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OBJECTIVE The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries. METHODS Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%). CONCLUSIONS Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I–II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%–93%) and 105/110 low-grade (95%, 95% CI 90%–98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%–18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%–28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%–9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov)

International audience; Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening pulmonary embolism's (PE) complication whose incidence and predictors are not precisely determined.Objective: To determine the frequency and predictors for CTEPH after a first unprovoked PE.Patients/methods: In a randomized trial comparing an additional 18-month warfarin versus placebo in patients after a first unprovoked PE initially treated with vitamin K antagonist for 6 months, we applied recommended CTEPH screening strategies through 8-year follow-up to determine cumulative incidence of CTEPH. CTEPH predictors were estimated using Cox models. Pulmonary vascular obstruction (PVO) and systolic pulmonary arterial pressure (sPAP) at PE diagnosis and 6 months were studied by receiver operating curves analysis. All CTEPH cases and whether they were incident or prevalent were adjudicated.Results: During a median follow-up of 8.7 years, 9 CTEPH cases were diagnosed among 371 patients, with a cumulative incidence of 2.8% (95% confidence interval [CI], 0.95-4.64), and of 1.31% (95%CI, 0.01-2.60) after exclusion of 5 cases adjudicated as prevalent. At PE diagnosis, PVO>45% and sPAP>56mmHg were associated with CTEPH with a hazard ratio (HR) of 33.00 (95%CI 1.64-667.00, p=0.02) and 12.50 (95%CI 2.10-74.80, p65 years, lupus anticoagulant antibodies and non-O blood groups were also predictive of CTEPH. PVO>14% and sPAP>34mmHg at 6-month were associated with CTEPH (HRs 63.90 [95%CI, 3.11-1310.00, p

Data on long-term venous thromboembolism (VTE) recurrence risk according to gender are conflicting.To evaluate long-term VTE recurrence risk after a first VTE in men and women under 50 years old.Since May 2000, 875 consecutive patients (315 men, 560 women) with a first symptomatic VTE under 50 years old were enrolled in a French prospective multicentre cohort study and were followed up as long as possible. The primary outcome was symptomatic recurrent VTE during follow-up.At baseline, men were older and had more comorbidities than women. First VTE was mainly unprovoked in men (80.6%) and hormone-related in women (84.3%). During a median follow-up of 7.0 years (inter-quartile range, 5.0-11.0), recurrent VTE occurred in 97 men (30.8%) and in 72 women (12.9%) (annual incidence rates of recurrent VTE of 4.8% versus 1.8%-person-years, P0.001). However, there was no difference according to gender in subgroups of patients with a first unprovoked VTE (5.8% versus 3.8%-person-years, P = 0.09). In women, duration of hormonal treatment before first VTE did not influence recurrence risk. In multivariable analysis, unprovoked VTE and family history of VTE were independently associated with recurrence (hazard ratio of 2.50 (95% confidence interval, 1.61 to 3.85) and 1.52 (1.11 to 2.09) respectively).Number of women with unprovoked VTE was low.In patients with a first VTE under 50 years old, a first unprovoked episode and a family history of VTE, but not gender, were associated with a high risk of long-term recurrence.

Background We aimed to assess whether high pulmonary vascular obstruction index (PVOI) measured at the time of pulmonary embolism (PE) diagnosis is associated with an increased risk of recurrent venous thromboembolism (VTE). Study Design and Methods French prospective cohort of patients with a symptomatic episode of PE diagnosed with spiral computerized tomography pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) lung scan and a follow-up of at least 6 months after anticoagulation discontinuation. PVOI was assessed based on the available diagnostic exam (V/Q lung scan or CTPA). All patients had standardized follow-up and independent clinicians adjudicated all deaths and recurrent VTE events. Main outcome was recurrent VTE after stopping anticoagulation. Results A total of 418 patients with PE were included. During a median follow-up period of 3.6 (1.2–6.0) years, 109 recurrences occurred. In multivariate analysis, PVOI ≥ 40% was an independent risk factor for recurrence (hazard ratio 1.77, 95% confidence interval 1.20–2.62, p Conclusion PVOI ≥ 40% at PE diagnosis was an independent risk factor for recurrence VTE. Further prospective validation studies are needed.

Purpose: Carotid artery stenting (CAS) appears as a promising alternative treatment to carotid endarterectomy for radiation therapy (RT)-induced carotid stenosis. However, this is based on a poor level of evidence studies (small sample size, primarily single institution reports, few long-term data). The purpose of this study was to report the long-term outcomes of a multicentric series of CAS for RT-induced stenosis. Methods: All CAS for RT-induced stenosis performed in 11 French academic institutions from 2005 to 2017 were collected in this retrospective study. Patient demographics, clinical risk factors, elapsed time from RT, clinical presentation and imaging parameters of carotid stenosis were preoperatively gathered. Long-term outcomes were determined by clinical follow-up and duplex ultrasound. The primary endpoint was the occurrence of cerebrovascular events during follow-up. Secondary endpoints included perioperative morbidity and mortality rate, long-term mortality rate, primary patency, and target lesion revascularization. Results: One hundred and twenty-one CAS procedures were performed in 112 patients. The mean interval between irradiation and CAS was 15 ± 12 years. In 31.4% of cases, the lesion was symptomatic. Mean follow-up was 42.5 ± 32.6 months (range 1–141 months). The mortality rate at 5 years was 23%. The neurologic event-free survival and the in-stent restenosis rates at 5 years were 87.8% and 38.9%, respectively. Diabetes mellitus (p=0.02) and single postoperative antiplatelet therapy (p=0.001) were found to be significant predictors of in-stent restenosis. Freedom from target lesion revascularization was 91.9% at 5 years. Conclusion: This study showed that CAS is an effective option for RT-induced stenosis in patients not favorable to carotid endarterectomy. The CAS was associated with a low rate of neurological events and reinterventions at long-term follow-up.

Uterine fibroids are benign tumors that could lead to symptoms complicating a patient's daily life. Those fibroids can be treated using uterine fibroid embolization (UFE), an effective non-surgical procedure. However, objectively quantifying the benefits of such a procedure, and the patient's quality of life, is rather challenging.With a novel multiscale three-dimensional (3D) entropy-based texture analysis, the multiscale 3D dispersion entropy (MDispEnAn inverse correlation is observed between MDispEnThe proposed MDispEn

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Background We aimed to identify risk factors for residual pulmonary vascular obstruction after a first unprovoked pulmonary embolism (PE). Methods Analyses were based on data from the double-blind randomized “PADIS-PE” trial that included 371 patients with a first unprovoked PE initially treated during 6 uninterrupted months; all patients underwent baseline ventilation–perfusion lung scanning at inclusion (i.e., after 6 months of anticoagulation). Each patient's pulmonary vascular obstruction indexes (PVOIs) at PE diagnosis and at inclusion were centrally assessed. Results Among the 371 included patients, residual PVOI was available in 356 patients, and 150 (42.1%) patients had PVOI ≥ 5%. At multivariable analysis, age > 65 years (odds ratio [OR], 2.81, 95% confidence interval [CI], 1.58–5.00), PVOI ≥ 25% at PE diagnosis (OR, 3.53, 95% CI, 1.94–6.41), elevated factor VIII (OR, 3.89, 95% CI, 1.41–10.8), and chronic respiratory disease (OR, 2.18, 95% CI, 1.11–4.26) were independent predictors for residual PVOI ≥ 5%. Patients with ≥ 1 of these factors represented 94.5% (123 patients) of all patients with residual PVOI ≥ 5%. Conclusion Six months after a first unprovoked PE, age > 65 years, PVOI ≥ 25% at PE diagnosis, elevated factor VIII, or chronic respiratory disease were found to be independent predictors for residual pulmonary vascular obstruction. Clinical Trials Registration URL: http://www.controlled-trials.com. Unique identifier: NCT00740883.

