The aim of our study was to assess the mid-term efficacy and safety of the FRED X flow diverting stent (FDS) in the treatment of intracranial aneurysms. The FRED X FDS is relatively new with limited data on its longer-term effectiveness and safety profile. Patients with intracranial aneurysms treated with the FRED X FDS at two UK centres, between March 2021 and July 2022 with at least 18 months follow-up, were retrospectively reviewed. Clinical, procedural and imaging data was analyzed. Twenty-two patients with 24 aneurysms treated with the FRED X device, and had completed at least 18 months of follow-up, were included in this study. The rate of complete aneurysm occlusion (Raymond-Roy Class I) was 83.3

The Woven EndoBridge (WEB) device is an intrasaccular flow disruption device designed for the treatment of wide-necked aneurysms. 1 , 2 Once deployed into the aneurysm it initiates intra-aneurysmal stasis, thrombosis and occlusion, and flow diversion at the interface of the neck of the aneurysm with the parent vessel. 3 The device offers the advantage of reduced operating time and reduced radiation exposure to the patient and the operator. We present a case of a patient in their 70s with a subarachnoid haemorrhage secondary to a ruptured aneurysm at the bifurcation of the right middle cerebral artery. Endovascular treatment was initially attempted with a 7 × 2 mm WEB single layer. Its inadvertent displacement following deployment occluded the superior M2 branch. A snare device was used to capture the proximal marker of the WEB and retrieve the device ( Video 1 ). 4 – 5 The aneurysm was subsequently treated during the same session with a balloon and Comaneci-assisted coiling.

This study examines the long-term outcomes of different endovascular techniques for unruptured middle cerebral artery (MCA) bifurcation aneurysms at a center with an endovascular-first policy over a 13-year period. We performed a retrospective analysis of endovascular treatment (EVT) for unruptured MCA bifurcation aneurysms at a tertiary neurocenter between 2008 and 2020, evaluating outcomes of different techniques and factors associated with aneurysm recurrence. A total of 169 aneurysms in 139 patients were analyzed. Adequate occlusion was achieved in 90.5

Ethmoidal dural arteriovenous fistulas are a rare entity accounting for 10 % of all dAVFs.3-6 Haemorrhage occurs in up to 91 % of cases, which is a particularly high risk and warrants therapeutic intervention.8-9 Endovascular treatment for these fistulas using the conventional detachable microcatheter technique is associated with certain limitations and risks; 8.3 % rate of incomplete obliteration and an 8.3 % rate of complications. Complications include reflux of liquid embolic agent, posterior ischaemic optic neuropathy, acute visual loss, and small subdural haematoma secondary to a micro-perforation.8,10-12 We present our recent experience with the Scepter Mini Balloon Microcatheter for the endovascular treatment of ethmoidal dural arteriovenous fistulas in 3 patients, involving bilateral simultaneous inflation of the balloon. It demonstrates a novel application of this technology with good outcomes. It supports the use of this microcatheter in treating ethmoidal dural arteriovenous fistulas endovascularly, either as a first-line option or as an adjunct to surgery.

PURPOSE:Intracranial arteriovenous malformations (AVMs) treated at our institution with modern techniques of endovascular intervention were analysed for the rate of complete occlusion, associated morbidity, and mortality. To our knowledge, this is the first series from the UK evaluating the effectiveness of endovascular embolisation as a primary treatment for selected cases.METHODS:All newly referred AVMs between January 2017 and June 2022 were reviewed and those treated with primary endovascular intervention were identified. Details of the endovascular procedures were retrospectively reviewed.RESULTS:In 5½ years, 41.1% of AVMs referred to our institution have been triaged for primary endovascular intervention. Sixty-eight AVMs were embolised and followed-up: 44 ruptured and 24 unruptured. Spetzler-Martin grading varied from I to III, and a single AVM was grade IV. The approach was arterial in 73.5%, solely venous in 7.4%, and combined in 19.1%. The mean follow-up was 18 months for imaging and 26 months for clinical assessment. Complete obliteration was achieved in 95.6%. Ruptured AVM cohort: The rate of functional deterioration was 13.6%. Unruptured AVM cohort: The rate of functional deterioration secondary to complications from embolisation was 4.2%.CONCLUSIONS:Endovascular embolisation may be a favourable option for primary AVM treatment in carefully selected patients. However, selection criteria need to be better delineated for more specialists to consider this as a primary therapy.

