83.39%, and 81.91%, respectively, which were higher than 56.25%, 65.12%, 61.33%, 54.55%, and 66.67% of CT plain scan, and the difference was statistically significant ( P < 0.05 ). There were no significant differences in nodule location, nodule density, vacuole sign, vessel convergence, and pleural depression sign between the two groups ( P > 0.05 ). There were statistically significant differences in age, nodule diameter, lobulation sign, burr sign, calcification components, and ground-glass components between the two groups ( P < 0.05 ). Multivariate analysis showed that age ≥ 60 years, nodule diameter ≥ 15 mm , the presence of lobulation sign, burr sign, ground-glass components, and noncalcification components were independent risk factors for malignant SPN. Conclusion. CT postprocessing reconstruction technique has high diagnostic value in the differentiation of benign and malignant SPN, age ≥ 60 years , nodule diameter ≥ 15 mm , lobulation signs, burr signs, ground-glass components, and noncalcification components are independent risk factors for malignant SPN.

Objective: This study aims to investigate the association between the arteries and veins surrounding a pulmonary nodule and its malignancy. Methods: A dataset of 146 subjects from a LDCT lung cancer screening program was used in this study. AI algorithms were used to automatically segment and quantify nodules and their surrounding macro-vasculature. The macro-vasculature was differentiated into arteries and veins. Vessel branch count, volume, and tortuosity were quantified for arteries and veins at different distances from the nodule surface. Univariate and multivariate logistic regression (LR) analyses were performed, with a special emphasis on the nodules with diameters ranging from 8 to 20 mm. ROC-AUC was used to assess the performance based on the k-fold cross-validation method. Average feature importance was evaluated in several machine learning models. Results: The LR models using macro-vasculature features achieved an AUC of 0.78 (95% CI: 0.71–0.86) for all nodules and an AUC of 0.67 (95% CI: 0.54–0.80) for nodules between 8–20 mm. Models including macro-vasculature features, demographics, and CT-derived nodule features yielded an AUC of 0.91 (95% CI: 0.87–0.96) for all nodules and an AUC of 0.82 (95% CI: 0.71–0.92) for nodules between 8–20 mm. In terms of feature importance, arteries within 5.0 mm from the nodule surface were the highest-ranked among macro-vasculature features and retained their significance even with the inclusion of demographics and CT-derived nodule features. Conclusions: Arteries within 5.0 mm from the nodule surface emerged as a potential biomarker for effectively discriminating between malignant and benign nodules.

Abstract Background: CDK 4/6 inhibitors (CDKI) with Endocrine therapy (ET) is mainstay treatment for hormone receptor-positive (HR+) Her2- metastatic breast cancer (MBC). Despite excellent efficacy, most patients develop resistance to CDKI limiting its utility. CDK4/6 are thought to act by upregulating VEGF causing tortuous angiogenesis and promoting cancer progression. Recent studies have shown aggressive tumors possess a higher density and tortuous vasculature. In this study, we evaluated if vascular radiomic features computationally extracted from liver CT scans pre- and post CDKI treatment could predict patient survival and treatment response. Method: From a registry of 350 patients on treatment with CDKI at institution 1(S1), 51 pts with HR+, Her2-, MBC patients with evidence of liver mets and disease progression (PFS) data were identified. 30 pts discontinued treatment due to progression or death, with a median time to progression of 195 days. Pre-treatment and first post-treatment CT exams were analyzed from 25 and 34 patients, respectively. Median time between scans was 128 days. To validate the prognostic value of our signature, a cohort of 29 patients with available OS data was identified from institution 2 (S2). A publicly available pre-trained deep learning model was applied to isolate liver metastases and vessels. Next, fast marching algorithm was applied to reduce vessels to their centerlines and divide the vasculature into constituent branches. 7 quantitative metrics were computed measuring vascularity of metastases and 3-D shape of hepatic vessels. First, the number (f1) and percentage (f2) of hepatic vessels arising from the tumor were computed. Vessel tortuosity - measuring the degree of twisting across a vessel - was computed separately for each branch. The mean (f3), standard deviation (f4), maximum (f5), skewness (f6), and kurtosis (f7) tortuosity values were calculated to summarize these measurements at patient level. The features were individually assessed at pre- and post-treatment for association with PFS at S1 in univariable Cox proportional hazards models. Features found to be associated in S1 were evaluated for association with OS in S2. Results: On the initial post-treatment scan, features of both tumor vascularization (f6 - HR=1.115 [1.039-1.196]; f7 - HR=10.646 [2.539-44.641]), as well as two features of vessel tortuosity (f3 - HR=0.011 [0.001-0.199]; f4 - HR=0.545 [0.313-0.949]) were significantly associated with PFS. Both tortuosity features were also significantly associated with OS in S2 (f3 - HR=0.085 [0.009-0.780]; f4 - HR=0.331 [0.130-0.842]). In addition the percentage (f7 - HR=6.445 [2.001-20.753]]),of vessels feeding the lesions was also significant in S2 while the number (f6 - HR=1.070 [0.966-1.184]), of vessels was not. No vessel metrics from the pre-treatment baseline exam were significantly associated with OS. Conclusions: Radiomic analysis of tumor vascularity and vessel tortuosity on CT scans post-CDK treatment was associated with patient survival and treatment response. Table 1.Association of vessel features with PFS in Institution 1(S1)and OS in Institution 2(S2)S1- Pretreatment CT (n=25)S1 - Post-Treatment CT (n=34)S2 - Post-treatment CT - Validation (n=29)f1Tortuosity - Mean0.9912702470.852294696–f2Tortuosity - St. Dev0.7563942230.273115373–f3Tortuosity - Max0.1387051870.0022517550.02931473f4Tortuosity - Skewness0.254463710.0318270370.02022882f5Tortuosity - Kurtosis0.3058266760.108967601–f6Number of vessels feeding lesions0.419096650.0025747910.19306052f7Percentage of vessels feeding lesions0.0517942660.0012205950.00179103 Citation Format: Vidya Sankar Viswanathan, Nathaniel Braman, Priyanka Reddy, Siddharth Kunte, Jame Abraham, Alberto J Montero, Anant Madabhushi. Post-treatment vascularity and vessel shape are associated with survival and response to CDK4/6 inhibitors in hormone receptor-positive metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-13-27.

Background Dual-phase cone beam computed tomography (DP-CBCT) and automatic vessel detection (AVD) software are helpful tools for detecting arteries before planned endovascular interventions. Purpose To evaluate the usefulness of DP-CBCT and AVD software in guiding the trans-arterial embolization (TAE) of challenging T2 lumbar endoleaks (T2-L-EL). Material and Methods Ten patients with T2-L-EL were included in this study. The accuracy of DP-CBCT and the AVD software was defined by the ability to detect the endoleak and arterial feeding vessel, respectively. Technical success was defined as the correct positioning of the microcatheter using AVD software and the successful embolization of the endoleak. Clinical success was defined as the absence of recurrent endoleaks during follow-up and the stability of the sac diameter for persistent endoleaks. The total volume of iodinated contrast medium, overall procedure time, mean procedural radiation dose, and mean fluoroscopy time were recorded. Results The EL was detected by DP-CBCT in all patients. The AVD software identified the feeding arterial branch in all cases. In one patient, the nidus of the endoleak was not reached due to the small caliber of the feeding artery, even though the software had clearly identified the vessel route. The mean contrast volume was 109 mL, the mean overall procedural time was 74.3 min. The mean procedural radiation dose was 140.97 Gy cm2, and the mean fluoroscopy time was 29.8 min. Conclusion The use of DP-CBCT and the AVD software is feasible and may facilitate successful embolization in challenging occult T2-L-EL with complex vasculature.

Objective. To improve the results of treatment in patients with benign nodular pathology of the thyroid gland (TG) by means of perfecting the technique of minimally invasive treatment with a high-intensive laser under the sonographic control.
 Materials and methods. An original technique of laser-induces thermotherapy (LITT) of the thyroid nodule with the ablation of the vessels, feeding the nodule was developed and introduced. The procedure was used in the treatment of 91 patients with benign nodular pathology of the thyroid gland, 116 patients underwent laser-induced thermotherapy by the standard technique (comparison group). Three months later, US was used to assess and compare the results of treatment in both groups. The results of thermometry were analyzed depending on the initial volume of the TG nodular neoplasm.
 Results. A decrease in the nodules with the initial volume up to 2 cm3 in both groups was statistically significant and took place practically similarly 78.7 % in the main group and 71.7 % in the comparison group. When exposing the nodules of larger sizes, the efficiency of standard LITT method fell. In the comparison group, patients with the nodular sizes of 68 cm2 had a decrease in the volume only by 25.8 % % (from 6.74 cm3 to 5.0 cm3). When using an original method of thermoablation (TA), a decrease in the nodules of the same size was 69.3 % (from 6.98 cm3 to 2.14 cm3). The difference was statistically significant (p = 0,003) that proves the efficiency of this technique. In the subgroup with the nodules 8 cm3, a nodular volume decrease was 33.3 % (from 11.05 to 7.36 cm3) in the main group and 28.8 % (from 14.07 to 10.02 cm3) in the comparison group. The difference was not statistically significant (p = 279).
 Conclusions. Laser-induces thermotherapy of the thyroid gland with the ablation of the vessel, feeding the nodule, leads to a statistically significant reduction of the benign colloid nodular neoplasms of any size. The original technique indicated higher efficiency compared with standard LITT in relation to the nodules sized from 6 to 8 cm.

This research is concerned with malignant pulmonary nodule detection (PND) in low-dose CT scans. Due to its crucial role in the early diagnosis of lung cancer, PND has considerable potential in improving the survival rate of patients. We propose a two-stage framework that exploits the ever-growing advances in deep neural network models, and that is comprised of a semantic segmentation stage followed by localization and classification. We employ the recently published DeepLab model for semantic segmentation, and we show that it significantly improves the accuracy of nodule detection compared to the classical U-Net model and its most recent variants. Using the widely adopted Lung Nodule Analysis dataset (LUNA16), we evaluate the performance of the semantic segmentation stage by adopting two network backbones, namely, MobileNet-V2 and Xception. We present the impact of various model training parameters and the computational time on the detection accuracy, featuring a 79.1% mean intersection-over-union (mIoU) and an 88.34% dice coefficient. This represents a mIoU increase of 60% and a dice coefficient increase of 30% compared to U-Net. The second stage involves feeding the output of the DeepLab-based semantic segmentation to a localization-then-classification stage. The second stage is realized using Faster RCNN and SSD, with an Inception-V2 as a backbone. On LUNA16, the two-stage framework attained a sensitivity of 96.4%, outperforming other recent models in the literature, including deep models. Finally, we show that adopting a transfer learning approach, particularly, the DeepLab model weights of the first stage of the framework, to infer binary (malignant-benign) labels on the Kaggle dataset for pulmonary nodules achieves a classification accuracy of 95.66%, which represents approximately 4% improvement over the recent literature.

