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Introduction: The Woven EndoBridge (WEB) device is emerging as a novel therapy for intracranial aneurysms, but its use for off-label indications requires further study. Using machine learning, we aimed to develop predictive models for complete occlusion after off-label WEB treatment and to identify factors associated with occlusion outcomes., Methods: This multicenter, retrospective study included 162 patients who underwent off-label WEB treatment for intracranial aneurysms. Baseline, morphological, and procedural variables were utilized to develop machine-learning models predicting complete occlusion. Model interpretation was performed to determine significant predictors. Ordinal regression was also performed with occlusion status as an ordinal outcome from better (Raymond Roy Occlusion Classification [RROC] grade 1) to worse (RROC grade 3) status. Odds ratios (OR) with 95 % confidence intervals (CI) were reported., Results: The best performing model achieved an AUROC of 0.8 for predicting complete occlusion. Larger neck diameter and daughter sac were significant independent predictors of incomplete occlusion. On multivariable ordinal regression, higher RROC grades (OR 1.86, 95 % CI 1.25-2.82), larger neck diameter (OR 1.69, 95 % CI 1.09-2.65), and presence of daughter sacs (OR 2.26, 95 % CI 0.99-5.15) were associated with worse aneurysm occlusion after WEB treatment, independent of other factors., Conclusion: This study found that larger neck diameter and daughter sacs were associated with worse occlusion after WEB therapy for aneurysms. The machine learning approach identified anatomical factors related to occlusion outcomes that may help guide patient selection and monitoring with this technology. Further validation is needed., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The Woven EndoBridge (WEB) device was approved to treat wide-necked bifurcation aneurysms. The device is designed as an intrasaccular flow disruptor covering aneurysm widths up to 10 mm. Although prior studies combined all aneurysm sizes, it is known that aneurysms behave differently in response to endovascular treatment based on their size. Therefore, the authors' objective was to identify ideal middle cerebral artery (MCA) aneurysm width and neck sizes most suitable for WEB treatment., Methods: The WorldWideWEB consortium is a large multicenter retrospective database that analyzes intracranial aneurysms treated with the WEB device. In this study, all unruptured MCA bifurcation aneurysms with available measurements were included. Cutoff values based on aneurysm width and neck in relation to aneurysm occlusion status were measured using the receiver operating characteristic (ROC) curve. Propensity score matching (PSM) was then used to compare treatment outcomes between aneurysms smaller and larger than the cutoff value for both width and neck size., Results: The ideal cutoff values for MCA bifurcation aneurysm width and neck were 6.1 mm and 4.6 mm, respectively. On PSM, 87 matched pairs were compared based on width size (≤ 6.1 mm and > 6.1 mm), and 77 matched pairs were compared based on neck size (≤ 4.6 mm and > 4.6 mm). There was a significant difference in adequate aneurysm occlusion between aneurysms smaller and larger than those cutoff values for both widths (93% vs 76%, p = 0.0017) and neck sizes (90% vs 70%, p = 0.0026). The retreatment rate was also significantly higher for larger aneurysms in both parameters., Conclusions: This study shows that MCA bifurcation aneurysms ≤ 6.1 mm in width and ≤ 4.6 mm in neck size are significantly better candidates for WEB treatment, leading to improved occlusion status and reduced retreatment rate, which are important considerations when using WEB devices.

Background: Endovascular treatment with the woven endobridge (WEB) device has been widely utilized for managing intracranial aneurysms. However, predicting the probability of achieving adequate occlusion (Raymond-Roy classification 1 or 2) remains challenging., Objective: Our study sought to develop and validate a predictive calculator for adequate occlusion using the WEB device via data from a large multi-institutional retrospective cohort., Methods: We used data from the WorldWide WEB Consortium, encompassing 356 patients from 30 centers across North America, South America, and Europe. Bivariate and multivariate regression analyses were performed on a variety of demographic and clinical factors, from which predictive factors were selected. Calibration and validation were conducted, with variance inflation factor (VIF) parameters checked for collinearity., Results: A total of 356 patients were included: 124 (34.8%) were male, 108 (30.3%) were elderly (≥65 years), and 118 (33.1%) were current smokers. Mean maximum aneurysm diameter was 7.09 mm (SD 2.71), with 112 (31.5%) having a daughter sac. In the multivariate regression, increasing aneurysm neck size (OR 0.706 [95% CI: 0.535-0.929], p  = 0.13) and partial aneurysm thrombosis (OR 0.135 [95% CI: 0.024-0.681], p  = 0.016) were found to be the only statistically significant variables associated with poorer likelihood of achieving occlusion. The predictive calculator shows a c -statistic of 0.744. Hosmer-Lemeshow goodness-of-fit test indicated a satisfactory model fit with a p -value of 0.431. The calculator is available at: https://neurodx.shinyapps.io/WEBDEVICE/., Conclusion: The predictive calculator offers a substantial contribution to the clinical toolkit for estimating the likelihood of adequate intracranial aneurysm occlusion by WEB device embolization., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This study was conducted to investigate the impact of antiplatelet administration in the periprocedural period on the occurrence of thromboembolic complications (TECs) in patients undergoing treatment using the Woven EndoBridge (WEB) device for intracranial wide-necked bifurcation aneurysms. The primary objective was to assess whether the use of antiplatelets in the pre- and postprocedural phases reduces the likelihood of developing TECs, considering various covariates., Methods: A retrospective multicenter observational study was conducted within the WorldWideWEB Consortium and comprised 38 academic centers with endovascular treatment capabilities. Univariable and multivariable logistic regression analyses were performed to determine the association between antiplatelet use and TECs, adjusting for covariates. Missing predictor data were addressed using multiple imputation., Results: The study comprised two cohorts: one addressing general thromboembolic events and consisting of 1412 patients, among whom 103 experienced TECs, and another focusing on symptomatic thromboembolic events and comprising 1395 patients, of whom 50 experienced symptomatic TECs. Preprocedural antiplatelet use was associated with a reduced likelihood of overall TECs (OR 0.32, 95% CI 0.19-0.53, p < 0.001) and symptomatic TECs (OR 0.49, 95% CI 0.25-0.95, p = 0.036), whereas postprocedural antiplatelet use showed no significant association with TECs. The study also revealed additional predictors of TECs, including stent use (overall: OR 4.96, 95% CI 2.38-10.3, p < 0.001; symptomatic: OR 3.24, 95% CI 1.26-8.36, p = 0.015), WEB single-layer sphere (SLS) type (overall: OR 0.18, 95% CI 0.04-0.74, p = 0.017), and posterior circulation aneurysm location (symptomatic: OR 18.43, 95% CI 1.48-230, p = 0.024)., Conclusions: The findings of this study suggest that the preprocedural administration of antiplatelets is associated with a reduced likelihood of TECs in patients undergoing treatment with the WEB device for wide-necked bifurcation aneurysms. However, postprocedural antiplatelet use did not show a significant impact on TEC occurrence.

