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Introduction: We sought to verify the predicting role of a favorable profile on computed tomography perfusion (CTP) in the outcome of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) undergoing effective mechanical thrombectomy (MT). Methods: We retrospectively enrolled 25 patients with AIS due to LVO and with a CTP study showing the presence of ischemic penumbra who underwent effective MT, regardless of the time of onset. The controls were 25 AIS patients with overlapping demographics and clinical and computed tomography angiography features at admission who had undergone successful MT within 6 h from onset and without a previous CTP study. The outcome measure was the modified Rankin Scale (mRS) score at 90 days. Results: Sixty-four percent of the study patients had an mRS score of 0–1 at 90 days versus 12% of the control patients (p < 0.001). Patients of the study group had a more favorable distribution of disability scores (median mRS [IQR] score of 0 [0–2] vs. 2 [2–3]). Multivariate analysis showed that the selection of patients based on a favorable CTP study was strongly associated (p < 0.001) with a better neurological outcome. Conclusions: In our small-sized and retrospective study, the presence of ischemic penumbra was associated with a better clinical outcome in patients with AIS due to LVO after MT. In the future, a larger and controlled study with similar criteria of enrollment is needed to further validate the role of CTP in patient selection for MT, regardless of the time from the onset of symptoms.

Background Postinfectious Moyamoya syndrome (MMS) is a rare vasculopathy that can follow meningitis. Only 9 cases of MMS after meningitis have been reported in the literature. We present a unique case of MMS after meningitis caused by Aspergillus fumigatus and Escherichia coli and review all cases of MMS postmeningitis in the literature. Case Description A 41-year-old man was admitted to our emergency department for sudden hypoesthesia in the left arm and an intense headache not responsive to drugs. Computed tomography scan and magnetic resonance imaging showed acute ischemic lesions in the right centrum semiovale associated with bilateral chronic watershed cerebral ischemic lesions. The cerebral digital subtraction angiography documented a typical Moyamoya pattern. In anamnesis, the patient suffered from meningitis caused by A. fumigatus and E. coli infection after neurosurgery for subependymoma of the fourth ventricle 2 years before. Laboratory tests, clinical investigation, and imaging ruled out any other cause of vasculopathy and led to the final diagnosis of postinfectious MMS. The patient started medical therapy with oral acetyl salicylic acid, verapamil, and prednisone while surgical approach was excluded in the first instance. Conclusions Physicians should be aware of an uncommon but severe complication of meningitis such as MMS, even several years after the infection. Neuroimaging is essential for the diagnosis and to exclude other causes of neurologic symptoms in these patients.

To retrospectively analyze interventional radiology (IR) activity changes in the COVID-19 era and to describe how to safely and effectively reorganize IR activity. All IR procedures performed between January 30 and April 8, 2020 (COVID-era group) and the same 2019 period (non-COVID-era group) were retrospectively included and compared. A sub-analysis for the lockdown period (LDP: 11 March–8 April) was also conducted. Demographic, hospitalization, clinical, and procedural data were obtained for both groups and statistically compared with univariable analysis. A total of 1496 procedures (non-COVID era, 825; COVID era, 671) performed in 1226 patients (64.9 ± 15.1 years, 618 women) were included. The number of procedures decreased by 18.6% between 2019 and 2020 (825 vs 671, p

Background The Barrel vascular reconstruction device is an electrolytically detachable laser-cut closed-cell stent used for neck reconstruction in wide-necked bifurcation aneurysms to support coiling without necessitating dual stent implantation. The purpose is to lower the metal-to-artery ratio and its inherent risk of thromboembolic complications of multiple stents. Case description A 53-year-old woman presenting with subarachnoid hemorrhage due to acutely ruptured basilar tip aneurysm underwent emergency endovascular embolization with the Barrel vascular reconstruction device. Since the stent did not cover the entire neck of the aneurysm, an Atlas stent was released in a Y configuration through the Barrel. The Neuroform Atlas correctly opened through the Barrel and allowed the complete exclusion of the aneurysm. Conclusion If necessary, releasing a Neuroform Atlas through a Barrel vascular reconstruction device is a feasible technique.

