Value of repeated imaging in patients with a stroke who are transferred for endovascular treatment
Laura C. C. van MeenenNerea Arrarte TerrerosAdrien E.D. GrootManon KappelhofLudo F.M. BeenenHenk A. MarqueringBart J. EmmerYvo B.W.E.M. RoosCharles B.L.M. MajoieJonathan M. Coutinho
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Patients with a stroke who are transferred to a comprehensive stroke center for endovascular treatment (EVT) often undergo repeated neuroimaging prior to EVT.To evaluate the yield of repeating imaging and its effect on treatment times.We included adult patients with a large vessel occlusion (LVO) stroke who were referred to our hospital for EVT by primary stroke centers (2016-2019). We excluded patients who underwent repeated imaging because primary imaging was unavailable, incomplete, or of insufficient quality. Outcomes included treatment times and repeated imaging findings.Of 677 transferred LVO stroke, 551 were included. Imaging was repeated in 165/551 patients (30%), mostly because of clinical improvement (86/165 (52%)) or deterioration (40/165 (24%)). Patients who underwent repeated imaging had higher door-to-groin-times than patients without repeated imaging (median 43 vs 27 min, adjusted time difference: 20 min, 95% CI 15 to 25). Among patients who underwent repeated imaging because of clinical improvement, the LVO had resolved in 50/86 (58%). In patients with clinical deterioration, repeated imaging led to refrainment from EVT in 3/40 (8%). No symptomatic intracranial hemorrhages (sICH) were identified. Ultimately, 75/165 (45%) of patients with repeated imaging underwent EVT compared with 326/386 (84%) of patients without repeated imaging (p<0.01).Neuroimaging was repeated in 30% of patients with an LVO stroke and resulted in a median treatment delay of 20 minutes. In patients with clinical deterioration, no sICH were detected and repeated imaging rarely changed the indication for EVT. However, in more than half of patients with clinical improvement, the LVO had resolved, resulting in refrainment from EVT.Keywords:
Stroke
Repeated measures design
Groin
Abstract Background Due to advances in hip arthroscopy, the number of surgical procedures has increased dramatically. The diagnostic challenge in patients with longstanding hip and groin pain, as well as the increasing number of hip arthroscopies, may lead to a higher number of patients referred to tertiary care for consideration for surgery. Therefore, the aims were: 1) to describe the prevalence of hip-related groin pain in patients referred to tertiary care due to longstanding hip and groin pain; and 2) to compare patient characteristics and patient-reported outcomes for patients categorized as having hip-related groin pain and those with non-hip-related groin pain. Methods Eighty-one patients referred to the Department of Orthopedics at Skåne University Hospital for longstanding hip and groin pain were consecutively included and categorized into hip-related groin pain or non-hip-related groin pain using diagnostic criteria based on current best evidence (clinical examination, radiological examination and intra-articular block injection). Patient characteristics (gender (%), age (years), BMI (kg/m 2 )), results from the Hip Sports Activity Scale (HSAS), the SF-36, the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain distribution (pain manikin) were collected. Parametric and non-parametric statistics were used as appropriate for between-group analysis. Results Thirty-three (47%) patients, (30% women, 70% men, p < 0.01), were categorized as having hip-related groin pain. The hip-related groin pain group had a higher activity level during adolescence ( p = 0.013), and a higher pre-injury activity level ( p = 0.034), compared to the non-hip-related groin pain group. No differences (mean difference (95% CI)) between hip-related groin pain and non-hip-related groin pain were observed for age (0 (− 4; 4)), BMI (− 1.75 (− 3.61; 0.12)), any HAGOS subscales ( p ≥ 0.318), any SF-36 subscales ( p ≥ 0.142) or pain distribution ( p ≥ 0.201). Conclusions Only half of the patients referred to tertiary care for long-standing hip and groin pain, who were predominantly men with a high activity level, had hip-related groin pain. Self-reported pain localization and distribution did not differ between patients with hip-related groin pain and those with non-hip-related groin pain, and both patient groups had poor perceived general health, and hip-related symptoms and function.
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To find out the prevalence of symptomatic non-palpable groin hernias in women under 40 years old with undiagnosed chronic groin pain.Retrospective analysis.University hospital, Sweden.116 women 14-39 years old (mean 27) with chronic undiagnosed groin pain who underwent herniography 1977-1994.Intraperitoneal injection of 80 ml iodine contrast medium (200 mg I/ml)Hernias were found in 28 patients (24%): 17 in the right groin alone, 6 in the left groin alone and 5 bilaterally. 19 patients had hernias on the symptomatic side only. 17 patients had indirect inguinal hernias and 7 had direct inguinal hernias (which are claimed to be extremely rare in women).A hernia is a relatively common finding during herniography in young women with groin pain.
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Before the advent of ultrasound, no noninvasive techniques were available for the evaluation of diseases of the groin. Ultrasound, because of its unique ability to visualize soft tissue structures distinctly, has been used as a diagnostic test in 95 patients with proved or suspected disease of the groin during a 15 month period. Seventy patients had operative verification of the sonographic diagnosis, and in 68 patients, the sonograms correctly predicted the surgical findings. We have found sonography clinically helpful in patients with undiagnosed pain in the groin, questionable inguinal or femoral region hernias, masses of the groin, postoperative complaints after inguinal or femoral herniorrhaphies and possible femoral aneurysms or pseudoaneurysms.
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Abstract A retrospective study was carried out on six patients with contralateral inguinallymph node metastasis from a melanoma of the lower extremity. All six patients were found to have had a previous homolateral groin dissection and in five patients there was intercurrent disease relapse in the leg before or at the same time as the appearance of contralateral node metastasis. Although the prognosis in these patients is unfavourable, two had a survival period of 24 and 32 months and two were still alive 27 months after contralateral groin dissection. In order to determine possible pathways of dissemination, lymphoscintigraphic studies of the leg were performed in another 16 melanoma patients who in the past had undergone a groin dissection. In 13 of them uptake in the contralateral inguinal lymph nodes was detected, indicating that groin dissection can lead to a different lymphatic flow pattern, which is often directed to the contralateral groin. Contralateral lymph node involvement may be an expression of regional disease. In such patients a contralateral groin dissection is advocated.
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One or more causes may be revealed underlying chronic pain in the groin. Knowledge of the complex anatomy of the groin may provide hints about the cause of the pain. In addition to clinical studies, imaging studies are often needed, with X-ray, ultrasonography and in particular MR imaging of the pelvis being the most important ones. The latter provides the best information on the structures of the groin region and the surrounding soft tissues. We present two rare causes of pain in the groin, the diagnosis of which was delayed due to insufficient imaging.
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This chapter discusses groin lymphadenectomy, citing the cases of two women whose clinical and MRI assessment of groin region neither showed enlarged groin nodes nor lymphadenopathy. The inguinal and femoral nodes are the sites of regional spread from vulval cancer, and appropriate groin lymphadenectomy is the single most important factor in reducing mortality from this cancer. Overall, 30% of patients with vulval cancer are diagnosed with metastatic disease to the inguinal or pelvic lymph nodes. MRI scan should be performed prior to surgery, and should include pelvic lymph nodes. When treating vulval cancers, both superficial and deep nodes are to be removed, because selective superficial inguinal lymphadenectomy constitutes undertreatment with a risk of nodal recurrence in 5% of patients before central recurrence. The mortality rate in these patients is high. Detecting vulval cancers in early stages can reduce the need for lymphadenectomy and related sequelae.
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