This technical note describes a novel CT scan protocol that includes a non-enhanced CT, dynamic CTA, and perfusion of the whole brain and CTA of the carotid arteries using a 320-row area detector CT scanner, with a unique contrast injection and acceptable radiation exposure dose in patients presenting with acute ischemic stroke. The acquisition parameters and reconstruction parameters will be discussed including the use of model-based iterative reconstruction (MBIR), time summing (tMIP), and subtraction techniques to optimize the results of this protocol.Key Points• Scanning on a 320-row area detector CT can achieve both brain perfusion with dynamic angiography and reconstructed arterial and venous CTA, and supra aortic trunk angiography, in a single acquisition. • It provides, in a single exam, a full diagnostic workup, i.e., all the acquisitions that are needed to make a quick decision, with reasonable exposure to ionizing radiation and reduced amount of medium contrast, in case of acute ischemic stroke presentation.

IMPORTANCE: The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain. OBJECTIVE: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms. DESIGN, SETTING, AND PARTICIPANTS: Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017. EXPOSURES: Acutely worsening respiratory symptoms in patients with COPD. MAIN OUTCOMES AND MEASURES: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not. RESULTS: Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P

Background We aimed to determine the prevalence of residual pulmonary vascular obstruction (RPVO) after symptomatic pulmonary embolism (PE) and to identify risk factors for RPVO. Methods On the basis of a prospective cohort of patients with a documented symptomatic venous thromboembolism, we included patients who had an acute PE and underwent a ventilation/perfusion lung scan at 3 to 24 months during the follow-up after PE. RPVO score was assessed for each patient. Initial pulmonary vascular obstruction at PE diagnosis was also assessed when available. Univariable and multivariable analyses were performed with preselected data to identify predictors for persistent defect defined as RPVO ≥ 5%. Results Among the 537 included patients, 278 (51.8%) had RPVO ≥ 5%, and 191 (35.6%) had RPVO ≥ 10%. In primary multivariate analysis on overall population, age ≥ 65 years (odds ratio [OR] 2.25, 95% CI, 1.45–3.52) and chronic respiratory failure (OR 3.19, 95% CI, 1.22–10.04) were independent predictors of RPVO ≥ 5%. In secondary multivariate analysis restricted to 256 patients with available initial pulmonary vascular obstruction score at index PE (IPVO), age ≥ 65 years (OR 2.78, 95% CI, 1.41–5.53), unprovoked PE (OR 2.11, 95% CI, 1.11–4.07) and IPVO ≥ 20% (OR 2.94, 95% CI, 1.68–5.20) were found to be independent risk factors for RVPO ≥5%. Conclusion In this selected population of patients with an acute PE, age ≥ 65 years, unprovoked PE and IPVO ≥ 20% at PE diagnosis appeared to be risk factors for residual pulmonary vascular obstruction measured at three to 24 months.

We aimed to validate the Men Continue and HERDOO2 (HERDOO2), D-dimer, age, sex, hormonal therapy (DASH), and updated Vienna recurrent venous thromboembolism prediction models in a population composed entirely of first unprovoked pulmonary embolism, and to analyze the impact of the addition of the pulmonary vascular obstruction index (PVOI) on score accuracy.Analyses were based on the double-blind, randomized PADIS-PE trial, which included 371 unprovoked pulmonary embolism patients initially treated for 6 months, successively randomized to receive an additional 18 months of warfarin or placebo, and subsequently followed-up for 2 years.The HERDOO2, DASH, and updated Vienna scores displayed C-statistics of 0.61 (95% CI 0.54-0.68), 0.60 (95% CI 0.53-0.66), and 0.58 (95% CI 0.51-0.66), respectively. Only the HERDOO2 score identified low recurrence risk patients (3%/year) after anticoagulation was stopped. When added to either of the prediction models, PVOI measured at pulmonary embolism diagnosis, after 6 months of anticoagulation, or both, improved scores' C-statistics between +0.06 and +0.11 points and consistently led to identifying at least 50% of patients who experienced recurrence but in whom the scores would have indicated against extended anticoagulation.In patients with a first unprovoked pulmonary embolism, the HERDOO2 score is able to identify patients with a low recurrence risk after treatment discontinuation. Addition of PVOI improves accuracy of all scores.URL: http://www.controlled-trials.com. Unique identifier: NCT00740883.

Compared with standard systematic transrectal ultrasound (TRUS)-guided biopsies (SBx), targeted biopsies (TBx) using magnetic resonance imaging (MRI)/TRUS fusion could increase the detection of clinically significant prostate cancer (PCa-s) and reduce non-significant PCa (PCa-ns). This study aimed to compare the performance of the two approaches.A prospective, single-center study was conducted on all consecutive patients with PCa suspicion who underwent prebiopsy multiparametric MRI (mpMRI) using the Prostate Imaging Reporting and Data System (PI-RADS). All patients underwent mpMRI/TRUS fusion TBx (two to four cores/target) using UroStation™ (Koelis, Grenoble, France) and SBx (10-12 cores) during the same session. PCa-s was defined as a maximal positive core length ≥4 mm or Gleason score ≥7.The study included 191 patients (at least one suspicious lesion: PI-RADS ≥3). PCa was detected in 55.5% (106/191) of the cases. The overall PCa detection rate and the PCa-s detection rate were not significantly higher in TBx alone versus SBx (44.5% vs 46.1%, p = .7, and 38.2% vs 33.5%, p = .2, respectively). Combined TBx and SBx diagnosed significantly more PCa-s than SBx alone (45% vs 33.5%, p = .02). PCa-s was detected only by TBx in 12% of cases (23/191) and only by SBx in 7.3% (14/191). Gleason score was upgraded by TBx in 16.8% (32/191) and by SBx in 13.6% (26/191) of patients (p = .4).The combination of TBx and SBx achieved the best results for the detection and prognosis of PCa-s. The use of SBx alone would have missed the detection of PCa-s in 12% of patients.

