Visceral artery pseudoaneurysms (VAPA) are associated with a high morbidity and mortality, but sometimes are missed in initial computed tomography (CT) examinations. The aims of this study were to determine the frequency and causes of misdiagnoses of VAPA with CT. We retrospectively identified 77 patients with VAPA in our database who underwent contrast-enhanced CT. The frequency of delayed diagnosis was determined and the reasons were noted. We identified the etiology of VAPA, measured size, and noted the affected vessels. Forty-five of the 77 patients (58 %) had a delayed diagnosis of VAPA. There was no difference in the rate of missed VAPA in symptomatic compared to asymptomatic patients (p = 0.255). The majority of VAPA were associated with previous surgery or interventions (n = 48/62 %). The major affected vessel was the hepatic (n = 31) followed by the splenic artery (n = 17). The main reasons for misdiagnosis were a missed arterial phase in CT (n = 16/36 %), artifacts masking the aneurysm (n = 9/20 %), overlooked pseudoaneurysm (n = 19/42 %), and misinterpretation by attending radiologists (n = 1/2 %). Missed VAPA were smaller (median 8 mm) than those VAPA that were initially diagnosed (median 13 mm, p < 0.01), but occurred with a similar frequency in larger and smaller visceral arteries (p = 0.601). Our study showed that 58 % of VAPA were diagnosed with delay, with the following four reasons for misdiagnosis: Lack of an arterial contrast phase in CT, no techniques for artifact reduction, and lack of awareness of the radiologists. Avoiding delayed diagnosis will most probably improve outcome of patients with VAPA.

Significant pelvic pain is a fairly common malady in the United States. At the same time, the opioid epidemic has changed how pain is thought about and treated, resulting in a clear call for alternative treatment strategies. One of the promising techniques that has emerged over the last several years is cryoneurolysis. Cryoneurolysis allows for personalization of treatment through targeting of specific peripheral nerves, which correspond to a patient’s pain. In the setting of pelvic pain, several viable targets, namely the pudendal nerve and impar ganglion, have been described. This review delineates the mechanism of action in cryoneurolysis, reviews the pertinent literature and describes patient workup and technique. Finally, future directions are discussed.

Background and purpose: Post-dural puncture headaches (PDPH) are caused by cerebrospinal fluid (CSF) leaks that occur after a lumbar puncture (LP). Epidural blood patch (EBP) is an effective treatment option for patients with PDPH in whom conservative treatment fails. Special consideration has to be taken if the patient is affected by any hematological malignancy, due to the fact that EBP carries a theoretical risk of seeding the malignancy into the neuroaxis. The frequent occurrence of immunocompromised status and thrombocytopenia in this patient population warrants individual assessment prior to decision-making. The purpose of our study was to demonstrate that EBP is a safe treatment option if used in the right clinical setting. Materials and methods: In our study, we report the imaging and clinical findings of five patients with hematologic malignancies who developed PDPH following LP. All patients failed to respond to conservative treatment and required EBP. Results: The EBP was successfully performed in all five patients. The preprocedural brain and spine MRI findings were concerning for CSF leak, demonstrating subdural fluid collections, pachymeningeal enhancement, and brain sagging. All patients responded favorably to EBP with the resolution of symptoms. In the long-term follow-up, none of them developed postprocedural infections or neuroaxis tumor seeding. Thrombocytopenia did not result in failure of the procedure or any bleeding complications. Conclusion: EBP is effective in treating conservative therapy-refractory PDPH in a patient population with underlying hematologic malignancies. Due to the increased risks of infection in the setting of immunosuppression, compromised coagulation status related to underlying malignancy, and possible tumor seeding to the neuroaxis, the procedure and possible associated risks should be discussed thoroughly with the patient and family. Clinical significance: We noticed in our practice that there is a lack of deep understanding of a specific patient population affected by hematologic malignancies developing postdural puncture headaches after an LP. As of today, there are no well-established guidelines regarding this specific situation, and every proceduralist has to make a decision whether they feel comfortable performing an EBP when conservative treatment fails, with the possible risk of disease spreading, infection, and bleeding. With our paper, we offered insights into our practice and results, and hope to serve as a helpful resource for proceduralists who are facing a similar clinical setting.