Prostatic Urethral Length on MRI Potentially Predicts Late Genitourinary Toxicity After Prostate Cancer Radiation.

RATIONALE AND OBJECTIVES: The purpose of our study was to evaluate pretreatment prostate quantitative magnetic resonance imaging (MRI) measurements and clinical characteristics in predicting genitourinary (GU) toxicity after radiotherapy (RT) for prostate cancer. MATERIALS AND METHODS: In this single-institution retrospective cohort study, we evaluated patients with prostate adenocarcinoma who underwent MRI within 6 months before completing definitive RT and follow-up information in our GU toxicity database from June 2016 to February 2023. MRI measurements included quantitative urethra, prostate, and bladder measurements. GU toxicity was physician-scored using the Common Terminology Criteria for Adverse Events (CTCAE v4.0) with acute toxicity defined as ≤180 days and late defined as >180 days. Multivariable logistic regression model was constructed for grade ≥2 acute toxicity and Cox proportional hazards regression for late toxicity, adjusted for clinical factors and RT method. RESULTS: A total of 361 men (median age 68 years, interquartile range [IQR] 62-73) were included; 14.4% (50/347) men experienced grade ≥2 acute toxicity. Brachytherapy (odds ratio [OR]: 2.9, 95% confidence interval [CI]: 1.5-5.8), P < 0.01) was associated with increased odds of acute GU toxicity, and longer MUL (OR: 0.41 [95%CI: 0.18-0.92], P = 0.03) with decreased odds. Median follow-up for late toxicity was 15.0 months (IQR: 9.0-28.0) with approximately 88.7% and 72.0% patients free of toxicity at 1 and 3 years, respectively. Only longer prostatic urethral length (hazard ratio [HR]: 1.6, 95%CI: 1.2-2.1, P < 0.01) was associated with increased risk of late GU toxicity, notably urinary frequency/urgency symptoms (HR: 1.7 [95%CI: 1.3-2.3], P < 0.01). CONCLUSION: Longer prostatic urethral length measured on prostate MRI is independently associated with higher risk of developing late grade ≥2 GU toxicity after radiation therapy for prostate cancer. This pretreatment metric may be potentially valuable in risk-stratification models for quality of life following prostate RT.

MRI of Benign Prostatic Hyperplasia: Important Pre- and Posttherapeutic Considerations.

New minimally invasive techniques that reduce morbidity while improving lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) have become attractive alternatives for patients, in comparison to traditional techniques such as transurethral resection of the prostate (TURP) and simple prostatectomy. Pre- and postprocedural MRI is not routinely performed for LUTS due to BPH treatments. However, because of the combination of rapidly evolving treatments available for LUTS due to BPH and increasing demand for prebiopsy prostate MRI for detection of clinically significant prostate cancer (PCa), an understanding of procedural techniques and expected changes are important for accurate interpretation of prostate MRI performed after treatment of BPH. The authors discuss the imaging evaluation of LUTS due to BPH and emerging predictors of treatment success. The posttreatment appearance and underlying anatomic changes in the prostate after medical, surgical, and minimally invasive treatments including TURP, simple prostatectomy, laser enucleations and ablations, prostatic urethral lift, water vapor thermal therapy, and prostate artery embolization are detailed. Most procedures reduce prostate volume, notably in the periurethral prostatic tissue. Ablations create areas of necrosis and can distort the normal zonal anatomy between the transition zone and the peripheral zone, and prostate artery embolization creates infarcts in the transition zone. Mechanical prostatic urethral lift devices open the anterior channel at the bladder base but create susceptibility artifacts that can obscure and prevent detection of a lesion in the transition zone. Also discussed are the detection of clinically significant prostate cancer in the postprocedural prostate and imaging of BPH procedure complications such as urethral strictures, abscesses, and hematuria. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Purysko in this issue.

Impact of the bladder detrusor muscular ring on lower urinary tract symptoms due to benign prostatic hyperplasia: A quantitative MRI analysis.