En salle d’angiographie, le capteur plan a la capacite d’evaluer la perfusion cerebrale. L’evaluation precoce du pronostic des patients atteints d’un accident vasculaire cerebral ischemique apres une thrombectomie est un enjeu diagnostique. Le but de cette etude est d’evaluer, chez les patients presentant un accident vasculaire cerebral ischemique sur une occlusion proximale des vaisseaux intra crâniens, la relation entre la perfusion acquise par un capteur plan apres une thrombectomie mecanique et la survenue sur le scanner de controle a 24 h d’une ischemie ou d’une transformation hemorragique. Cette etude retrospective, multicentrique a inclus 41 patients ayant effectue une acquisition par un capteur plan immediatement apres thrombectomie, et un scanner de suivi a 24 heures. 10 regions d’interet ont ete analysees selon les territoires de l’Alberta stroke program early CT sur chaque examen. Sur les reconstructions du capteur plan il a ete mesure : le volume sanguin parenchymateux (PBV) quantitatif, avec calcul du ratio PBV, le PBV semi-quantitatif visuel et l’evaluation de la presence d’une hyperdensite initiale sur le CBCT ; sur le scanner de suivi a 24 h : la survenue d’une ischemie constituee ou d’un remaniement hemorragique. L’analyse multivariee a mis en evidence une association statistiquement significative de la survenue d’une ischemie ou d’une transformation hemorragique avec une diminution des valeurs du ratio PBV mesurees par le capteur plan (avec respectivement un Odds ratio ajuste de 0,55, IC 95 % 0,34–0,88 et un Odds ratio ajuste de 0,22, IC 95 % 0,08–0,59). De plus, l’ischemie et la transformation hemorragique ont ete plus frequemment retrouvees dans les territoires presentant une hypoperfusion visuelle ou une hyperdensite initiale sur l’acquisition CBCT du capteur plan. Cette etude a montre la correlation entre la mesure du ratio PBV par le capteur plan et une transformation hemorragique ou une ischemie. Des etudes complementaires seront necessaires pour confirmer nos resultats ( Fig. 1 , Tableau 1 ).

Objectives/Hypothesis The aim of this study was to assess and compare the diagnostic accuracy of 18fluorodesoxyglucose positron emission/computed tomography (FDG-PET/CT) and magnetic resonance imaging (MRI) to detect T1-T2 head and neck squamous cell carcinoma (HNSCC). Study Design Prospective case series. Methods Thirty-five consecutive patients with histologically proven T1-T2 HNSCC were prospectively included. All patients underwent pretherapeutic FDG-PET/CT and MRI. Two nuclear medicine physicians and 2 radiologists blindly reviewed all FDG-PET/CT and MRI, respectively. A five-point qualitative scale was used to estimate tumor detection ability. Sensitivity of each modality was compared together using a McNemar test. Interobserver variability was assessed by kappa index (κ) of Cohen statistics. Maximal standardized uptake value (SUVMAX), metabolic tumor volume (MTV) in FDG-PET/CT, and gadolinium enhancement (%GE) in MRI of each tumor were recorded and compared with T stage using a Mann-Whitney test. Tumor-to-normal tissue ratios in FDG-PET/CT and MRI (TNRPET and TNRMRI) were calculated and compared together using a Student t test. Results Among the 35 primary tumors, 29 were detected by FDG-PET/CT and 22 by MRI. MRI detected none of the six lesions incorrectly identified by FDG-PET/CT. FDG-PET/CT correctly identified seven of the 13 MRI false-negative results. Sensitivity of FDG-PET/CT to detect T1-T2 HNSCC was significantly higher than MRI (83% vs. 63%, P = .015). T stage was significantly correlated with MTV (P = .002) unlike with SUVMAX (P = .06) and %GE (P = .70). TNRPET was significantly higher than TNRMRI (3.5 ± 3.2 vs. 1.2 ± 0.3, P < .0001). Conclusions Our study showed a higher diagnostic accuracy of FDG-PET/CT than MRI to detect T1-T2 HNSCC with a good interobserver agreement. Level of Evidence 4 Laryngoscope, 2017

Objectives The aim of this work was to study physiological aortic arch three-dimensional displacement using non-rigid registration methods and magnetic resonance imaging (MRI). Materials and methods Ten healthy volunteers underwent thoracic MRI. Prospective cardiac gating was performed with a 3D turbo field echo sequence to obtain end-systolic and end-diastolic MR images. The rigid and elastic behavior between these two cardiac phases was detected and compared using either an affine or an elastic registration method. To assess reproducibility, a second MRI acquisition was performed 14 days later. Results Affine registration between the end-systolic and end-diastolic MR images showed significant global translations of the aortic arch and the supra-aortic vessels in the x, y, and z directions (2.02 ± 1.6, −0.71 ± 1.1, and −1.21 ± 1.4 mm, respectively). Corresponding elastic registration indicated significant local displacement with a vector magnitude of 5.1 ± 0.89 mm for the brachiocephalic artery (BCA), of 4.26 ± 0.83 mm for the left common carotid artery (LCCA), and of 4.8 ± 0.86 mm for the left subclavian artery (LSCA). There was a difference in displacement between the supra-aortic trunks of the order of 2 mm. Vector displacement was not statistically different between the repeated acquisitions. Conclusions The present results showed important deformations in the ostia of supra-aortic vessels during the cardiac cycle. It seems that aortic arch motions should be taken into account when designing and manufacturing fenestrated endografts. The elastic registration method provides more precise results, but is more complex and time-consuming than other methods.

To assess the diagnostic accuracy of iodine map computed tomography pulmonary angiography (CTPA), for segment-based evaluation of lung perfusion in patients with acute pulmonary embolism (PE), using perfusion single-photon emission CT (SPECT) imaging as a reference standard. Thirty participants who have been diagnosed with acute pulmonary embolism on CTPA underwent perfusion SPECT/CT within 24 h. Perfusion SPECT and iodine map were independently interpreted by 2 nuclear medicine physicians and 2 radiologists. For both modalities, each segment was classified as normoperfused or hypoperfused, as defined by a perfusion defect of more than 25% of a segment. The primary end point was the diagnostic accuracy (sensitivity and specificity) of iodine map for segment-based evaluation of lung perfusion, using perfusion SPECT imaging as a reference standard. Following blinded interpretation, a retrospective explanatory analysis was performed to determine potential causes of misinterpretation. The median time between CTPA with iodine maps and perfusion SPECT was 14 h (range 2–23 h). A total of 597 segments were analyzed. Sensitivity and specificity of iodine maps with CTPA for the detection of segmental perfusion defects were 231/284 = 81.3% (95% CI 76.4 to 85.4%) and 247/313 = 78.9% (95% CI 74.1 to 83.1%), respectively. In retrospect, false results were explained in 48.7%. Iodine map CTPA showed promising results for the assessment of pulmonary perfusion in patients with acute PE, with sensitivity of 81.3% and specificity of 78.9%, respectively. Recognition of typical pitfalls such as atelectasis, fissures, or beam-hardening artifacts may further improve the accuracy of the test. • Sensitivity and specificity of iodine subtraction maps for the detection of segmental perfusion defects were 81.3% (95% CI 76.4 to 85.4%) and 78.9% (95% CI 74.1 to 83.1%), respectively. • Recognition of typical pitfalls such as atelectasis, fissures, or beam-hardening artifacts may further improve the diagnostic accuracy of the test.