The segmentation and detection of various types of nodules in a Computer-aided detection (CAD) system present various challenges, especially when (1) the nodule is connected to a vessel and they have very similar intensities; (2) the nodule with ground-glass opacity (GGO) characteristic possesses typical weak edges and intensity inhomogeneity, and hence it is difficult to define the boundaries. Traditional segmentation methods may cause problems of boundary leakage and “weak” local minima. This paper deals with the above mentioned problems. An improved detection method which combines a fuzzy integrated active contour model (FIACM)-based segmentation method, a segmentation refinement method based on Parametric Mixture Model (PMM) of juxta-vascular nodules, and a knowledge-based C-SVM (Cost-sensitive Support Vector Machines) classifier, is proposed for detecting various types of pulmonary nodules in computerized tomography (CT) images. Our approach has several novel aspects: (1) In the proposed FIACM model, edge and local region information is incorporated. The fuzzy energy is used as the motivation power for the evolution of the active contour. (2) A hybrid PMM Model of juxta-vascular nodules combining appearance and geometric information is constructed for segmentation refinement of juxta-vascular nodules. Experimental results of detection for pulmonary nodules show desirable performances of the proposed method.

Abstract A 66-year-old male with history of Type 2 diabetes and adrenal incidentaloma presented to the hospital with significant left lower limb edema and was found to have severe peripheral vascular disease. CT surgery was consulted and performed an angiogram as well as an angioplasty; however, the patient had severe stenosis and stenting was not possible. Femoral popliteal bypass was planned. Due to the patient's acute kidney injury from renovacular hypertension, preoperative evaluation included a MRI abdomen w/wo contrast which showed a 1.4 cm right adrenal nodule with early contrast enhancement which appeared fairly avid and uniform. This nodule had been previously noted by CT scan three years prior. Previous outpatient labs showed elevated metanephrines of 543 pg/mL, which determined the adrenal nodule to be consistent with a pheochromocytoma. Subsequently, femoral popliteal bypass was postponed and the patient was started on an alpha blocker, doxazosin. Urology was consulted and right laproscopic adrenalectomy was planned. Preoperatively, patient developed chest pain due to ventricular tachycardia and NSTEMI was diagnosed by EKG. Patient then underwent a LHC which revealed severe left main 3 vessel coronary artery disease, postponing planned adrenalectomy. CABG was performed with pericardiectomy. After initial recovery, patient was discharged to in-patient rehabilitation, indefinitely delaying definitive pheochromocytoma therapy. Reference Jacques W. M. Lenders, Quan-Yang Duh, Graeme Eisenhofer, Anne-Paule Gimenez-Roqueplo, Stefan K. G. Grebe, Mohammad Hassan Murad, Mitsuhide Naruse, Karel Pacak, William F. Young, Jr, Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 99, Issue 6, 1 June 2014, Pages 1915–1942, https://doi.org/10.1210/jc.2014-1498 Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Extra-cranial arteriovenous malformations of head and neck are rare and may present with acute haemorrhage. Their management varies and requires a multidisciplinary approach. Intra-arterial embolisation alone or followed by surgery is recommended. We present here a case of a huge pulsatile lesion extending from the neck to the temporo-parietal region with the main feeding vessel being the right external carotid artery. It was treated with surgical resection only as the feeding artery was very tortuous making selective embolization of artery impossible. The excision of the portion of the artery in the neck was carried out a week later. The patient recovered smoothly except for transient facial nerve palsy. Keywords: arteriovenous malformation, vascular anomalies, CT angiogram. Continuous...

IntroductionLow-dose CT (LDCT) is currently used in lung cancer screening of high-risk populations for early lung cancer diagnosis. However, 96% of individuals with detected nodules are false positives.MethodsIn order to develop an efficient early lung cancer predictor from clinical, demographic and LDCT features, we studied a total of 218 subjects with lung cancer or benign nodules. Probabilistic graphical models (PGMs) were used to integrate demographics, clinical data and LDCT features from 92 subjects (training cohort) from the Pittsburgh Lung Screening Study cohort.ResultsLearnt PGMs identified three variables directly (causally) linked to malignant nodules and the largest benign nodule and used them to build the Lung Cancer Causal Model (LCCM), which was validated in a separate cohort of 126 subjects. Nodule and vessel numbers and years since the subject quit smoking were sufficient to discriminate malignant from benign nodules. Comparison with existing predictors in the training and validation cohorts showed that (1) incorporating LDCT scan features greatly enhances predictive accuracy; and (2) LCCM improves cancer detection over existing methods, including the Brock parsimonious model (p<0.001). Notably, the number of surrounding vessels, a feature not previously used in predictive models, significantly improves predictive efficiency. Based on the validation cohort results, LCCM is able to identify 30% of the benign nodules without risk of misclassifying cancer nodules.DiscussionLCCM shows promise as a lung cancer predictor as it is significantly improved over existing models. Validated in a larger, prospective study, it may help reduce unnecessary follow-up visits and procedures.

Superselective intra-arterial chemotherapy (SSIAC) for oral cancer can deliver a higher concentration of anticancer agent into a tumor-feeding artery than intravenous systemic chemotherapy. However, the agent distribution between the lingual artery and facial artery (FA) is not clear in SSIAC for patients with the linguofacial trunk. The agent distribution in the SSIAC method was investigated using computational fluid dynamics (CFD). Ten three-dimensional vessel models were created from CT images of two patients with oral cancer (patients A and B) with the linguofacial trunk. Catheter models were combined with vessel models to mimic intra-arterial infusion, and the agent flow was analyzed. In patient A models, the agent distribution varied depending on the catheter tip position in the linguofacial trunk, while all anticancer agents flowed into the FA only in patient B models. This study revealed that the behavior of the agent in the common trunk is determined by the blood flow field which depends on the topography of the vessels in each patient. Therefore, the catheter tip position should be changed according to the vessel topography to deliver anticancer agents into the tumor-feeding artery. Moreover, CFD can be a useful method to predict the agent flow for each patient before SSIAC.

This study was aimed to explore the effect of CT image feature extraction of pulmonary nodules based on an artificial intelligence algorithm and the image performance of benign and malignant pulmonary nodules. In this study, the CT images of pulmonary nodules were collected as the research object, and the lung nodule feature extraction model based on expectation maximization (EM) was used to extract the image features. The Dice similarity coefficient, accuracy, benign and malignant nodule edges, internal signs, and adjacent structures were compared and analyzed to obtain the extraction effect of this feature extraction model and the image performance of benign and malignant pulmonary nodules. The results showed that the detection sensitivity of pulmonary nodules in this model was 0.955, and the pulmonary nodules and blood vessels were well preserved in the image. The probability of burr sign detection in the malignant group was 73.09% and that in the benign group was 8.41%. The difference was statistically significant ( P < 0.05 ). The probability of malignant component leaf sign (69.96%) was higher than that of a benign component leaf sign (0), and the difference was statistically significant ( P < 0.05 ). The probability of cavitation signs in the malignant group (59.19%) was higher than that in the benign group (3.74%), and the probability of blood vessel collection signs in the malignant group (74.89%) was higher than that in the benign group (11.21%), with statistical significance ( P < 0.05 ). The probability of the pleural traction sign in the malignant group was 17.49% higher than that in the benign group (4.67%), and the difference was statistically significant ( P < 0.05 ). In summary, the feature extraction effect of CT images based on the EM algorithm was ideal. Imaging findings, such as the burr sign, lobulation sign, vacuole sign, vascular bundle sign, and pleural traction sign, can be used as indicators to distinguish benign and malignant nodules.

Primary hepatic lymphoma (PHL) is a rare form of non-Hodgkin lymphoma primarily affecting the liver. We present a case of an 84-year-old man diagnosed with PHL, incidentally detected during abdominal ultrasonography. The ultrasonography showed a hypoechoic nodule. When examined by CEUS, the nodule showed hyperenhancement in the arterial phase and hypoenhancement in the portal and late phases. Conversely, CECT demonstrated hypoenhancement through all the phases. The patient declined a tumor biopsy and opted for follow-up care. Ten months later, the lobular mass had increased from 15 mm to 65 mm, presenting as hypoechogenic and demonstrating the “vessel-penetrating sign” on color Doppler imaging. CEUS revealed reticulated enhancement, indicating intratumoral vessels. The mass displayed hypoattenuation on plain CT, hypointensity in T1-weighted images, and hyperintensity in T2-weighted images and exhibited significant restriction in diffusion-weighted images. Both CECT and contrast-enhanced MRI exhibited hypoenhancement. The patient underwent a partial hepatic segmentectomy, and the mass was pathologically diagnosed as a diffuse large B-cell lymphoma. Subsequent postoperative radiological examinations revealed no other lesions, confirming the diagnosis of PHL. Our report highlights specific ultrasonographic signs of PHL observed from an early stage and presents a review of the relevant literature.

Scalp arteriovenous malformation (AVM) are rare conditions that usually need surgical treatment. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complication. The etiology of scalp AVM may be spontaneous or traumatic. This vascular lesion present as scalp lump or a mass, grotesque, pulsatile mass with a propensity to massive haemorrhage. Various treatment option that have been adopted to treat these lesions include surgical excision, ligation of feeding vessel, trans arterial and transvenous embolization, injection of sclerosant into the nidus and electro thrombosis. A 22-years-old-female referred to cardiothoracic division with a 10 years history of a large fronto-parietal pulsatile reddish soft mass, progressively increasing in size, measuring about 15x6x2 cm, ulcerated area; without any symptoms and history of trauma. Three-dimensional CT angiography demonstrated a mass that was completely within the scalp and prominent vascular that was completely within the scalp and was not associated with bone or periosteum. The feeding arteries were originated from angular artery, supratrochlear artery, left and right superficial temporal artery. Surgical excision and ligation of feeding vessel was performed without complication. With pre-operative appropriate surgical planning, scalp AVM can be excised safely without any major complication. Though some cases may be treated with percutaneous or endovascular embolization, surgery remains the treatment of choice. In the event of scalp ulceration and haemorrhage, total excision is the only option.

