Ankaj Khosla

Age-Related Complications Following Endovascular Treatment of Unruptured Intracranial Aneurysms

BACKGROUND AND PURPOSE: The factors that led us to do the research for this paper was a desire to see if elderly patients did as well as non-elderly patients during endovascular intracranial aneurysm treatment. By doing this research, we could better stratify the most appropriate treatment for each patient with an aneurysm. The purpose of this study was to determine whether the incidence of procedural complications was greater in the elderly, defined as patients older than 65 years of age, compared with nonelderly patients undergoing elective endovascular treatment for intracranial aneurysms. MATERIALS AND METHODS: A retrospective review was performed in patients undergoing elective endovascular treatment of intracranial aneurysms between 2000 and 2010 at 1 institution. “Minor complications” were defined as those resulting in minimal or no loss of function that resolved before dismissal; “major complications” were complications that resulted in loss of function or complications that required a subsequent invasive therapy. Major complications were further stratified into those with and without neurologic disability, defined as an mRS score of >3. T tests and χ2 analyses were used to compare groups. RESULTS: Three hundred fifty-five patients underwent 394 endovascular procedures treating 75 aneurysm recurrences and 319 untreated aneurysms. One hundred eight (30%) were elderly. There was no significant difference in the rate of complications in the elderly compared with the nonelderly (33% versus 26%, respectively; P = .18). Major complications were significantly more prevalent in the elderly than in the nonelderly (17% versus 7.4%, respectively, P = .004). Major complications with neurologic disability were also significantly more prevalent in the elderly compared with the nonelderly (8.2% versus 1.8%, respectively, P = .004). CONCLUSIONS: Major functional complications were markedly more common in the elderly compared with the nonelderly.

Correlating first- and second-rib fractures noted on spine computed tomography with major vessel injury

First- and second-rib fractures diagnosed on plain radiographs have been associated with traumatic aortic injury. We examined whether such fractures diagnosed on computed tomography (CT), which is of greater sensitivity than plain radiograms for rib fractures, are associated with traumatic vascular injury. We identified 1,894 patients who had undergone a chest CT angiogram with indication of trauma between 2005 and 2008. Among these, 185 patients were selected at random. The main mechanism of injury was motor vehicle accident or a fall. The patients were divided into two groups: patients with first- and/or second-rib fractures and those without. Proportions of patients with major vessel injury noted on CT angiography were compared between groups. Information regarding displacement of the fracture, location of the fracture, detection upon plain film, and gender of the patients was also evaluated and correlated with incidence of major vessel injury. Fisher’s test and χ2 analysis were used to determine significance of the data. Incidence of major vessel injury was similar between patients with and without first- and/or second-rib fractures (7% vs. 9%, respectively; p = 0.59). No subset of type of rib fracture was associated with greater incidence of aortic injury. First- and second-fractures are not associated with greater incidence of aortic injury. Thus, the previous axiom that first- and second-rib fractures should result in increased examination for aortic injury may not hold true.

Clinical outcomes in patients with renal artery stenosis treated with stent placement with embolic protection compared with those treated with stent alone.

Purpose: To compare the clinical outcomes in patients with chronic renal insufficiency (CRI) and renal artery stenosis (RAS) following renal artery (RA) stent placement with and without embolic protection device (EPD) usage. Materials and Methods: Eighteen patients who had RA stent placement with EPD were matched to control patients (RA stent only). Blood pressure, number of hypertensive medications, and estimated glomerular filtration rate (eGFR) at 3 months before the procedure and after 12 months were determined. An increase of ≥ 20% in eGFR at 12 months from baseline was defined as “improvement,” decrease of ≥20% as “deterioration,” and an eGFR change between those values as “stabilization” at 12 months. Results: At 12 months, stage 4 patients treated with EPD had significantly higher eGFR than controls (P = .01). There was no statistical difference in blood pressure outcomes between the 2 groups. Conclusions: Patients with stage 4 CRI did significantly better with EPD than those treated without it.

Neither Subendplate Cement Deposition nor Cement Leakage into the Disk Space during Vertebroplasty Significantly Affects Patient Outcomes