Competing Interests: Competing interests: The following authors have disclosures: Joshua A Hirsch - consultant for Medtronic, Relievant Medsystems, Sanofi, Data Management Committee chair for Balt, Rapid Medical, and Grant recipient for Neiman Health Policy Institute; Diane M Sahr - consultant for Relievant Medsystems and Sollis Therapeutics; Allan Brook - consultant for NEVRO, Medtronic, Vizo, Alio; Ronil V Chandra - advisor/consultant for Remedy Robotics; Stefano Marcia - consultant for Stryker and Techlamed; James Milburn - consultant for Microvention, consultant and steering committee member for Imperative Care Inc, and Scientific Advisory Committee for Optimize Neurovascular. The following authors have no disclosures: Luige Manfre and Mario Muto.

Background: The Woven EndoBridge (WEB) devices have been used for treating wide neck bifurcation aneurysms (WNBAs) with several generational enhancements to improve clinical outcomes. The original device dual-layer (WEB DL) was replaced by a single-layer (WEB SL) device in 2013. This study aimed to compare the effectiveness and safety of these devices in managing intracranial aneurysms., Methods: A multicenter cohort study was conducted, and data from 1,289 patients with intracranial aneurysms treated with either the WEB SL or WEB DL devices were retrospectively analyzed. Propensity score matching was utilized to balance the baseline characteristics between the two groups. Outcomes assessed included immediate occlusion rate, complete occlusion at last follow-up, retreatment rate, device compaction, and aneurysmal rupture., Results: Before propensity score matching, patients treated with the WEB SL had a significantly higher rate of complete occlusion at the last follow-up and a lower rate of retreatment. After matching, there was no significant difference in immediate occlusion rate, retreatment rate, or device compaction between the WEB SL and DL groups. However, the SL group maintained a higher rate of complete occlusion at the final follow-up. Regression analysis showed that SL was associated with higher rates of complete occlusion (OR: 0.19; CI: 0.04 to 0.8, p = 0.029) and lower rates of retreatment (OR: 0.12; CI: 0 to 4.12, p = 0.23)., Conclusion: The WEB SL and DL devices demonstrated similar performances in immediate occlusion rates and retreatment requirements for intracranial aneurysms. The SL device showed a higher rate of complete occlusion at the final follow-up., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The Woven EndoBridge (WEB) device is frequently used for the treatment of intracranial aneurysms. Postoperative management, including the use of aspirin, varies among clinicians and institutions, but its impact on the outcomes of the WEB has not been thoroughly investigated., Methods: This was a retrospective, multicenter study involving 30 academic institutions in North America, South America, and Europe. Data from 1492 patients treated with the WEB device were included. Patients were categorized into two groups based on their postoperative use of aspirin (aspirin group: n=1124, non-aspirin group: n=368). Data points included patient demographics, aneurysm characteristics, procedural details, complications, and angiographic and functional outcomes. Propensity score matching (PSM) was applied to balance variables between the two groups., Results: Prior to PSM, the aspirin group exhibited significantly higher rates of modified Rankin scale (mRS) mRS 0-1 and mRS 0-2 (89.8% vs 73.4% and 94.1% vs 79.8%, p<0.001), lower rates of mortality (1.6% vs 8.6%, p<0.001), and higher major compaction rates (13.4% vs 7%, p<0.001). Post-PSM, the aspirin group showed significantly higher rates of retreatment (p=0.026) and major compaction (p=0.037) while maintaining its higher rates of good functional outcomes and lower mortality rates. In the multivariable regression, aspirin was associated with higher rates of mRS 0-1 (OR 2.166; 95% CI 1.16 to 4, p=0.016) and mRS 0-2 (OR 2.817; 95% CI 1.36 to 5.88, p=0.005) and lower rates of mortality (OR 0.228; 95% CI 0.06 to 0.83, p=0.025). However, it was associated with higher rates of retreatment (OR 2.471; 95% CI 1.11 to 5.51, p=0.027)., Conclusions: Aspirin use post-WEB treatment may lead to better functional outcomes and lower mortality but with higher retreatment rates. These insights are crucial for postoperative management after WEB procedures, but further studies are necessary for validation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate clinical outcomes of endovascular thrombectomy (EVT) for acute basilar artery occlusion (BAO) using population-level data from the United States., Methods: Weighted discharge data from the National Inpatient Sample were queried to identify adult patients with acute BAO during the period of 2015 to 2019 treated with EVT or medical management only. Complex samples statistical methods and propensity-score adjustment using inverse probability of treatment weighting (IPTW) were performed to assess clinical endpoints., Results: Among 3,950 BAO patients identified, 1,425 (36.1%) were treated with EVT [mean age 66.7 years, median National Institute of Health Stroke Scale (NIHSS) score 22]. On unadjusted analysis, 155 (10.9%) EVT patients achieved favorable functional outcomes (discharge disposition to home without services), while 515 (36.1%) experienced in-hospital mortality, and 20 (1.4%) developed symptomatic intracranial hemorrhage (sICH). Following propensity-score adjustment by IPTW accounting for age, stroke severity, and comorbidity burden, EVT was independently associated with favorable functional outcome [adjusted odds ratio (aOR) 1.25, 95% confidence interval (CI) 1.07, 1.46; p = 0.004], but not with in-hospital mortality or sICH. In an IPTW-adjusted sub-group analysis of patients with NIHSS scores >20, EVT was associated with both favorable functional outcome (discharge disposition to home or to acute rehabilitation) (aOR 1.55, 95% CI 1.24, 1.94; p < 0.001) and decreased mortality (aOR 0.78, 95% CI 0.69, 0.89; p < 0.001), but not with sICH., Interpretation: This retrospective population-based analysis using a large national registry provides real-world evidence of a potential benefit of EVT in acute BAO patients. ANN NEUROL 2023;94:55-60., (© 2023 American Neurological Association.)