Benign lesions, atypical adenomatous hyperplasia (AAH), and malignancies such as adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), and invasive adenocarcinoma (IA) may feature a pure ground-glass nodule (pGGN) on a thin-slide computed tomography (CT) image. According to the World Health Organization (WHO) classification for lung cancer, the prognosis of patients with IA is worse than those with AIS and MIA. It is relatively risky to perform a core needle biopsy of a pGGN less than 2 cm to obtain a reliable pathological diagnosis. The early and adequate management of patients with IA may provide a favorable prognosis. This study aimed to disclose suggestive signs of CT to accurately predict IA among the pGGNs. A total of 181 pGGNs of less than 2 cm, in 171 patients who had preoperative CT-guided localization for surgical excision of a lung nodule between December 2013 and August 2019, were enrolled. All had CT images of 0.625 mm slice thickness during CT-guided intervention to confirm that the nodules were purely ground glass. The clinical data, CT images, and pathological reports of those 171 patients were reviewed. The CT findings of pGGNs including the location, the maximal diameter in the long axis (size-L), the maximal short axis diameter perpendicular to the size-L (size-S), and the mean value of long and short axis diameters (size-M), internal content, shape, interface, margin, lobulation, spiculation, air cavity, vessel relationship, and pleural retraction were recorded and analyzed. The final pathological diagnoses of the 181 pGGNs comprised 29 benign nodules, 14 AAHs, 25 AISs, 55 MIAs, and 58 IAs. Statistical analysis showed that there were significant differences among the aforementioned five groups with respect to size-L, size-S, and size-M (p = 0.029, 0.043, 0.025, respectively). In the univariate analysis, there were significant differences between the invasive adenocarcinomas and the non-invasive adenocarcinomas with respect to the size-L, size-S, size-M, lobulation, and air cavity (p = 0.009, 0.016, 0.008, 0.031, 0.004, respectively) between the invasive adenocarcinomas and the non-invasive adenocarcinomas. The receiver operating characteristic (ROC) curve of size for discriminating invasive adenocarcinoma also revealed similar area under curve (AUC) values among size-L (0.620), size-S (0.614), and size-M (0.623). The cut-off value of 7 mm in size-M had a sensitivity of 50.0% and a specificity of 76.4% for detecting IAs. In the multivariate analysis, the presence of air cavity was a significant predictor of IA (p = 0.042). In conclusion, the possibility of IA is higher in a pGGN when it is associated with a larger size, lobulation, and air cavity. The air cavity is the significant predictor of IA.

Intracranial dural arteriovenous fistulas (dAVFs) are commonly encountered in centers specializing in cerebrovascular diseases. Knowing the precise site of fistulous communication with the venous structures is essential in targeting the appropriate surgical or endovascular therapy once a decision to treat has been made. Such sites can usually be located with digital subtraction angiography alone. The authors describe a case in which localization was best performed using cone-beam volume CT in the angiography suite after selective microcatheterization of the feeding vessel and injection of a contrast agent in a dAVF related to the petrous temporal bone. Imaging studies showed the lesion was related to the inferior aspect of the tentorium, warranting a suboccipital surgical approach to treat the fistula.

11566 Background: Immune-checkpoint blockade treatments, particularly drugs targeting the programmed death-1 (PD-1) receptor, demonstrate promising clinical efficacy in patients with non-small cell lung cancer (NSCLC). We sought to evaluate whether computer extracted measurements of tortuosity of vessels in lung nodules on baseline CT scans in NSCLC patients(pts) treated with a PD-1 inhibitor, nivolumab could distinguish responders and non-responders. Methods: A total of 61 NSCLC pts who underwent treatment with nivolumab were included in this study. Pts who did not receive nivolumab after 2 cycles due to lack of response or progression per RECIST were classified as ‘non-responders’, patients who had radiological response per RECIST or had clinical benefit (defined as stable disease >10 cycles) were classified as ‘responders’. A total of 35 quantitative tortuosity features of the vessels associated with lung nodule were investigated. In the training cohort (N=33), the features were ranked in their ability to identify responders to nivolumab using a support vector machine (SVM) classifier. The three most informative features were then used for training the SVM, which was then validated on a cohort of N=28 pts. Results: The maximum curvature ( f1), standard deviation of the torsion ( f2) and mean curvature ( f3) were identified as the most discriminating features. The area under Receiver operating characteristic (ROC) curve (AUC) of the SVM was 0.84 for the training and 0.72 for the validation cohort. Conclusions: Vessel tortuosity features were able to distinguish responders from non-responders for patients with NSCLC treated with nivolumab. Large scale multi-site validation will need to be done to establish vessel tortuosity as a predictive biomarker for immunotherapy. [Table: see text]

AbstractSpiral CT angiography is a new, minimally invasive technique for vascular imaging that is made possible bycombining two recently developed techniques: slip-ring CT scanning and computerized three-dimensional (3D)reconstruction. CT angiography done to diagnose and evaluate blood vessel disease or related conditions, suchas aneurysms or blockages, Arteriovenous malformation (AVM), hemangioma, stenosis, AV fistula, aorticdissection, pulmonary embolism, thoracic outlet syndrome etc.Over the past decade, noninvasive imaging of the arteries has evolved into a highly reliable alternative toinvasive digital subtraction angiography. Here we presents few rare cases where diagnosis was made possible byCT Angiography.(1) Bilateral renal AVM with aneurysmal dilatation of feeding arteries on left side, which was diagnosedby renal CT Angiography.(2) Cerebral arterio-venous malformation involving left temporo-parietal lobes, diagnose by carotid CTAngiography.(3) Takayasu arteritis (Type-V), diagnosed by Aortogram.(4) Arterio-venous malformation involving postero-lateral aspect of middle third of left leg, diagnosed byperipheral CT Angiography.(5) Non-calcified soft tissue plaque seen at the proximal part of LAD near its origin results inmoderate luminal stenosis with negative remodeling, diagnosed by Cardiac CT Angiography.CT angiography is a type of medical test that combines a CT scan with an injection of a special dye to producepictures of blood vessels and tissues in a part of our body. The dye is injected through an intravenous (IV) linestarted in our arm or hand. Before Multi-Detector Computed Tomography (MDCT), the main barriers to theclinical implementation of CT angiography (CTA) were acquisition speed and both spatial and temporalresolution.

Vascular territory mapping (VTM) software estimates which intracerebral vessel provides peak arterial flow to a brain voxel. This observational study was performed to assess the hypothesis that the VTM algorithm may correlate to visual measurements of leptomeningeal grading and stroke outcome measures in acute middle cerebral artery (MCA) occlusion. VTM software assigned regions of the brain to an estimated feeding intracerebral vessel. Whole brain dynamic CT angiography was used to visually grade the extent of flow in either anterior or posterior cerebral leptomeningeal arteries. The final dataset included 115 patients with MCA occlusion. The median age was 74 years (IQR 62–82). The time from onset of symptoms to scan was a median of 129 min (IQR 85–241) and the median National Institutes of Health Stroke Scale (NIHSS) was 15 (IQR 12–19). Baseline imaging revealed a median ischaemic core of 19 mL (IQR 6–39) and perfusion lesion of 92 mL (IQR 68–122). Ischaemic core and posterior cerebral artery VTM volume were significantly associated with less robust posterior collateral flow on visual grading. VTM variables were not predictive of anterior collateral grade or stroke outcome measures. There did not appear to be a significant relationship between VTM volumes and visualised leptomeningeal collateral flow direction. The clinical utility and diagnostic value of VTM software in predicting collateral flow patterns remain to be elucidated, and further validation studies are warranted to determine the potential applications in acute stroke assessment.

Background Due to the broad variability of the prostatic artery (PA), its origin, small calibers, and tortuous courses, prostatic arterial embolization (PAE) is challenging, time-consuming, and results in high radiation doses. Purpose To evaluate the accuracy of PA detection using cone-beam computed tomography (CBCT) performed from the aortic bifurcation in combination with a semi-automatic detection software in comparison to oblique view digital subtraction angiography (DSA) with internal iliac artery (IIA) injection. Material and Methods Twenty-two consecutive patients were included in this retrospective, IRB-approved study between July and December 2017. CBCT from the aorta and 30° oblique-view DSA from both IIAs were obtained for PA detection. Results of suggested PAs from the semi-automatic vessel detection software after CBCT and IIA DSA were compared. Moreover, dose area product (DAP) was recorded. Statistical analysis included Spearman’s correlation, Mann–Whitney U test, and the Wilcoxon test considering P<0.05 as significant. Results PA type was classified significantly better with CBCT compared to DSA ( P=0.047). In IIA DSA, PAs could not be identified in 18% on the left and in 17% on the right side. CBCT detected all PAs, although truncation occurred in 59% because of the limited field of view. Mean DAP of the whole procedure was 257,161.32±127,909.36 mGy*cm2. Mean DAPs were for a single DSA 14,502.51±9,437.67 mGy*cm2 and for one CBCT 15,589.23±2,722.49 mGy*cm2. A mean of 14.82 DSAs and only one CBCT were performed. CBCT accounted for 6% and DSA for 84% of the entire DAP of the procedure. Conclusion CBCT with semi-automatic feeding vessel detection software detects PAs more accurately than IIA DSA and may reduce radiation dose.