PURPOSE To determine the impact of cement placement immediately adjacent to and through the endplate during percutaneous vertebroplasty on postprocedural pain and subsequent fracture rate. MATERIALS AND METHODS Institutional review board approval with waived consent was obtained. Medical records of 424 patients undergoing first-time, single-level vertebroplasty for osteoporotic or traumatic compression fractures were examined. Data regarding pain at rest and with activity before the procedure, along with timing and level of subsequent fractures over a 24-month period, were collected. Group 1 (n=64) included patients with no cement extension to the endplate(s), group 2 (n=216) included those with cement extension to the endplate(s) but no leakage into the disk space(s), and group 3 (n=144) included those with cement extension to the endplate(s) and cement leakage into the disk space(s). Analysis of variance and Fisher test were used to analyze the data, with significance set at P<.05. RESULTS Baseline characteristics and demographics were similar among the groups. At 1 month, for groups 1, 2, and 3, the respective mean postprocedural pain numeric scores at rest were 1.4±2.7, 1.4±2.4, and 1.6±2.5 (P=.51), while the respective pain scores with activity were 4.3±2.9, 3.8±3.1, and 3.9±3.3 (P=.50). Total subsequent fractures were noted in five (8%), 26 (12%), and 15 (10%) patients in group 1, 2, and 3, respectively (P=.77). CONCLUSION Neither extension of cement to the endplate nor cement leakage into the disk space has significant impact on postprocedural pain or subsequent fracture rate at 2 years.

Mortality and Renal Replacement Therapy after Renal Artery Stent Placement for Atherosclerotic Renovascular Disease

PURPOSE To identify risk factors for progression to renal replacement therapy (RRT) and all-cause mortality in patients who underwent renal artery (RA) stent placement for atherosclerotic renal artery stenosis (RAS). MATERIALS AND METHODS A retrospective study from June 1996 to June 2009 identified 1,052 patients who underwent RA stent placement. Glomerular filtration rate at time of RA stent placement was estimated from serum creatinine level and divided into chronic kidney disease (CKD) stages 1-5. Univariate and multivariable Cox proportional hazards models were used to determine which factors were associated with each endpoint. RESULTS Times to progression to all-cause mortality and RRT were similar for CKD stages 1/2/3A and served as the reference group. In multivariable analysis, high-grade proteinuria (P < .001) and higher CKD stage (5 vs 1/2/3A [P < .001], 4 vs 1/2/3A [P < .001], 3B vs 1/2/3A [P = .02]) remained independently associated with increased risk of progression to RRT. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use was associated with decreased risk of progression to RRT (P = .03). Higher CKD stage (5 vs 1/2/3A [P < .001], 4 vs 1/2/3A [P = .004]), carotid artery disease (P < .001), diabetes mellitus (P = .002), and high-grade proteinuria (P < .001) remained independently associated with all-cause mortality. Statin use was associated with decreased risk of all-cause mortality (P < .001). CONCLUSIONS Patients with atherosclerotic RAS who undergo RA stent placement and have high-grade proteinuria and CKD stage 3B/4/5 have increased risk of progression to RRT. Patients with high-grade proteinuria, CKD stage 3B/4/5, carotid artery disease, or diabetes have increased risk for all-cause mortality after renal artery stent placement. Patients receiving ACEI/ARBs have a decreased risk of progression to RRT, and patients receiving statins have a decreased risk of all-cause mortality.

Getting to Yes: The Fate of Neuroradiology Manuscripts Rejected by Radiology over a 2-year Period

Among 371 neuroradiology and head and neck radiology manuscripts initially rejected by Radiology between January 2005 and December 2006, 293 (79%) were subsequently published by July 2009.

A Predictive Model for Postembolization Syndrome after Transarterial Hepatic Chemoembolization of Hepatocellular Carcinoma

Purpose To develop and validate a predictive model for postembolization syndrome (PES) following transarterial hepatic chemoembolization (TACE) for hepatocellular carcinoma. Materials and Methods In this single-center, retrospective study, 370 patients underwent 513 TACE procedures between October 2014 and September 2016. Seventy percent of the patients were randomly assigned to a training data set and the remaining 30% were assigned to a testing data set. Variables included demographic, laboratory, clinical, and procedural details. PES was defined as pain and/or nausea beyond 6 hours after TACE that required intravenous medication for symptom control. The predictive model was developed by using conditional inference trees and Lasso regression. Results Demographics, laboratory data, performance, tumor characteristics, and procedural details were statistically similar for the training and testing data sets. Overall, 83 of 370 patients (22.4%) after 107 of 513 TACE procedures (20.8%) met the predefined criteria. Factors identified at univariable analysis included large tumor burden (P = .004), drug-eluting embolic TACE (P = .03), doxorubicin dose (P = .003), history of PES (P < .001) and chronic pain (P < .001), of which history of PES, tumor burden, and drug-eluting embolic TACE were identified as the strongest predictors by the multivariable analysis and were used to develop the predictive model. When applied to the testing data set, the model demonstrated an area under the curve of 0.62, sensitivity of 79% (22 of 28), specificity of 44.2% (53 of 120), and a negative predictive value of 90% (53 of 59). Conclusion The model identified history of postembolization syndrome, tumor burden, and drug-eluting embolic chemoembolization as predictors of protracted recovery because of postembolization syndrome.