Recommendations to Improve Management of Incidental Pulmonary Nodules in Canada: Expert Panel Consensus.

Introduction: Incidental pulmonary nodules (IPN) are common radiologic findings, yet management of IPNs is inconsistent across Canada. This study aims to improve IPN management based on multidisciplinary expert consensus and provides recommendations to overcome patient and system-level barriers. Methods: A modified Delphi consensus technique was conducted. Multidisciplinary experts with extensive experience in lung nodule management in Canada were recruited to participate in the panel. A survey was administered in 3 rounds, using a 5-point Likert scale to determine the level of agreement (1 = extremely agree, 5 = extremely disagree). Results: Eleven experts agreed to participate in the panel; 10 completed all 3 rounds. Consensus was achieved for 183/217 (84.3%) statements. Panellists agreed that radiology reports should include a standardized summary of findings and follow-up recommendations for all nodule sizes (ie, <6, 6-8, and >8 mm). There was strong consensus regarding the importance of an automated system for patient follow-up and that leadership support for organizational change at the administrative level is of utmost importance in improving IPN management. There was no consensus on the need for standardized national referral pathways, development of new guidelines, or establishing a uniform picture archiving and communication system. Conclusion: Canadian IPN experts agree that improved IPN management should include standardized radiology reporting of IPNs, standardized and automated follow-up of patients with IPNs, guideline adherence and implementation, and leadership support for organizational change. Future research should focus on the implementation and long-term effectiveness of these recommendations in clinical practice.

CAR and CSTR Cardiac Computed Tomography (CT) Practice Guidelines: Part 2-Non-Coronary Imaging.

The cardiac computed tomography (CT) practice guidelines provide an updated review of the technological improvements since the publication of the first Canadian Association of Radiologists (CAR) cardiac CT practice guidelines in 2009. An overview of the current evidence supporting the use of cardiac CT in the most common clinical scenarios, standards of practice to optimize patient preparation and safety as well as image quality are described. Coronary CT angiography (CCTA) is the focus of Part I. In Part II, an overview of cardiac CT for non-coronary indications that include valvular and pericardial imaging, tumour and mass evaluation, pulmonary vein imaging, and imaging of congenital heart disease for diagnosis and treatment monitoring are discussed. The guidelines are intended to be relevant for community hospitals and large academic centres with established cardiac CT imaging programs.

CAR and CSTR Cardiac Computed Tomography (CT) Practice Guidelines: Part 1 Coronary CT Angiography (CCTA).

Imaging the heart is one of the most technically challenging applications of Computed Tomography (CT) due to the presence of cardiac motion limiting optimal visualization of small structures such as the coronary arteries. Electrocardiographic gating during CT data acquisition facilitates motion free imaging of the coronary arteries. Since publishing the first version of the Canadian Association of Radiologists (CAR) cardiac CT guidelines, many technological advances in CT hardware and software have emerged necessitating an update. The goal of these cardiac CT practice guidelines is to present an overview of the current evidence supporting the use of cardiac CT in various clinical scenarios and to outline standards of practice for patient safety and quality of care when establishing a cardiac CT program in Canada.

Core and Advanced Thoracic Imaging Curricula to Guide Residency and Fellowship Training: A Framework From the Canadian Society of Thoracic Radiology.

RATIONALE: A well-defined curriculum with goals and objectives is an inherent part of every radiology training program. MATERIALS AND METHODS: Following a needs assessment, the Canadian Society of Thoracic Radiology Education Committee developed a thoracic imaging curriculum using a mixed- method approach, complimentary to the cardiac curriculum published as a separate document. RESULTS: The Thoracic Imaging Curriculum consists of two separate yet complimentary parts: a Core Curriculum, aimed at residents in-training, with the main goal of building a strong foundational knowledge, and an Advanced Curriculum, designed to build upon the core knowledge and guide a more in-depth subspecialty training. CONCLUSION: The curricular frameworks aim to enhance the educational experience of residents and fellows and provide an educational framework for clinical supervisors and residency and fellowship program directors. SUMMARY STATEMENT: The Canadian Society of Thoracic Radiology championed the creation of Cardiovascular and Thoracic Imaging curricula encompassing clinical knowledge and technical, communication, and decision-making skills with the goal of providing direction to a strong foundational knowledge for residents and to guide specialty training for fellowship programs.

Arterial Age and Early Vascular Aging, But Not Chronological Age, Are Associated With Faster Thoracic Aortic Aneurysm Growth.