PurposeHyperprogression is an atypical response pattern to immune checkpoint inhibition that has been described within non-small cell lung cancer (NSCLC). The paradoxical acceleration of tumor growth after immunotherapy has been associated with significantly shortened survival, and currently, there are no clinically validated biomarkers to identify patients at risk of hyperprogression.Experimental designA total of 109 patients with advanced NSCLC who underwent monotherapy with Programmed cell death protein-1 (PD1)/Programmed death-ligand-1 (PD-L1) inhibitors were included in the study. Using RECIST measurements, we divided the patients into responders (n=50) (complete/partial response or stable disease) and non-responders (n=59) (progressive disease). Tumor growth kinetics were used to further identify hyperprogressors (HPs, n=19) among non-responders. Patients were randomized into a training set (D1=30) and a test set (D2=79) with the essential caveat that HPs were evenly distributed among the two sets. A total of 198 radiomic textural patterns from within and around the target nodules and features relating to tortuosity of the nodule associated vasculature were extracted from the pretreatment CT scans.ResultsThe random forest classifier using the top features associated with hyperprogression was able to distinguish between HP and other radiographical response patterns with an area under receiver operating curve of 0.85±0.06 in the training set (D1=30) and 0.96 in the validation set (D2=79). These features included one peritumoral texture feature from 5 to 10 mm outside the tumor and two nodule vessel-related tortuosity features. Kaplan-Meier survival curves showed a clear stratification between classifier predicted HPs versus non-HPs for overall survival (D2: HR=2.66, 95% CI 1.27 to 5.55; p=0.009).ConclusionsOur study suggests that image-based radiomics markers extracted from baseline CTs of advanced NSCLC treated with PD-1/PD-L1 inhibitors may help identify patients at risk of hyperprogressions.

Abstract We present two cases of traumatic pseudoaneurysm of the superficial temporal artery (STA). An 87-year-old woman was referred to the dermatology 2-week-wait clinic with a 4-cm painless nodule on the left forehead. Three weeks prior she sustained a fall at home, and computed tomography revealed a subgaleal haematoma over the left forehead. She was on warfarin for deep vein thromboses (international normalized ratio 4.2). The nodule was compressible and had a purple hue. A diagnosis of haematoma was made and incision and drainage was booked. On the day of surgery her procedure was cancelled as clinical re-examination revealed the mass was pulsatile and overlying the STA. The diagnosis was revised to STA pseudoaneurysm. She was referred to plastic surgery and underwent ligation of the artery and excision of the pseudoaneurysm. A 51-year-old man presented to dermatology with a 1-month history of a 1-cm painless, pulsatile subcutaneous mass on the right forehead continuous with the STA. Further questioning revealed a cycling accident 3 months prior with polytrauma. STA pseudoaneurysm was diagnosed clinically. He underwent ligation of the artery and resection of the pseudoaneurysm under local anaesthetic in dermatology theatres successfully, with no complications or recurrence. STA pseudoaneurysm is a rare presentation of an enlarging nodule on the forehead or temple, which typically occurs following blunt head trauma. However, cases have been reported following Botox injections, hair transplants and other procedures. The interval between the causative trauma and the onset of the lump can vary (reported range 2–6 weeks to 10 years), and therefore it may not be obvious or volunteered by the patient. Although STA pseudoaneurysm is usually asymptomatic, ear pain, headache and facial nerve palsies have been described. Examination reveals a typically spherical subcutaneous lesion, continuous with the course of the STA. Unless thrombosed, palpation should reveal a characteristic pulse or thrill and a bruit on auscultation. Diagnosis is usually clinical. Doppler ultrasound (demonstrating vessel dilatation and turbulent flow), magnetic resonance imaging, computed tomography (CT), and CT angiography can confirm the diagnosis and are useful to investigate other post-traumatic injuries. Treatment is usually surgical ligation of the artery and resection of the pseudoaneurysm. Embolization is an alternative if surgery cannot easily be performed. In summary, STA pseudoaneurysm is a rare but important clinical diagnosis to consider in a subcutaneous mass on the forehead, before biopsy or aspiration is performed. A history of trauma does not always directly precede its onset despite it being the likely causative factor. Although the clinical history can be suggestive, examination to identify the pulsatile nature is important, so the diagnosis may be missed on reviewing teledermatology images only.

Pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. In this paper, we present a case of a 74-year-old man, who was admitted to our clinic with a diagnosis of an acute on chronic pancreatitis complicated by walled-off-pancreatic-necrosis, with subsequent development of peripancreatic pseudoaneurysm. After initial conservative management, the patient recovered and was discharged from the hospital. However, he soon returned feeling anxious due to a pulsatile abdominal mass. Abdominal Color–Doppler examination, CT scan, and angiography revealed large pancreatic necrotic collection in the total size of 9 cm, with centrally enhancing area of 3.5 cm that corresponded to pseudoaneurysm originating from the posterior pancreaticoduodenal vascular arcade. Considering the size, location of the pseudoaneurysm, feeding vessel, and poor general patients condition, we opted for minimally invasive treatment. Pseudoaneurysm was successfully managed by endovascular coil embolization, i.e., “sandwich technique”.

Background: The prevalence of Angiofibroma of juvenile variety is infrequent tumor of nasopharynx7. It grows aggressively and is locally destructive and extends into the cranium as well. Its symptoms usually involve nasal obstruction with or without nasal bleed. Histopathology shows spindle cells scattered between collagen fibers and vascular tissue. MRI and CT angiogram are the two most important investigations used in its diagnosis. Many methods have been used for its excision since ancient times and many researches have been done to control per operative bleeding as it is a vascular tumor. Aim: This study was performed to compare two methods i.e., 1. Carotid artery ligation per operatively and 2. Embolization of the feeding artery pre operatively in order to assess which method is better in controlling per operative bleeding during its excision. Design: Comparative Setting & duration: Department of Otorhinolaryngology, Jinnah Hospital, Lahore from 01st January 2020 to 31st January 2022. Methodology: A group 20 patients were taken having angiofibroma. 10 patients went for pre operative embolization of the feeding vessel of the angiofibroma after localizing the vessel by having MRA. The other 10 patients had their external carotid artery ligated before excising the angiofibroma. The bleeding which occurred during both procedures was quantified by weighing the gauze pieces soaked per operatively , the blood collected in suction bottle and then comparing the values. Results: The 10 patients who had embolization had far more bleeding during excision as compared to the 10 patients who had their external carotid artery ligated per operatively before excision. Conclusion: Results showed that pre operative embolization is not a better procedure to control per op bleeding as compared to external carotid artery ligation during angiofibroma excision. Keywords: Embolization , angiofibroma , per operative ,

ABSTRACT Objective: Hemangioblastoma is a rare vascular sporadically occurring CNS tumor that can be associated with von Hippel-Lindau disease. Hemangioblastomas account for 2-6% of all spinal cord neoplasms and rank third among intramedullary space-occupying lesions. Methods: This was the first time in our practice that we had dealt with paravertebral hemangioblastoma with the sandglass growth pattern. The world literature describes only 3 case of a tumor with this growth pattern. Surgical and diagnostic aspects of patient treatment are considered. Results: During the operation, we adhered to the following stages: localization of the feeding vessel and of the poles of the tumor, surface dissection of the tumor, en bloc resection of the tumor, and hemostasis of the tumor cavity. Conclusions: Hemangioblastoma of extradural localization is a very rare pathology. However, when MRI signs characteristic of a vascular lesion are identified, it is necessary to carry out additional examinations, which may include CT perfusion study and, if required, selective angiography. Level of Evidence 5; Case report.

Pulmonary sequestration (PS) is a rare congenital malformation, which mainly contains two variants involving extralobar and intralobar sequestrations. Extralobar sequestrations (ELS) are isolated from the remaining lung tissue and have their visceral pleura. Herein, we report the first case of a torsed ELS associated with congenital lobar emphysema. We described a boy who mainly presented with abdominal and chest pain. A contrast-enhanced computed tomography (CT) scan revealed a mildly enhanced posterior mediastinal mass with left lower lobar emphysema. Thoracoscopic surgery identified a dark and hemorrhagic mass that was connected to the thoracic aorta by a twisted feeding vessel and had its visceral pleura. Pathological findings were consistent with an ELS that had undergone torsion and infarction. The postoperative recovery was uneventful. For the left lower lobar emphysema, he was required for a regular outpatient follow-up. In conclusion, although extremely rare, physicians should maintain a high index of suspicion for torsed ELS when a posterior mediastinal mass with abdominal or chest pain is presented in children.

Background: Septic pulmonary embolism (SPE) is an associated complication of Klebsiella pneumoniae liver abscess (KPLA). However, previous studies have reported that its incidence varies widely. We conducted a systematic review and meta-analysis to investigate the incidence of SPE in patients with KPLA. We further analyzed their clinical and computed tomography (CT) features. Methods: Two researchers reviewed PubMed, EMBASE, Web of Science, and Cochrane Library databases to identify the articles that reported SPE in patients with KPLA. The search was conducted from the date of establishment of each database up to January 2021. After screening the articles and extracting the data, we used Review Manager 5.3 for analysis and processing. Results: We selected six articles that included 1,158 patients with KPLA. Of these, 70 patients had SPE. The pooled incidence of SPE was 6% (95% confidence interval, 3%–9%). Among patients with SPE, 85% were men, 72% had diabetes, and 52% displayed the feeding vessel sign on the chest CT. The mortality rate was 12%. Quality assessment revealed that half of the included studies had a high quality. Conclusion: The pooled incidence of SPE in patients with KPLA was 6%. Men and patients with diabetes were more prone to SPE. For patients with KPLA who had SPE as an associated complication, the mortality rate was approximately 12%.

Purpose: To describe the characteristic features of pulmonary sequestration (PS), to evaluate the usefulness of various imaging modalities, and to find a rational approach to accurate diagnosis. Material and Methods: Twenty-four patients with PS proved by operation and pathology were reviewed retrospectively. Plain chest films were done in all patients, bronchography in 3, sonography in 14, CT in 6 (including CT angiography in 1 case), MR in 8 (including MR angiography in 1 case) and aortography in 12 (including DSA in 1 case). Results: Plain chest films demonstrated a solid mass in 14 patients and a cystic mass in 10. Bronchograms showed displacement of adjacent bronchi with no filling of contrast medium within the lesion in 2 cases, while another case had a blind intermediate portion of the right bronchus (hypoplasia of middle and lower lobes associated with extralobar sequestration). Sonography demonstrated a solid lung mass in 12 cases and a solid mass with cystic areas in 2, and detected vessel-like structures within the mass or in its surroundings in 12. Doppler analysis showed arterial spectral wave confirming a feeding artery. CT revealed a solid mass in all patients, a mass with low density area in 4, and emphysema surrounding the mass in 3. MR imaging depicted anomalous arteries in all patients and venous drainage in 4 cases. Aortography demonstrated anomalous systemic arterial supply to the PS in all patients. In this series, 21 cases (87.5%) were correctly diagnosed preoperatively by the imaging modalities. Conclusion: Plain chest films can provide a diagnostic clue to PS. Sonography, CT and MR are helpful for showing arterial blood supply and for making a definite diagnosis. We recommend a rational imaging approach for the diagnosis of PS.