Background: The frequency of PE in patients with acute exacerbation of COPD remains uncertain. Aims: To determinate PE frequency in patients with an acute COPD exacerbation, whether PE was clinically suspected or not. Method: In the “PEP” multicentre prospective cohort, patients admitted to hospital for an acute COPD exacerbation were included in 7 French Centres. A predefined and validated PE diagnosis algorithm based on GENEVA score, D-dimer, CT-scan and legs’ ultrasound was performed in all patients within 48 hours following admission with a prospective 3-month follow-up. The primary outcome was PE diagnosed at admission. Secondary outcomes were venous thromboembolism (VTE, including isolated deep vein thrombosis (DVT)) at inclusion and at 3-month follow-up in patients where PE or DVT was initially excluded and 3-month mortality. All VTE events were centrally adjudated by an independant committee. Results: At inclusion, among the 740 included patients, PE was confirmed in 44 (5.9%) and isolated DVT in 10 (1.6%), yielding a VTE prevalence of 7.3% (95%CI 5.6-9.4). In patients with (n=299) and without (n=441) clinical suspicion of PE, VTE prevalence was 11.7% (95%CI 8.6-15.9) and 4.4% (95%CI 2.8-6.6), respectively. At 3 months, among the 686 patients where PE or DVT was excluded at inclusion, PE occurred in 5 patients (2/264 patients with suspected PE and 3/422 with no PE suspicion). At 3 months, 50 patients (6.8%) died (12/44 patients with PE (27.3%) and 38/686 patients with no PE (5.5%)). Conclusion: The prevalence of PE in patients hospitalized for an acute COPD exacerbation is high and of poor prognosis, whether PE was suspected or not.

​Background and purposeIntracranial aneurysms are a frequently occurring disease, with an estimated prevalence of 2–5% in the general population. They usually remain silent until rupture occurs, with a mortality rate of 35–50% and a high rate of morbidity, including long-term disability. However, preventative treatments have their own risk of complications and morbi-mortality rates, including stroke and hemorrhage. ECG-gated four-dimensional CT angiography (4D-CTA) allows the acquisition of time-resolved three-dimensional reconstructions. The aim of our study was to evaluate different intracranial aneurysm metrics over the cardiac cycle using ECG-gated 4D-CTA.​Materials and methodsECG-gated 4D-CTA datasets were acquired in patients presenting with intracranial aneurysms. Seven aneurysm metrics, including aneurysm height, aneurysm length, ostium width, aspect ratio, ostium area, volume, and volume-to-ostium ratio, were analysed over different cardiac phases. Intra-reader agreement, inter-reader agreement, and inter-cycle agreement were calculated through the intraclass correlation coefficient.​ResultsTwenty-one aneurysms from 11 patients were considered for inclusion. Post-processing failed for three aneurysms, and 18 aneurysms were finally analysed. There was good intra-reader agreement for each metric (ICC >0.9). Agreements among three consecutive cardiac cycles were calculated for six aneurysms and were especially good for the volume metric (ICC >0.9). Volume variation appears to be the most relevant metric and seems especially perceptible for aneurysms larger than 5 mm.​ConclusionsQuantification of aneurysm volume changes during the cardiac cycle seems quantitatively possible and reproducible, especially for aneurysms larger than 5 mm. Further studies need to be conducted to validate this parameter for intracranial aneurysm assessment.

Background To date, clinical and experimental studies on stent graft (SG) migration have focused on aortic morphology and blood flow. However, thoracic endovascular aortic repair (TEVAR) is not an instant fixation of the SG in the aortic lumen but rather a continuous process of deformation and three-dimensional change in the configuration and the geometry of the SG. The aim of this study was to analyze the geometric evolution of the aortic SG in the proximal attachment zone at midterm follow-up and its impact on the SG migration. Methods Sixty-two patients underwent TEVAR for thoracic aortic aneurysm from 2007 till 2013. Thirty patients were treated and had a complete clinical and morphological follow-up at 1 month and 3 years. We calculated the SG radius of curvature (RC) change at the proximal attachment zone “P” on the postoperative computed tomography scan at 1 month and 3 years. Results There were 19 atheromatous aneurysms, 8 postdissection aneurysms, and 3 posttraumatic aneurysms. Two patients were treated at zone 1, seven at zone 2, and twenty-one at zone 3. The median decrease of the RC at “P” was 11 mm (interquartile range, 6.5 mm; range, 1–29 mm. A greater decrease in RC was identified in patients with hostile proximal neck having a large diameter (P = 0.006), short neck length (P = 0.04), and neck thrombus grade II and III (P = 0.02). In the migration group, the RC of “P” decreased significantly at 3 years (27.5 mm vs 18.25 mm; P = 0.03). Three patients had type I endoleak and showed a decrease of the RC at “P” (42 vs 13 mm; 28 vs 15 mm; 24 vs 9 mm). Conclusions The SG seems to have geometric changes in the proximal attachment zone over time. The increase of SG curvature might be a predictor for SG migration and may prompt prophylactic reintervention.

We aimed to identify risk factors for recurrent venous thromboembolism (VTE) after unprovoked pulmonary embolism.Analyses were based on the double-blind randomised PADIS-PE trial, which included 371 patients with a first unprovoked pulmonary embolism initially treated during 6 months who were randomised to receive an additional 18 months of warfarin or placebo and followed up for 2 years after study treatment discontinuation. All patients had ventilation/perfusion lung scan at inclusion (i.e. at 6 months of anticoagulation).During a median follow-up of 41 months, recurrent VTE occurred in 67 out of 371 patients (6.8 events per 100 person-years). In main multivariate analysis, the hazard ratio for recurrence was 3.65 (95% CI 1.33–9.99) for age 50–65 years, 4.70 (95% CI 1.78–12.40) for age >65 years, 2.06 (95% CI 1.14–3.72) for patients with pulmonary vascular obstruction index (PVOI) ≥5% at 6 months and 2.38 (95% CI 1.15–4.89) for patients with antiphospholipid antibodies. When considering that PVOI at 6 months would not be available in practice, PVOI ≥40% at pulmonary embolism diagnosis (present in 40% of patients) was also associated with a 2-fold increased risk of recurrence.After a first unprovoked pulmonary embolism, age, PVOI at pulmonary embolism diagnosis or after 6 months of anticoagulation and antiphospholipid antibodies were found to be independent predictors for recurrence.

Background and purpose The Spetzler and Martin (SM) cerebral arteriovenous malformation (AVM) classification is a widely used 5-tier classification. This common language allows specialists to exchange about AVMs and must be reliably characterized by the imaging methods. We presented an agreement study on a new method of digital subtracted 3D rotational angiography resolved in time (four-dimensional DSA: 4D DSA) compared to the gold standard (two-dimensional DSA: 2D DSA) in AVM grading using the SM classification. Methods Ten patients with AVMs were included during one year, they had an angiographic exploration with both 4D DSA and 2D DSA. Three readers assessed the SM classification. One reader conducted a second reading. The inter-, intra-observer and intermodality agreements were calculated by Kappas. Dose to patient was reported. Results Considering the SM grade, the inter-observer agreement between 4D DSA and 2D DSA was equivalent (κ = 0.45 and 0.46), and calculated as substantial κ = 0.76 between the 2 methods. The agreement between 4D DSA and 2D DSA was calculated as moderate κ = 0.46 assessing the size of the nidus, slight κ = 0.18 analyzing the drainage and almost perfect κ = 0.95 depicting the localization. 4D DSA performed during a standard initial angiographic assessment of AVM represented approximately 6% of the total dose. Conclusion The addition of this new technique 4D DSA could be performed regularly in addition to the 2D DSA if available, to assess SM grading, with an acceptable exposure to ionizing radiation.