Background Context: The treatment of vertebral compression fractures using percutaneous augmentation is an effective method to reduce pain and decrease mortality rates. Surgical methods include vertebroplasty, kyphoplasty, and vertebral augmentation with implants. A previous study suggested that a titanium implantable vertebral augmentation device (TIVAD) produced superior height restoration compared to balloon kyphoplasty (BKP) but was based on a less clinically relevant biomechanical model. Moreover, the introduction of high pressure balloons and directional instruments may further aid in restoring height., Purpose: The objective was to evaluate three procedures (BKP, BKP w/ Kyphon Assist (KA; directional instruments), and TIVAD) used for percutaneous augmentation of vertebral fractures with respect to height restoration and sustainability post-operatively., Study Design/setting: This is an in vitro cadaver study performed in a laboratory setting., Methods: Five osteoporotic female human cadaver thoracolumbar spines (age: 63-77 years, T-score: -2.5 to -3.5, levels: T7-S1) were scanned using computed tomography and dissected into 30 two-functional spine units (2FSUs). Vertebral wedge compression fractures were created by reducing the anterior height of the vertebrae by 25% and holding the maximum displacement for 15 minutes. Post-fracture, surgery was performed on each 2FSU with a constant 100 N load. Surgeries included BKP, BKP w/ KA, or TIVAD (n=10 per treatment group). Post-surgery, cyclic loading was performed on each 2FSU for 10,000 cycles at 600 N (walking), followed by 5,000 cycles at 850 N (standing up/sitting down), and 5,000 cycles at 1250 N (lifting a 5-10kg weight from the floor). Fluoroscopic images were taken and analyzed at the initial, post-fracture, post-surgery, and post-loading timepoints. Anterior, central, and posterior heights, Beck Index, and angle between endplates were assessed., Results: No difference in height restoration was observed among treatment groups (p=.72). Compared to the initial height, post-surgery anterior height was 96.3±8.7% for BKP, 94.0±10.0% for BKP w/ KA, and 95.3±5.8% for TIVAD. No difference in height sustainability in response to 600 N (p=.76) and 850 N (p=.20) load levels was observed among treatment groups. However, after 1250 N loading, anterior height decreased to 93.8±6.8% of the post-surgery height for BKP, 95.9±6.4% for BKP w/ KA, and 86.0±6.6% for TIVAD (p=.02). Specifically, the mean anterior height reduction between post-surgery and post-1250 N loading timepoints was lower for BKP w/ KA compared to TIVAD (p=.02), but not when comparing BKP to TIVAD (p=.07). No difference in Beck Index or angle between endplates was observed at any timepoint among the treatment groups., Conclusions: The present study, utilizing a clinically relevant biomechanical model, demonstrated equivalent height restoration post-surgery and at relatively lower-level cyclic loading using BKP, BKP w/ KA, and TIVAD, contrary to results from a previous study. Less anterior height reduction in response to high-level cyclic loading was observed in the BKP w/ KA group compared to TIVAD., Clinical Significance: All three treatments can restore height similarly after a vertebral compression fracture, which may lead to pain reduction and decreased mortality. BKP w/ KA may exhibit less height loss in higher-demand patients who engage in physical activities that involve increased weight resistance., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Interest in incorporating art into radiology has been growing in recent years. Radiological societies have begun to acknowledge the benefits art can bring to our field. Given this growing interest, a task force was created in 2021 to carry out integration of the arts into the annual American College of Radiology (ACR) meeting. Experiences of this task force are described, including consideration of benefits of integrating art in radiology practice and education as well as strategies, outcomes, and future directions for melding arts with radiology., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Despite the high prevalence of vertebral compression fractures (VCFs) associated with refractory pain, deformity, or progressive neurological symptoms, minimally invasive vertebral augmentation procedures, including vertebroplasty and kyphoplasty, have been declining in their relative utilization, along with expenditures., Objectives: This investigation was undertaken to assess utilization and expenditures for vertebral augmentation procedures, including vertebroplasty and kyphoplasty, in the fee-for-service (FFS) Medicare population from 2009 to 2018., Study Design: The present study was designed to assess utilization and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript:• A patient was described as receiving vertebral augmentation over the course of the year.• An episode was considered as one treatment per region per day utilizing primary codes only. • Services or procedures were considered to be procedures including multiple levels.A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted for inflation to 2018 US dollars., Results: In 2009, there were 76,860 episodes of vertebral augmentation with a rate of 168 per 100,000 Medicare population, which declined to 58,760, or 99 per 100,000 population for a total decline of 41%, or an annual rate of decline of 5.7% per 100,000 Medicare population. Vertebroplasty interventions declined more dramatically than kyphoplasty from 2009. Total episodes of vertebroplasty were 27,380 with an annual rate of 60 per 100,000 Medicare population, decreasing to 9,240, or 16 per 100,000 Medicare population, a 66% decline in episodes and a 74% decline in overall rate with an annual decline of 11.4% and 13.9%. In contrast, kyphoplasty interventions were 49,480, for a rate per 100,000 population of 108 in 2009 compared to 49,520 in 2018 with a rate of 83, for a decrease of 23% and 2.9% annual decrease. Evaluation of expenditures showed a net decrease of $30,102,809, or 8%, from $378,758,311 in 2009 to $348,655,502 in 2018. However, inflation-adjusted expenditures decreased overall by 21% and 3% annually from $443,147,324 in 2009 to $345,655,502 in 2018. In addition, inflation-adjusted total expenditures per 100,000 Medicare population decreased from $967,549 to $584,992, for an overall decrease of 40%, or an annual decrease of 5%. Per patient expenditures decreased 2% overall with 0% decrease per year., Limitations: Vertebral augmentation procedures were assessed only in the FFS Medicare service population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans., Conclusions: This study shows a significant decline in relative utilization patterns of vertebroplasty and kyphoplasty procedures, along with reductions in overall expenditures. The inflation-adjusted total expenditures of kyphoplasty and vertebroplasty decreased 21% with an annual decline of 3%. The inflation-adjusted expenditures per 100,000 of Medicare population decreased 40% overall and 5% per year. In addition, vertebroplasty has seen substantial declines in utilization and expenditure patterns compared to kyphoplasty procedures, which showed trends of decline.