To compare three commonly used large-bore aspiration catheters in terms of final successful recanalization rate and first-passage successful and complete recanalization rates (the so called "first-passage effect").it is an observational retrospective multicenter study conducted in three Italian high-volume tertiary stroke centers between January 2017 and May 2019. The study population included all consecutive patients with an ischemic stroke due to middle cerebral artery occlusion (M1 segment only) that underwent intra-arterial mechanical thrombectomy with contact aspiration as first-line strategy within 24 hours from symptoms onset.Three hundred twenty-one patients were included in the study. Multivariable logistic regression analysis comparing the three catheters revealed no differences in terms of successful recanalization. Sofia 6 Plus catheter was associated with better first-passage successful recanalization [OR, 9.09; 95% CI, 2.66-31.03] (p0.001) and first-passage complete recanalization [OR: 3.73; 95% CI: 1.43-9.72] (p=0.007) whereas rt-PA was associated with worse first-passage recanalization [OR: 0.52; 95% CI: 0.29-0.93] (p=0.028).No differences between the three catheters were reported in terms of successful recanalization. Sofia 6 Plus has proven to be superior in achieving both successful and complete first-passage recanalization. Conversely, rt-PA was found to be a negative predicting factor of first-passage effect.

Objective The authors have evaluated their experience in pre-operative direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12, an embolic liquid agent. Methods Between July 2016 and March 2019, the authors retrospectively reviewed clinical, embolization and surgical data of 11 consecutive patients with 12 hypervascular head and neck tumors who had undergone pre-operative embolization using SQUID 12. Percutaneous embolizations were performed by inserting a 19-22 Gauge needle directly into the tumor under ultrasound, fluoroscopic and/or endoscopic guidance. The hub of the needle was connected to a 15-cm DMSO-compatible extension tube, and the SQUID 12 was injected. Results Total or near-total devascularization was achieved in 11 over 12 cases. Complete en-bloc tumor removal by surgery was achieved in all cases. Only one patient required blood transfusion. No major periprocedural adverse events were recorded. Conclusions Direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12 seems to be safe and effective. It may offer almost complete devascularization due to homogenous, deep penetration in the tumor, with optimal visibility of the agent throughout the percutaneous procedure. It may reduce intraoperative blood loss and the need for transfusion, thus facilitating complete surgical resection.

Purpose: Intracranial carotid artery occlusion represents an underinvestigated cause of acute ischemic stroke as well as an indication for mechanical thrombectomy. We investigated baseline and procedural characteristics, outcomes and predictors of outcome in patients with acute ischemic stroke secondary to intracranial carotid artery occlusion. Methods: A retrospective analysis of the Italian Registry of Endovascular Treatment in Acute Stroke was performed. Patients with intracranial carotid artery occlusion (infraclinoid and supraclinoid) with or without cervical artery occlusion but with patent intracranial arteries were included. The 3‑month functional independence, mortality, successful reperfusion and symptomatic intracranial hemorrhage were evaluated. Results: Intracranial carotid artery occlusion with patent intracranial arteries was diagnosed in 387 out of 4940 (7.8%) patients. The median age was 74 years and median baseline National Institute of Health Stroke Scale (NIHSS) was 18. Functional independence was achieved in 130 (34%) patients, successful reperfusion in 289 (75%) and symptomatic intracranial hemorrhage in 33 (9%), whereas mortality occurred in 111 (29%) patients. In univariate analysis functional independence was associated with lower age, lower NIHSS at presentation, higher rate of successful reperfusion and lower rate of symptomatic intracranial hemorrhage. Multivariable regression analysis found age (odds ratio, OR:1.03; P = 0.006), NIHSS at presentation (OR: 1.07; P < 0.001), diabetes (OR: 2.60; P = 0.002), successful reperfusion (OR:0.20; P < 0.001) and symptomatic intracranial hemorrhage (OR: 4.17; P < 0.001) as the best independent predictors of outcome. Conclusion: Our study showed a not negligible rate of intracranial carotid artery occlusion with patent intracranial arteries, presenting mostly as severe stroke, with an acceptable rate of 3‑month functional independence. Age, NIHSS at presentation and successful reperfusion were the best independent predictors of outcome. © 2020, Springer-Verlag GmbH Germany, part of Springer Nature.