The aim of this study was to assess and compare the diagnostic accuracy ofProspective case series.Thirty-five consecutive patients with histologically proven T1-T2 HNSCC were prospectively included. All patients underwent pretherapeutic FDG-PET/CT and MRI. Two nuclear medicine physicians and 2 radiologists blindly reviewed all FDG-PET/CT and MRI, respectively. A five-point qualitative scale was used to estimate tumor detection ability. Sensitivity of each modality was compared together using a McNemar test. Interobserver variability was assessed by kappa index (κ) of Cohen statistics. Maximal standardized uptake value (SUVAmong the 35 primary tumors, 29 were detected by FDG-PET/CT and 22 by MRI. MRI detected none of the six lesions incorrectly identified by FDG-PET/CT. FDG-PET/CT correctly identified seven of the 13 MRI false-negative results. Sensitivity of FDG-PET/CT to detect T1-T2 HNSCC was significantly higher than MRI (83% vs. 63%, P = .015). T stage was significantly correlated with MTV (P = .002) unlike with SUVOur study showed a higher diagnostic accuracy of FDG-PET/CT than MRI to detect T1-T2 HNSCC with a good interobserver agreement.4. Laryngoscope, 128:378-385, 2018.

Resume Introduction Les tumeurs des voies aerodigestives superieures (VADS) classees T1 et T2, du fait de leur petite taille, sont plus difficiles a diagnostiquer en imagerie que les tumeurs de stade plus eleve. Le but de cette etude etait d’evaluer et de comparer la performance diagnostique de la TEP/TDM-FDG et de l’IRM dans la detection des tumeurs de petite taille des VADS. Patients et methodes Une etude retrospective a ete menee sur 21 patients presentant des tumeurs histologiquement prouvees des VADS, T1 ou T2 selon la classification TNM, ayant beneficie d’une IRM et d’une TEP/TDM-FDG pretherapeutiques. La capacite de detection tumorale etait evaluee en IRM et en TEP/TDM-FDG a l’aide d’une echelle qualitative. Les sensibilites des deux modalites d’imagerie etaient comparees entre elles. Le SUVmax et le pourcentage de rehaussement etaient mesures pour chaque tumeur et analyses en fonction du classement T. Resultats Parmi les 21 tumeurs, 17 etaient retrouvees en TEP/TDM-FDG contre 12 en IRM. Aucune des 4 lesions non identifiees en TEP/TDM-FDG n’etait visible en IRM. La TEP/TDM-FDG avait correctement identifie 5 des 9 resultats faux-negatifs de l’IRM. La sensibilite de la TEP/TDM-FDG etait de 80,9 % contre 57,1 % pour l’IRM, a la limite de la significativite statistique ( p = 0,06). Il n’a pas ete retrouve de correlation significative entre le SUVmax et le classement T. Conclusion La TEP/TDM-FDG peut etre utile pour l’identification de localisations tumorales primitives des VADS, meme de petite taille, classees T1 ou T2, avec une sensibilite superieure a celle de l’IRM.

Purpose Intracranial aneurysms are frequent with a prevalence estimated over 2–5% in the general population. They usually remain silent until rupture occurs with a mortality rate of 35–50% and a high rate of morbidity including long-term disability. However, preventative treatments have their own risk of complication and morbi-mortality rate including stroke and hemorrhage. ECG-gated 4D CTA allows acquisition of time-resolved 3D reconstructions. The aim of our study is to evaluate different intracranial aneurysm metrics over cardiac cycle using ECG-gated 4D-CTA. Materials and methods ECG-gated 4D-CTA datasets were acquired in patients presenting with intracranial aneurysms. Seven aneurysm metrics including height, length, width, ostium area, volume aspect ratio and volume ostium ratio were analyzed for different cardiac phases. An intra-reader agreement, inter-reader agreement and inter-cycles agreement were calculated through intraclass correlation coefficient. Results Twenty one aneurysms from 11 patients were considered for inclusion. The post-processing failed for 3 aneurysms, and eighteen aneurysms were analyzed. There were significant differences between the minimum and the maximum of every metrics during the cardiac cycle (P 0.9). Agreements between three following cardiac cycles were calculated for 6 aneurysms and was especially good for the volume (ICC > 0.9). Conclusions Aneurysm volume changes over cardiac cycle is quantitatively possible and a reproducible measurement. Further studies need to be conducted to evaluate this new parameter for intracranial aneurysm assessment.

Resume Introduction Dans la polyarthrite rhumatoide (PR), l’examen clinique est plus rapide a realiser que l’echographie. La connaissance de la concordance clinico-echographique des differentes articulations pourrait aider a ameliorer la selection des articulations les plus propices a l’evaluation echographique. Objectifs Evaluer la concordance entre l’examen clinique et l’echographie articulaire dans un groupe heterogene de patients atteints de PR. Methode Quarante patients ont ete inclus dans une etude prospective, transversale, monocentrique, quel que soit le niveau d’activite de la maladie, la duree d’evolution ou le traitement recu. Pour chaque patient, 40 articulations ont ete evaluees pour un total de 1600 articulations. La synovite a ete scoree en utilisant l’examen clinique, l’echographie en mode B (E-B), le Doppler puissance (DP) et l’association mode B + DP. La concordance entre le gonflement articulaire apprecie par l’examen clinique, l’epaississement synovial apprecie par l’E-B (grade 1 ou plus) et l’inflammation appreciee par le DP (grade 1 ou plus) a ete evaluee en calculant le coefficient Kappa (κ). Resultats La concordance entre l’examen clinique et l’echographie etait tres basse aux epaules et aux metatarso-phalangiennes (MTP) (κ Conclusion L’evaluation d’un groupe heterogene a demontre que l’echographie complete l’information de l’examen clinique, particulierement au niveau des epaules, des poignets et des MTP. La concordance etait moderee a bonne concernant les autres sites articulaires.

SummaryIn 1998 we estimated the incidence of venous thromboembolism (VTE) to be 1.8/1,000 per year. The aim of this study was to compare current VTE incidence to that observed in 1998. We prospectively recorded all cases of symptomatic pulmonary embolism (PE) and deep vein thrombosis (DVT) of the lower limbs diagnosed between March 1, 2013 and February 28, 2014 in hospitals and in the community, using the same method and geographic area than in 1998. The 2013 incidence rates of VTE were computed and compared with those of 1998 using age- and sex-specific standardised incidence ratios (SIRs). In 2013, we recorded 576 VTE cases (279 isolated DVT and 297 PE ± DVT). Among 367,911 inhabitants, the overall incidence of VTE was 1.57/1,000 (95 % CI 1.44–1.69). The overall VTE incidence was significantly lower in 2013 as compared with 1998: SIR 0.72 (95 % CI 0.67–0.79) as well as the incidence of isolated DVT: SIR 0.53 (95 % CI 0.47–0.60); conversely, the overall incidence of PE was unchanged: SIR 1.10 (95 % CI, 0.98–1.23) despite an increase in the incidence of isolated PE: SIR 1.29 (95 % CI, 1.10–1.52). In 1998, 4.4 % of PE cases were diagnosed using CTPA as compared with 73.7 % in 2013 (p < 0.001). In conclusion, between 1998 and 2013, the incidence of symptomatic DVT decreased. Conversely, we found no similar reduction in the incidence of symptomatic PE; whether this is due to changes in diagnostic tests and algorithms in the management of suspected PE requires further investigations.Supplementary Material to this paper is available online at www.thrombosis-online.com.