AIM: To investigate whether the radiation dose in neurointerventional procedures is reduced if the interventionalist has a better working knowledge and skill to operate the biplane angiographic system (BAS).MATERIALS AND METHODS: It is common practice in most centres in the UK for radiogra-phers to drive many of the functions of the BAS under the instruction of the interventionalist who performs the procedure. The dose profile of a neurointerventionalist who was trained to perform procedures while operating the BAS independently was evaluated against that of a highly experienced neurointerventionalist when operating with a radiographer-assisted BAS.RESULTS: The dose-area product for 57 procedures was collected retrospectively. Working independently resulted in a statistically significant lower mean dose of 4,655 mGy & BULL;m2 compared to mean doses above 7,000 mGy & BULL;m2 with a radiographer-assisted BAS (p < 0.05). Effectively this allowed for the mean dose to be reduced by as much as 38%.CONCLUSION: This study suggests that improved knowledge and skill in operating the BAS gives the neurointerventionalist the opportunity to minimise radiation dose. Therefore, this should be part of the skillset acquired by a qualified neurointerventionalist and be formally addressed in the interventional radiology curriculum.18 Crown Copyright (c) 2022 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved.

The advent of the COVID-19 pandemic in Malta led to a number of innovations in terms of work practices, including the introduction of blanket swabbing of all hospital admissions for Covid-19 using PCR nasopharyngeal swab as well as the temporary indiscriminate use of Low dose CT Thorax (CT Pneumonia) as a screening tool in all patients with respiratory symptoms or fever, a recent positive contact, history of travel abroad and all health care workers presenting to hospital. Our aim was to assess the performance of CT pneumonia as a screening tool for Covid-19 in a cohort of patients presenting to large teaching hospital. 661 screening CTs performed between 29/3/20 and 14/4/20 were included. 4 CTs (0.6%) were reported as positive for Covid-19, 45 (6.8%) were reported as 9indeterminate9 with the remaining 612 (92.6%) reported as 'alternative diagnosis' or negative. Covid-19-PCR-swab was positive in 21 patients (3.2%). Of these, 14 (66.7%) had a Negative CT Pneumonia, 6 (28.6%) had a CT reported as 9Alternative Diagnosis9 and 1 (4.8%) had a positive CT for Covid-19. Among the remaining cases testing negative on PCR swab, 3 were reported as having a positive CT and in 2 of these cases, Covid-19 was confirmed using serology testing. Within the entire population of patients who underwent CT Pneumonia, the overall sensitivity for Covid-19 was 13.0%, specificity was 99.8%, positive predictive value was 75.0% and negative predictive value was 96.7%. CT Pneumonia had a low sensitivity for Covid-19 in our cohort of patients making it a poor screening tool, however it may have a role in those who test negative on PCR swab where a high index of suspicion persists.

To describe the diagnostic features of intracranial dural arteriovenous fistulae (DAVF) presenting with cervical cord or brainstem swelling. Retrospective case note and neuroimaging review of patients with angiographically confirmed DAVF diagnosed during January 2015–June 2020 at a tertiary neuroscience centre (Walton Centre NHS Foundation Trust, Liverpool, UK). Six intracranial DAVF causing cervical cord or brainstem oedema (all males aged 60–69 years) and 27 spinal DAVF (88% thoracolumbar) were detected over a 5.5-year period. Significantly more patients with intracranial DAVF received steroids for presumed inflammatory myelitis than those with spinal DAVF (5/6 vs 1/27, p = 0.0001, Fisher’s exact test). Several factors misled the treating clinicians: atypical rostral location of cord oedema (6/6); acute clinical deterioration (4/6); absence (3/6) or failure to recognise (3/6) subtle dilated perimedullary veins on MRI; intramedullary gadolinium enhancement (2/6); and elevated CSF protein (4/5). Acute deterioration followed steroid treatment in 4/5 patients. The following features may suggest DAVF rather than myelitis: older male patients (6/6), symptomatic progression over 4 or more weeks (6/6) and acellular CSF (5/5). Intracranial DAVF are uncommon but often misdiagnosed and treated as myelitis, which can cause life-threatening deterioration. Neurologists must recognise suggestive features and consider angiography, especially in older male patients. Dilated perimedullary veins are an important clue to underlying DAVF, but may be invisible or easily missed on routine MRI sequences.

INTRODUCTION:Holmes Tremor (HT) is a unique and debilitating movement disorder. It usually results from lesions of the midbrain and its connection but can also result from posterior thalamic injury. Clinical examination can help lesion localization between these two areas. We studied the clinical features and their radiological correlations to distinguish midbrain HT (HT-m) from thalamic HT (HT-t).METHODS:Retrospective review of 17 patients with a HT-type presentation was conducted. Tremor characteristics, associated clinical signs and radiological findings were studied.RESULTS:Eleven patients had a myorythmic rest tremor, large amplitude proximal tremor with goal-directed worsening, with or without mild distal dystonic posturing, representing HT-m. Six patients had slow, large amplitude proximal tremors and distal choreathetoid movements, significant proximal/distal dystonic posturing, associated with proprioceptive sensory loss, representing HT-t. Haemorrhagic lesions were the predominant cause of HT-m; whereas, ischaemia was more commonly associated with HT-t.CONCLUSION:When assessing patients with HT, attentiveness to the presence of associated signs in the affected limb, such as a proprioceptive sensory deficits and additional movement disorders, can aid lesion localisation, which can have implications for management.