To compare size and morphologic features of three-dimensional aneurysm models, obtained with a semi-automated segmentation software (Stroke VCAR, GE, USA) from cerebral CT angiography (CTA) data, to three-dimensional aneurysm models obtained with digital subtraction angiography (DSA, with 3D rotational angiography acquisition—3DRA), considered as the reference standard. In this retrospective study, we reviewed 132 patients, with a total number of 137 intracranial aneurysm, who underwent CTA and subsequent DSA examination, supplemented with 3DRA. We compared neck length, short axis and long axis measured on 3DRA model to the same variables measured on 3D-CTA model by two blinded readers and to the automatic software dimensions. Therefore, statistics analysis assessed intra-observer and inter-observer variability and differences between patients with or without subarachnoid hemorrhage (SAH). There were no significant differences in short-axis and long-axis measurements between 3D angiographic and 3D-CTA models, while comparison of neck lengths revealed a statistically significant difference, which tended to be greater for smaller neck lengths (partial volume effect and “kissing vessels” artifact). There were significant differences between manual and automatic data measured for the same three variables, and the presence of SAH did not affect aneurysm 3D reconstruction. Inter-observer agreement resulted moderate for neck length and substantial for short axis and long axis. The examined 3D-CTA segmentation system is a reproducible procedure for aneurysm morphologic characterization and, in particular, for assessment of aneurysm sac dimensions, but considerable carefulness is required in neck length interpretation.

The scope of the paper is to further present and discuss, in continuation of OTC-28839-MS paper, the results of our technology development program regarding very long oil tiebacks architectures (50-100km) and enabling technologies. It is arrived the time when long tieback solutions are considered for real development projects. The paper will describe how those technological solutions compare with more conventional development schemes in concept selection phases and how our Operating Company is getting prepared for potential implementation. The paper will review key enabling technologies, together with their readiness level and discuss drivers for integration and operation. Sizing references will be presented as a result of Front End Engineering and Design activities developed for real project development opportunities. Technical performances will be discussed and technical-economic indicators will be provided. Risks during development and production will be analyzed and mitigation will be evaluated. A combination of heated high thermal performance flowlines, subsea multiphase boosting, subsea power management, innovative preservation procedures, newest subsea production components together with a reliable integrated control system and digital technologies are the key enablers of a very long tieback solution that may work as kind of highways to bring back production of a whole area to a production hub. Technically the way to go and the gap to cross appear manageable in mid to short terms opening new opportunities for deepwater asset development. It appears now possible to reduce deepwater development costs by increasing the distance between new assets and existing production hubs, shallow water areas or even connecting those assets to shore.

Background High-grade dural arteriovenous fistulas (dAVFs) can present shunts with very different angio-architectural characteristics. Specific hemodynamic factors may affect clinical history and determine very different clinical courses. Objectives To evaluate the relationship between some venous angio-architectural features in high-grade dAVFs and clinical presentation. Specific indicators of moderate or severe venous hypertension were analyzed, such as altered configurations of the dural sinuses (by a single or a dual thrombosis), or overload of cortical vessels (restrictions of outflow, pseudophlebitic cortical vessels, and venous aneurysms). Methods The institutional series was retrospectively reviewed (49 cases), and the pattern of venous drainage was analyzed in relationship with clinical presentation (benign/aggressive/hemorrhage). Results Thirty-five of 49 cases displayed cortical reflux (high-grade dAVFs). This subgroup displayed a benign presentation in 31.42% of cases, an aggressive in 31.42%, and hemorrhage in 37.14%. Conclusions Our data confirm that within high-grade dAVFs, 2 distinct subpopulations exist according to severity of clinical presentation. Some indicators we examined showed correlation with aggressive nonhemorrhagic manifestations (outflow restriction and pseudophlebitic cortical vessels), while other showed a correlation with hemorrhage (dual thrombosis and venous aneurysms). Current classifications appear insufficient to identify a wide range of conditions that ultimately determine the organization of the cortical venous drainage. Intermediate degrees of venous congestion correlate better with the clinical risk than the simple definition of cortical reflux. The angiographic aspects of venous drainage presented in this study may prove useful to assess dAVF hemodynamic characteristics and identify conditions at higher clinical risk.