Resume Objectifs Le diagnostic de syndrome de Sjogren primaire repose sur un faisceau d’arguments cliniques et biologiques. L’apport de l’echographie des glandes salivaires a ete recemment reconnu pour le diagnostic et l’evaluation therapeutique au cours de celui-ci. Notre objectif etait d’estimer par la technique echographique du mode ARFI, les valeurs d’elasticite des glandes salivaires de patients souffrant d’une maladie de Sjogren et de les comparer aux valeurs de temoins sains. Methode Dix patients souffrant de ce syndrome et 15 temoins sains ont subi un examen echographique couple au mode Acoustic radiation force impulse (ARFI). Dix tirs impulsionnels par glande ont ete realises sur leurs parotides et submandibulaires afin de determiner s’il existait des differences entre les valeurs moyennes de shear waves velocity (SWV) en m/s entre malades et temoins. La significativite a ete appreciee par le test U de Mann-Whitney. Resultats Les valeurs moyennes en m/s de SWV parotidiennes du groupe « Sjogren » (2,335 ± 0,315) apparaissent significativement plus elevees que celles des temoins (1,785 ± 0,384) ; (p = 0,001). Il n’existe pas de difference significative des valeurs submandibulaires entre malades et temoins, respectivement 1,812 ± 0,308 et 1,766 ± 0,187 ; (p = 0,892). Conclusion L’elastometrie en mode ARFI semble pouvoir constituer une aide diagnostic au syndrome de Sjogren en decelant, par une technique non invasive, rapide et peu couteuse, les remaniements architecturaux pathologiques des glandes parotides.

Resume Objectif Verifier in vivo et sur poumons de cadavres la constance du mode collateral de distribution des arteres pulmonaires droite et gauche telle que la decrivent les traites classiques et les travaux modernes ; evaluer la frequence des branches observees et definir un arbre arteriel de reference, porteur des arteres les plus frequentes, pour l’interpretation des angioscanners pulmonaires. Patients et methode Soixante reconstructions 3D en mode VRT d’arbres arteriels pulmonaires (30 droits et 30 gauches) a partir des angioscanners pulmonaires de 30 patients indemnes de pathologie bronchique, vasculaire et parenchymateuse pulmonaire. Injection–dissection de 16 arteres pulmonaires (huit droites et huit gauches) sur des poumons de cadavres. Au total, 76 arteres pulmonaires (38 droites et 38 gauches) ont ete etudiees. Resultats La modalite d’arborisation la plus frequente est une distribution de type collateral, mais une division des arteres pulmonaires de type terminal en deux ou trois troncs lobaires a ete observee sept fois sur 38 a droite (18,4 %) et une fois sur 38 a gauche (2,6 %) ; l’artere mediastinale du lobe superieur droit etait constante, completee par une scissurale dans 89,5 % des cas. Une artere lobaire moyenne a ete individualisee 22 fois sur 38 (57,9 %) ; a gauche, quatre arteres mediastinales differentes, mais habituellement non coexistantes ont ete identifiees, trois pour le culmen et un destinee a la lingula ; six varietes d’arteres scissurales gauches ont ete notees, trois pour le culmen et trois pour la lingula ; le segment 6 recevait une a deux arteres segmentaires, exceptionnellement trois ; un arbre arteriel de reference a pu etre defini a droite comme a gauche. Conclusion La division en troncs lobaires terminaux des arteres pulmonaires est une variation demontree pour la premiere fois ; les donnees obtenues par l’imagerie in vivo en reconstruction 3D concordent avec les resultats des travaux realises sur des poumons cadaveriques injectes sur ce point et pour la definition de l’arbre arteriel de reference.

MR angiography of peripheral arterial disease of the distal legs: is time resolved MRA (TRICKS) necessary ? Purpose. To demonstrate the added diagnostic value of time-resolved imaging of contrast kinetics (TRICKS) in the evaluation of lower limb arteries compared to standard 3 level MRA with stepping table method. Patients and methods. Forty patients (30% diabetics) with lower extremity peripheral arterial disease (87.5% with chronic ischemia) underwent standard contrast MRA including TRICKS of the distal arteries. Five arterial segments were defined per leg, and 395 arterial segments were compared (one patient with amputation). Two reviewers evaluated the quality of arterial imaging, presence of venous return and degree of stenosis per segment. The degree of interobserver agreement for arterial stenosis measurement was calculated. Results. More arterial segments could be analyzed on the TRICKS sequence (good or excellent analysis in 63.03%-66.32% of arterial segments compared to 41.51%-47.08% on routine MRA). There was less venous contamination on TRICKS images (25.57% to 27.60% gain). The degree of interobserver agreement was superior with TRICKS compared to standard MRA (kappa 0.85 vs 0.69). Conclusion. The TRICKS sequence can be added to standard MRA for pre-therapeutic evaluation of distal arteries in patients with peripheral arterial disease, especially with chronic ischemic with rest pain and/or trophic changes.

International audience; BACKGROUND: Multislice CT (MSCT) combined with D-dimer measurement can safely exclude pulmonary embolism in patients with a low or intermediate clinical probability of this disease. We compared this combination with a strategy in which both a negative venous ultrasonography of the leg and MSCT were needed to exclude pulmonary embolism. METHODS: We included 1819 consecutive outpatients with clinically suspected pulmonary embolism in a multicentre non-inferiority randomised controlled trial comparing two strategies: clinical probability assessment and either D-dimer measurement and MSCT (DD-CT strategy [n=903]) or D-dimer measurement, venous compression ultrasonography of the leg, and MSCT (DD-US-CT strategy [n=916]). Randomisation was by computer-generated blocks with stratification according to centre. Patients with a high clinical probability according to the revised Geneva score and a negative work-up for pulmonary embolism were further investigated in both groups. The primary outcome was the 3-month thromboembolic risk in patients who were left untreated on the basis of the exclusion of pulmonary embolism by diagnostic strategy. Clinicians assessing outcome were blinded to group assignment. Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00117169. FINDINGS: The prevalence of pulmonary embolism was 20.6% in both groups (189 cases in DD-US-CT group and 186 in DD-CT group). We analysed 855 patients in the DD-US-CT group and 838 in the DD-CT group per protocol. The 3-month thromboembolic risk was 0.3% (95% CI 0.1-1.1) in the DD-US-CT group and 0.3% (0.1-1.2) in the DD-CT group (difference 0.0% [-0.9 to 0.8]). In the DD-US-CT group, ultrasonography showed a deep-venous thrombosis in 53 (9% [7-12]) of 574 patients, and thus MSCT was not undertaken. INTERPRETATION: The strategy combining D-dimer and MSCT is as safe as the strategy using D-dimer followed by venous compression ultrasonography of the leg and MSCT for exclusion of pulmonary embolism. An ultrasound could be of use in patients with a contraindication to CT.