Competing Interests: Competing interests: None declared.

Background Context: Vertebral fragility fractures (VFFs), mostly due to osteoporosis, are very common and are associated with significant morbidity and mortality. There is a lack of consensus on the appropriate management of patients with or suspected of having a VFF., Purpose: This work aimed at developing a comprehensive clinical care pathway (CCP) for VFF., Study Design/setting: The RAND/UCLA Appropriateness Method was used to develop patient-specific recommendations for the various components of the CCP. The study included two individual rating rounds and two plenary discussion sessions., Methods: A multispecialty expert panel (orthopedic and neurosurgeons, interventional [neuro]radiologists and pain specialists) assessed the importance of 20 signs and symptoms for the suspicion of VFF, the relevance of 5 diagnostic procedures, the appropriateness of vertebral augmentation versus nonsurgical management for 576 clinical scenarios, and the adequacy of 6 aspects of follow-up care., Results: The panel identified 10 signs and symptoms believed to be relatively specific for VFF. In patients suspected of VFF, advanced imaging was considered highly desirable, with MRI being the preferred diagnostic modality. Vertebral augmentation was considered appropriate in patients with positive findings on advanced imaging and in whom symptoms had worsened and in patients with 2 to 4 unfavorable conditions (eg, progression of height loss and severe impact on functioning), dependent on their relative weight. Time since fracture was considered less relevant for treatment choice. Follow-up should include evaluation of bone mineral density and treatment of osteoporosis., Conclusions: Using the RAND/UCLA Appropriateness Method, a multispecialty expert panel established a comprehensive CCP for the management of VFF. The CCP may be helpful to support decision-making in daily clinical practice and to improve quality of care., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Intracavernous aneurysms constitute up to 9% of all intracranial aneurysms and 6% are infectious (IIA). First line therapy is a protracted antibiotic course, yet with failure, surgery and endovascular parent vessel sacrifice have been utilized. Reconstructive endovascular therapies have emerged for aneurysm control and may demonstrate a safer therapeutic alternative., Objective: To present an IIA treated with a flow-diverting Pipeline stent (ev3 Neurovascular, Irvine, California)., Methods: A 41-yr-old female presented with visual loss, ophthalmoplegia, and cavernous sinus thrombosis with an associated phlegmon. Transsphenoidal evacuation was performed without complication or bleeding and she continued on medical therapy. Two weeks postoperatively, she developed a worsening right third cranial nerve palsy and MRA demonstrated a 1-cm right IIA, not evident on postoperative MRI. Three days of dual antiplatelet therapy preceded successful pipeline embolization. Angiography demonstrated aneurysm obliteration at 3 mo and her right ophthalmoplegia resolved., Results: A literature review identified 6 reported cases of IIAs treated with stent embolization. Only 1 documented a flow-diverting Silk stent used in a child. All lesions were obliterated at follow-up without neurological sequelae. No complication arose with implantation in the setting of infection, and as few as 3 d of dual antiplatelet therapy was sufficient for preprocedural prophylaxis, although in Vivo antiplatelet activity may be more significant., Conclusion: We report the first case of an IIA treated with a flow-diverting pipeline stent. These devices preserve native vasculature and neurological function compared to surgical and endovascular vessel sacrifice strategies. They appear to be safe management options for the treatment of IIAs.

