Adrian Mizzi

Functional outcomes and recanalization rates of stent retrievers in acute ischaemic stroke: A systematic review and meta-analysis

Background and purpose Intra-arterial therapy for acute ischaemic stroke has evolved rapidly in the last few years. Stent retrievers have now replaced ‘first-generation’ devices, which have been the principle devices tested in stroke trials. Our aims were to determine the rates of successful recanalization and functional independence in acute stroke patients treated with stent retrievers. We also sought to assess the safety outcomes of stent retrievers by assessing the rates of mortality and intra-cranial haemorrhage. Materials and methods We conducted a systematic review and meta-analysis of studies which utilized stent retrievers as sole treatment or as part of a multi-modal approach in acute ischaemic stroke. Results We identified 20 eligible studies: 17 on Solitaire (ev3/Covidien, Irvine, California, USA) (n = 762) and three on Trevo (Stryker, Kalamazoo, Michigan, USA) (n = 210). The mean age of participants was 66.8 (range 62.1–73.0) years and the M:F ratio was 1.1:1. The average stroke severity score (National Institutes of Health Stroke Scale (NIHSS)) at presentation was 17.2. The weighted mean symptom onset to arterial puncture and procedural duration were 265.4 minutes and 54.8 minutes, respectively. Successful recanalization was achieved in 84.5% of patients with a weighted mean of 2.0 stent retriever passes. Independent functional outcome was achieved in 51.2% and the mortality rate was 16.8%. Conclusion Stent retrievers have the potential to achieve a high rate of recanalization and functional independence whilst being relatively safe. They should be assessed in well-designed randomized controlled trials to determine their efficacy and assess whether they compare favourably with ‘standard treatment’ in stroke.

Imaging of Adult Ocular and Orbital Pathology - a Pictorial Review

Orbital pathology often presents a diagnostic challenge to the reporting radiologist. The aetiology is protean, and clinical input is therefore often necessary to narrow the differential diagnosis. With this manuscript, we provide a pictorial review of adult ocular and orbital pathology.

Intracranial calcifications. A pictorial review.

Brain calcifications are a common radiographic finding. The pathogenesis is diverse and ranges from benign physiological calcifications to a variety of pathological disorders. Whereas certain calcifications are considered an incidental finding, their presence can sometimes be crucial in making a specific diagnosis. Several pathological conditions affecting the brain parenchyma are associated with calcifications and their recognition and location might help in narrowing the differential. Knowledge of physiological calcifications is essential to avoid misinterpretation. This review illustrates a broad spectrum of CNS disorders associated with calcifications, and tries to highlight the salient radiological findings.

Teaching NeuroImages: Chordoma

A 30-year-old man presented with recurrent headaches. CT head revealed a clival chordoma (figure 1A). Chordomas originate from the embryonic remnants of the notochord and account for 2%–4% of all malignant bone tumors. They have a predilection for the axial skeleton, with 35% affecting the spheno-occipital region. The incidence peaks at ages 20–40 years. Male patients are affected twice as commonly as female patients.1 Clinical symptoms often result from local mass effect. On imaging, the tumor appears as a midline lesion and can contain heterogeneous calcifications. MRI demonstrates high signal on T2-weighted sequences and heterogeneous enhancement with a honeycomb appearance (figure 1).2 Indenting of the pons results in the characteristic thumb sign (figure 2). Differential diagnosis based on imaging appearance includes chondrosarcoma and metastasis.

Benign cystic mediastinal teratoma presenting as a massive pleural effusion in a 17-year–old boy

Mediastinal teratomas are a rare, albeit an important differential diagnosis of anterior/middle mediastinal masses in young adults and various atypical presentations have been reported. The authors report a case of a 17-year-old boy who presented with a 2-month history of worsening shortness of breath and pleuritic chest pain. A massive left-sided pleural fluid collection was seen on a chest radiograph (CXR). The pleural fluid was drained and a CT Thorax confirmed the presence of a cystic mass. Following re-accumulation of the fluid, thoracotomy was performed and a benign mediastinal teratoma excised. The patient remained well with no evidence of recurrence on follow-up CXRs a year post operatively.

A rare case of pulmonary alveolar microlithiasis

A 47-year-old asymptomatic man with no significant family history was referred to our faculty because of an abnormal chest X-ray (CXR). The CXR, similar to his CXR 10 years previously, showed bilaterally increased interstitial markings suggestive of pulmonary fibrosis. High-resolution CT (HRCT) showed multiple bilateral branching calcifications, mostly in the lung bases (figures 1 and 2), with ground-glass opacities in the lingula, and no enlarged mediastinal lymph nodes. Spirometry was normal (forced expiratory volume in 1 s 102%, forced vital capacity 118%), as were total lung capacity, 117%, and diffusion capacity of the lung …

Adult colorectal intussusception.

### Case report A 30-year-old woman presented with severe lower, colicky abdominal pain and difficulty in passing flatus. Clinical examination revealed suprapubic tenderness. An abdominal CT was performed which revealed a soft-tissue mass in the pelvis demonstrating ‘a target sign’ appearance confirming the diagnosis of intussusception (figure 1). The effect of the intussusceptum within the intussuscipiens creates a layered appearance. There is loss of gas within the rectum, instead, this is replaced by a soft-tissue mass of fat density (Hounsfield units −10) (figure 2). A …

Caseous mitral annular calcification mimicking a lung tumor on chest X-ray

Mitral annular calcification (MAC) is a common condition of the mitral valve apparatus. A case involving caseous calcification, a rare variant of MAC is presented. This variant which has a benign course can present as an intracardiac mass and needs to be differentiated from more sinister causes of calcified cardiac masses such as tumor, abscess, and infective vegetation. Often, this requires multimodality imaging with echocardiography, computed tomography, and magnetic resonance imaging. Features of caseous calcification of the mitral valve on these imaging modalities are reviewed as the associations and clinical features.

Atypical Cavitary Lung Lesions: A Case Report and Review of Radiologic Manifestations

A 68-year-old woman presented to our emergency department with a 15 day history of epigastric discomfort radiating to the back. She had undergone a hysterectomy with bilateral salpingo-oophorectomy ten years before, for a FIGO stage 1 endometrioid adenocarcinoma. While abdominal examination was unremarkable, her liver function tests showed a cholestatic picture. An ultrasound scan of the abdomen revealed several gallstones as to the cause of this pain. Incidentally on chest radiograph, several lung lesions were noted bilaterally (Figure 1). On further questioning, the lady admitted to a one-year history of asthma with cough during the day and exertional dyspnoea. Inhaled corticosteroids prescribed for her ‘asthma’ proved to be ineffective. She was a non-smoker. She denied other respiratory symptoms, night sweats, chills, rigors or weight loss. She managed a good appetite and a good exercise tolerance for her age. There was no history of old TB, recurrent chest infections, recent travel or the presence of any mould at home.

Lower back pain in a patient on long-term haemodialysis.

A 60-year-old woman with end-stage renal disease secondary to adult polycystic kidney disease, presented with a 6-month history of worsening sacral and rectal pain. She reported anorexia and significant weight loss. She was on haemodialysis for 5 years prior to receiving a renal transplant, which failed after 8 years. She was then recommenced haemodialysis for another 4 years to date. She underwent bilateral nephrectomy of her native kidneys prior to transplantation. Clinical examination showed cachexia, hepatomegaly and a right iliac fossa graft. Rectal examination was normal. Passive movements of both lower limbs were painful; however, there was no neurological deficit. Investigations showed a chronic normocytic …