Objectives The diagnosis of primary Sjogren's syndrome (pSS) rests on a converging set of clinical and laboratory findings. Salivary-gland ultrasonography (SGUS) was recently shown to assist in the diagnosis and therapeutic monitoring of pSS. Our objective here was to measure salivary-gland elasticity using Acoustic Radiation Force Impulse (ARFI) ultrasonography in patients with pSS and to compare the results to those obtained in healthy controls. Methods SGUS with ARFI elastometry was performed in 10 patients with pSS and 15 healthy controls. Ten impulses per gland were used for both submandibular and both parotid glands of each participant. Mean shear wave velocity (SWV) in m/s was compared between the patients and controls using the Mann–Whitney U test. Results For the parotid glands, mean SWV was significantly higher in the pSS group than in the control group (2.335 ± 0.315 vs 1.785 ± 0.384, respectively; P = 0.001). Mean SWV values for the submandibular glands were not significantly different between the patients and controls (1.812 ± 0.308 vs 1.766 ± 0.187, respectively; P = 0.892). Conclusion ARFI elastometry may contribute to the diagnosis of pSS, as this noninvasive, fast, and inexpensive investigation can demonstrate abnormal architectural changes in the parotid glands.

International audience; The optimal duration of anticoagulation after a first episode of unprovoked pulmonary embolism is uncertain. To determine the benefits and harms of an additional 18-month treatment with warfarin vs placebo, after an initial 6-month nonrandomized treatment period on a vitamin K antagonist. Randomized, double-blind trial (treatment period, 18 months; median follow-up, 24 months); 371 adult patients who had experienced a first episode of symptomatic unprovoked pulmonary embolism (ie, with no major risk factor for thrombosis) and had been treated initially for 6 uninterrupted months with a vitamin K antagonist were randomized and followed up between July 2007 and September 2014 in 14 French centers. Warfarin or placebo for 18 months. The primary outcome was the composite of recurrent venous thromboembolism or major bleeding at 18 months after randomization. Secondary outcomes were the composite at 42 months (treatment period plus 24-month follow-up), as well as each component of the composite, and death unrelated to pulmonary embolism or major bleeding, at 18 and 42 months. After randomization, 4 patients were lost to follow-up, all after month 18, and 1 withdrew due to an adverse event. During the 18-month treatment period, the primary outcome occurred in 6 of 184 patients (3.3%) in the warfarin group and in 25 of 187 (13.5%) in the placebo group (hazard ratio [HR], 0.22; 95% CI, 0.09-0.55; P = .001). Recurrent venous thromboembolism occurred in 3 patients in the warfarin group and 25 patients in the placebo group (HR, 0.15; 95% CI, 0.05-0.43); major bleeding occurred in 4 patients in the warfarin group and in 1 patient in the placebo group (HR, 3.96; 95% CI, 0.44 to 35.89). During the 42-month entire study period (including the study treatment and follow-up periods), the composite outcome occurred in 33 patients (20.8%) in the warfarin group and in 42 (24.0%) in the placebo group (HR, 0.75; 95% CI, 0.47-1.18). Rates of recurrent venous thromboembolism, major bleeding, and unrelated death did not differ between groups. Among patients with a first episode of unprovoked pulmonary embolism who received 6 months of anticoagulant treatment, an additional 18 months of treatment with warfarin reduced the composite outcome of recurrent venous thrombosis and major bleeding compared with placebo. However, benefit was not maintained after discontinuation of anticoagulation therapy. clinicaltrials.gov Identifier: NCT00740883.

An infrarenal duplication of the inferior vena cava with both channels lying on the right side of the aorta was fortuitously found during an abdominal Computed Tomography performed on a 52 year-old woman. Only two same cases seem to be reported in the literature. This very uncommon abnormality probably results from persistence of the infra-renal part of the right subcardinal vein. Radiologists have to be aware of this right-sided ipsilateral duplication for it may be a trap in abdominal imaging as well as "classical" inferior vena cava duplication located on both sides of the abdominal aorta.

Background and Purpose— To replace digital subtraction angiography (DSA) in carotid stenosis evaluation, noninvasive imaging techniques have to reach a high concordance rate. Our purpose is to compare the concordance rates of contrast-enhanced MR angiography (CEMRA) and CT angiography (CTA) with Doppler ultrasound (DUS) in clinical routine practice. Methods— We evaluated prospectively with DUS, CEMRA, and CTA 150 patients suspected of carotid stenosis. The overall concordance rates of the 3 techniques were calculated for symptomatic stenosis ≥50% and ≥70%, for asymptomatic stenosis ≥60%, and for occlusion. For the carotid arteries treated by surgery (n=97), the results of each method and combined techniques were recorded, and misclassification rates were evaluated from surgical reports. Results— The overall concordance rates of DUS-CEMRA, DUS-CTA, and CEMRA-CTA were not statistically different. However, the concordance rate of DUS-CEMRA (92.53%) was significantly higher than that for DUS-CTA (79.10%) in the surgical asymptomatic stenosis group ( P =0.0258). CTA considered alone would misclassify the stenosis in a significant number of cases (11 of 64) in the surgical asymptomatic group compared with CEMRA (3 of 67) and DUS (1 of 66) ( P =0.0186 versus MRA, P =0.0020 versus DUS). Conclusions— With the techniques as utilized in our study, the overall concordance rates of combined noninvasive methods are similar for measuring carotid stenosis in clinical routine practice, but in asymptomatic carotid stenosis, the decision making for surgery is significantly altered if DUS and CTA are considered in place of DUS and CEMRA.

PURPOSE To evaluate the midterm results of limited embolization of the uterine arteries in the management of symptomatic uterine fibroids and to evaluate the efficacy and safety of limited uterine artery embolization (UAE) with use of calibrated tris-acryl gelatin microspheres in the management of symptomatic uterine fibroids. MATERIALS AND METHODS Twenty women (mean age, 43 years) with symptomatic uterine fibroids underwent bilateral embolization of the uterine arteries with use of calibrated microspheres. Devascularization of the fibroids was achieved and the main uterine artery was left patent in all women. Embolization was offered as an alternative to surgery in all women who had been treated unsuccessfully with medical therapy. RESULTS All procedures were technically successful. Microspheres 700–900 μm in diameter were used in 14 women (70%). After a mean follow-up duration of 30.2 months (range, 24–48 mo), all women reported improvement in their symptoms, with 85% reporting complete resolution of menorrhagia at the most recent follow-up. One woman with multiple fibroids required a second embolization procedure because of persisting symptoms at 6 months. She is currently symptom-free after 48 months. In two women with submucosal fibroids, expulsion of necrotic fibroids occurred 2 and 7 months after the procedure, respectively. All women resumed normal menstruation after the procedure. One woman had a successful full-term pregnancy after embolization. CONCLUSION Early experience with UAE with use of calibrated tris-acryl gelatin microspheres indicates that it is safe and efficacious in controlling menorrhagia.