Objective: To investigate effect of July admission on short-term outcome after endovascular coiling of patients with subarachnoid hemorrhage (SAH) owing to ruptured aneurysms., Methods: Data from the National Inpatient Sample (2012-2014) were gathered. Adult patients with SAH who underwent endovascular therapy at a teaching hospital were identified. Admissions during July were compared with other months as well as based on admission quarter (AQ): AQ1 (July to September), AQ2 (October to December), AQ3 (January to March), and AQ4 (April to June). Outcome measures included inpatient morbidity (death, iatrogenic stroke, or myocardial infarction), inpatient mortality, and nonroutine discharges., Results: The National Inpatient Sample database yielded 8515 patients with a diagnosis of SAH who underwent endovascular coiling between 2012 and 2014. Among these, 665 (7.8%) were admitted in July, and 7850 (92.2%) were admitted in other months. Overall, there were no differences in any of the examined outcomes, including morbidity (15.0% vs. 17.3%, P = 0.513), mortality (10.5% vs. 11.8%, P = 0.665), or nonroutine discharge (57.1% vs. 59.7%, P = 0.567), for patients admitted in July versus other months. Based on AQ, 24.5% of patients were admitted in AQ1, 26.0% in AQ2, 23.8% in AQ3, and 25.7% in AQ4. Similar to July versus other month admissions, there were no significant differences in outcomes based on AQ., Conclusions: Based on findings of this national investigation, patients with SAH owing to ruptured aneurysms who undergo endovascular therapy during the beginning of the academic year in July may not have worse short-term outcome compared with patients with admissions during other months., (Copyright © 2017 Elsevier Inc. All rights reserved.)

On 8 November 2016 the American electorate voted Donald Trump into the Presidency and a majority of Republicans into both houses of Congress. Since many Republicans ran for elected office on the promise to 'repeal and replace' Obamacare, this election result came with an expectation that campaign rhetoric would result in legislative action on healthcare. The American Health Care Act (AHCA) represented the Republican effort to repeal and replace the Affordable Care Act (ACA). Key elements of the AHCA included modifications of Medicaid expansion, repeal of the individual mandate, replacement of ACA subsidies with tax credits, and a broadening of the opportunity to use healthcare savings accounts. Details of the bill and the political issues which ultimately impeded its passage are discussed here., Competing Interests: Competing interests: ABR and RD are supported by research grants from the Harvey L Neiman Health Policy Institute., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Image guidance for spine pain control procedures, including epidural steroid injection, nerve root block, and facet block, can be performed with either computed tomography (CT) or conventional fluoroscopy. CT has the advantage of improved anatomic localization and use of air for contrast; however, there are concerns that CT leads to higher radiation dose and longer procedure time., Objective: To evaluate procedure time and radiation dose for multiple types of spine pain control procedures performed under CT guidance., Study Design: Retrospective evaluation., Setting: Department of radiology in single academic medical center., Methods: Institutional review board approval was obtained. We reviewed CT-guided spine procedures performed over a 12-month period from January 2012 to December 2012. Procedure type, procedure time, and dose-length product were recorded. Patient age and gender were recorded for each case; additionally, demographic and medical history data were obtained for a sub-group of patients., Results: Nine hundred ninety-four studies (performed in 699 patients) were reviewed, including 585 epidural steroid injections, 228 nerve root blocks, and 90 facet blocks. For all studies, procedure time averaged 7:34 ± 5:05, and dose-length product averaged 75 mGy·cm ± 61. Additional medical history (available for 483 patients) revealed high rate of obesity (body mass index [BMI] = 30 ± 6.8, with 76% of patients overweight [BMI > 25] and 42% obese [BMI > 30]), and frequent medical comorbidities (including hypertension [n = 179], diabetes [n = 101], renal failure [n = 30], and heart failure [n = 17])., Limitations: This study was performed retrospectively, and limited to a single institution., Conclusion: These findings add to the growing evidence that CT guidance is a safe and effective technique for epidural steroid injection. These results further demonstrate that other spine intervention procedures, including nerve root block and facet block, can also be performed under CT guidance with short procedure time and reasonable levels of radiation exposure. This approach can be effectively used in a patient population with a high rate of obesity and medical comorbidities.