We sought to verify the benefit of mechanical thrombectomy in patients with acute ischemic stroke due to large vessel occlusion in the anterior circulation and low National Institute of Health stroke scale score at presentation. The prospective database of our stroke center was screened for patients with acute ischemic stroke due to large vessel occlusion and a baseline National Institute of Health stroke scale score ≤5 that had undergone mechanical thrombectomy. Outcome measures were the modified Rankin Scale (mRS) score at 90 days, brain bleeding events and death at 90 days. Out of 459 patients, 17 (12 females, mean age 70 ± 14 years) with occlusion of M1 or M2 segment of middle cerebral artery and baseline National Institute of Health stroke scale score ≤5 underwent mechanical thrombectomy. Eight patients (47%) were treated within 6 hours from the onset, 5 (29%) were treated beyond 6 hours, and 4 (24%) were wake-up strokes. Effective mechanical thrombectomy was achieved in 16 patients (94%) and associated with excellent functional outcomes at 3 months (mRS 0–1) in 13 (76%). The asymptomatic brain-bleeding event was observed in one patient 4 days after effective mechanical thrombectomy concerning safety issues. One patient died 1 month after mechanical thrombectomy of a cause unrelated to stroke. Our findings favor a potential benefit of mechanical thrombectomy in patients with stroke due to large vessel occlusion and low National Institute of Health stroke scale score at presentation. These patients may also benefit from a prolonged time window for treatment.

Background DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion. The aim of our study is to evaluate results of endovascular thrombectomy in large intracranial vessel occlusion without perfusion CT patient selection. Methods we reviewed our prospectively collected endovascular databases for patients with an acute stroke from March 2016 to October 2018, treated after 6 h from stroke onset, without perfusion CT selection. Baseline characteristics, procedural data, and outcomes were evaluated. A good outcome was defined as a 90-day modified Rankin Scale score of 0–2. The association between clinical and procedural parameters and functional outcome was assessed. Results out of 212 patients 55 were treated after 6 h from stroke onset, 49 of which for an anterior circulation occlusion. 18/49 were functional independent at 90 days (mRS 0–2), Successful recanalization (mTICI 2b to 3) was achieved in 38/49 patients (77 %). Multivariate logistic regression indicated that a low baseline NIHSS was associated with favorable outcome (OR 0.66, 95 % CI 0.52−0.83, p-value 0.001). Conclusions in our retrospective analysis, baseline NIHSS is the only parameter that can predict good outcome (90-days mRS 0–2). We confirm data from recent papers assessing that perfusion CT can provide a better patients' selection compared to mCTA for large vessels occlusion treated beyond six hours from symptom onset.

Brain death (BD) is defined as the irreversible destruction of all brain functions. It is usually diagnosed through a clinical examination, but in certain circumstances, ancillary examinations (such as digital subtraction angiography (DSA), transcranial color Doppler (TCD), computed tomography angiography (CTA), magnetic resonance angiography (MRA), or radionuclide scanning) are required as confirmatory tests. In many countries, cervical color Doppler sonography (CCD) is not recognized as a valid test. The aim of our study is to assess its accuracy as a non-invasive, inexpensive, and easily available examination to determine cerebral circulatory arrest (CCA). We performed a retrospective study in which 123 patients with clinical diagnosis of BD underwent bedside cervical color Doppler as an additional examination for CCA assessment. We compared these cervical color Doppler findings with the results of validated ancillary tests such as CTA, TCD, and DSA. Cervical color Doppler exams showed a sensitivity of 78% (96/123 patients) in detecting CCA compared to standard ancillary tests. Twenty-seven patients showed a persistent diastolic flow in one or two of the four arterial vessels examined and thus considered as false negatives. Our results show that cervical color Doppler may become a reliable and safe technique in detecting CCA, which can shorten the time for declaring brain death. In particular, in patients lacking good bone windows at transcranial color Doppler, cervical color Doppler of the cervical internal carotids and vertebral arteries could be recommended to increase the sensitivity of transcranial color Doppler, or as an alternative bedside examination.

