Impact Analysis of the Routine Use of Dual-Energy Computed Tomography for Characterization of Incidental Renal Lesions.

OBJECTIVE: The aim of this study was to quantify the prevalence of incidental, indeterminate renal lesions on routine contrast-enhanced abdominal computed tomography (CT) and the proportion of such lesions that could be exonerated by dual-energy CT (DECT) postprocessing as benign hyperdense cysts. METHODS: The reports for 2729 consecutive contrast-enhanced DECT scans in the emergency department setting were reviewed for the mention of any renal lesion. For scans with a reported lesion, images were reviewed to assess for the presence of an indeterminate lesion that could not be definitively characterized as benign. All indeterminate lesions were reviewed with DECT postprocessing by 2 radiologists to assess for enhancement and other imaging characteristics and characterized by readers as benign or not definitively benign. Agreement between readers was assessed statistically, and disagreement was resolved by consensus. RESULTS: Two thousand seven hundred twenty-nine scans were performed in 2406 unique patients; a renal lesion was reported in 805 unique patient scans (33.4%). Review of these 805 scans led to discovery of 137 indeterminate lesions in 125 scans (5.2% of patients). Of the 137 lesions, 70 (51.1%) were classified as benign hyperdense cysts by readers, with the remaining 67 lesions classified as not definitively benign (43 solid masses, 9 Bosniak IIF cysts, 8 Bosniak III cysts, 7 Bosniak IV cysts). CONCLUSIONS: Incidental indeterminate renal lesions are common on routine contrast-enhanced CT. More than half of these lesions could potentially be exonerated with DECT as benign Bosniak II cysts, which could avert the need for further workup in 2.8% of patients undergoing routine abdominal CT.

Beyond appendicitis: ultrasound findings of acute bowel pathology.

Bowel pathology is a common unexpected finding on routine abdominal and pelvic ultrasound. However, radiologists are often unfamiliar with the ultrasound appearance of the gastrointestinal tract due to the underutilization of ultrasound for bowel evaluation in the USA. The purpose of this article is to familiarize radiologists with the characteristic ultrasound features of a variety of bowel pathologies. Basic ultrasound technique for bowel evaluation, ultrasound appearance of normal bowel, and key ultrasound features of common acute bowel abnormalities will be reviewed.

Dual-Energy CT for Abdominal and Pelvic Trauma.

Computed tomography (CT) is key to the assessment of hemodynamically stable patients with blunt or penetrating trauma to the abdomen and pelvis. Dual-energy (DE) CT is a technology that allows acquisition of data at both high and low kilovolt peaks, allowing materials that have different x-ray absorption behaviors as a function of kilovolt peak (such as iodine) to be differentiated and quantified. DE CT has a variety of postprocessing applications that may be helpful in abdominal and pelvic trauma, including iodine-selective imaging, virtual monenergetic imaging, and virtual noncalcium imaging. Both iodine-selective imaging and virtual monoenergetic imaging can increase the conspicuity of traumatic solid-organ and hollow visceral injuries, making injuries easier to detect and categorize. Iodine-selective imaging, through the use of iodine maps and virtual noncontrast images, can assist in the evaluation of active contrast extravasation. Virtual noncalcium images can unmask bone marrow edema, improving detection of subtle fractures. The purpose of this review article is to familiarize radiologists with the basic physics and technical principles of DE CT, common postprocessing techniques, and the potential added value of DE CT in patients with abdominal and pelvic trauma. The technical limitations of DE CT are also reviewed, as are diagnostic pitfalls and common challenges in interpretation. ©RSNA, 2018.

Motion Artifact Reduction From High-Pitch Dual-Source Computed Tomography Pulmonary Angiography.

PURPOSE: The purpose of this study was to compare quantitative and qualitative measures of aortic, cardiac, and respiratory motion artifact between high-pitch dual-source (DS) and single-source (SS) computed tomography pulmonary angiography (CTPA) protocols. METHODS: This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study retrospectively reviewed 80 non-electrocardiogram-gated CTPA examinations acquired with a second-generation DS system at 100 kVp following 50 mL iodinated contrast injection - 40 consecutive SS and 40 consecutive DS studies. Quantitative measures of aortic, left ventricular, and diaphragmatic motion were recorded as the maximal excursion of a structure's "double image," and 3 independent readers performed qualitative motion assessments. Pulmonary arterial contrast enhancement, image noise, and radiation dose metrics were recorded. Statistical analyses were performed with 1-way analysis of variance and Fisher exact test. RESULTS: Dual source outperformed SS technique in both quantitative and qualitative measures of motion. Mean distances between motion-artifact double images were reduced with DS protocol at each location (all P ≤ 0.004), and DS examinations were more likely to receive an assessment of no motion in all locations (all P < 0.0001). The DS protocol demonstrated increases in contrast enhancement, although increased image noise resulted in lower enhancement to noise ratio. Mean radiation dose was 60% lower using the DS protocol. CONCLUSION: High-pitch DS CTPA significantly reduces artifacts resulting from ascending aortic, cardiac, and diaphragmatic motion.

Dual-Energy CT of Incidental Findings in the Abdomen: Can We Reduce the Need for Follow-Up Imaging?