Objective: To evaluate procedure utilization patterns for vertebroplasty and kyphoplasty in the US Medicare population from 2004 to 2014., Methods: The analysis was performed using the Centers for Medicare and Medicaid Services database of specialty utilization files for the fee for service (FFS) Medicare population., Results: The FFS Medicare population increased by 28% with an annual increase of 2.5% from 2004 to 2014. Utilization of vertebroplasty procedures decreased by 63% with an average annual decrease of 9.5% from 2004 to 2014 per 100 000 FFS Medicare beneficiaries. During the same time period, kyphoplasty procedures decreased by a total of 10%, with an average annual decrease of 1.3%. For augmentation generally (combined vertebroplasty/kyphoplasty data) there was thus an overall decrease in the rate per 100 000 Medicare population of 32% from 2004 to 2014, with an average annual decrease of 4.8%. The majority of vertebroplasty procedures were performed by radiologists whereas the majority of kyphoplasties were performed by orthopedic surgeons and neurosurgeons., Conclusions: There has been a significant decline in vertebroplasty and kyphoplasty procedures in the FFS Medicare population between 2004 and 2014., Competing Interests: Competing interests: JAH has an ongoing consulting relationship with Medtronic and in the past 36 months consulted for Carefusion. Both companies make products for vertebral augmentation. JB: shareholder in Medtronic and Stryker; research support from Merit/DFine and Medtronic., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Epidural steroid injections (ESIs) are a common method for treating lower back pain, which is one of the most prevalent health-related complaints in the adult US population. Although the safety of CT-guided ESIs has been extensively studied in adults, there is limited data concerning the procedure's safety profile in an older patient population., Objective: This retrospective study analyzed safety data among a single-center cohort of patients > 65 years-old who received one or more CT-guided interlaminar ESIs from 2012 to 2015., Study Design: An Institutional Review Board (IRB)-approved retrospective chart review., Setting: University hospital center., Methods: A total of 688 CT-guided ESI procedures were evaluated and a linear regression analysis was conducted to examine the relationship between dose length product (DLP), body mass index (BMI), procedure duration, and kVp/mA settings. Further analysis was performed on a sample of long procedure time, average-DLP and high-DLP procedures., Results: Average age was 75.77 years, with 44% having a BMI > 30. The mean DLP was 55.58 mGy x cm and the mean procedure duration was 5.94 minutes. All procedures were technically successful and no complications were observed during or after any of the procedures, including at one-month follow-up office visits. The kVp and mA settings were the strongest predictors of DLP, followed by procedure time. The high-DLP cases had a greater number of needle placement series, more intervertebral disc spaces included in each planning series and higher machine settings (kVp 120; mA 87.5) than the average-DLP cases (kVp 100; mA 49.9)., Limitations: This study is limited by its retrospective design., Conclusion: CT-guided interlaminar ESIs can be performed safely, with low procedure times, relatively low DLP's and without complications in an older patient population. Key words: Epidural steroid injection, interlaminar approach, CT-guidance, older adults, back pain, lumbar spine, thoracic spine, cervical spine, dose length product, radiation exposure.

Diabetes imparts a substantial increased risk for cardiovascular disease-related mortality and morbidity. Because of this, current medical guidelines recommend prophylactic treatment with once-daily, low-dose aspirin (acetylsalicylic acid) for primary and secondary prevention of cardiovascular (CV) events in high-risk patients. However, only modest reductions in CV events and mortality have been observed with once-daily aspirin treatment in patients with diabetes, including patients with a previous CV event, perhaps because of disparity between aspirin pharmacokinetics and diabetes-related platelet abnormalities. Once-daily aspirin irreversibly inactivates platelets for only a short duration (acetylsalicylic acid half-life, approximately 15-20 minutes), after which time newly generated, active platelets enter the circulation and weaken aspirin's effect. Platelets from patients with diabetes are more reactive and are turned over more rapidly than platelets from normal individuals; the short inhibitory window provided by once-daily aspirin may therefore be insufficient to provide 24-h protection against CV events. Alternative conventional aspirin regimens (e.g. higher daily dose, twice-daily dosing, combination with clopidogrel) and newer formulations (e.g. 24-h, extended-release) have been proposed to overcome the apparent limited efficacy of conventional aspirin in patients with diabetes; however, tolerability concerns and limited clinical efficacy data need to be taken into account when considering the use of such regimens.