Background Aneurysm size is an imperfect risk assessment tool for those with thoracic aortic aneurysm (TAA). Assessing arterial age may help TAA risk stratification, as it better reflects aortic health. We sought to evaluate arterial age as a predictor of faster TAA growth, independently of chronological age. Methods and Results We examined 137 patients with TAA. Arterial age was estimated according to validated equations, using patients' blood pressure and carotid-femoral pulse wave velocity. Aneurysm growth was determined prospectively from available imaging studies. Multivariable linear regression assessed the association of chronological age and arterial age with TAA growth, and multivariable logistic regression assessed associations of chronological and arterial age with the presence of accelerated aneurysm growth (defined as growth>median in the sample). Mean±SD chronological and arterial ages were 62.2±11.3 and 54.2±24.5 years, respectively. Mean baseline TAA size and follow-up time were 45.9±4.0 mm and 4.5±1.9 years, respectively. Median (interquartile range) TAA growth was 0.31 (0.14-0.52) mm/year. Older arterial age (ß±SE for 1 year: 0.004±0.001, P<0.0001) was independently associated with faster TAA growth, while chronological age was not (P=0.083). In logistic regression, each 5-year increase in arterial age was associated with a 23% increase in the odds of accelerated TAA growth (95% CI, 1.085-1.394; P=0.001). Conclusions Arterial age is independently associated with accelerated aneurysm expansion, while chronological age is not. Our results highlight that a noninvasive and inexpensive assessment of arterial age can potentially be useful for TAA risk stratification and disease monitoring as compared with the current clinical standard (chronological age).

Incidence of Atrial Fibrillation as the Initial Manifestation of Cardiac Sarcoidosis: Insights From a Catheter Ablation Registry.

Background: Cardiac sarcoidosis (CS) is a rare form of arrhythmogenic cardiomyopathy; a delayed diagnosis can lead to significant consequences. Patients with clinically manifest CS often have minimal extracardiac involvement and thus frequently present initially to cardiology. Indeed, certain specific arrhythmic scenarios should trigger investigations for undiagnosed CS. Atrial fibrillation (AF) has been described as one of the presenting features of CS; however, the incidence of this presentation is not known. Methods: At our institution, cardiac computerized tomography is routinely performed prior to catheter ablation for AF. Noncardiac incidental findings are described by radiologists and are followed-up by interval investigations. We systematically reviewed noncardiac reports from 1574 consecutive patients in our prospective AF ablation registry. Specifically, we used text-scraping techniques to search on the following keywords: "adenopathy" and "sarcoidosis." Detailed chart review of identified cases was then performed to evaluate results of interval investigations and assess long-term outcomes. Results: Twenty of 1574 patients (1.3%) had noncardiac reports containing "adenopathy" and/or "sarcoidosis." After interval imaging and a follow-up period averaging 60 ± 35 months, only 2 patients of 1574 (0.13%) were diagnosed with CS. Four of 20 (20%) had a previous history of extracardiac sarcoidosis, and another 1 of 20 (5%) was subsequently diagnosed with extracardiac sarcoidosis. However, none of these 5 patients had evidence of cardiac involvement. Conclusions: CS is a rare finding among patients undergoing a first-time AF ablation. Our findings suggest that AF is an uncommon initial presentation of CS. Thus, investigations for CS in patients with AF are not warranted routinely, unless additional suggestive clinical features are present.

Contexte: La sarcoïdose cardiaque (SC) est une forme rare de cardiomyopathie arythmogène; un retard dans le diagnostic peut entraîner d'importantes conséquences. Les patients qui présentent une SC cliniquement manifeste ont souvent une atteinte extracardiaque minime, et consultent donc souvent d'abord en cardiologie. En effet, certains scénarios arythmiques précis devraient déclencher la recherche de signes d'une SC non diagnostiquée. La fibrillation auriculaire (FA) a été décrite comme un signe indicateur de SC; on ne connaît toutefois pas l'incidence de ce signe. Méthodologie: Dans notre établissement, la tomodensitométrie cardiaque est souvent réalisée avant une ablation par cathéter de la FA. Les découvertes non cardiaques fortuites sont décrites par les radiologues, puis font l'objet d'un suivi par des examens d'imagerie réalisés à intervalles déterminés. Nous avons systématiquement évalué les éléments non cardiaques signalés chez 1 574 patients consécutifs dans notre registre prospectif sur l'ablation de la FA. Nous avons utilisé des techniques de dépouillement du texte pour trouver les mots-clés suivants : « adenopathy ¼ (adénopathie) et « sarcoidosis ¼ (sarcoïdose). Un examen du dossier médical complet des cas retenus a été réalisé pour évaluer les résultats des examens de suivi et évaluer les résultats à long terme. Résultats: Parmi les 1 574 patients, 20 (1,3 %) présentaient des notes non cardiaques contenant les termes « adenopahy ¼ (adénopathie) ou « sarcoidosis ¼ (sarcoïdose). Après l'examen d'imagerie et une période de suivi d'une durée moyenne de 60 ±35 mois, seuls deux patients (0,13 %) ont reçu un diagnostic de SC. Quatre des 20 patients visés (20 %) présentaient des antécédents de sarcoïdose extracardiaque, et un patient sur 20 (5 %) a reçu un diagnostic de sarcoïdose extracardiaque à la suite de l'intervention. Toutefois, aucun de ces cinq patients ne montrait de signes d'atteinte cardiaque. Conclusions: La SC est une occurrence rare chez les patients qui subissent une première ablation de la FA. Nos constats indiquent que la FA est une présentation initiale peu commune de la SC. Aussi, la recherche de la SC chez les patients atteints de FA n'est pas justifiée dans une procédure de routine, à moins que d'autres caractéristiques cliniques pointant vers cette affection ne soient présentes.