BACKGROUND: The etiology of lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH) remains uncertain. OBJECTIVE: The purpose of our study was to quantitatively analyze anatomic characteristics on magnetic resonance imaging (MRI) to assess novel independent factors for symptoms. METHODS: This retrospective single-institution study evaluated treatment-naïve men who underwent prostate MRI within 3 months of international prostate symptom score (IPSS) scoring from June 2021 to February 2022. Factors measured on MRI included: size of the detrusor muscular ring (DMR) surrounding the bladder outlet, central gland (CG) mean apparent diffusion coefficient (ADC), levator hiatus (LH) volume, intrapelvic volume, intravesicular prostate protrusion (IPP) volume, CG volume, peripheral zone (PZ) volume, prostate urethra angle (PUA), and PZ background ordinal score. Multivariable logistic regression and receiver operating characteristic analysis were used to analyze factors for moderate/severe (IPSS ≥ 8) and severe LUTS/BPH (IPSS ≥ 20). RESULTS: A total of 303 men (mean age: 66.1 [SD: 8.1]) were included: 154 demonstrated moderate or severe symptoms with 28 severe and 149 with asymptomatic/mild symptoms. Increasing age [p = 0.02; odds ratio (OR): 1.05 (1.01-1.08)], PUA [p = 0.02; OR: 1.05 (1.01-1.09)], LH volume [p = 0.04; OR: 1.02 (1.00-1.05)], and DMR size measured as diameter [p < 0.001; OR: 5.0 (3.01-8.38)] or area [p < 0.001; OR: 1.92 (1.47-2.49)] were significantly independently associated with moderate/severe symptoms, with BMI [p = 0.02; OR: 0.93 (0.88-0.99)] inversely related. For every one cm increase in DMR diameter, patients had approximately five times the odds for moderate/severe symptoms. Increasing DMR size [diameter p < 0.001; OR: 2.74 (1.76-4.27) or area p < 0.001; OR: 1.37 (1.18-1.58)] was independently associated with severe symptoms. Optimal criterion cutoff of DMR diameter for moderate/severe symptoms was 1.2 cm [sensitivity: 77.3; specificity: 71.8; AUC: 0.80 (0.75-0.84)]. Inter-reader reliability was excellent for DMR diameter [ICC = 0.92 (0.90-0.94)]. CONCLUSION: Expansion of the DMR surrounding the bladder outlet is a novel anatomic factor independently associated with moderate and severe LUTS/BPH, taking into account prostate volumes, including quantified IPP volume, which were unrelated. Detrusor ring diameter, easily and reliably measured on routine prostate MRI, may relate to detrusor dysfunction from chronic stretching of this histologically distinct smooth muscle around the bladder neck.

Which measurement method should be used for prostate volume for PI-RADS? A comparison of ellipsoid and segmentation methods.

PURPOSE: Prostate volume and PSA density (PSAd) are important in the risk stratification of suspected prostate cancer (Pca). PI-RADS v2.1 allows for determining volume via segmentation or ellipsoid calculation. The purpose of our study was to compare ellipsoid and segmentation volume calculation methods and evaluate if PSAd diagnostic performance is altered. METHODS: We retrospectively assessed 397 patients (mean age/standard deviation: 63.7/7.4 years) who underwent MRI and prostate biopsy or prostatectomy, with Pca classified by Gleason ≥3 + 4 and ≥4 + 4 disease. Prostate total volumes were determined with ellipsoid calculations (TVe) and with semi-automated segmentation (TVs), along with inter-rater reliability with intraclass correlation coefficient (ICC). PSAd was calculated for TVe and TVs and ROC curves were created to compare performance for Gleason ≥3 + 4 and ≥4 + 4 disease. RESULTS: TVe was significantly higher than TVs (p < 0.0001), with mean TVe = 55.4 mL and TVs = 51.0 mL. ROC area under the curve for PSAd derived with TVe (0.63, 95%CI:0.59-0.68) and TVs (0.64, 95%CI:0.59-0.68) showed no significant difference for Gleason ≥3 + 4 disease (p = 0.45), but PSAd derived with TVs (0.63, 95%CI: 0.58-0.68) significantly outperformed TVe (0.61, 95%CI: 0.57-0.67) for Gleason ≥4 + 4 disease (p = 0.02). Both methods demonstrated excellent inter-rater reliability with TVe with ICC of 0.93(95%CI: 0.92-0.94) and TVs with ICC of 0.98(95%CI: 0.98-0.99). CONCLUSION: Traditional ellipsoid measurements tend to overestimate total prostate volume compared to segmentation, but both methods demonstrate similar diagnostic performance of derived PSA density for PI-RADS clinically significant disease. For higher grade disease, PSAd derived from segmentation volumes demonstrates statistically significant superior performance. Both methods are viable, but segmentation volume is potentially better.

Benign prostate hyperplasia as a potential protective factor against prostate cancer: Insights from a magnetic resonance imaging study of compositional characteristics.