High flow arteriovenous malformations (AVMs) are infiltrative, invading tissue planes and structures and may be life threatening when they bleed.1 They have a feeding artery and an anomalous capillary bed shunting blood from the arterial system to the venous system.1 The present trend of management of small AVMs is surgical excision with a high success rate. The problematic cases are diffuse AVMs infiltrating structures that render them impossible to totally extirpate surgically without causing much blood loss and tissue damage. The mainstay of management is embolization, surgical resection and reconstruction.2 Ligation or proximal embolization (alone) of feeding vessels should never be done because such maneuvers result in rapid recruitment of new vessels from adjacent arteries to supply the AVM nidus.2 Incomplete surgical excision definitely leads to recurrences, making this type of AVM very difficult to manage.
 What is the point of this paper? The complete destruction of the “nidus” of the AVM, from the artery to the capillary to the venous component, is the only potential cure.3 Well and good if there could be a way of doing this by sclerosing the entire vascular malformation. But since sclerosis only works well in low flow vascular malformations and tumors like hemangiomas, and poorly or not at all in high flow lesions,4 we have to convert this high flow AVM into a “no-flow” or “low flow” AVM by ligating the feeding and draining vessel and injecting the sclerosant intra-arterially thereafter at a dose sufficient enough to blanch out the AVM even up to its peripheral branches. This paper aims to demonstrate how we do this.
 Definition of Terms
 Vascular malformation: They are a result of abnormal development of vascular elements during embryonic or fetal stages of life.2 They originate from mesenchymal cells at an early stage of embryogenesis.3 and most are present at birth but there are several case reports of these lesions presenting after trauma in adults.1 Some AVMs appear as part of a familial genetic disorder called angiomatous syndrome i.e. Rendu-Osler-Weber Syndrome presenting with telangiectasia of the skin and mucous membranes.3 Some propose that a defect in vascular stabilization like TGF-beta signaling could be a cause of AVM development.5,6 Still, progesterone receptors have been isolated in AVMs explaining their expansion during puberty.7
 Hemangioma: These are vascular tumors that exhibit endothelial proliferation.2 A hemangioma of infancy usually undergoes 3 stages: a proliferative phase of rapid growth up to 10 to 12 months of age; an involuting phase where growth slows down and signs of regression appear usually at 1 to 7 years; and an involuted phase.2
 Sclerosants: Agents used in sclerotherapy that induce a toxic effect on the vascular endothelium and results in fibrosis. There are 3 types: Detergents that disrupt cell membranes by protein theft desaturation ie: ethanolamine oleate, sodium morrhuate, polidocanol, sodium tetradecyl sulfate; Osmotic agents ie: sclerodex; and Chemical irritants that damage cell walls by direct contact ie: chromatin glycerine, polyiodinated iodine.8
 Sclerodex: an osmotic sclerosant that is a combination of dextrose monohydrate 250mg/ml and sodium chloride 100mg/ml. It shifts water balance through cellular gradient (osmotic) dehydration that leads to endothelial destruction. Since component materials are naturally occurring bodily, it has no molecular toxicity in calibrated dosages. If extravasated, it could cause tissue necrosis.8 It is manufactured by OMEGA Laboratories, Ltd. Montreal, QC, Canada.
 REVIEW OF PRESENT PRACTICE AND LITERATURE
 The first task of the physician is to establish a diagnosis, whether the lesion is a vascular malformation or a vascular tumor. Taking the history of the patient could point to a diagnosis as vascular tumors like hemangiomas usually proliferate and involute from the time of infancy to about the age of 10. Vascular malformations grow as the child grows and do not involute. Vascular malformations have an arterial supply and a venous drainage and are classified into high or low flow. Capillary, venous and lymphatic types are low flow while arteriovenous malformations are usually high flow.
 A high flow AVM has an arterial blood supply and a venous drainage. In rare instances, a vascular malformation could co-exist with a hemangioma forming a mass effect.2 On physical examination, a bruit and a strong pulsation (thrill) is appreciated.
 The head and neck is the most common location of AVMs at 70%. When fully developed, they are deeper in color with increasing erythema, local warmth, palpable mass and a bruit.9 These malformations are composed of vascular channels lined by flat mature epithelium and are not hypercellular and not proliferative.10 
 Schobinger proposed a staging system for Head and Neck AVM. Stage 1 are AVMs that are quiescent and remain stable for long periods of time. Stage 2 is a time for expansion followed by pain and bleeding. Stage 3 is heralded by destruction of adjacent tissues and ulceration. Stage 4 is presented by decompensation where symptoms of cardiac failure are present.11
 Ultrasound with color Doppler imaging, Magnetic Resonance Imaging and Phlebography (arteriography/venography) contribute to diagnosis, classification and management.3 In our setting were we do not have the facilities, we use CT- angiography. These imaging modalities should be used to evaluate the characteristics of the lesion, such as size, flow velocity, flow direction, relation to surrounding structures and lesion content.3 Ultrasound demonstrates flow rates, contrast-enhanced magnetic resonance imaging (MRI) shows presence or absence of a mass, and CT angiography reveals the arborization (the blood supply and drainage) of the vascular anomaly.
 Vascular tumors like hemangioma, if located in non-strategic areas where function is not impaired can be observed over its developmental phases until involution at about 10 years old.2 For hemangiomas that impair function or are possibly life threatening because of potential hemorrhage, these tumors are treated with the following modalities: 1. Intralesional corticosteroids ie: triamcinolone; 2.Systemic corticosteroids in a tapered dose like prednisolone and some second choice pharmacotherapeutics like interferon, vincristine; and 3. Propranolol. Surgery is indicated in ulcerating, bleeding, and life threatening lesions like airway obstruction.2
 Over 90% demonstrate dramatic reduction in size of hemangioma in one to two weeks from the above medical therapeutic modalities. Propranolol has been successfully used as hemangioma treatment since 2008 and is believed to have an antiproliferative effect on the vascular endothelium. The mechanism of action may involve the regulation of growth factors.1
 Low flow vascular malformations are treated with sclerotherapy or surgical excision for accessible tumors. These malformations do not regress like hemangioma but grow in time. High flow AVMs are treated with surgical excision if they have limited extent and are surgically accessible. Embolization before surgery decreases bleeding and is the standard. Embolization followed by repeated sclerotherapy is recommended for surgically inaccessible areas.4 There is a 64 to 96% response rate , defined as improvement in symptoms or a reduction in the lesion size after ethanol sclerotherapy of venous low flow malformations.3 Partial surgical excision leads to only temporary improvement followed by re-expansion of tumor overtime.9 Sometimes, complete resection is not possible in diffuse or infiltrating AVMs and surgery can result in severe disfigurement and impairment of function of involved structures.9
 
 METHODS
 After establishing the diagnosis of a high flow AVM with identification of an arterial feeding vessel and a venous draining vessel, surgery is commenced away from the malformation to expose the arterial and venous supplies. The procedure is done under general anesthesia because sclerotherapy of large malformations and vascular tumors is very painful. We do this because we have no interventional radiology services in our hospital. We ligate the feeding artery and if possible, the draining vein to convert the AVM into a “ low or no flow” and to allow ample contact time between the sclerosant (sclerogen) and the vessel endothelium. The sclerosant is then injected intravascularly distal to the ligation until all visible malformation blanches out. Aspirating the blood content of the ligated (arterial supply and venous drainage) malformation before introduction of the sclerosant will further potentiate the action of the sclerosant. While injecting the sclerosant slowly, the patient’s vital signs are monitored. A drop in the pulse rate is a signal to stop or slow down the injection of the sclerosant because it may be a sign that some sclerosant is escaping the venous drainage and reaching the general circulation in a concentration picked up by the sensors of the vascular system. Injections resume in a slower manner as the vital signs revert to normal. Our sclerosing agent sclerogen is an osmotic agent composed of sodium chloride and dextrose which are naturally present in our body so they are not toxic in manageable concentrations. Other sclerosants can be nephrotoxic so we must be very careful in injecting not to overload the vascular system. The objective is to push the sclerosant to all branches of the malformation to eliminate all possible nidus. The end point of injection is when all cutaneous or mucosal components of the malformation blanch out.
 Injection of the sclerosant intravascularly is done under direct visualization to prevent extravascular introduction. A review of literature has this to say about sclerotherapy. Extravascular injection of the sclerosant causes tissue necrosis.4 Ethanol injection to high flow fistulous lesions is contraindicated because of high risk of” early wash “ into the systemic circulation.4 Sclerosants could cause hemolysis, denaturation of blood proteins, thrombus formation and nephrotoxicity.3,4,12 Ethanolamine oleate, in comparison to ethanol, has less effect in the deep vascular layer and no penetrative effect. It is not associated with neuronal side effects despite of the proximity of the nervous system to the vascular system.3 
 CASES
 Our first case was a 62-year-old woman with a pinna and periauricular vascular malformation, noted since 5 years prior to consultation. The inferior concha was bulging and pulsating with a strong bruit. The periauricular area was elevated with microvascular malformations in reddish discoloration. The left posterior auricular artery was identified as the feeding artery and the diagnosis was a high flow AVM. She consulted a hospital in Sacramento, California where she worked and was advised to have a resection of her left ear. She got frightened and decided to come home to the Philippines for a second opinion. I suggested our procedure which she gladly accepted but warned her of possible pinna necrosis. At least, she said, it is just a possibility and not an outright pinna loss. I dissected 1 cm below the malformation avoiding any of its extensions below the pinna and mandibular angle and moved towards the external carotid. I immediately located the pulsating, abnormally dilated posterior auricular artery feeding vessel and ligated it. Further dissection deep towards the styloid process revealed the venous drainage that penetrated the mastoid bone toward the direction of the sigmoid sinus. I too did the venous drainage ligation. I injected sclerogen distal to the posterior artery ligation after aspiration of 8 cc of AVM blood until all the malformation main mass and the peripheral branches blanched out. Total volume of sclerosant was 10 cc. There was no change in the vital signs as I slowly introduced the sclerosant. I closed the surgical defect and observed the patient for three days in the hospital. There was post-operative pain and swelling in the sclerosed malformation, relieved by ice packs and celecoxib 200 mg every 12 hours. After three days, the swelling started to subside and the pain lessened so the patient was sent home. She followed up in a week and the malformation had shrunk. Sutures were removed. Two weeks post-operatively, the malformation was just a trace skin discoloration with no tissue necrosis, no more bulge and pulsations and no pain. She asked permission to go back to work the following week in California.
 Our second case was a 13-year-old girl with a right tonsillar and hypopharyngeal vascular malformation. She had recurrent bleeding episodes necessitating blood transfusions in their province. I suggested our procedure which the parents and the patient consented to. We did surgery, ligating the right external carotid artery and external jugular vein and introduced the sclerosant (sclerogen) slowly until the tonsillar and hypopharyngeal malformation blanched out. There was no abnormal fluctuation of the patient’s vital signs. After closing the surgical access wound, I did tonsillectomy of the right since the bulging tonsillar malformation was obstructing the airway. There was very minimal bleeding and I was able to cauterize the remaining sclerosed malformation not included in the tonsil with ease. Two weeks post-surgery, she followed up with healed tonsillectomy wound and a disappearing malformation. She however had gastritis because of her co-amoxiclav antibiotic and her inability to eat well because of pain in swallowing. She eventually recovered from her gastric problems. At one-month follow-up, there was no trace of the malformation on visual examination. Looking back, doing tonsillectomy in an AVM would have been very bloody without sclerotherapy.
 Our third case was a nasopharyngeal AV malformation in a 35-year-old woman. She had episodes of severe bleeding requiring emergency tracheostomy, oral packing and blood transfusions. CT-angiography revealed two feeding vessels, one from the left external carotid artery and a minor one from the internal carotid artery. We decided to sclerose the left external carotid artery and see what happened to the internal carotid artery branch that could not be accessed. Since CT angiography did not identify the venous drainage, we introduced the sclerosant (sclerogen) very slowly, stopping when the pulse rate started to drop below 60 beats per minute and resuming slow injection when the pulse rate was normal. Oxygen saturation was noted to be stable at 98 to 100 %. We stopped when the AVM blanched out, injecting 15 ml of sclerosant. In two weeks time the AVM shrank except for a 1 x 1 cm bulge at the left posterior nasopharynx that was supplied by the internal carotid artery branch that could not be sclerosed at the time of surgery. The patient was decannulated from tracheostomy and was able to resume normal diet and activity. She is on regular follow-up and is being maintained with propranolol 40 mg once a day hoping that it may work as it does in hemangioma. 1 year post operatively, the bulge has not grown nor disappeared. Looking back, had we done surgery as suggested by colleagues, we could have encountered massive bleeding, inability to take the AVM all out, and eventual recurrence. Pondering upon the case of a second arterial blood supply of the AVM, the malformation could have recruited this second blood supply. The forward force of introduction of the sclerosant was not able to overcome the arterial pressure of the internal carotid artery feeding branch so the sclerotherapy effect stopped where the flow forces where at equilibrium. Note that in this case, we did not ligate the specific venous drainage as the CT-angiography did not identify it.
 