National Core and Advanced Cardiac Imaging Curricula: A Framework From the Canadian Society of Thoracic Radiology Education Committee.

RATIONALE: Well-defined curriculum with goals and objectives is an inherent part of every radiology residency program. MATERIALS AND METHODS: Following a needs assessment, the Canadian Society of Thoracic Radiology education committee developed a cardiac imaging curriculum using a mixed method collaborative approach. RESULTS: The Cardiovascular Imaging Curricula consist each of two separate yet complimentary granular parts: a Core Curriculum, aimed at residents in-training, with the main goal of building a strong foundational knowledge and an Advanced Curriculum, designed to build upon the core knowledge and guide a more in-depth fellowship subspecialty training. CONCLUSION: The curricular frameworks aim to enhance the educational experience of trainees (residents and fellows) and provide an educational framework for clinical supervisors and residency and fellowship program directors. SUMMARY STATEMENT: The Canadian Society of Thoracic Radiology (CSTR) championed the creation of Cardiovascular and Thoracic Imaging curricula encompassing clinical knowledge and technical, communication, and decision-making skills with the goal of providing direction to a strong foundational knowledge for residents and to guide specialty training for fellowship programs.

Combining Aortic Size With Arterial Hemodynamics Enhances Assessment of Future Thoracic Aortic Aneurysm Expansion.

BACKGROUND: Thoracic aortic aneurysm (TAA) is a deadly disease whose current method for risk stratification (aneurysm size) is imperfect. We sought to evaluate whether combining aortic size with hemodynamic measures that reflect the aorta's function was superior to aortic size alone in the assessment of TAA expansion. METHODS: One hundred thirty-seven nonoperated participants with TAA were followed prospectively. Aortic stiffness and pulsatile hemodynamics were noninvasively assessed at baseline with a combination of arterial tonometry with echocardiography using validated methodology. Aneurysm growth was calculated from standard imaging modalities. Multivariable linear regression models adjusted for potential confounders evaluated the association of aneurysm size and arterial hemodynamics, alone and in combination, with TAA growth. RESULTS: Sixty-nine percent of participants were male. Mean ± SD age, baseline aneurysm size, follow-up, and aneurysm expansion were, respectively, 62.2 ± 11.4 years, 45.9 ± 4.0 mm, 4.5 ± 1.9 years, and 0.41 ± 0.46 mm/year. In the linear regression models, the standardised ß (ß∗) for the association of aneurysm size with aneurysm expansion was 0.178 (P = 0.044). This was improved by combining aortic size with most measures of aortic function, with ß∗ ranging from 0.192 (for aneurysm size combined with central diastolic blood pressure) to 0.484 (for aneurysm size combined with carotid-femoral pulse-wave velocity) (P ≤ 0.05 for each). CONCLUSIONS: Combining aneurysm size with measures of arterial function improves assessment of aneurysm growth over TAA size alone, which is the standard for clinical decisions in TAA. Thus, combining aneurysm size with measures of aortic function provides a clinical advantage in the assessment of TAA disease activity.

Canadian Association of Radiologists/Canadian Association for Interventional Radiology/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions.

Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association for Interventional Radiology and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.

Estimated Aortic Pulse Wave Velocity Is Associated With Faster Thoracic Aortic Aneurysm Growth: A Prospective Cohort Study With Sex-Specific Analyses.

