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Objectives: A case of delayed popliteal artery injury (PA-INJ) onset after total knee arthroplasty (TKA) in a patient under postoperative anticoagulation therapy is reported. The role of anticoagulation both in late PA-INJ presentation and in PA-INJ management is discussed. Report: An obese 76-year-old woman was presented with a common femoral vein thrombosis coupled with pulmonary embolism five days after TKA. She was immediately placed under anticoagulation therapy. Four days later, during physiotherapy-supervised mobilization, she developed a calf haematoma and large retro-articular pseudoaneurysm. Angiography revealed a minor PA-INJ successively treated with a covered stent-graft. Conclusions: In cases of initially undetected and staunched TKA-related PA-INJs, postoperative anticoagulation therapy may act as a potential trigger for final arterial rupture during mobilization exercises, followed by acute bleeding; in these cases, endovascular management represents an excellent treatment option. Close clinical and instrumental monitoring is strongly recommended after TKA, in patients who imperatively require full-dose anticoagulation therapy. [ABSTRACT FROM AUTHOR]

Advance healthcare directives are legal documents, in which the patient, foreseeing a potential loss of capacity and autonomy, makes in advance decisions regarding future care and, in particular, end-of-life arrangements. In Italy, advance healthcare directives  are regulated by the Law 219 of 22 December 2017. Objectives of the study were: i) to develop and validate a questionnaire dedicated to evaluate the knowledge of the Law in a sample of 98 anesthesiologists, and ii) to shed light on the process of health-related decision-making and its determinants (age, gender, doctor/training resident, religious beliefs). A second part of the survey  not analyzed  in the present study, aimed to assess, through two simulated clinical scenarios, how patient' directives, relatives and the medical staff could influence physicians' clinical decision. Overall Cronbach's alpha coefficient of the questionnaire resulted 0.83. Three factors explaining up to 38.4% of total variance (communication and relationship with the patient; critical life-threatening situations and binding nature of the advance directive for the physician; and involvement of patients). Most of the doctors (58.7%) did not fully know the recent legislative provision. The lack of knowledge is critical in view of the specificity of the clinical area investigated (anesthesiology and intensive care), which has to cope with ethical issues. An adequate revision and implementation of the traditional curricula could help medical students and trainees develop the aptitudes and skills needed in their future profession.

Cerebral complications are common in perioperative settings even in non-neurosurgical procedures. These include postoperative cognitive dysfunction or delirium as well as cerebrovascular accidents. During surgery, it is essential to ensure an adequate degree of sedation and analgesia, and at the same time, to provide hemodynamic and respiratory stability in order to minimize neurological complications. In this context, the role of neuromonitoring in the operating room is gaining interest, even in the non-neurolosurgical population. The use of multimodal neuromonitoring can potentially reduce the occurrence of adverse effects during and after surgery, and optimize the administration of anesthetic drugs. In addition to the traditional focus on monitoring hemodynamic and respiratory systems during general anesthesia, the ability to constantly monitor the activity and maintenance of brain homeostasis, creating evidence-based protocols, should also become part of the standard of care: in this challenge, neuromonitoring comes to our aid. In this review, we aim to describe the role of the main types of noninvasive neuromonitoring such as those based on electroencephalography (EEG) waves (EEG, Entropy module, Bispectral Index, Narcotrend Monitor), near-infrared spectroscopy (NIRS) based on noninvasive measurement of cerebral regional oxygenation, and Transcranial Doppler used in the perioperative settings in non-neurosurgical intervention. We also describe the advantages, disadvantage, and limitation of each monitoring technique., Competing Interests: Declaration of competing interest The authors have no conflict of interest to declare., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Neuropatients often require invasive mechanical ventilation (MV). Ideal ventilator settings and respiratory targets in neuro patients are unclear. Current knowledge suggests maintaining protective tidal volumes of 6-8 ml/kg of predicted body weight in neuropatients. This approach may reduce the rate of pulmonary complications, although it cannot be easily applied in a neuro setting due to the need for special care to minimize the risk of secondary brain damage. Additionally, the weaning process from MV is particularly challenging in these patients who cannot control the brain respiratory patterns and protect airways from aspiration. Indeed, extubation failure in neuropatients is very high, while tracheostomy is needed in one-third of the patients. The aim of this manuscript is to review and describe the current management of invasive MV, weaning, and tracheostomy for the main four subpopulations of neuro patients: traumatic brain injury, acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose of Review: The aim of this review is to provide an update on the pathophysiology and treatment of severe traumatic brain injury (TBI)-related complications on extracranial organs., Recent Findings: Extracranial complications are common and influence the outcome from TBI. Significant improvements in outcome in a sizeable proportion of patients could potentially be accomplished by improving the ability to prevent or reverse nonneurological complications such as pneumonia, cardiac and kidney failure. Prompt recognition and treatment of systemic complications is therefore fundamental to care of this patient cohort. However, the role of extracranial pathology often has been underestimated in outcome assessment since most clinicians focus mainly on intracranial lesions and injury rather than consider the systemic effects of TBI., Summary: Robust evidence about pathophysiology and treatment of extracranial complications in TBI are lacking. Further studies are warranted to precisely understand and manage the multisystem response of the body after TBI.