 DISCUSSION
 Managing AVMs that are diffuse and infiltrative can be very difficult. Surgical extirpation of all the nidus may not be possible and will surely lead to recurrences. Besides, malformations located in functionally strategic areas may present with structural deformities and functional disturbances when they are damaged by surgery. Small AVMs can be resected with high rates of success and no recurrences. In one series, all 16 patients with surgically accessible, localized, non-infiltrating AVMs who underwent angio-embolization with subsequent surgical excision demonstrated no evidence of recurrence on angiography during follow-up averaging 3 months.9
 In low flow venous malformations, sclerotherapy administered by trans-arterial, trans-venous or direct puncture injection without embolization or feeding vessel ligation has a 64 to 96% response rate, defined as improvement in symptoms or reduction of the lesion and not necessarily cure.3
 The cure rate for small malformations was 69% with excision only and 62% for extensive lesions with combined embolization and resection. At 6 years average follow-up, cure rate was 75% for stage 1; 67% for stage 2; and 48% for stage 3 malformations. The outcomes were not significantly affected by age at treatment, Schobinger stage, or treatment method.11
 Embolo-sclerotherapy is a new therapeutic modality for surgically inaccessible lesions like diffuse and infiltrating AVMs.4 This procedure is done repeatedly since the embolus recanalizes and the sclerosant is injected distal to the embolus. This method is reserved as an adjunct to subsequent surgical resection.4
 Our immediate results for ligation of feeding artery or draining vein before sclerotherapy were dramatic without functional or anatomic compromise. With sclerogen, whose components exist in the body naturally, we found no significant complications in our 3 cases. This technique could be ideal for diffuse and infiltrating AVMs. It is more effective if the feeding artery and the draining vein are identified and ligated so that the sclerosant can be pushed to all branches of the AVM. With a “no-flow or a slow-flow” AVM, we are able to prolong the contact of the sclerosant with the vascular endothelium thereby increasing the success rate of totally eliminating the nidus of the vascular malformation. 
 More studies and experience are needed to prove the durability of this technique. Are we able to eliminate all the nidus of the AVM if we are able to ligate all feeding arteries and draining veins before sclerotherapy? Our center is not so equipped so more technically advanced institutions dealing with vascular tumors and malformations can validate the efficacy of this technique. After all, it might not be bane to ligate AVM feeding and draining vessels if we are able to destroy the entire nidus of the AVM by whatever means like sclerotherapy in this case.
 
 Acknowledgements
 I wish to acknowledge my anesthesiologist Dr. Julius Apostol who encouraged me to try new things and promised to research on management of possible egress of sclerosants in the systemic circulation as he puts my patients to sleep. My residents at the Department of Otolaryngology-Head and Neck Surgery, Baguio General Hospital did the pre- and post-operative patient care while I was away, and the photography: Dr. Carlo Pagalilauan, Chief Resident and photographer, Dr. Sherwin Valdez, Dr. Beverly Carbonel, Dr. Jeff Peckley and Dr. Wingleaf Yu who are my assistants. Thank you.
 

Background:Takayasu arteritis (TA) is a form of chronic large vessel vasculitis. Recently, we found that some patients had lung manifestations and abnormal computed tomography (CT) results that cannot be explained by other causes. And so far, the prevalence of pulmonary features of TA is uncertain.Objectives:To investigate the imaging findings of lung involvement in patients with TA by high-resolution CT (HRCT) at a single center of China, and analyze the associations with mortality.Methods:A retrospective study was carried out of TA patients (n = 237, 200 women) who had routine HRCT scanning performed at the time of diagnosis from 2008 to 2018 at Xijing Hospital, Xi’an (China). Radiological manifestations of pulmonary involvement were evaluated from the HRCT images by two experienced radiologists. Patients with a confirmed diagnosis of pulmonary disorder (i.e., infections, tumors, except tuberculosis) have been excluded.Results:The median age of patients was 33 years (range 18-74), and the duration of disease was 66±55 months. Of all the patients, 57.8% (137/237) had abnormal lung HRCT results. Among them, 29.2% (40/137) of patients had pulmonary arterial involvement, including artery stenosis or occlusion. Mild pulmonary interstitial hyperplasia was the most common abnormal HRCT findings (27.4%, 65/237) observed in TA patients. Moreover, the frequencies of stripe/patchy shadows and nodule were 22.7% (53/237) and 15.6% (37/237), respectively. Pleural effusion was rare in these patients (10/237). Additionally, there are 9 cases of active pulmonary tuberculosis, 14 cases of suspected tuberculosis, and 9 cases of obsolete pulmonary tuberculosis. The common symptoms associated with lung were dyspnea (42%), cough (14%), chest pain (9.1%), and hemoptysis (4.9%). In a Cox regression model, there was no significant correlation between pulmonary involvement and mortality (P = 0.001).Conclusion:Pulmonary abnormalities on HRCT scanning is common among patients with TA. Apart from tuberculosis-related lesions and pulmonary arterial involvement, these manifestations are probably part of non-specific systemic inflammation of TA.Disclosure of Interests:None declared

Background During transarterial chemoembolization (TACE), cone-beam computed tomography (CBCT) can be used for tumor and feeding vessel detection as well as postembolization CT imaging. However, there will be additional radiation exposure from CBCT. Purpose To evaluate the additional dose raised through CBCT-assisted guidance in comparison to TACE procedures guided with pulsed digital subtraction angiography (DSA) alone. Material and Methods In 70 of 140 consecutive patients undergoing TACE for liver cancer, CBCT was used to facilitate the TACE. Cumulative dose area product (DAP), cumulative kerma(air), DAP values of DSA, total and cine specific fluoroscopy times (FT) of 1375 DSA runs, and DAP of 91 CBCTs were recorded and analyzed using Spearman's correlation, Mann–Whitney U-test, and Kruskal–Wallis test. P values < 0.05 were considered significant. Results Additional CBCT increased DAP by 2% ( P = 0.737), kerma(air) by 24.6% ( P = 0.206), and FT by 0.02% ( P = 0.453). Subgroup analysis revealed that postembolization CBCT for detection of ethiodized oil deposits added more DAP to the procedure. Performing CBCT-assisted TACE, DSA until first CBCT contributed about 38% to the total DAP. Guidance CBCT acquisitions conduced to 6% of the procedure's DAP. Additional DSA for guidance after CBCT acquisition required approximately 46% of the mean DAP. The last DSA run for documentation purposes contributed about 10% of the DAP. Conclusion CBCT adds radiation exposure in TACE. However, the capability of CBCT to detect vessels and overlay in real-time during fluoroscopy facilitates TACE with resultant reduction of DAPs up to 46%.