PURPOSE: The structural relationship between benign prostate hyperplasia (BPH) and prostate cancer (Pca) is controversial. The purpose of our study was to examine the association between quantitative prostate compositional metrics by magnetic resonance imaging (MRI) and Pca. METHODS: We identified 405 patients who underwent prostate MRI and biopsy and/or prostatectomy from January 2019 to January 2021 at our institution. Segmentation volumetric methods were used to assess central gland (CG) and peripheral zone (PZ) volume. PZ mean thickness and mean apparent diffusion coefficient (ADC), marker of underlying histologic components, were measured. Multivariable logistic regression was performed with outcomes of ≥Grade Group (GG) 2 Pca and for multifocal disease. RESULTS: On multivariable analysis, higher CG volumes were at lower odds of ≥GG2 disease (n = 227) (OR: 0.97, 95% CI 0.96-0.98, p < 0.0001), taking into account PZ volume (p = 0.18) and thickness (p = 0.70). For every one cc increase in CG volume, there was an approximately 3% decrease in odds of ≥GG2 disease. Similar findings were noted for multifocal disease (n = 180) (OR: 0.97, 95% CI 0.96-0.98, p < 0.0001). Notably, ADC of the normal PZ was not significantly associated with CG volume (p = 0.21) nor a predictor of disease (p = 0.49). CONCLUSIONS: Increasing central gland volume, driven by BPH, is associated with lower odds of significant Pca, including multifocal disease, while PZ anatomic and histologic surrogate changes were noncontributory. Findings support BPH impediment of global tumor growth predicted by theoretical mechanobiological model. This potential stabilizing factor should be further studied for risk stratification and in consideration for BPH therapy.

Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Tissue in Patients with Localized Prostate Cancer: A Prospective Phase 1 Clinical Trial.

BACKGROUND: Magnetic resonance imaging-guided transurethral ultrasound ablation (MRI-TULSA) is a novel minimally invasive technology for ablating prostate tissue, potentially offering good disease control of localized cancer and low morbidity. OBJECTIVE: To determine the clinical safety and feasibility of MRI-TULSA for whole-gland prostate ablation in a primary treatment setting of localized prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: A single-arm prospective phase 1 study was performed at three tertiary referral centers in Canada, Germany, and the United States. Thirty patients (median age: 69 yr; interquartile range [IQR]: 67-71 yr) with biopsy-proven low-risk (80%) and intermediate-risk (20%) PCa were treated and followed for 12 mo. INTERVENTION: MRI-TULSA treatment was delivered with the therapeutic intent of conservative whole-gland ablation including 3-mm safety margins and 10% residual viable prostate expected around the capsule. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary end points were safety (adverse events) and feasibility (technical accuracy and precision of conformal thermal ablation). Exploratory outcomes included quality of life, prostate-specific antigen (PSA), and biopsy at 12 mo. RESULTS AND LIMITATIONS: Median treatment time was 36min (IQR: 26-44) and prostate volume was 44ml (IQR: 38-48). Spatial control of thermal ablation was ±1.3mm on MRI thermometry. Common Terminology Criteria for Adverse Events included hematuria (43% grade [G] 1; 6.7% G2), urinary tract infections (33% G2), acute urinary retention (10% G1; 17% G2), and epididymitis (3.3% G3). There were no rectal injuries. Median pretreatment International Prostate Symptom Score 8 (IQR: 5-13) returned to 6 (IQR: 4-10) at 3 mo (mean change: -2; 95% confidence interval [CI], -4 to 1). Median pretreatment International Index of Erectile Function 13 (IQR: 6-28) recovered to 13 (IQR: 5-25) at 12 mo (mean change: -1; 95% CI, -5 to 3). Median PSA decreased 87% at 1 mo and was stable at 0.8 ng/ml (IQR: 0.6-1.1) to 12 mo. Positive biopsies showed 61% reduction in total cancer length, clinically significant disease in 9 of 29 patients (31%; 95% CI, 15-51), and any disease in 16 of 29 patients (55%; 95% CI, 36-74). CONCLUSIONS: MRI-TULSA was feasible, safe, and technically precise for whole-gland prostate ablation in patients with localized PCa. Phase 1 data are sufficiently compelling to study MRI-TULSA further in a larger prospective trial with reduced safety margins. PATIENT SUMMARY: We used magnetic resonance imaging-guided transurethral ultrasound to heat and ablate the prostate in men with prostate cancer. We showed that the treatment can be targeted within a narrow range (1mm) and has a well-tolerated side effect profile. A larger study is under way. TRIAL REGISTRATION: NCT01686958, DRKS00005311.