SGLT2 inhibitors are only approved for use in adults with type 2 diabetes. However, because SGLT2 inhibitors have a mechanism of action that does not require the presence of endogenous insulin, these drugs should also be efficacious in type 1 diabetes where endogenous insulin production is greatly reduced or absent. Herein, I present five cases which illustrate the benefits of utilizing an SGLT2 inhibitor with type 1 diabetes. In these cases the use of SGLT2 inhibitors resulted not only in better glycemic control in most patients but also in some patients' less hypoglycemia, weight loss, and decreased doses of insulin. In type 1 diabetes Candida albicans vaginitis and balanitis may occur more frequently than in type 2 diabetes. These cases show that a large randomized clinical trial of SGLT2 inhibitors in type 1 diabetes needs to be performed.

Patient: Male, 57 FINAL DIAGNOSIS: Diabetes mellitus type 2 SYMPTOMS: Weight loss Medication: - Clinical Procedure: - Specialty: Endocrinology and Metabolic., Objective: Unusual or unexpected effect of treatment., Background: Studies of the efficacy of the combination of the incretin mimetic liraglutide and the SGLT2 inhibitor canagliflozin or indeed studies of the combination of any incretin mimetic with an SGLT2 inhibitor have neither been performed nor published. Pharmacologically, the combination of an incretin-mimetic and an SGLT2-receptor blocker should result in a more significant weight loss and a greater reduction in postprandial glucose and HbA1c., Case Report: An insulin-dependent type 2 diabetic patient with multiple diabetic complications was placed on the combination of liraglutide and canagliflozin and 4 weeks later was able to discontinue insulin. In addition, in spite of discontinuing insulin, his HbA1c dropped from 7.0% to 6.8%, and he had reductions in body (weight from 247 to 218 lbs), BMI (from 34 to 29.5 Kg/m(2)), waist circumference (from 47 to 44 ½ inches), and neck circumference (from 19 ½ to 18 ¼ inches)., Conclusions: The combination of an SGLT2 inhibitor and an incretin mimetic/analog results in improved glycemic control accompanied by significant weight loss. This combination needs to be studied in a prospective randomized trial because the effect of each of the components of this combination is synergistically magnified by the addition of the partner drug.

Background and Purpose: CT guidance is increasingly being used to localize the epidural space during epidural steroid injections. A common concern is that CT may be associated with significantly higher radiation doses compared with conventional fluoroscopy. The goal of this retrospective study was to determine the average dose-length product and effective dose delivered while interlaminar epidural steroid injections are performed and allow comparison with other modalities., Materials and Methods: A total of 281 patients who had undergone 345 consecutive CT-guided epidural steroid injections of the lumbar spine were evaluated for radiation exposure. The dose-length product for each scan was derived from the CT dose index volume and scan length. Effective dose was then calculated from the dose-length product and a κ coefficient of 0.015. Procedure time was calculated from the PACS time stamp on the scout image to the last CT image of the last image series., Results: The average dose-length product across all procedures was 89.6 ± 3.33 mGy·cm, which represents an effective dose of 1.34 ± 0.05 mSv. No complications from the procedure were observed, and average procedure time was 8 minutes., Conclusions: The use of a stationary table and an intermittent scanning technique allow for short procedures and doses that are significantly lower than those of conventional diagnostic CT scans. Furthermore, because CT dose index overestimates radiation dose in stationary table procedures, the actual radiation dose may be even lower than stated here.

Recurrent hyperparathyroidism can occur following quadruple parathyroidectomy and during radical parathyroidectomy and so that future hypoparathyroidism is avoided autotransplantation of parathyroid tissue is often preformed. Herein, I describe a patient who was thought to have recurrent hyperparathyroidism following a quadruple parathyroidectomy based solely on a high intact parathyroid hormone level. The patient neither had clinical symptoms or signs of hyperparathyroidism nor did the laboratory data other than the increased intact PTH level suggest hyperparathyroidism. A more comprehensive history revealed the cause of the elevated intact PTH so that further expensive, invasive, and potentially dangerous investigations were avoided.

Major ischemic strokes secondary to proximal artery occlusions are responsible for significant morbidity and mortality. Owing to extensive clot burden, these strokes are poorly responsive to intravenous tissue plasminogen activator. The introduction of endovascular therapy, particularly mechanical devices, has resulted in markedly improved recanalization rates of large vessel occlusions. With increasing experience with the Penumbra Stroke System and the 054 reperfusion catheter, there has been further improvement in TIMI 2 and 3 revascularization rates with faster times to vessel opening. The aim of this technical review is to convey various tips and tricks learnt from this experience.

Sacral vertebroplasty, or sacroplasty, entails the percutaneous insertion of 1 or more bone needles into the sacral ala and, less commonly, the sacral vertebra with fluoroscopic and/or computed tomographic guidance. Acrylic bone cement is then injected under imaging guidance to treat the lesion and stabilize the sacrum. Sacroplasty is indicated for the treatment of painful sacral insufficiency fractures and painful sacral masses, both of which destabilize the sacrum. In properly selected patients, sacroplasty is an extremely efficacious procedure with a low-risk profile when performed with meticulous imaging guidance and a thorough appreciation of the complex sacral anatomy. Complete pain relief is observed in the overwhelming majority of patients that are treated for sacral insufficiency fractures. While the success rate is lower in patients with painful sacral neoplastic lesions, many of these patients experience a reduction in analgesic use and a return to ambulation.