BACKGROUND AND PURPOSE: The flow-diverter stent has been proved a feasible, safe, and efficient technique, particularly for the treatment of large and broad-neck carotid siphon aneurysms. Wide-neck bifurcation aneurysms remain, in some cases, a challenge for neurointerventionalists. We report the outcomes of the treatment of saccular middle cerebral artery bifurcation aneurysms with flow diversion in our institution. MATERIALS AND METHODS: From the institution data base, all saccular, nondissecting MCA bifurcation aneurysms, treated with flow-diverter stents, were retrospectively reviewed. Technical issues, immediate posttreatment and follow-up angiographic findings, and clinical outcomes were assessed. RESULTS: Fourteen patients with 15 aneurysms were included in the study. Ischemic complications, as confirmed by MR imaging, occurred in 6 patients (43%). Procedure-related morbidity and mortality at last follow-up were 21% and 0%, respectively. Angiographic follow-up was available for 13 aneurysms, with a mean follow-up of 16 months. Complete occlusion was obtained for 8 aneurysms (62%). CONCLUSIONS: Compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms.

BACKGROUND AND PURPOSE: Flow-diverting stents can be used to treat intracranial aneurysms that are not amenable to treatment with coils. We analyzed ophthalmic consequences due to coverage of the origin of the ophthalmic artery by flow-diverting stents for the treatment of internal carotid artery aneurysms. MATERIALS AND METHODS: From April 2009 to April 2013, the clinical and angiographic outcomes of all 28 patients treated for aneurysms with flow-diverting stents covering the origin of the ophthalmic artery were prospectively collected. The origin of the ophthalmic artery in relation to the target aneurysm was classified by using a 4-type classification. A complete ophthalmic examination was performed by a single ophthalmologist 48 hours before and 1 week after covering the ophthalmic artery. RESULTS: Ophthalmic artery patency was normal at the end of endovascular treatment in 24/28 cases (85.7%). With extensive ophthalmic examinations, 11 patients (39.3%) showed new ophthalmic complications. Patients with the ophthalmic artery originating from the aneurysm sac were at high risk for retinal emboli (4/5, 80%). Patients with the ophthalmic artery originating from the inner curve of the carotid siphon were at high risk for optic nerve ischemic atrophy (3/4, 75%). CONCLUSIONS: This prospective study shows that covering the ophthalmic artery with a flow-diverting stent is not without potential complications. Ophthalmic complications can occur but are often not diagnosed. The anatomic disposition of the ophthalmic artery in relation to the carotid siphon and aneurysm should be clearly understood because some configurations have a higher risk. When not required, covering of the ophthalmic artery by flow-diverting stents should be avoided.

Endovascular treatment of ruptured wide-neck bifurcation aneurysms presents a challenge. While still under evaluation, the Woven Endobridge (WEB) aneurysm embolization system has so far shown promising results in the treatment of complex bifurcation aneurysms. We aimed to evaluate the feasibility and short-term follow-up of endovascular treatment of ruptured wide-neck aneurysm with the WEB device. Six patients referred to our institution for acute symptomatic subarachnoid hemorrhage (SAH) and treated with the WEB device were enrolled in this study. Clinical presentations, technical details, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 3-month angiographic results were also evaluated. Three middle cerebral artery (MCA) and three anterior communicating artery aneurysms were treated between 1 and 14 days after rupturing. Average dome width was 5.8 mm (range 5–7), average neck size was 4.5 mm (range 4–5), and average dome-to-neck ratio was 1.3 (range 1–1.7). The WEB system was the exclusive treatment and was successfully deployed in all cases. Per procedural thromboembolic events occurred in two cases and were treated with intra-arterial administration of antiplatelet agents without any clinical consequences. The modified Rankin Scale (mRS) score at discharge was 0 for all patients. The 3-month angiographic follow-up showed adequate occlusion in four of our six patients (67 %). From this preliminary study, the high feasibility rate and lack of need for systematic antiplatelet agents favor the WEB device providing a solution for endovascular treatment of ruptured wide-neck bifurcation aneurysms during the acute phase. However, further studies are needed to evaluate the complication rate and long-term efficiency.

Giant aneurysms of the basilar artery are rare and are frequently associated with obstructive hydrocephalus and brainstem compression. Treatment still remains a challenge both for neurosurgeons and for interventional neuroradiologists. Cases reported in the literature are anecdotal and, overall, their outcomes are poor. We present the case of a patient with a giant aneurysm of the basilar artery tip, involving the origin of both the posterior cerebral and superior cerebellar arteries, who underwent coiling and ventriculoperitoneal shunting for associated obstructive hydrocephalus. A pCONus ® stent (Phenox; Bochum, Germany) was detached with its petals opened over the ostia of the parent vessels, with the aim being to reconstruct the neck of the aneurysm and to preserve the flow in the parent vessel. Moreover, the presence of the stent was useful to maintain the coils within the dome of the aneurysm. The pCONus is a new neurovascular device that is also useful for treating cases of complex basilar artery aneurysms when the ostia of the parent vessel origin is at the level of the aneurysm neck.