SummaryThe prevention of venous thromboembolism in medical patients remains questioned. All consecutive outpatients admitted in our medical unit were considered for inclusion in this study which aimed to estimate the prevalence of asymptomatic venous thrombosis on admission and the incidence during hospital stay. Exclusion criteria were: age

OBJECTIVE AND IMPORTANCE: Cases of intraorbital arteriovenous malformations are rare, and their management presents a challenge for multidisciplinary teams. CLINICAL PRESENTATION: A 39-year-old woman developed a pulsating exophthalmos, visual loss, and ocular pain within 1 month, revealing the presence of intraorbital arteriovenous malformations. She underwent only surgical treatment. INTERVENTION: A fronto-orbital approach with removal of the orbital rim was performed. A CO 2 laser facilitated all the surgical steps. CONCLUSION: Full recovery of vision and correction of the proptosis have been achieved, and postoperative magnetic resonance imaging and angiography confirmed the total removal of the malformations. The literature is reviewed regarding the management of such lesions. Surgery remains the treatment of choice. The role of embolization is discussed.

International audience

This study aims to investigate the role of spatial and temporal physical, biological and biogeochemical gradients on sediment biogeochemistry along a macrotidal and Si-rich estuary. Scanning and biogeochemical analyses were performed in the inner, mid and outer Aulne Estuary (France) at four seasons. The inner estuary shows high diagenetic activity linked to fluid mud dynamics and river loads. The highest authigenic phosphorus (Aut-P) concentrations ever found in the literature are observed in the inner estuary (18 μmol g−1 PS sediment). This is explained by a combination of favorable factors, i.e. the high organic matter and nutrient loads, the reductive conditions, the freshwater properties (low pH, OH−, sulfate and Mg2+ concentrations), the increase of particle residence time by the upward convergence of particles due to residual currents, and allochthonous riverine Aut-P. We suggest that the high Si(OH)4 concentrations (>400 μM) may even increase Aut-P precipitation through the increase of Fe–P formation in these low salinity conditions. In the mid estuary, erosion–deposition dynamics dominate in point bars and lead to the succession of poor and rich organic and authigenic phosphorus layers, recording thus the seasonality of matter loads and its seasonal translocation from the inner estuary. In the outer estuary, deposition rates are high and constant and biogeochemical properties are characteristic of marine environments. The precipitation of Aut-P from free phosphate (PO4 3−) is lower than in the inner estuary and might be limited by higher Mg2+ concentrations in saline waters. This study highlights that small macrotidal estuaries, and especially their freshwater sediments, may constitute an important phosphorus sink through the precipitation of Aut-P. This precipitation could even be enhanced in fresh or brackish environments, thus increasing long term phosphorus storage and altering benthic fluxes of PO4 3− to the pelagic ecosystem.

Objectifs Les carcinomes epidermoides (CE) des voies aerodigestives superieures (VADS) de stades T1–T2 selon la classification OMS sont plus difficiles a caracteriser que les tumeurs localement avancees par les differentes techniques d’imagerie. Cela reste cependant un veritable challenge diagnostique avant d’etablir une prise en charge therapeutique optimale pour le patient. L’objectif de cette etude a ete d’evaluer et de comparer les performances diagnostiques de la tomographie par emission de positons (TEP/TDM) au 18fluorodesoxyglucose (FDG) et de l’imagerie par resonance magnetique (IRM) avec injection de gadolinium (Gd) pour la mise en evidence des CE des VADS de petite taille. Materiels et methodes Trente-cinq patients consecutifs presentant un CE des VADS histologiquement prouve de stade T1 ou T2 ont ete retrospectivement inclus. Tous les patients avaient beneficie avant traitement d’une TEP/TDM au FDG et d’une IRM cervicale avec injection de Gd. Les examens TEP/TDM et IRM ont tous ete, respectivement, relus en aveugle par 2 medecins nucleaires et 2 radiologues. Les sensibilites de detection tumorale pour chaque modalite ont ete comparees entre elles statistiquement a l’aide d’un test de McNemar. Le SUVmax en TEP/TDM et le rehaussement au gadolinium (R-Gd) en IRM de chaque lesion ont ete enregistres et correles au stade tumoral T1 ou T2 en utilisant un test de Mann-Whitney. La variabilite inter-observateur a ete evaluee par le calcul d’index Kappa (k) de Cohen. Resultats Sur les 35 tumeurs evaluees, 29 ont ete detectees par la TEP/TDM et 22 par l’IRM. Aucune des 6 tumeurs non identifiees par la TEP/TDM n’ont ete mise en evidence en IRM. La TEP/TDM a permis de diagnostiquer 7 des 13 resultats faux negatifs en IRM. La sensibilite de detection tumorale en TEP/TDM (83 %) etait significativement superieure a celle de l’IRM (63 %) ( p = 0,015). Aucune correlation statistique entre le stade tumoral T et le SUVmax ( p = 0,16) ou le R-Gd ( p = 0,97) n’a ete retrouvee. L’analyse inter-observateur a revele, respectivement, un accord fort (k = 0,73) et un accord modere (k = 0,53) pour l’interpretation des TEP/TDM et IRM. Conclusions Nos resultats suggerent une meilleure performance diagnostique de la TEP/TDM au FDG que celle de l’IRM cervicale avec injection de Gd pour la detection des CE des VADS de stades T1–T2. Des etudes prospectives complementaires meritent d’etre realisees pour confirmer ces resultats.

Les caracteristiques angio-architecturale d’une malformation arterio-veineuse (MAV) fournissent des informations majeures a la planification du traitement. En particulier, la decision therapeutique est orientee par la potentialite de la MAV a saigner. Ces facteurs de risques sont representes par : la presence d’anevrysmes arteriels intra-nidaux, d’anevrysme ou de dilatation veineuse importante ou de stenose veineuse. L’abord et la technique therapeutique adaptee peut etre discutee par la caracterisation globale de la MAV : ensemble des afferences et efferences vasculaires, situation, taille. En raison du remplissage rapide de la malformation au cours du temps, et du chevauchement vasculaire, en deux et en trois dimensions, les techniques de soustraction numerique angiographique (DSA), et d’IRM 3D ou a quatre dimensions (4D) peuvent etre mise a defaut pour l’evaluation de ces caracteristiques. Les nouvelles tables d’angiographies disposent depuis peu d’un algorithme valide qui tire une serie de volumes 3D-DSA entierement resolues dans le temps : 4D-DSA ( Fig. 1 ) [1] . Une serie consecutive de 5 acquisitions 4D-DSA pour des bilans de MAV cerebrale a ete realise au CHRU de Brest en 2015. La resolution temporelle et la resolution spatiale de ces reconstructions 4D sont plus elevees que celles fournies par les techniques conventionnelles d’angiographie par resonance magnetique ou par scanner. Elles permettent une detection optimum des facteurs de risques de saignement et leur cartographie spatiale. La reconstruction 4D permet aussi et surtout de visualiser la MAV sous tous les angles a tout moment au cours de son opacification, afin d’orienter l’attitude therapeutique.