Venous Angioplasty Lacks Efficacy in Multiple Sclerosis

Siddiqui et al report in Neurology the results of a trial regarding the safety and efficacy of venous angioplasty in patients with multiple sclerosis (MS) and extracranial venous anomalies, causing Chronic Cerebrospinal Venous Insufficiency (CCSVI).

The Prospective Randomized Endovascular Therapy in MS (PREMiSe) study included 19 patients with MS and extracranial venous anomalies causing CCSVI.  Nine patients were randomly allocated to undergo balloon angioplasty and 10 to sham angioplasty.  All study patients fulfilled the Zamboni Doppler flow criteria for CCSVI. Assessment was at 1, 3, and 6 months post-procedure with MRI, clinical, and hemodynamic outcomes. Primary endpoints were safety at 24 hours and 1 month, venous outflow restoration >75% at 1 month, and effect of angioplasty on new lesion activity and relapse rate over 6 months. Secondary endpoints included changes in disability, brain volume, cognitive tests, and quality of life.

No perioperative complications were noted; however, one patient with history of syncope was diagnosed with episodic bradycardia requiring placement of a pacemaker before discharge. Doppler evidence-based venous hemodynamic insufficiency severity score (VHISS) was reduced >75% compared to baseline in phase 1 (at 1 month) but not phase 2. In phase 2, higher MRI activity (cumulative number of new contrast-enhancing lesions [19 vs 3, p = 0.062] and new T2 lesions [17 vs 3, p = 0.066]) and relapse activity (4 vs 1, p = 0.389) were identified as non-significant trends in the treated vs sham arm over 6 months. Using analysis of covariance, significant cumulative new T2 lesions were related to larger VHISS decrease (p = 0.028) and angioplasty (p = 0.01) over the follow-up. No differences in other endpoints were detected.

The authors concluded that clinical and imaging outcomes are no better or worse in patients with MS and venous outflow restriction who were treated with venous angioplasty compared to sham controls who did not receive angioplasty, therefore venous angioplasty is not an effective treatment for MS over the short term and may exacerbate underlying disease activity.

MRI-Guided Focused Ultrasound for Uterine Fibroid Treatment

In the article by Kong et al published at the AJR they report on the cost effectiveness of MR-guided focused ultrasound in the treatment of symptomatic uterine fibroids.  They compared this novel treatment with more accepted therapies such as uterine artery embolization (UAE) and hysterectomy.

In their base-case analysis, UAE as a first-line treatment of symptomatic fibroids was the most effective and expensive strategy (22.75 QALYs; $22,968), followed by MRI-guided focused ultrasound (22.73 QALYs; $20,252) and hysterectomy (22.54 QALYs; $11,253). MRI-guided focused ultrasound was cost effective relative to hysterectomy, with an associated incremental cost-effectiveness ratio (ICER) of $47,891/QALY. The ICER of UAE relative to MRI-guided focused ultrasound was $234,565/QALY, exceeding the WTP threshold of $50,000/QALY, therefore rendering MRI-guided focused ultrasound also cost effective relative to UAE.

The authors concluded that MRI-guided focused ultra-sound, an outpatient procedure, with a cost of approximately $20,000 per treatment is a cost-effective noninvasive therapy. For those not eligible for MRI-guided focused ultra-sound, UAE remains a cost-effective option.  Their recommendations took into account short and long-term changes in probabilities of recurrence, symptom relief and quality of life associated with the studied treatments.

Top Three Posts

In the last 6 months Radiology Weekly published 22 reviews of interesting articles.  Most of the readings were from the United States, Greece and Turkey.  The three most visited articles were:

1.  iPad is accurate in the diagnosis of bone fractures.

http://radiologyweekly.blogspot.com/2014/08/ipad-is-accurate-in-diagnosis-of-bone.html

2.  Circulating Tumor Cells Culture Promises Individualized Testing and Treatment.
http://radiologyweekly.blogspot.com/2014/07/circulating-tumor-cells-culture.html

3.  Benefits and Risks of Mammography Screening.
http://radiologyweekly.blogspot.com/2014/04/an-assessment-of-benefits-and-risks-of.html

IPad is accurate in the diagnosis of bone fractures

In the 99^th annual meeting of the Radiologic Society of North America Yarmenitis S et al from Hygeia Hospital, University of Athens, and Ohio State University presented their findings regarding the accuracy of the iPad in the diagnosis of bone fractures.  Seventy-eight trauma cases that included 39 upper extremities, 28 lower extremities, 7 spinal, 3 rib cages and 1 skull x-rays were evaluated retrospectively. Of the cases reviewed, 35 had fractures. The images were anonymized and distributed after randomization to two attending radiologists and to two radiology residents. They used diagnostic monitors and a non-retina display iPad device for interpretation.  The attendings made 130 correct and 26 incorrect diagnoses, while the residents made 127 correct and 29 incorrect diagnoses on the diagnostic monitors.  On the iPad, the attendings made 128 correct and 28 incorrect diagnoses, while the residents made 125 correct and 31 incorrect diagnoses.  The iPad’s sensitivity was 70.9%, specificity 89.4%, positive predictive value 84.7%, and negative predictive value 78.8% in the diagnosis of fractures. As a group, the attendings and residents made 257 correct and 55 incorrect diagnoses on the monitors and 253 correct and 59 incorrect diagnoses on the iPad. There was no difference in the accuracy of interpretation among attendings and residents and no difference was found in their performance depending on the device used.   The authors concluded that tablets would play an essential role in the future as they are mobile and can be used for emergency cases or for teleradiology purposes.

Summary by John T. Spigos, BS

RSNA abstract number 13022609