The aim of this paper is to demonstrate the usefulness of 2D multiplanar reformatting images (MPR) obtained from rotational acquisitions with cone-beam computed tomography technology during percutaneous extra-vascular spinal procedures performed in the angiography suite. We used a 3D rotational angiographic unit with a flat panel detector. MPR images were obtained from a rotational acquisition of 8 s (240 images at 30 fps), tube rotation of 180° and after post-processing of 5 s by a local work-station. Multislice CT (MSCT) is the best guidance system for spinal approaches permitting direct tomographic visualization of each spinal structure. Many operators, however, are trained with fluoroscopy, it is less expensive, allows real-time guidance, and in many centers the angiography suite is more frequently available for percutaneous procedures. We present our 6-year experience in fluoroscopy-guided spinal procedures, which were performed under different conditions using MPR images. We illustrate cases of vertebroplasty, epidural injections, selective foraminal nerve root block, facet block, percutaneous treatment of disc herniation and spine biopsy, all performed with the help of MPR images for guidance and control in the event of difficult or anatomically complex access. The integrated use of “CT-like” MPR images allows the execution of spinal procedures under fluoroscopy guidance alone in all cases of dorso-lumbar access, with evident limitation of risks and complications, and without need for recourse to MSCT guidance, thus eliminating CT-room time (often bearing high diagnostic charges), and avoiding organizational problems for procedures that need, for example, combined use of a C-arm in the CT room.

Background Endovascular treatment of posterior cerebral artery aneurysms is challenging because of the particular features of posterior circulation vessels. We performed a systematic review of the literature, to assess safety and efficacy associated to their endovascular treatment. Methods Through a literature search, we identified 20 studies that met our inclusion criteria. We also performed a retrospective analysis of patients treated at our institution during the last 10 years. Demographics, angiographic features, clinical presentation, and outcome were extracted from each study. Data were combined using a random effects model and heterogeneity was assessed by I2. Results We retrieved 7 patients from our institutional series and 246 from the literature. Overall, 253/259 patients/aneurysms were included in this study. A selective coiling was performed in 27% of cases, a stent-assisted coiling in 2%, and a parent artery occlusion in 62%. Immediate complete/near-complete occlusion was obtained in 96% of cases and maintained in 90% at follow-up. No differences were observed between ruptured and unruptured aneurysms. Ischemic complications were reported in 15% of cases, although the most frequent was a hemianopsia in 7%; a hemiparesis was reported in only 2% of cases. Mortality was overall 1%. Ischemic complications were more frequent among patients who underwent nonselective treatment (P Conclusions Endovascular treatment of posterior cerebral artery aneurysms is associated with increased degree of occlusion and low recurrence rate. However, a parent artery occlusion implies complications, even although most of them are minor events such as hemianopsia.

Pilocytic astrocytoma (PA) is the most common pediatric brain glioma and is considered the prototype of benign circumscribed astrocytoma. Despite its low malignancy, the CT and MRI features of brain PA may resemble those of much more aggressive brain tumors. Misdiagnosis of PA is particularly easy when it demonstrates MR morphological and non-morphological findings that are inconsistent with its non-aggressive nature and that overlap with the features of more aggressive brain tumors. Basing on the evidence that the variation in the histological, genetic, and metabolic “fingerprint” for brain PA is dependent on tumor location, and the hypothesis that tumor location is related to the broad spectrum of morphological and non-morphological MR imaging findings, the authors discuss the MR imaging appearance of brain PA using a location-based approach to underline the typical and less typical imaging features and the main differential diagnosis of brain PA. A brief summary of the main pathological and clinical features, the natural history, and the treatment of brain PA is also provided. A combination of morphological and non-morphological MR imaging features and a site-based approach to differential diagnosis are required for a pre-operative diagnosis. The new “cutting-edge” MR imaging sequences have the potential to impact the ease and confidence of pediatric brain tumor interpretation and offer a more efficient diagnostic work-up. Although the typical imaging features of brain pilocytic astrocytoma make radiological diagnosis relatively easy, an atypical and more aggressive appearance can lead to misdiagnosis. Knowing the broad spectrum of imaging characteristics on conventional and advanced MR imaging is important for accurate pre-operative radiological diagnosis and correctly interpreting changes during follow-up.