Background: The objective of this study is to determine the morphological computed tomography features of the tumor and texture analysis parameters, which may be a useful diagnostic tool for the preoperative prediction of high-risk gastrointestinal stromal tumors (HR GISTs). Methods: This is a prospective cohort study that was carried out in the period from 2019 to 2022. The study included 79 patients who underwent CT examination, texture analysis, surgical resection of a lesion that was suspicious for GIST as well as pathohistological and immunohistochemical analysis. Results: Textural analysis pointed out min norm (p = 0.032) as a histogram parameter that significantly differed between HR and LR GISTs, while min norm (p = 0.007), skewness (p = 0.035) and kurtosis (p = 0.003) showed significant differences between high-grade and low-grade tumors. Univariate regression analysis identified tumor diameter, margin appearance, growth pattern, lesion shape, structure, mucosal continuity, enlarged peri- and intra-tumoral feeding or draining vessel (EFDV) and max norm as significant predictive factors for HR GISTs. Interrupted mucosa (p < 0.001) and presence of EFDV (p < 0.001) were obtained by multivariate regression analysis as independent predictive factors of high-risk GISTs with an AUC of 0.878 (CI: 0.797–0.959), sensitivity of 94%, specificity of 77% and accuracy of 88%. Conclusion: This result shows that morphological CT features of GIST are of great importance in the prediction of non-invasive preoperative metastatic risk. The incorporation of texture analysis into basic imaging protocols may further improve the preoperative assessment of risk stratification.

Background: Cerebral proliferative angiopathy (CPA) is a rare vascular malformation with intervening normal brain tissue interspersed among abnormal vascular channels. There are 77 reported cases, the youngest being 9 years old, with persistent symptoms and recurring symptoms being rare. Methods: A three-year-old girl with CPA is described and compared to the literature. Results: A previously healthy girl with early left-handedness and a left forehead nevus flammeus presented with sudden onset of right arm and leg weakness, along with abrupt speech arrest and right homonymous hemianopia. Head CT Angiogram and MRI revealed an abnormal vascular network with densely packed, moderately enlarged vessels arising within the white matter with no dominant feeding vessel and both old and acute infarcts in the left hemisphere. Eye exam was unremarkable. The clinical and radiologic features were most consistent with a diagnosis of CPA. Her visual deficits and motor symptoms persisted, and she had a recurrent event shortly after. Conclusions: This is the youngest reported case of CPA, with novel features including radiologic evidence of previous infarcts, clinical recurrence of symptoms, and permanent deficits. This case demonstrates the need for further research into the surveillance and management of this rare entity, possibly unique in young children

Abstract A 71-year-old male patient presented to the dermatology department with a nontender erythematous nodule on the left arm. Incisional biopsy illustrated a dermal-based perivascular plasma-cell infiltrate with kappa-light chain restriction. There was also marked deposition of dermal amorphous eosinophilic material, with similar amorphous material deposition within vessel walls. Apple green birefringence under polarized light with Congo red staining was observed. Review at the UK National Amyloidosis Centre concluded that this was consistent with cutaneous amyloid-L (AL) amyloidosis. A bone marrow trephine and PET-CT ruled out systemic involvement. The patient was listed for surgical resection and monitored clinically by the dermatology and haematology teams. Amyloidosis represents a spectrum of disease including systemic and localized cutaneous subtypes. There is much discussion regarding the nosology of AL amyloidosis; however, there is consensus among clinicians, who consider cutaneous amyloidoma to be a rare variant (< 1%) of primary cutaneous marginal zone lymphoproliferative disorder. Cutaneous amyloidoma presents as small waxy nodules and/or plaques usually located on the extremities, and is histologically characterized by prominent amyloid deposition and few perivascular plasma cells. Surgical excision is the treatment of choice. AL amyloidosis presents in an older population and has a more indolent clinical course compared with the systemic subtype, leading to the proposal that cutaneous amyloidosis (AL type) may represent a precursor to the systemic process. Although progression to high-grade lymphoma or systemic amyloidosis is rare, it is recommended that patients undergo staging of the disease, eradication of the cutaneous disease and close clinical follow-up. Classification of cutaneous AL amyloidosis is hindered by its rarity; however, the authors hope that this case will add to the growing literature available on the condition.

Abstract Background: Primary aldosteronism (PA) is the most common form of secondary hypertension. Patients with PA are more likely to suffer from end-organ damage compared to matched controls with essential hypertension. We present a case of PA identified in a patient who presented with hypertensive emergency and hemorrhagic stroke. Clinical Case: A 52-year-old man with hypertension and chronic kidney disease presented with sudden onset left-sided weakness. He had a ten year history of hypertension and was taking carvedilol, losartan, and hydralazine prior to presentation. On arrival, his blood pressure was 263/142 mmHg. He had 3/5 grade weakness in the left upper and lower extremities. Laboratory analysis showed a potassium level of 2.8 mmol/L (n = 3.5–5 mmol/L) and a bicarbonate level of 33 mmol/L (n = 21–29 mmol/L). Screening labs for PA were drawn after potassium repletion. CT Head without contrast revealed an acute 2.5-centimeter intracerebral hemorrhage of the right basal ganglia. He was admitted to the intensive care unit and was started on a nicardipine drip with an improvement of blood pressure. His weakness improved and he was discharged home on carvedilol, hydralazine, nifedipine, and losartan. Screening for PA revealed a plasma aldosterone concentration (PAC) of 22.8 ng/dL (n < 16 ng/dL) and a plasma renin activity (PRA) of 0.1 ng/ml/hr (n = 0.2–1.6 ng/ml/hr). The PAC/PRA ratio was therefore extremely elevated at 228. The presence of spontaneous hypokalemia, very low renin, and PAC >20 ng/dL confirmed the diagnosis of primary aldosteronism. He underwent an adrenal MRI which revealed two left adrenal nodules, the largest measuring 10 mm, and a 7.3 mm right adrenal nodule, consistent with bilateral adrenal adenomas. The patient did not desire surgery, therefore adrenal vein sampling was deferred. His hypertension improved with the addition of a mineralocorticoid receptor antagonist. Eight weeks after his stroke the patient was readmitted due to chest pain. He was found to have severe multi-vessel coronary artery disease and underwent a four vessel coronary artery bypass. Conclusion: Patients with PA have higher rates of adverse cardiovascular events compared to age-, sex-, and blood pressure-matched controls with essential hypertension. Studies demonstrate that aldosterone excess has blood pressure independent proinflammatory and profibrotic effects on the vessel wall which leads to endothelial dysfunction and thus accelerated atherosclerosis. Appropriate treatment can eliminate the excess cardiovascular risk associated with PA. This case highlights the importance of including PA in the differential diagnosis of secondary hypertension, particularly among patients presenting with spontaneous hypokalemia, severe uncontrolled hypertension and early onset cardiovascular or cerebrovascular disease.

Lung sequestration is a developmental anomaly in the form of a separate non-functioning fragment of lung tissue that does not communicate with the bronchial tree and is supplied with blood by the aorta or arteries of the large circulatory circle. Lung sequestration is a developmental anomaly characterized by a separate nonfunctioning fragment of lung tissue that does not communicate with the bronchial tree and is supplied with blood by the aorta or arteries of the large circulatory circle. Lung sequestration accounts for 0.15%–6.4% of all lung malformations. This study presents a clinical case of a 7-month-old girl with extralobaric lung sequestration. The patient presented with complaints of cough; noisy, rapid breathing; and a history of gastroesophageal reflux. Gastroenterological pathology was excluded at the place of residence. During physical examination, wet wheezing was heard on both lungs, and the respiratory rate was 36 per minute. Chest X-ray showed a right-sided, upper-lobe pneumonia. Community-acquired right-sided, upper-lobe pneumonia, moderate form, was diagnosed. CT scan of the chest organs with contrast revealed a congenital malformation: tracheal bronchus and extralobar lung sequestration on the right. Indications for minimally invasive intervention were formulated. After surgical treatment, thoracoscopy showed an extrapulmonary sequester in the posterior hemithorax, with a feeding vessel from the thoracic aorta. Then, sequestrectomy was performed. In the postoperative period, positive dynamics was observed against the background of antibacterial, infusion, and symptomatic therapy. The patient was discharged in satisfactory condition. In children with long-term, recurrent lung infections, without positive dynamics against the background of conservative therapy and in the presence of respiratory disorders against the background of normal body temperature and absence of signs of inflammation in blood tests, congenital malformations of the respiratory tract should be excluded. Computed tomography with contrast enhancement and subsequent 3B reconstruction is the most appropriate method for diagnosing lung sequestration. Moreover, thoracoscopic resection of a separate nonfunctioning fragment of lung tissue is an effective minimally invasive surgical treatment method.

Background:Giant cell arteritis (GCA) is a systemic vasculitis affecting large to medium-sized vessels. Cranial nerve lesions are frequently documented secondary to GCA, however peripheral nerves are rarely involved.Objectives:We present an unusual case of a GCA-associated isolated high median nerve palsy.Methods:Case report.Results:A 76 year old white British female presented in Spain with three weeks of frontotemporal headaches, mandibular claudication, photopsia and constitutional symptoms, followed by acute-onset right hand paresis and dysaesthesia. Acute-phase reactants were elevated. COVID-19 PCR was negative. Shortly after admission she developed acute bilateral anterior ischaemic optic neuropathy and tongue necrosis with autoamputation. Temporal artery ultrasound and biopsy confirmed GCA. PET-CT showed no evidence of a diffuse large-vessel vasculitis. She was repatriated to the UK for ongoing inpatient care. Upper limb neurophysiology two months later demonstrated an isolated right high median nerve lesion, with reduced median motor responses and absent sensory responses with denervation in extensor carpi radialis. Imaging excluded a central lesion. The timing of her symptoms suggested the lesion was secondary to GCA. Treatment was with tocilizumab, methotrexate and tapering corticosteroids, alongside PEG feeding and careful multi-disciplinary rehabilitation.Conclusion:We suggest there are two important learning points from this complex case. Firstly, peripheral nerve lesions can occur in GCA, although they are rare. A literature search identified a modest number of case reports of brachial plexus or lower cervical nerve lesions1,2. Neurologic manifestations in GCA are attributed to vasculitis of the vasa nervorum, or extension of inflammation from arteries to contiguous nerves1,2. The restriction of clinical involvement to the median nerve alone would appear to favour the former mechanism. Functional recovery of neurological deficits is typically partial at best.Secondly, this case highlights the difficulty faced by clinicians in recognising GCA and the importance of urgent treatment with glucocorticoids. The patient developed GCA during the ongoing COVID-19 pandemic when Spain was the second-worst affected European country (5% seroprevalence; 95% CI 4.7-5.4)3. The partial overlap in symptoms between GCA and COVID-19 (e.g. headache, pyrexia, malaise, elevated acute-phase reactants) can cause diagnostic confusion and treatment delay4. GCA should be considered in the differential diagnosis of older patients with suspected COVID-19, or the non-specifically unwell elderly patient.References:[1]Blaise S, et al. Horton’s disease revealed by brachial C5 plexopathy [French]. Rev Med Interne. 2005;26(7):578-82.[2]Merianos P, et al. Giant cell arteritis of the median nerve simulating carpal tunnel syndrome. Hand. 1983;15(3): 249-251.[3]Pollán M, et al. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet. 2020; 396(10250): 535-544.[4]Monti S, Delvino P, et al. Impact of delayed diagnoses at the time of COVID-19: increased rate of preventable bilateral blindness in giant cell arteritis. Ann Rheum Dis. 2020;79:1658-1659.Table 1.Area/movementResultAbductor pollicis brevisGrade 2 weaknessOpponens pollicisGrade 4 weaknessPronator teres/quadratusGrade 4 weaknessFlexor pollicis longusGrade 1-2 weaknessFlexor digitorum profundus (digit 2 and 3)Grade 1-2 weaknessFinger abductionPreservedFinger extensionPreservedOther commentsDysaesthesia in distribution of median nerveDisclosure of Interests:Kundan Iqbal: None declared, James Miller Speakers bureau: Dr Miller has participated in pharmaceutical-sponsored symposiums previously but not in last five years., Consultant of: Dr Miller has participated in pharmaceutical-sponsored consultancy previously but not in last five years., Ming Lai: None declared, Mia Charnley: None declared, Muhammad Meraj: None declared, Ben Thompson Speakers bureau: Dr Thompson has participated in educational talks for Roche, Novartis, Lilly and UCB., Consultant of: Dr Thompson has participated in advisory boards for Roche, Novartis, Lilly, Gilead, Abbvie and UCB.