Shielding artificially increases the attenuation of water: study of CT gradient attenuation induced by shielding (CT GAINS).

RATIONALE AND OBJECTIVES: Quantitatively analyze the computed tomography (CT) attenuation effects caused by bismuth shields, which are used to reduce superficial organ dose. MATERIALS AND METHODS: The solid water uniformity section of the American College of Radiology CT phantom was scanned with a modified chest CT protocol. Scans were performed with a bismuth breast shield in multiple configurations, emphasizing three clinically relevant orientations. Attenuation effects were measured as changes in mean Hounsfield unit (HU) values of equal midsagittal regions of interest (ROI). Multiple statistical techniques were used in regression analysis. RESULTS: Bismuth shielding resulted in significant positive shifts of the expected Hounsfield unit values. The mean nonshielded CT attenuation was -0.16 ± 0.75 HU. Based on the clinically relevant ROI distance from the shield (~3-16 cm), the shielded values ranged from 43.8-4 HU, 45.8-10.1 HU, and 50.6-4.5 HU for shields 1, 2, and 3, respectively. All shield configurations displayed a statistically significant shift (P < .0001) at all distance ranges. The best fitting regression model was a quadratic function of distance versus logarithmic function of HU. A prediction table of the approximate shift in water HU values as a function of ROI distance from the shield was generated per shield type from their respective close-fitting regressions. CONCLUSIONS: The data support the claim that bismuth shields increase the attenuation of water, which can cause inaccurate characterization of simple fluid, giving the appearance of complex fluid or even solid density. However, there is potential for anticipation of the attenuation effects to validate continued use of these shields for dose reduction.

Diagnostic performance of dual-time 18F-FDG PET in the diagnosis of pulmonary nodules: a meta-analysis.

RATIONALE AND OBJECTIVE: Perform a comprehensive meta-analysis evaluating the diagnostic performance of dual time point deoxy-2-[(18)F]fluoro-D-glucose positron emission tomography (FDG-PET) in the diagnosis of pulmonary nodules. MATERIALS AND METHODS: MEDLINE, EMBASE, and PUBMED were queried between January 2000 and January 2011. Studies were included if they: 1) used dual time point FDG-PET as a diagnostic test for pulmonary nodules, 2) used pathology or clinical follow-up as the reference standard, and 3) reported absolute number of true-positive (TP), true-negative (TN), false-positive (FP), and false-negative (FN) results or stated sufficient data to derive these values. Summary sensitivity (SN), summary specificity (SP), positive and negative likelihood ratios (LR+) and (LR-), and diagnostic odds ratio were calculated. Heterogeneity of the results was assessed using Forest plots and the value of inconsistency index (I(2)). RESULTS: Inclusion criteria were fulfilled by 10 articles with a total of 816 patients and 890 pulmonary nodules. The summary sensitivity was 85% (82%-89% at 95% confidence interval [CI]) and summary specificity was 77% (CI: 72%-81%), with a LR+ of 2.7 (CI: 1.4-5.2) and a LR- of 0.26 (CI: 0.14-0.49). Diagnostic odds ratio was 11 (CI: 3.8-32.2). Significant heterogeneity was found in the sensitivity (I(2) = 77%) and specificity (90.3%). CONCLUSION: Dual time point FDG-PET demonstrates similar sensitivity and specificity to single time point FDG-PET in the diagnosis of pulmonary nodules. The additive value of the dual time point FDG-PET is questionable, primarily because of the significant overlap of benign and malignant nodule FDG-PET characteristics and lack of consensus criteria for quantitative thresholds to define nodules as malignant.

Magnetic resonance imaging of carotid atherosclerotic plaque in clinically suspected acute transient ischemic attack and acute ischemic stroke.