Purpose We aimed to compare the intra- and interoperator variability of lobar volumetry and emphysema scores obtained by semi-automated and manual segmentation techniques in lung emphysema patients. Materials and methods In two sessions held three months apart, two operators performed lobar volumetry of unenhanced chest computed tomography examinations of 47 consecutive patients with chronic obstructive pulmonary disease and lung emphysema. Both operators used the manual and semi-automated segmentation techniques. The intra- and interoperator variability of the volumes and emphysema scores obtained by semi-automated segmentation was compared with the variability obtained by manual segmentation of the five pulmonary lobes. Results The intra- and interoperator variability of the lobar volumes decreased when using semi-automated lobe segmentation (coefficients of repeatability for the first operator: right upper lobe, 147 vs. 96.3; right middle lobe, 137.7 vs. 73.4; right lower lobe, 89.2 vs. 42.4; left upper lobe, 262.2 vs. 54.8; and left lower lobe, 260.5 vs. 56.5; coefficients of repeatability for the second operator: right upper lobe, 61.4 vs. 48.1; right middle lobe, 56 vs. 46.4; right lower lobe, 26.9 vs. 16.7; left upper lobe, 61.4 vs. 27; and left lower lobe, 63.6 vs. 27.5; coefficients of reproducibility in the interoperator analysis: right upper lobe, 191.3 vs. 102.9; right middle lobe, 219.8 vs. 126.5; right lower lobe, 122.6 vs. 90.1; left upper lobe, 166.9 vs. 68.7; and left lower lobe, 168.7 vs. 71.6). The coefficients of repeatability and reproducibility of emphysema scores also decreased when using semi-automated segmentation and had ranges that varied depending on the target lobe and selected threshold of emphysema. Conclusion Semi-automated segmentation reduces the intra- and interoperator variability of lobar volumetry and provides a more objective tool than manual technique for quantifying lung volumes and severity of emphysema.

In environments characterized by steep slopes or arranged in terraces, among the shallow tillage systems, rototilling is extensively used. However, the effect of the repeated use of rototilling has a considerable influence on soil characteristics; it appears finely powdered, soft and without structure. In order to limit these inconveniences, an innovative self-propelled machine equipped with working tools as a spade, to be used in steep slopes or arranged in terraces areas, was designed by the Mechanics Section of the SAF (Scienze Agrarie e Forestali) Department of the University of Palermo in cooperation with Agrotec company, Padua, Italy. The aim of this study is to compare the effects of three machines for shallow tillage: a chisel plough (CP), a rototilling (RT) and a spading machine (SM) on penetration resistance in semi-arid environments of the Mediterranean basin. No tillage was also included. Penetration resistance (PR) was surveyed for all the treatments to a depth of 300 mm with an electronic dynamometer. The treatments consisted in the execution of a shallow tillage to a depth of 150 mm. SP treatment allowed us to obtain PR lower values throughout the tillage profile than RT, CP and NT. It follows that the type of machine used influences soil PR, and then the soil water storage capacity, key factor for the agricultural productions in semi-arid environments as in Sicily.

Background The goal of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus and consequently in the ophthalmic veins. The traditional approach in the treatment of these fistulae is transvenous endovascular occlusion of the cavernous sinus. Transvenous embolization has been proven to be safe and can provide complete and permanent occlusion of the fistula in a single session. The most commonly used venous pathway is the inferior petrosal sinus, but, if it is inaccessible, then, the superior ophthalmic vein is considered; nonetheless, it can require a surgical exposure. Other pathways include the transfemoral transfacial vein. An arterial approach is considered usually when venous approach pathways fail. Arterial occlusion of feeders supplying the fistula is associated with a greater risk of embolic complications. Case Description We report a case of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein. Conclusions We propose an alternative pathway when the conventional transvenous approach through the inferior petrosal sinus is excluded. An ultrasound-guided facial vein approach can be considered as a direct and safe alternative to reach the cavernous sinus and obtain exclusion of the fistula.