BACKGROUND: Thoracic aortic aneurysm (TAA) is associated with high morbidity and mortality, and there is a critical need for improved tools for risk assessment and prognostication. We have previously shown that aortic stiffness, measured from arterial tonometry (carotid-femoral pulse wave velocity [cfPWV]), is independently associated with TAA expansion. To increase clinical applicability, we sought to determine the association of mathematically estimated aortic pulse wave velocity (e-PWV) with TAA expansion. METHODS: One-hundred and five consecutive unoperated subjects with TAA were recruited. We used arterial tonometry to measure cfPWV and used mean arterial pressure and age to calculate e-PWV according to validated equations. Multivariable linear regression assessed associations of baseline e-PWV with future aneurysm growth. Given sex differences in TAA outcomes, sex-stratified analyses were performed. RESULTS: Seventy-eight percent of subjects were men. Mean ± standard deviation (SD) age, baseline aneurysm size, and follow-up time were 62.6 ± 11.4 years, 46.2 ± 3.8 mm, and 2.9 ± 1.0 years, respectively. Aneurysm growth was 0.43 ± 0.37 mm per year; e-PWV was independently associated with future aneurysm expansion (ß ± SE: 0.240 ± 0.085, P = 0.006). In sex-specific analyses, e-PWV was associated with aneurysm growth in both men (ß ± standard error (SE) : 0.076 ± 0.022, P = 0.001) and women (ß ± SE : 0.145 ± 0.050, P = 0.012), but the strength of association nearly twice as strong in women as in men. CONCLUSIONS: Greater aortic stiffness reflects worse aortic health and provides novel insights into disease activity; e-PWV is independently associated with TAA growth. This finding increases clinical applicability, as e-PWV can be estimated simply, quickly, and free of cost without the need for specialized equipment.

Thoracic imaging tests for the diagnosis of COVID-19.

BACKGROUND: Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID-19 pneumonia. This new edition is an update of the review. OBJECTIVES: Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID-19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT-PCR) negative result and a positive RT-PCR result on follow-up; and evaluate the accuracy of thoracic imaging for screening COVID-19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy. SEARCH METHODS: We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID-19 publications through to 17 February 2021. We did not apply any language restrictions. SELECTION CRITERIA: We included diagnostic accuracy studies of all designs, except for case-control, that recruited participants of any age group suspected to have COVID-19. Studies had to assess chest CT, chest X-ray, or ultrasound of the lungs for the diagnosis of COVID-19, use a reference standard that included RT-PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results. DATA COLLECTION AND ANALYSIS: The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS-2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta-analysis model where appropriate. MAIN RESULTS: We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID-19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT-PCR negative results and positive RT-PCR results on follow-up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID-19 We included 94 studies. Eighty-seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT-PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID-19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X-ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X-ray was 73.1% (95% CI 64. to -80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X-ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P=0.42). All modalities had similar specificities (CT versus X-ray P = 0.36; CT versus ultrasound P = 0.32; X-ray versus ultrasound P = 0.89). Imaging in PCR-negative people who subsequently became positive For rate of positive imaging in individuals with initial RT-PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID-19, all of whom had a final diagnosis of COVID-19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT-PCR who had positive RT-PCR results on follow-up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR-positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X-ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID-19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7). AUTHORS' CONCLUSIONS: Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID-19. Chest X-ray is moderately sensitive and moderately specific in diagnosing COVID-19. Thus, chest CT and ultrasound may have more utility for ruling out COVID-19 than for differentiating SARS-CoV-2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results.

Central Hypertension in Patients With Thoracic Aortic Aneurysms: Prevalence and Association With Aneurysm Size and Growth.

BACKGROUND: Hypertension (HTN) has the greatest population-attributable risk for aortic dissection and is highly prevalent among patients with thoracic aortic aneurysms (TAAs). Although HTN is diagnosed based on brachial blood pressure (bBP), central HTN (central systolic blood pressure [cSBP] ≥130 mm Hg) is of interest as it better reflects blood pressure (BP) in the aorta. We aimed to (i) evaluate the prevalence of central HTN among TAA patients without a diagnosis of HTN, and (ii) assess associations of bBP vs. central blood pressure (cBP) with aneurysm size and growth. METHODS: One hundred and five unoperated subjects with TAAs were recruited. With validated methodology, cBP was assessed with applanation tonometry. Aneurysm size was assessed at baseline and follow-up using imaging modalities. Aneurysm growth rate was calculated in mm/year. Multivariable linear regression adjusted for potential confounders assessed associations of bBP and cBP with aneurysm size and growth. RESULTS: Seventy-seven percent of participants were men and 49% carried a diagnosis of HTN. Among participants without diagnosis of HTN, 15% had central HTN despite normal bBP ("occult central HTN"). In these patients, higher central systolic BP (cSBP) and central pulse pressure (cPP) were independently associated with larger aneurysm size (ß ± SE = 0.28 ± 0.11, P = 0.014 and cPP = 0.30 ± 0.11, P = 0.010, respectively) and future aneurysm growth (ß ± SE = 0.022 ± 0.008, P = 0.013 and 0.024 ± 0.009, P = 0.008, respectively) while bBP was not (P > 0.05). CONCLUSIONS: In patients with TAAs without a diagnosis of HTN, central HTN is prevalent, and higher cBP is associated with larger aneurysms and faster aneurysm growth.