BACKGROUND: Carotid atherosclerotic plaque rupture is thought to cause transient ischemic attack (TIA) and ischemic stroke (IS). Pathological hallmarks of these plaques have been identified through observational studies. Although generally accepted, the relationship between cerebral thromboembolism and in situ atherosclerotic plaque morphology has never been directly observed noninvasively in the acute setting. METHODS AND RESULTS: Consecutive acutely symptomatic patients referred for stroke protocol magnetic resonance imaging/angiography underwent additional T1- and T2-weighted carotid bifurcation imaging with the use of a 3-dimensional technique with blood signal suppression. Two blinded reviewers performed plaque gradings according to the American Heart Association classification system. Discharge outcomes and brain magnetic resonance imaging results were obtained. Image quality for plaque characterization was adequate in 86 of 106 patients (81%). Eight TIA/IS patients with noncarotid pathogenesis were excluded, yielding 78 study patients (38 men and 40 women with a mean age of 64.3 years, SD 14.7) with 156 paired watershed vessel/cerebral hemisphere observations. Thirty-seven patients had 40 TIA/IS events. There was a significant association between type VI plaque (demonstrating cap rupture, hemorrhage, and/or thrombosis) and ipsilateral TIA/IS (P<0.001). A multiple logistic regression model including standard Framingham risk factors and type VI plaque was constructed. Type VI plaque was the dominant outcome-associated observation achieving significance (P<0.0001; odds ratio, 11.66; 95% confidence interval, 5.31 to 25.60). CONCLUSIONS: In situ type VI carotid bifurcation region plaque identified by magnetic resonance imaging is associated with ipsilateral acute TIA/IS as an independent identifier of events, thereby supporting the dominant disease pathophysiology.

Assessment of advanced coronary artery disease: advantages of quantitative cardiac magnetic resonance perfusion analysis.

OBJECTIVES: The purpose of this paper was to compare quantitative cardiac magnetic resonance (CMR) first-pass contrast-enhanced perfusion imaging to qualitative interpretation for determining the presence and severity of coronary artery disease (CAD). BACKGROUND: Adenosine CMR can detect CAD by measuring perfusion reserve (PR) or by qualitative interpretation (QI). METHODS: Forty-one patients with an abnormal nuclear stress scheduled for X-ray angiography underwent dual-bolus adenosine CMR. Segmental myocardial perfusion analyzed using both QI and PR by Fermi function deconvolution was compared to quantitative coronary angiography. RESULTS: In the 30 patients with complete quantitative data, PR (mean +/- SD) decreased stepwise as coronary artery stenosis (CAS) severity increased: 2.42 +/- 0.94 for <50%, 2.14 +/- 0.87 for 50% to 70%, and 1.85 +/- 0.77 for >70% (p < 0.001). The PR and QI had similar diagnostic accuracies for detection of CAS >50% (83% vs. 80%), and CAS >70% (77% vs. 67%). Agreement between observers was higher for quantitative analysis than for qualitative analysis. Using PR, patients with triple-vessel CAD had a higher burden of detectable ischemia than patients with single-vessel CAD (60% vs. 25%; p = 0.02), whereas no difference was detected by QI (31% vs. 21%; p = 0.26). In segments with myocardial scar (n = 64), PR was 3.10 +/- 1.34 for patients with CAS <50% (n = 18) and 1.91 +/- 0.96 for CAS >50% (p < 0.0001). CONCLUSIONS: Quantitative PR by CMR differentiates moderate from severe stenoses in patients with known or suspected CAD. The PR analysis differentiates triple- from single-vessel CAD, whereas QI does not, and determines the severity of CAS subtending myocardial scar. This has important implications for assessment of prognosis and therapeutic decision making.

Diagnostic performance of magnetic resonance imaging in the detection of appendicitis in adults: a meta-analysis.

RATIONALE AND OBJECTIVES: Perform a meta-analysis evaluating the diagnostic performance of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis. MATERIALS AND METHODS: MEDLINE and EMBASE were queried between January 1995 and December 2009. Prospective and retrospective studies were included if they: used MRI as a diagnostic test for appendicitis, used pathology or clinical follow-up as the reference standard, and reported absolute number of true-positive, true-negative, false-positive, and false-negative results, or stated sufficient data to derive these values. Summary sensitivity, summary specificity, positive and negative likelihood ratios (LR+) and (LR-), and diagnostic odds ratio were calculated. Heterogeneity of the results was assessed using Forest plots and the value of inconsistency index (I(2)). RESULTS: The inclusion criteria were fulfilled by eight articles with a total of 363 patients (mean age 26.9 ± 7.2 years; 86.2 % female). The appendix was not found in eight patients, with one article not reporting such data. The summary sensitivity was 97% (92%-99% at 95% confidence interval [CI]) and summary specificity was 95% (CI: 94%-99%), with a LR+ of 16.3 (CI: 9.1-29.1) and a LR- of 0.09 (CI: 0.04-0.197). Diagnostic odds ratio was 299.85 (CI: 97.5-921.61). No heterogeneity was found in the sensitivity (I(2) = 0.0, P = .4589). Minimal heterogeneity was found in the specificity (I(2) = 21.9%, P = .2553). CONCLUSION: MRI appears promising in the evaluation of acute appendicitis, although larger future studies are warranted to confirm the results.