Purpose To determine whether the sensitivity and specificity of four-dimensional CTA (4D-CTA) are equivalent to digital subtraction angiography (DSA) in the detection of underlying vascular abnormalities in patients with intracerebral haemorrhage (ICH). Methods A systematic review of studies comparing 4D-CTA with DSA in the detection of the underlying structural causes of ICH was performed on the literature published between 1998 and 2019. Results We identified a total of 237 articles from PubMed, SCOPUS and Web of Science using the following Medical Subject Headings (MeSH) terms: primary intracerebral haemorrhage, 4D-CTA, DSA, cerebral haemorrhage, angiography, digital subtraction, arteriovenous malformations, 4D, CTA, dynamic-CTA and time-resolved CTA. Following the removal of duplicate publications and articles failing to meet our inclusion criteria, there were four articles potentially viable for analysis. Therefore, there were not sufficient studies to provide a statistically meaningful meta-analysis. Conclusion The review of current literature has demonstrated that there are few published studies comparing 4D-CTA with DSA in spontaneous ICH, with only four suitable studies identified for potential analysis. However, due to the restricted number of patients and high sensitivity and specificity of 3 studies (100%), performing a meta-analysis was not meaningful. Qualitative analysis of the data concluded that 4D-CTA has the diagnostic potential to replace invasive DSA in certain cases with vascular abnormalities. However, further research studies directly comparing 4D-CTA with DSA using larger prospective patient cohorts are required to strengthen the evidence base.

INTRODUCTION:Due to demographic changes, growing demands, technological developments and rising healthcare costs, analysis of resources in rural and urban primary care clinics is crucial. However, data on primary care provision in rural and suburban areas are lacking. Moreover, health inequities in small island communities tend to be reduced by social homogeneity and an almost indiscernible urban-rural difference. The aim of the study was to examine the urban-suburban differences in the indications for lumbosacral spine radiographs in a public primary healthcare centre in Malta. METHODS:A list of all patients who underwent lumbosacral spine radiography in a public primary healthcare centre between January and June 2014 was obtained. The indications for lumbosacral spine radiographs were compared against the evidence-based indications posited by the America College of Radiology, the American Society of Spine Radiology, the Society for Pediatric Radiology and the Society of Skeletal Radiology in 2014. Differences between suburban and urban areas were analysed using the &chi;&sup2; test. Direct logistic regression was used to estimate the influences of different patients' characteristics and imaging indications in urban and suburban areas. RESULTS:The logistic regression model predicting the likelihood of different factors occurring with suburban patients as opposed to those residing in urban areas contained four independent variables (private/public sector, examination findings, osteoporosis, infection). The full model containing all predictors was statistically significant, c2 (4, N=1112) = 26.57, p&le;0.001, indicating that the model was able to distinguish between patients residing in rural and urban areas. All four of the independent variables made a unique, statistically significant contribution to the model. The model as a whole explained between 2.4% (Cox and Snell R2) and 3.6% (Nagelkerke R2) of the variance in suburban/urban areas, and correctly classified 78.5% of cases. All four of the independent variables made a unique statistically significant contribution to the model. General practitioner (GP) requests for patients residing in suburban areas were more likely to be submitted from the private sector whereas urban GPs tended to include more examination findings. Requests by GPs for lumbosacral spine radiographs due to osteoporosis and infection tended to be more prevalent for urban patients. CONCLUSIONS:Such findings provide information for policymakers to improve equity in health care and resource allocations within the settings of urbanity and rurality.

Over the past 3 years, gadolinium-based contrast agents have been linked to MRI signal changes in the brain, which have been found to be secondary to gadolinium deposition in the brain, particularly in the dentate nuclei and globus pallidus even in patients having an intact blood-brain barrier and a normal renal function. This tends to occur more in linear agents than with macrocyclic agents. Nonetheless, there has been no significant evidence that this has any clinical consequence. We reviewed the current evidence related to this new phenomenon and the precautionary approach taken by regulatory agencies.

A patient presented with fulminant pulmonary oedema and required acute intubation and ventilation. There was no history of a prior cardiac disorder. As he was weaned from sedation, following stabilisation of his pulmonary status, neurological signs suggestive of brainstem dysfunction became apparent. Investigations showed infarcts in the posterior cerebral circulation secondary to a vertebral artery dissection. Neurogenic pulmonary oedema needs to be considered in any patient with fulminant pulmonary oedema without overt evidence or history of cardiac disease.