Most patients with ischaemic stroke are managed on the ward or in specialty stroke units, but a significant number requires higher-acuity care and, consequently, admission to the intensive care unit. Mechanical ventilation is frequently performed in these patients due to swallowing dysfunction and airway or respiratory system compromise. Experimental studies have focused on stroke-induced immunosuppression and brain-lung crosstalk, leading to increased pulmonary damage and inflammation, as well as reduced alveolar macrophage phagocytic capability, which may increase the risk of infection. Pulmonary complications, such as respiratory failure, pneumonia, pleural effusions, acute respiratory distress syndrome, lung oedema, and pulmonary embolism from venous thromboembolism, are common and found to be among the major causes of death in this group of patients. Furthermore, over the past two decades, tracheostomy use has increased among stroke patients, who can have unique indications for this procedure-depending on the location and type of stroke-when compared to the general population. However, the optimal mechanical ventilator strategy remains unclear in this population. Although a high tidal volume (V T ) strategy has been used for many years, the latest evidence suggests that a protective ventilatory strategy (V T  = 6-8 mL/kg predicted body weight, positive end-expiratory pressure and rescue recruitment manoeuvres) may also have a role in brain-damaged patients, including those with stroke. The aim of this narrative review is to explore the pathophysiology of brain-lung interactions after acute ischaemic stroke and the management of mechanical ventilation in these patients.

Objectives: To correlate the degree of ascites enhancement during hepatobiliary phase after gadobenate dimeglumine (Gd-BOPTA) administration with ascites aetiology., Methods: IRB-approved retrospective study, need for informed consent was waived. We included 74 consecutive ascitic patients who underwent Gd-BOPTA-enhanced liver MRI including hepatobiliary phase (HBP) images between January 2014 and December 2017. Ascites appearance on unenhanced and HBP images was classified as hypo-, iso- or hyperintense in comparison to paraspinal muscles. Ascites signal intensity on unenhanced and HBP images was measured using round ROIs and was normalised to paraspinal muscles (NSI). Normalised relative enhancement (NRE) between native phase and HBP was calculated. The results were related to ascites aetiology using Wilcoxon and Mann-Whitney tests., Results: On native images, ascites appeared hypointense in 95.9% of the cases and isointense in 4.1%, whereas on HBP images, it appeared hyperintense in 59.4% of the cases, isointense in 36.5% and hypointense in 4.1%. Mean ascites NSI was 0.52 on unenhanced images and 1.50 on HBP ones (p < 0.0001). Mean ascites NRE was 201 ± 133%. Ascites of non-malignant aetiology showed mean NRE of 210 ± 134%, whereas malignant ascites showed mean NRE of 92 ± 20% (p = 0.001). ROC analysis showed that a NRE < 112.5% correlates with malignant aetiology with 100% sensitivity and 83.4% specificity (LR = 5.667). NRE did not show any significant correlation with ascites thickness, eGFR and time interval between contrast administration and HBP acquisition (p > 0.05)., Conclusions: Ascites NRE in HBP after Gd-BOPTA administration is significantly lower in patients with ascites secondary to peritoneal carcinomatosis than in patients with non-malignant ascites., Key Points: • Ascites enhancement in the hepatobiliary phase after Gd-BOPTA administration may determine false positive findings when looking for biliary leaks. • Ascites enhancement in the hepatobiliary phase after Gd-BOPTA administration is lower in patients with peritoneal carcinomatosis than in patients with portal hypertension or congestive heart failure. • None of the patients with peritoneal carcinomatosis showed an ascites enhancement of more than 112% as compared with unenhanced images.