Arteriovenous malformations (AVMs) are vascular pathologies in which tissue trophism and blood outflow are disrupted due to the congenital or acquired absence of capillaries and the formation of a single conglomerate in which the arteries pass directly into the veins. Aim: to share our experience in the diagnosis and treatment of AVM of the colon in children. Material and methods. Clinical case No. 1. A 4-year-old girl was admitted to the N.F. Filatov State Clinical Hospital with a clinical picture of gastrointestinal bleeding (GCC). For the first time, an episode of stool with streaks of blood was observed at 2 years and 4 months. The examination revealed ulcerative colitis in the rectum, multiple erosions covered with fibrin were found. Long-term conservative therapy with no effect. Upon admission to the clinic, the child’s condition is moderate, the stool is light brown, and there is dark blood on top of it in the amount of 3-4 drops. According to ultrasound data, a thickening of the walls of the rectum with a slight increase in blood flow in them is determined above the anus. During the radioisotope study, an increase in the accumulation of RFP in the lower abdominal cavity was revealed. CT scans of the abdominal cavity and pelvis with contrast indicate increased vascularization of the walls of the middle and lower third of the rectum. Ultrasound of the sigmoid and rectum was performed: at a distance of 40 mm from the anus, an area in the rectal wall was visualized in which blood flow was increased during CDK, and venous vessels with arterial pulsation in them were also detected there. Endovascular angiography was performed, and intestinal AVM was detected (in the venous phase, dilated pathological veins can be traced projectively to the ampoule of the rectum). Taking into account the intensity of bleeding (5-6 times a day), it was decided to remove the pathological part of the colon. Laparoscopic resection of the sigmoid and rectum according to Swanson was performed in two stages. During the first stage, during the revision and mobilization of the colon at the level of the superior sigmoid artery, a large number of dilated vessels were found in the mesentery, and pathological vessels were also detected along the posterior wall of the rectum. On 4-5 postoperative days, the bleeding resumed, which indicated the formation of collateral blood flow. On the 14th day after stabilization, the second stage of Swanson surgery was performed - a direct coloctal anastomosis was performed. The bleeding continued. A decision was made to disconnect the rectum and apply an ileostomy. However, in the postoperative period, abundant mucous discharge with a hemorrhagic component remained from the rectum. Repeated angiography was performed - the vessel feeding the AVM was identified and embolized - the volume of bleeding decreased, but it was not possible to completely stop it. A decision was made to perform a colectomy and form an ileoanal anastomosis. Intraoperatively, marked lymphorrhea, tortuosity, and vasodilation of the mesentery were noted during intestinal discharge. In the postoperative period, blood in the stool was observed in the form of rare veins, which eventually disappeared. Clinical case No. 2. A 10-year-old girl was admitted to the clinic complaining of blood in her stool. It is known from the medical history that for 2 years the child has been worried about periodic pain in the left side of the abdomen. A year ago, the first episode of blood in the stool. During the examination, the diagnosis of UAC was established - conservative therapy was prescribed, against which remission was noted for about 3 months. Further, the resumption of GCC was noted, despite the ongoing treatment. A radioisotope study was performed, and an increased accumulation of RFP was detected in the left abdominal cavity. Upon admission, the condition is of moderate severity, the child is malnourished. The abdomen is soft on palpation, moderately painful in the left abdomen. The stool is mushy, with an admixture of blood and mucus, a tendency to diarrhea. According to the results of angiography, AVM of the colon was detected: in the descending part of the colon and in the rectum, the pathological tortuosity of small arterioles with increased capillary blood flow was contrasted. To eliminate life-threatening bleeding, a left-sided hemicolectomy with the formation of a colostomy was performed. Intraoperatively, telangiectasia was detected along the anterior surface of the rectum, the vessels in the colon and the left half of the intestine were dilated to 4-5 mm. In the postoperative period, the child had minor bleeding from the distal rectum. Clinical remission was achieved within 1 year. Discussion. It is believed that AVM occurs in 1 in 10,000 people, while in the literature, the localization of AVM in the colon or small intestine is described in no more than a hundred observations, of which 80% of cases are localized in the left half of the colon or rectum. The most common symptoms of this pathology are GCC, accompanied by the development of iron deficiency anemia. It is worth noting that AVM of the large intestine is often hidden under the guise of inflammatory bowel diseases. Children have been receiving inappropriate therapy for years, which can be misdiagnosed as drug resistance. Conclusion. The diagnosis of AVM is established using imaging research methods. In case of accidental detection of AVM, wait-and-see tactics are used due to the high traumatic nature of surgical treatment. If symptoms are present, endoscopic laser or thermocoagulation, resection of the affected area, or endovascular treatment is possible.

Septic pulmonary embolism is an uncommon disorder that is most often seen in patients with predisposing situations (intravenous drug use, endocarditis, septic thrombophlebitis, central venous catheter infections…). The clinical signs are non-specific. CT scan is useful for diagnosis showing bilateral pulmonary nodules with some orienting signs. We report a case of a 43-year-old woman, with a history of hemodialysis via a tunneled jugular catheter, who presented with acute respiratory distress and fever, chest CT showed multiple bilateral nodules, some of which are excavated. Blood cultures showed a staphylococcus aureusbacteremia. The diagnosis of septic emboli was made in view of all the clinical, biological, and radiological elements.  

Abstract OBJECTIVE The aim of this study was to evaluate the CT features of pulmonary metastases in dogs with hemangiosarcoma (HSA) at various sites. Additionally, the CT characteristics of extrapulmonary metastases in the same population were assessed. METHODS Retrospective, observational, and descriptive study conducted from April 2013 to January 2024. Dogs with histologically confirmed HSA and suspected or cytologically/histologically confirmed lung metastases were included. Dogs were excluded if they had a second primary tumor or only 1 unsampled pulmonary nodule. RESULTS 33 dogs were included, with 26/33 [78.8%] having more than 10 metastatic pulmonary nodules. Most nodules were generalized (24/33 [72.7%]), miliary (29/33 [87.9%]) to subcentimetric (32/33 [97%]) in size, well-defined margins (29/33 [87.9%]), or a perilesional halo sign (24/33 [72.7%]). When more than 10 nodules were present, a generalized distribution was prevalent, while a peripheral location was more common when 2 to 10 nodules were present (P < .0001). In 32/33 (97%) cases, a pulmonary vessel was directly connected to the nodule (feeding vessel). After contrast administration, most lung metastases appeared homogenous (26/33 [78.8%]), although some showed areas of intense enhancement (5/33 [15.1%]) a feature also observed in extrapulmonary metastases with varying frequency (0% to 85.7%). CONCLUSIONS Pulmonary HSA metastases were characterized by generalized, small (miliary/subcentimetric), well-defined nodules, commonly associated with a halo sign and feeding vessel. Intralesional areas of spotty postcontrast linear or amorphous strong hyperdensity were frequently observed especially in extrapulmonary metastases. CLINICAL RELEVANCE These features may help radiologists and clinicians orient their diagnosis toward metastatic HSA.

Abstract Background A mediastinal aberrant goiter is extremely rare, characterized by independence from the thyroid gland. This tumor most commonly develops in the anterior mediastinum and should be differentiated from a thymoma. Moreover, as mediastinal aberrant goiters frequently have a blood supply arising from the thoracic great vessels, preoperative diagnosis and evaluation of the feeding vessel are vital for safe surgery. Herein, we report a rare case of mediastinal aberrant goiter characterized by high radiodensity on non-enhanced computed tomography (CT). Case presentation A 77-year-old woman underwent non-enhanced CT, which showed a 2.2-cm, well-circumscribed, homogeneous anterior mediastinal nodule with high radiodensity. The CT attenuation value of the nodule was as high as 91.9 Hounsfield units. A thymoma or mediastinal goiter was suspected owing to the tumor location and the lack of a cystic component. We performed anterior mediastinal tumor resection using video-assisted thoracoscopic surgery. Pathologically, variably sized follicles, indicative of thyroid tissue, were observed with hemorrhage and hemosiderin deposition. Moreover, papillary projections of small follicles (Sanderson’s polsters) were scattered without atypia of the follicular epithelium, indicative of an adenomatous goiter. The diagnosis of a mediastinal aberrant goiter was supported by the absence of an anatomical connection with the thyroid gland. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. Conclusion The thyroid gland has a high radiodensity on non-enhanced CT, which correlates with iodine concentration. This radiological feature may be useful for the preoperative differentiation of mediastinal aberrant goiters containing thyroid tissue.