The natural history of acute non-traumatic aortic diseases.

Acute non-traumatic aortic vascular disease is a significant cause of mortality although remains poorly understood in clinical practice. In this pictorial essay, the natural history of three entities will be considered: penetrating aortic ulcer, aortic dissection, and aortic intramural hematoma. It is important to recognize that these disease entities have the potential for rapid evolution to severe complications.

Possible biliary disease: diagnostic performance of high-spatial-resolution isotropic 3D T2-weighted MRCP.

PURPOSE: To retrospectively assess the diagnostic performance of magnetic resonance cholangiopancreatography (MRCP) performed by using a high-spatial-resolution isotropic three-dimensional (3D) fast-recovery fast spin-echo (FSE) sequence with parallel imaging for the evaluation of possible biliary disease. MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board; informed consent was waived. Ninety-five patients (58 female, 37 male; mean age, 51 years; range, 15-91 years) underwent MRCP by using the respiratory-triggered isotropic 3D fast-recovery FSE sequence and endoscopic or percutaneous direct visualization between March 2003 and June 2007. Two independent readers evaluated the MRCP images for strictures, dilatation, and intraductal filling defects. Sensitivity, specificity, and interobserver agreement (kappa statistics) were determined. RESULTS: The respective sensitivity and specificity for strictures, dilatation, and intraductal filling defects (all choledocholithiasis) were 86% (40 of 47) and 94% (45 of 48), 98% (57 of 58) and 100% (37 of 37), and 68% (19 of 28) and 97% (65 of 67) for reader 1 and 88% (41 of 47) and 94% (45 of 48), 96% (56 of 58) and 100% (37 of 37), and 75% (21 of 28) and 99% (66 of 67) for reader 2. The sensitivity for stones larger than 3 mm was 94% (15 of 16) for reader 1 and 100% (16 of 16) for reader 2, whereas the sensitivity for stones 3 mm or smaller was 33% (four of 12) for reader 1 and 42% (five of 12) for reader 2. Agreement between readers was good to excellent, with kappa values of 0.76, 0.85, and 0.98 for strictures, dilatation, and choledocholithiasis, respectively. CONCLUSION: MRCP by using the respiratory-triggered isotropic 3D fast-recovery FSE sequence with parallel imaging demonstrates excellent diagnostic capabilities for possible biliary disease, although it is limited for stones 3 mm or smaller in size.

Diagnostic performance of positron emission tomography in the detection of coronary artery disease: a meta-analysis.

RATIONALE AND OBJECTIVES: Although myocardial perfusion positron emission tomography (PET), using either cyclotron-produced ammonia or generator-produced rubidium 82, has reported excellent diagnostic capabilities in the detection of coronary artery disease (CAD) in individual studies, the technique is not widely used in practice. This may be driven by cost and availability or by unawareness of performance. The purpose of our study was to conduct an evidence-based evaluation of PET in the diagnosis of CAD. MATERIALS AND METHODS: We examined studies from January 1977 to July 2007 using MEDLINE and EMBASE. A study was included if it (1) used PET as a diagnostic test for CAD and (2) used catheter x-ray angiography as the reference standard (> or =50% diameter stenosis). Analysis was performed on a subject and coronary territory level. RESULTS: Nineteen studies (1442 patients) met the inclusion criteria. On a patient level, PET demonstrated a sensitivity of 0.92 (95% confidence interval [CI]: 0.90-0.94) and specificity of 0.85 (CI: 0.79-0.90), with a positive likelihood ratio (LR+) of 6.2 (CI: 3.3-11.8) and negative likelihood ratio (LR-) of 0.11 (CI: 0.08-0.14). On a coronary territory level (n = 1130), PET showed a sensitivity of 0.81 (CI: 0.77-0.84) and specificity of 0.87 (CI: 0.84-0.90), with an LR+ of 5.9 (CI: 4.5-7.9) and an LR- of 0.19 (CI: 0.09-0.38). CONCLUSION: PET demonstrates excellent diagnostic properties in the diagnosis of CAD, especially at the patient level. The capabilities appear superior to those reported in meta-analyses for perfusion imaging with Tl-201 and sestamibi, or anatomical imaging with coronary MDCT angiography or MRA. Given that previous studies have found PET to be cost-effective and the current findings of excellent sensitivity and specificity, the modality should be more widely considered as an initial test in the diagnosis of CAD.

Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis.

OBJECTIVES: The purpose of our study was to conduct an evidence-based evaluation of stress cardiac magnetic resonance imaging (MRI) in the diagnosis of coronary artery disease (CAD). BACKGROUND: Stress cardiac MRI has recently emerged as a noninvasive method in the detection of CAD, with 2 main techniques in use: 1) perfusion imaging; and 2) stress-induced wall motion abnormalities imaging. METHODS: We examined studies from January 1990 to January 2007 using MEDLINE and EMBASE. A study was included if it: 1) used stress MRI as a diagnostic test for CAD (> or =50% diameter stenosis); and 2) used catheter X-ray angiography as the reference standard. RESULTS: Thirty-seven studies (2,191 patients) met the inclusion criteria, with 14 datasets (754 patients) using stress-induced wall motion abnormalities imaging and 24 datasets (1,516 patients) using perfusion imaging. Stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 (95% confidence interval [CI] 0.79 to 0.88) and specificity of 0.86 (95% CI 0.81 to 0.91) on a patient level (disease prevalence = 70.5%). Perfusion imaging demonstrated a sensitivity of 0.91 (95% CI 0.88 to 0.94) and specificity of 0.81 (95% CI 0.77 to 0.85) on a patient level (disease prevalence = 57.4%). CONCLUSIONS: In studies with high disease prevalence, stress cardiac MRI, using either technique, demonstrates overall good sensitivity and specificity for the diagnosis of CAD. However, limited data are available regarding use of either technique in populations with low disease prevalence.

Vasopressor use in the critical care unit for treatment of persistent post-carotid artery stent induced hypotension.

INTRODUCTION: Hypotension is common following carotid artery stenting (CAS), and may be mediated by vagal stimulation and/or suppression of spinal sympathetic outflow. Both mixed alpha/beta agonists (dopamine (DA)), and more selective alpha- agonists (norepinephrine (NE) and phenylephrine (PE)), have been used, but the most effective treatment of post-CAS hypotension is unknown. MATERIALS AND METHODS: We analyzed data for consecutive patients requiring vasopressor treatment of post-CAS hypotension. The treating physician made choice of vasopressor. Endpoints included infusion duration, coronary care unit (CCU) length of stay (LOS), and any major adverse events (death, stroke, myocardial infarction, arrhythmia). RESULTS: During the study period, CAS stenting was performed in 623 patients. CCU admission in atropine non-responders for vasopressor treatment was required in 42 patients (6.7%). DA was used in 20 patients (48%), NE in 13 patients (31%), and PE in nine patients (21%). Vasopressor infusion time was 31.8 +/- 10.6 h for DA, compared with 23.8 +/- 8.1 h for NE (P = 0.052) and 22.1 +/- 6.1 h (P = 0.028) for PE. CCU LOS was 46.5 +/- 14.1 h for DA compared with 36.9 +/- 9.1 h for the NE and PE groups combined (P = 0.056). Major adverse events were more common in patients receiving DA than among patients receiving NE or PE (P = 0.04). CONCLUSIONS: Compared with DA, treatment of post-CAS hypotension with a selective alpha-agonist (NE or PE) is associated with shorter drug infusion time, shorter CCU LOS, and fewer major adverse events.

Composition of the stable carotid plaque: insights from a multidetector computed tomography study of plaque volume.