Introduction: Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnoea (OSA), with limited data about the prevalence of respiratory infections and microbial colonization in these patients. Objectives: The aim of this study was to determine if CPAP use is associated with respiratory infections and to identify the organisms that colonize or infect these patients. Method: A retrospective, case-controlled study in patients diagnosed with OSA was carried out. 137 patients were recruited and interviewed using a questionnaire. A nasal swab was taken from each patient. Patients using CPAP machines had swabs taken from masks and humidifiers. Results: 66 (48.2%) patients received CPAP treatment with 60.6% of them having a heated humidifier. 78.8% were male, with the majority using a full face mask (63.6%). No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively. Conclusions: This study shows that the use of CPAP, choice of mask and humidifier have no significant impact on the prevalence of infections and microorganisms isolated. This is very reassuring to the physician prescribing CPAP therapy and users.

Gadolinium-based contrast agents have greatly expanded the capability of magnetic resonance imaging and have been used extensively in neuroradiology over the past 30 years. When initially developed they were thought to be relatively harmless; it was later discovered they are associated with nephrogenic systemic fibrosis and should be used with caution in certain patient groups, especially those with renal failure. Lately it has been found that the use of these contrast agents may result in deposition of gadolinium in the brain even in patients with an intact blood-brain barrier. While this has not been shown to be associated with any clinical effects, a precautionary approach has been advised by the regulatory authorities. Here we review the development of the gadolinium contrast agents, their use and the advice related to this new information.

Magnetic resonance imaging is being increasingly used to optimize the diagnostic process for low back pain and to manage the risk of missing life-threatening pathology. The aim of the study was to examine the care pathway of low back pain with respect to the utilisation of CT and MRI service utilisation. A descriptive, retrospective, cross-sectional study was performed. A random sample of 1000 primary care patients presenting with low back pain who underwent lumbar spine radiography within a specified period was explored. 20% (n=198) of patients who underwent lumbosacral spine X-ray were referred for MRI investigation. Subsequently, 15 (7.6%) patients underwent joint infiltration whilst 6 (3%) patients underwent neurosurgical intervention during 2 years of follow-up. Such findings provide information for policy makers about the utility of MRI and CT scans.

During the last decade, global interest in the multiple benefits of formal peer teaching has increased. This study aimed to explore the perceptions of first‐year medical students towards the use of peer teaching to learn anatomy using cadaveric specimens. A descriptive, cross‐sectional, retrospective survey was carried out. Data were collected using an online questionnaire which was administered to all medical students who were in their second year of their medical school curriculum and who had participated in sessions taught by their peers during their first year. Peer teaching was perceived as an effective method of learning anatomy by more than half of the participants. Analysis of mean responses revealed that the peer teachers created a positive, non‐intimidating learning environment. Overall, participants gave positive feedback on their peer teachers. Six categories emerged from the responses given by participants as to why they would or would not recommend peer teaching. Ways of improvement as suggested by the respondents were also reported. Variables found to be significantly associated with the perceived benefits of the peer teaching program included sex differences, educational level and recommendations for peer teaching. This study brings to light the merits and demerits of peer teaching as viewed through the eyes of the peer learners. Peer teaching provides a sound platform for teaching and learning anatomy. Further discussions at higher levels are encouraged in order to explore the feasibility of introducing formal peer teaching in the medical curriculum. Anat Sci Educ 11: 346–357. © 2017 American Association of Anatomists.

AIM: To assess the recanalisation rates and long-term functional outcomes of the Solitaire and Trevo devices; to compare these results to those from the Solitaire With the Intention For Thrombectomy (SWIFT) trial and TREVO 2 studies; and to assess for statistical differences in the outcomes between the two devices.MATERIALS AND METHODS: A systematic review and meta-analysis of studies that utilised stentrievers in the treatment of acute ischaemic stroke was conducted. The results were compared to those of the SWIFT and TREVO 2 trials and outcome differences between Trevo (Stryker, Kalamazoo, Michigan, USA) and Solitaire (ev3/Covidien, Irvine, California, USA) were analysed statistically.RESULTS: Solitaire had a lower mortality rate compared to Trevo (16.2% [95% confidence interval {CI}: 13.1%, 19.8%] versus 22.2% [95% CI: 10.8%, 40.2%]) and achieved a higher rate of functional independence (52.1% [95% CI: 46.3%, 57.8%] versus 47.6% [95% CI: 36.7%, 58.8%]). Statistical tests, however, failed to demonstrate significant differences in either functional outcomes or 3-month mortality rates. No significant differences were noted in weighted mean recanalisation rates between the Solitaire and Trevo groups.CONCLUSION: Stentrievers achieve a high rate of recanalisation and functional independence in acute ischaemic stroke and have a relatively good safety profile. No significant differences in functional outcomes, mortality, and symptomatic intra-cranial haemorrhage could be demonstrated between two popular stentrievers designs, namely Trevo and Solitaire. (C) 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.