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 1: Acquisition and Safety Considerations.

Acute pulmonary embolism (APE) is a well-recognized cause of circulatory system compromise and even demise which can frequently present a diagnostic challenge for the physician. The diagnostic challenge is primarily due to the frequency of indeterminate presentations as well as several other conditions which can have a similar clinical presentation. This often obliges the physician to establish a firm diagnosis due to the potentially serious outcomes related to this disease. Computed tomography pulmonary angiography (CTPA) has increasingly cemented its role as the primary investigation tool in this clinical context and is widely accepted as the standard of care due to several desired attributes which include great accuracy, accessibility, rapid turn-around time and the ability to suggest an alternate diagnosis when APE is not the culprit. In Part 1 of this guidance document, a series of up-to-date recommendations are provided to the reader pertaining to CTPA protocol optimization (including scan range, radiation and intravenous contrast dose), safety measures including the departure from breast and gonadal shielding, population-specific scenarios (pregnancy and early post-partum) and consideration of alternate diagnostic techniques when clinically deemed appropriate.

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 2: Technical Issues and Interpretation Pitfalls.

The investigation of acute pulmonary embolism is a common task for radiologists in Canada. Technical image quality and reporting quality must be excellent; pulmonary embolism is a life-threatening disease that should not be missed but overdiagnosis and unnecessary treatment should be avoided. The most frequently performed imaging investigation, computed tomography pulmonary angiogram (CTPA), can be limited by poor pulmonary arterial opacification, technical artifacts and interpretative errors. Image quality can be affected by patient factors (such as body habitus, motion artifact and cardiac output), intravenous (IV) contrast protocols (including the timing, rate and volume of IV contrast administration) and common physics artifacts (including beam hardening). Mimics of acute pulmonary embolism can be seen in normal anatomic structures, disease in non-vascular structures and pulmonary artery filling defects not related to acute pulmonary emboli. Understanding these pitfalls can help mitigate error, improve diagnostic quality and optimize patient outcomes. Dual energy computed tomography holds promise to improve imaging diagnosis, particularly in clinical scenarios where routine CTPA may be problematic, including patients with impaired renal function and patients with altered cardiac anatomy.

Limited Chest Ultrasound to Replace CXR in Diagnosis of Pneumothorax Post Image-Guided Transthoracic Interventions.

PURPOSE: To assess the diagnostic accuracy of limited chest ultrasound in detecting pneumothorax following percutaneous transthoracic needle interventions using chest X-ray (CXR) as the reference standard. METHODS: With IRB approval, after providing consent, asymptomatic patients after percutaneous transthoracic needle interventions were enrolled to undergo limited chest ultrasound in addition to CXR. A chest Radiologist blinded to the patient's prior imaging performed a bedside ultrasound, scanning only the first 3 anterior intercostal spaces. Pneumothorax diagnosed on CXR was categorized as small or large and on ultrasound as grades 1, 2, or 3 when detected in 1, 2, or 3 intercostal spaces, respectively. RESULTS: 38 patients underwent 36 biopsies (34 lungs, 1 pleura, and 1 mediastinum) and 2 coil localizations. CXR showed pneumothorax in 13 patients. Ultrasound was positive in 10 patients, with 9 true-positives, 1 false-positive, 4 false-negatives, and 24 true-negatives. The false positive results were due to apical subpleural bullae. The false-negative results occurred in 2 small apical and 2 focal pneumothoraces at the needle entry sites. Four pneumothoraces were categorized as large on CXR, all of which were categorized as grade 3 on ultrasound. Sensitivity and specificity of US for detection of pneumothorax of any size were 69.23% (95%CI 38.6%, 90.1%) and 96.0% (95%CI 79.6%, 99.9%), and for detection of large pneumothorax were 100% (95%CI 39.8%, 100%) and 100% (95%CI 89.7%, 100%). CONCLUSIONS: Results of this prospective study is promising. Limited chest ultrasound could potentially replace CXR in the management of postpercutaneous transthoracic needle intervention patients.