Introduction: As the prevalence of obesity increases, so does the number of obese patients undergoing surgical procedures and being admitted into intensive care units. Obesity per se is associated with reduced lung volume. The combination of general anaesthesia and supine positioning involved in most surgeries causes further reductions in lung volumes, thus resulting in alveolar collapse, decreased lung compliance, increased airway resistance, and hypoxemia. These complications can be amplified by common obesity-related comorbidities. In otherwise healthy obese patients, mechanical ventilation strategies should be optimised to prevent lung damage; in those with acute distress respiratory syndrome (ARDS), strategies should seek to mitigate further lung damage. Areas covered: This review discusses non-invasive and invasive mechanical ventilation strategies for surgical and critically ill adult obese patients with and without ARDS and proposes practical clinical insights to be implemented at bedside both in the operating theatre and in intensive care units. Expert opinion: Large multicentre trials on respiratory management of obese patients are required. Although the indication of lung protective ventilation with low tidal volume is apparently translated to obese patients, optimal PEEP level and recruitment manoeuvres remain controversial. The use of non-invasive respiratory support after extubation must be considered in individual cases.

Over the past decade, the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) for respiratory support has widely expanded as a treatment strategy for patients with acute respiratory distress syndrome (ARDS). Despite considerable attention has been given to the indications, the timing and the management of patients undergoing ECMO for refractory respiratory hypoxemic failure, little is known regarding the management of mechanical ventilation (MV) in this group of patients. ECMO enables to minimize ventilatory induced lung injury (VILI) and it has been successfully used as rescue therapy in patients with ARDS when conventional ventilator strategies have failed. However, literature is lacking regarding the best strategies and MV settings, including positive end expiratory pressure (PEEP), tidal volume (VT), respiratory rate (RR) and plateau pressure (PPLAT). The aim of this review is to summarize current evidence, the rationale and provide recommendations about the best ventilator strategy to adopt in patients with ARDS undergoing VV-ECMO support., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objectives: To evaluate the ability of MRI in predicting histological grade of endometrial cancer (EC)., Methods: IRB-approved retrospective study; requirement for informed consent was waived. 90 patients with histologically proven EC who underwent preoperative MRI and surgery at our Institution between Sept2011 and Nov2016 were included. Myometrial invasion (50%) was assessed. Neoplasm and uterus volumes were estimated according to the ellipsoid formula; neoplasm/uterus volume ratio (N/U) was calculated. ADC maps were generated and histogram analysis was performed using commercially available software. MRI parameters were compared with the definitive histological grade (G1 = 28 patients, G2 = 29, G3 = 33) using ANOVA and Tukey-Kramer tests., Results: Deep myometrial invasion was significantly more frequent in G2-G3 lesions than in G1 ones (p < 0,005). N/U ratio was significantly higher for high-grade neoplasms (mean 0,08 for G1, 0,16 for G2 and 0,21 in G3; P = 0,002 for G1 vs. G2-G3); a cut off value of 0,13 enabled to distinguish G1 from G2-G3 lesions with 50% sensibility and 89% specificity. ADC values didn't show any statistically significant correlation with tumour grade., Conclusions: N/U ratio >0.13 and deep myometrial invasion are significantly correlated with high grade EC, whereas ADC values are not useful for predicting EC grade., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background and Purpose: Intracerebral hemorrhage represents a potentially severe complication of revascularization of acute ischemic stroke. The aim of our study was to assess the capability of iodine extravasation quantification on dual-energy CT performed immediately after mechanical thrombectomy to predict hemorrhagic complications., Materials and Methods: Because this was a retrospective study, the need for informed consent was waived. Eighty-five consecutive patients who underwent brain dual-energy CT immediately after mechanical thrombectomy for acute ischemic stroke between August 2013 and January 2017 were included. Two radiologists independently evaluated dual-energy CT images for the presence of parenchymal hyperdensity, iodine extravasation, and hemorrhage. Maximum iodine concentration was measured. Follow-up CT examinations performed until patient discharge were reviewed for intracerebral hemorrhage development. The correlation between dual-energy CT parameters and intracerebral hemorrhage development was analyzed by the Mann-Whitney U test and Fisher exact test. Receiver operating characteristic curves were generated for continuous variables., Results: Thirteen of 85 patients (15.3%) developed hemorrhage. On postoperative dual-energy CT, parenchymal hyperdensities and iodine extravasation were present in 100% of the patients who developed intracerebral hemorrhage and in 56.3% of the patients who did not ( P = .002 for both). Signs of bleeding were present in 35.7% of the patients who developed intracerebral hemorrhage and in none of the patients who did not ( P < .001). Median maximum iodine concentration was 2.63 mg/mL in the patients who developed intracerebral hemorrhage and 1.4 mg/mL in the patients who did not ( P < .001). Maximum iodine concentration showed an area under the curve of 0.89 for identifying patients developing intracerebral hemorrhage., Conclusions: The presence of parenchymal hyperdensity with a maximum iodine concentration of >1.35 mg/mL may identify patients developing intracerebral hemorrhage with 100% sensitivity and 67.6% specificity., (© 2018 by American Journal of Neuroradiology.)