Chronic back pain and other refractory pain syndromes are a documented burden on our society. They also are a huge cost in quality of life and dollars spent on health care. Neuromodulation and specifically dorsal column stimulation of the spinal cord has been shown to decrease pain with minimal risk to the patient. We describe in this article the basic techniques and methods of both the stimulation trial and the permanent implantation of the leads and generator. With advanced imaging and the minimally invasive approach we further explain how to minimize any risk associated with this percutaneous procedure.

Sinus pericranii (SP) is an abnormal communication between the intra- and extracranial venous drainage pathways. Treatment of this condition has mainly been recommended for reasons of cosmesis and prevention of hemorrhage. The authors report a novel endovascular transvenous route for definitive treatment of SP.

This report details a trial demonstrating the viability of a blunt-tipped curved needle for use as a cement injection device for vertebral body augmentation. Between January and September 2007, 17 consecutive patients (eight men and nine women; average age, 76 years; age range, 52-97 years) underwent vertebral body augmentation with a blunt-tipped curved nitinol injection needle via a single pedicle to treat pain due to acute vertebral body compression fractures. All patients were successfully treated without complication. The results of the trial demonstrate that a curved blunt-tipped nitinol needle is a viable alternative to a rigid injection cannula when performing vertebral body augmentation with cement.

The authors describe a technique for lumbar drain placement using CT guidance. Midline or paramidline interlaminar approaches to the thecal sac can be used. The major advantage to CT guidance is direct visualization of the needle tip in relation to the thecal sac. This technical approach is a safe and rapid alternative to fluoroscopic guidance for the placement of lumbar drains in patients in whom standard lumbar drain placement techniques have failed.

Purpose: To evaluate the safety and effectiveness of computed tomography (CT)-guided radiofrequency (RF) ablation in the palliative treatment of recurrent advanced head and neck cancers., Materials and Methods: From November 2002 to January 2005, the authors identified 14 patients (median age, 61 years) with 14 recurrent advanced primary head and neck malignancies who underwent 27 CT-guided RF ablation applications during 20 sessions at their institution. RF ablation was performed in all patients with the intent of palliative therapy. Radiologic tumor response was assessed by using Response Evaluation Criteria in Solid Tumors. Patients were assessed clinically by means of University of Washington Head and Neck Quality of Life questionnaires., Results: Technical success in tumor targeting and electrode deployment was 100%. University of Washington quality of life surveys completed by six of 14 patients (43%) showed an index increase by a median of 3.1 percentage points, with four of six patients (67%) demonstrating improvement. Three major complications (in 27 applications, 11%) occurred 7 days to 2 weeks after the procedure. These included stroke, carotid blowout leading to death, and threatened carotid blowout with subsequent stroke. Retrospective analysis of intraprocedural CT scans revealed that the retractable electrodes were within 1 cm of the carotid artery during ablation in these cases., Conclusions: RF ablation in patients with advanced head and neck malignancies is feasible and effective for palliation. CT-guidance provides accurate probe placement and electrode deployment. The energy level used and proximity of the ablation sphere to the carotid artery may predispose to vascular complications.

We present a case of a patient with systemic lupus erythematosus and secondary antiphospholipid syndrome. The patient presented with acute right cerebellar infarction and clinical and imaging evidence of brain stem and bilateral thalamic encephalopathy that resolved completely.

Study Design: Small case series projecting widespread therapeutic implications., Objective: To promote sacroplasty as a feasible treatment for sacral insufficiency fractures., Summary of Background Data: Osteoporosis, a major cause of vertebral and sacral insufficiency fractures, is an increasingly serious problem in the elderly population. Painful sacral fractures often cause patients to be immobile, and at increased risk for comorbidities and osteoporosis progression. Currently, there is no therapy available for the treatment of these fractures. Vertebroplasty has evolved as a standard of care for treating fractures as a result of malignant and nonmalignant spinal pathology. Sacroplasty represents a reasonable adaptation of this interventional technique., Methods: Computerized tomography (CT) guidance was used to monitor percutaneous polymethylmethacrylate injection into sacral insufficiency fractures., Results: We report 2 cases of elderly patients with posttraumatic sacral insufficiency fractures, whose symptoms were completely relieved following CT-guided internal fixation by percutaneous polymethylmethacrylate injection., Conclusion: Under CT guidance, sacroplasty is a safe, practical, and effective solution to this underdiagnosed problem, with potential for comorbidities resulting in prolonged, costly hospital admissions for the elderly.

Historically, imaging evaluation before carotid revascularization by endarterectomy or stenting has relied on targeting the cervical carotid using catheter angiography as the gold standard. This approach underestimates the anatomic and functional importance of the brain as the target organ by focusing the decision-making process on an isolated segment of the circulation. Since revascularization alternatives have been expanded to include the more proximal aortic and more distal intracranial circulations, it is essential to image the vascular tree from the heart to the brain. Equally important is accurate clinical correlation and functional imaging correlation, so that unnecessary surgery is avoided and there is no lost opportunity for stroke prevention.