OBJECTIVE: The purpose of this article is to review the added value of dual-energy CT for characterization of incidental lesions discovered during routine abdominal CT. CONCLUSION: Dual-energy CT allows acquisition of virtual unenhanced images, iodine maps, and virtual monochromatic images, all of which can aid in characterizing incidental lesions at the time of detection. Virtual unenhanced images and iodine maps are used for assessment of enhancement of incidental lesions, which can help differentiate suspicious enhancing lesions from benign nonenhancing lesions. Virtual monochromatic images can be obtained at low energy to improve conspicuity and detection of subtle lesions. Routine use of dual-energy CT may eliminate the need for additional imaging in the workup of some of these incidental lesions.

Use of Dual-Energy CT and Iodine Maps in Evaluation of Bowel Disease.

Dual-energy computed tomography (CT) relies on material-dependent x-ray absorption behavior from concurrently acquired high- and low-kilovolt peak data and has a range of imaging applications. This article focuses on use of dual-energy CT in assessment of bowel disease. After a summary of relevant dual-energy CT image acquisition and postprocessing principles, the authors describe dual-energy techniques of greatest utility in evaluation of benign and malignant pathologic conditions in the bowel, including neoplastic, vascular, infectious, and inflammatory disorders, as well as in assessment of abdominopelvic trauma. The dual-energy postprocessing techniques of iodine-selective imaging and virtual monochromatic imaging have the broadest applicability in bowel imaging. They may be used for improved visualization of subtle differences in bowel wall enhancement or for quantitative assessment of altered enhancement for evaluation of a neoplasm or bowel ischemia. Iodine images and virtual monochromatic low-kiloelectron volt images are particularly helpful for assessment of a neoplasm, ischemia, infection, or inflammation, while iodine maps paired with virtual nonenhanced images are most helpful to differentiate iodine from other dense materials, as in gastrointestinal bleeding or trauma. In most applications, radiation doses at dual-energy CT are comparable to those at traditional CT. However, dual-energy CT may allow reduction in radiation dose by using virtual nonenhanced images that obviate an additional nonenhanced CT acquisition. Limitations of dual-energy CT are discussed, including potential challenges in acquisition, postprocessing, and interpretation.

BWH emergency radiology--surgical correlation: small-bowel GI stromal tumor perforation.

We present the radiological and intraoperative correlation of a large necrotic gastrointestinal stromal tumor (GIST) with features of a tumor-bowel fistula and perforation in a 49-year-old woman presenting to the emergency department with a 4-day history of worsening abdominal pain, vomiting, and diarrhea. The patient underwent urgent exploratory laparotomy for partial resection of the small bowel, with primary anastomosis. The purpose of this article is to emphasize the importance for emergency radiologists to be familiar with this entity and its possible complications to help guide the surgeons in the patient's management.

Dual energy CT applications in pancreatic pathologies.

Dual energy CT (DECT) is a technology that is gaining widespread acceptance, particularly for its abdominopelvic applications. Pancreatic pathologies are an ideal application for the many advantages offered by dual energy post-processing. This article reviews the current literature on dual energy CT pancreatic imaging, specifically in the evaluation of pancreatic adenocarcinoma, other solid and cystic pancreatic neoplasms, and pancreatitis. The advantages in characterization and quantification of enhancement, detection of subtle lesions, and potential reduction of imaging phases and contrast usage are reviewed. We also discuss directions for future research, and the ideal use of dual energy CT in routine clinical practice.

CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know.

Acute gastrointestinal (GI) bleeding is a common cause of both emergency department visits and hospitalizations in the USA and can have a high morbidity and mortality if not treated rapidly. Imaging is playing an increasing role in both the diagnosis and management of GI bleeding. In particular, CT angiography (CTA) is a promising initial test for acute GI bleeding as it is universally available, can be performed rapidly and may provide diagnostic information to guide management. The purpose of this review was to provide an overview of the uses of imaging in the diagnosis and management of acute GI bleeding, with a focus on CTA.

Accuracy and reproducibility of automated, standardized coronary transluminal attenuation gradient measurements.

Coronary computed tomography angiography (CCTA) contrast opacification gradients, or transluminal attenuation gradients (TAG) offer incremental value to predict functionally significant lesions. This study introduces and evaluates an automated gradients software package that can potentially supplant current, labor-intensive manual TAG calculation methods. All 60 major coronary arteries in 20 patients who underwent a clinically indicated single heart beat 320 × 0.5 mm detector row CCTA were retrospectively evaluated by two readers using a previously validated manual measurement approach and two additional readers who used the new automated gradient software. Accuracy of the automated method against the manual measurements, considered the reference standard, was assessed via linear regression and Bland-Altman analyses. Inter- and intra-observer reproducibility and factors that can affect accuracy or reproducibility of both manual and automated TAG measurements, including CAD severity and iterative reconstruction, were also assessed. Analysis time was reduced by 68% when compared to manual TAG measurement. There was excellent correlation between automated TAG and the reference standard manual TAG. Bland-Altman analyses indicated low mean differences (1 HU/cm) and narrower inter- and intra-observer limits of agreement for automated compared to manual measurements (25 and 36% reduction with automated software, respectively). Among patient and technical factors assessed, none affected agreement of manual and automated TAG measurement. Automated 320 × 0.5 mm detector row gradient software reduces computation time by 68% with high accuracy and reproducibility.

Alcohol sclerosis of a giant liver cyst following failed deroofings.

Percutaneous alcohol sclerotherapy for simple liver cysts is an established and safe procedure. We report alcohol ablation of a very large (5.5 liters) liver cyst that had failed laparoscopic deroofing procedures twice. The cyst responded to multisession alcohol sclerotherapy.