Objective: To evaluate the diagnostic performance of virtual non-contrast (VNC) images in detecting intracranial haemorrhages (ICHs)., Methods: Sixty-seven consecutive patients with and 67 without ICH who underwent unenhanced brain CT and DECT angiography were included. Two radiologists independently evaluated VNC and true non-contrast (TNC) images for ICH presence and type. Inter-observer agreement for VNC and TNC image evaluation was calculated. Sensitivity and specificity of VNC images for ICH detection were calculated using Fisher's exact test. VNC and TNC images were compared for ICH extent (qualitatively and quantitatively) and conspicuity assessment., Results: On TNC images 116 different haemorrhages were detected in 67 patients. Inter-observer agreement ranged from 0.98-1.00 for TNC images and from 0.86-1.00 for VNC images. VNC sensitivity ranged from 0.90-1, according to the different ICH types, and specificity from 0.97-1. Qualitatively, ICH extent was underestimated on VNC images in 11.9% of cases. Haemorrhage volume did not show statistically significant differences between VNC and TNC images. Mean haemorrhage conspicuity was significantly lower on VNC images than on TNC images for both readers (p < 0.001)., Conclusion: VNC images are accurate for ICH detection. Haemorrhages are less conspicuous on VNC images and their extent may be underestimated., Key Points: • VNC images represent a reproducible tool for detecting ICH. • ICH can be identified on VNC images with high sensitivity and specificity. • Intracranial haemorrhages are less conspicuous on VNC images than on TNC images. • Intracranial haemorrhages extent may be underestimated on VNC images.

The objective of this study is to compare in vivo, the accuracy of single-energy CT (SECT) and dual-energy CT (DECT) in renal stone characterization. Retrospective study approved by the IRB. 30 patients with symptomatic urolithiasis who underwent CT on a second-generation dual-source scanner with a protocol that included low-dose 120 kV scan followed by 100/Sn140 kV dual-energy scan have been included. Stone composition was classified as uric acid, cystine or calcium oxalates, and phosphates according to attenuation values at 120 kV and to 100/Sn140 kV attenuation ratios and compared with the infrared spectroscopy analysis. 50 stones were detected in 30 patients. SECT correctly assessed stone composition in 52 % of the cases, DECT in 90 %. Sensitivity, specificity, positive predictive value, and negative predictive value in differentiating uric acid vs. non-uric acid stones were 0.94, 0.72, 0.64, and 0.96 for SECT and 1.00, 0.94, 1.00, and 0.96 for DECT, respectively. DECT significantly performs better than SECT in characterising renal stones in vivo, and may represent a useful tool for treatment planning.