BACKGROUND AND PURPOSE: Calcification has been associated with carotid plaque stability; however, an acceptable in vivo method to define plaques based on this component remains to be developed. The purpose of our study was to compare calcified and noncalcified volumes of carotid artery culprit symptomatic plaques with asymptomatic plaques using multidetector computed tomography. METHODS: We identified 102 patients with > or =50% stenosis using NASCET criteria by multidetector computed tomography angiography between January 2004 and May 2006, which included 35 symptomatic (stenosis: 82.0+/-11.9%) and 67 asymptomatic patients (stenosis: 79.4+/-10.8%). Total plaque volume, noncalcified plaque volume, calcified plaque volume, and calcified/total ratio were measured for the 102 index plaques causing stenosis. RESULTS: In a model including age, stenosis, and cardiovascular risk factors, calcified plaque volume/total plaque volume was significantly inversely associated with the occurrence of symptoms (P=0.012; odds ratio, 0.047; 95% CI, 0.004 to 0.511). There was a notable overlap in the calcified plaque volume/total plaque volume ratio between 0% and 45% for symptomatic and asymptomatic plaques. However, calcification >45% of the total plaque was very specific: 97.1% (34/35) for absence of symptoms (sensitivity: 28.4% 19/67). No significant association between total plaque volume, noncalcified plaque volume, or calcified plaque volume and symptomatology was found. CONCLUSIONS: The proportion of carotid plaque calcification, rather than absolute volume, is associated with stability in patients with stenosis. Specifically, for a subset of patients, plaque calcification >45% of the total volume may represent a clinically useful cutoff. The carotid plaque calcium ratio, determined by multidetector computed tomography volume measurements, may help noninvasively risk stratify patients with asymptomatic stenosis.

Carotid artery calcification on CT may independently predict stroke risk.

OBJECTIVE: The purpose of our study was to quantitatively evaluate calcified atherosclerotic burden in the cervical carotid arteries using MDCT to determine the relationship of scores with luminal stenosis and symptomatology. MATERIALS AND METHODS: Calcium plaque volume was measured in 106 cervical carotid arteries (53 patients) using MDCT angiography. The study group included 32 asymptomatic patients (mean age, 70.2 +/- 8.7 [SD] years; 15 women, 17 men) and 21 patients with ischemic neurologic symptoms (69.6 +/- 12.9 years; eight women, 13 men). By vessel, there were 43 high-grade stenotic (> or = 60% by North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria), 15 moderate-grade stenotic (30-59%), and 44 mild-grade stenotic or normal (0-29%) vessels, with four excluded for prior carotid endarterectomy. Volume scores were calculated by summing the area of calcium in the common and extracranial internal carotid arteries on axial slices and multiplying by the slice increment. RESULTS: Controlling for cardiovascular risk factors and luminal stenosis, we found that scores were significantly related to the occurrence of symptoms (p = 0.003). Even with patient age as a covariant, patients with high-grade stenosis had significantly higher scores than those without high-grade disease (p = 0.004). Moreover, quantitative burden was associated with luminal stenosis on adjusted multivariate analysis (p = 0.034). The specificity and positive predictive value for high-grade luminal narrowing were notably lower on individual vessel analysis than on total score analysis, likely secondary to variability in vascular remodeling. CONCLUSION: Calcium scores in the cervical carotid arteries may represent an independent marker for luminal stenosis and ischemic symptoms. A prospective longitudinal study examining calcium levels and morbidity may be warranted to examine whether burden has a role in risk stratification.

Accuracy of computed tomography attenuation values in the characterization of pleural fluid: an ROC study.

RATIONALE AND OBJECTIVES: To assess the accuracy of computed tomography (CT) in characterizing pleural fluid based on attenuation values. MATERIALS AND METHODS: Protocol was approved by the local institutional review board and informed consent was waived. We retrospectively analyzed 145 pleural effusions of 145 patients (mean/standard deviation age: 60.7/15.9 years; 69 females) who underwent CT of the thorax and diagnostic thoracentesis within 7 days of each other. Effusions were classified as transudates or exudates using laboratory markers based on Light's criteria. The mean Hounsfield units (HU) of an effusion was determined by a region of interest on the three slices with the greatest anteroposterior diameter. A receiver operating characteristic curve was constructed to determine threshold values for classification on the basis of mean HU and to examine overall accuracy, using the area under the curve (A(z)). RESULTS: Of the 101 exudates and 44 transudates, the mean attenuation of exudates (17.1 HU/standard deviation 4.4) was significantly higher than transudates (12.5 HU/6.3), (P < .001). There was a modest but significant positive relationship between mean HU and laboratory markers, with the strongest relationship with pleural/serum protein (r = 0.57, P < .001) and total pleural protein (r = 0.56, P < .001). The overall accuracy of attenuation values for identifying exudates was moderate, Az = 0.775, standard error = 0.039, with the largest limitation being the overlap with transudates in the 10-20 HU range, which constituted 66% (90/145) of the total effusions measured. CONCLUSION: Although the mean attenuation of exudates is significantly higher than transudates, the clinical use of CT numbers to characterize pleural fluid is not recommended, as their accuracy is only moderate. Moreover, there is a notable overlap in attenuation values between transudates and exudates for a majority of effusions.