Comparison of image quality between a novel mobile CT scanner and current generation stationary CT scanners.

PURPOSE: Point-of-care imaging with mobile CT scanners offers several advantages, provided that the image quality is satisfactory. Our aim was to compare image quality of a novel mobile CT to stationary scanners for patients in a neurosurgical intensive care unit (ICU). METHODS: From November 2020 to April 2021, all patients above 18 years of age examined by a mobile CT scanner at a neurosurgical ICU were included if they also had a stationary head CT examination during the same hospitalization. Quantitative image quality parameters included attenuation and noise in six predefined regions of interest, as well as contrast-to-noise ratio between gray and white matter. Subjective image quality was rated on a 4-garde scale, by four radiologists blinded to scanner parameters. RESULTS: Fifty patients were included in the final study population. Radiation dose and image attenuation values were similar for mobCT and stationary CTs. There was a small statistically significant difference in subjective quality rating between mobCT and stationary CT images. Two radiologists favored the stationary CT images, one was neutral, and one favored mobCT images. For overall image quality, 14% of mobCT images were rated grade 1 (poor image quality) compared to 8% for stationary CT images. CONCLUSION: Point-of-care brain CT imaging was successfully performed on clinical neurosurgical ICU patients with small reduction in image quality, predominantly affecting the posterior fossa, compared to high-end stationary CT scanners.

The potential role of T2*-weighted multi-echo data image combination as an imaging marker for intraplaque hemorrhage in carotid plaque imaging.

BACKGROUND: Carotid atherosclerotic plaques with intraplaque hemorrhage (IPH) are associated with elevated stroke risk. IPH is predominantly imaged based on paramagnetic properties of the upstream hemoglobin degradation product methemoglobin. This is an explorative observational study to test the feasibility of a spoiled gradient echo based T2* weighted MRI sequence (3D MEDIC) for carotid plaque imaging, and to compare signs suggestive of the downstream degradation product hemosiderin on 3D MEDIC with signs of methemoglobin on a T1wBB sequence. METHODS: Patients with recent TIA or stroke were selected based on the presence on non-calcified plaque components on CTA to promote an enriched prevalence of IPH in the material. Patients (n = 42) underwent 3T MRI with 3D MEDIC and 2D turbo spin echo T1w black blood (T1wBB). Images were independently evaluated by two neuroradiologists and Cohens Kappa was used for inter-reader agreement for each sequence. RESULTS: The technical feasibility for 3D MEDIC, was 34/42 patients (81%). Non-calcified plaque components with susceptibility effect without simultaneous T1-shortening-a combination suggestive of hemosiderin, was seen in 13/34 of the plaques. An equally large group display elevated T1w signal in combination with signal loss on 3D MEDIC, a combination suggestive of both hemosiderin and methemoglobin. Cohen's kappa for inter-reader agreement was 0.64 (CI 0.345-0.925) for 3D MEDIC and 0.94 (CI 0.81-1.00) for T1wBB. CONCLUSIONS: 3D MEDIC shows signal loss, without elevated T1w signal on T1wBB, in non-calcified tissue in many plaques in this group of patients. If further studies, including histological verification, confirm that the 3D MEDIC susceptibility effect is indeed caused by hemosiderin, 3D MEDIC could aid in the detection of IPH, beyond elevation of T1w signal.

Impact of iterative reconstructions on image noise and low-contrast object detection in low kVp simulated abdominal CT: a phantom study.

BACKGROUND: Low kilovoltage (kVp) computed tomography (CT) may be used to reduce contrast medium dose in patients at risk of contrast nephropathy, at the cost of increased image noise. PURPOSE: To evaluate: (i) the impact of iterative reconstructions (Siemens SAFIRE) on low-contrast object detection to compensate for increased noise instead of increased tube loading when decreasing tube potential; and (ii) the change in iodine attenuation in simulated abdominal CT. MATERIAL AND METHODS: A phantom was scanned at 70, 80, 100, and 120 kVp at fixed effective tube loading (170 mAsEFF) and fixed radiation dose (CTDIVOL 10 mGy). Images were reconstructed with filtered back-projection (FBP) and SAFIRE strengths S1-S5. Iodine attenuation, objective image noise, contrast-to-noise ratio (CNR), noise power spectrum (NPS), spatial resolution, and subjective detectability of low-contrast objects were evaluated. RESULTS: Compared with 120 kVp iodine attenuation increased by a factor 1.6 and 2.0, and image noise increased by a factor 1.9 and 2.5 at 80 and 70 kVp, respectively. Compared with FBP, SAFIRE showed objective reduction in image noise and increased CNR without loss of spatial resolution or any significant NPS alteration, with general tendency to improve subjective detectability of low-contrast objects. At 170 mAsEFF the number of discernible 1.0% contrast objects at 70 kVp/S5 and 80 kVp/S5 was similar to that at 120 kVp/FBP. CONCLUSION: With the SAFIRE algorithm image noise, CNR and detectability of low-contrast objects may be kept unchanged without increased tube loading when using low kVp settings to reduce contrast medium dose in azotemic patients.

CT angiography in non-traumatic subarachnoid hemorrhage: the importance of arterial attenuation for the detection of intracranial aneurysms.

BACKGROUND: Computed tomography angiography (CTA) is today the primary method for the detection of intracranial aneurysms. The technique has evolved considerably during the last decade, and it is important to establish criteria for high image quality, especially with regard to improving the diagnosis of small aneurysms. PURPOSE: To evaluate diagnostic accuracy and image quality by arterial attenuation of CTA in patients with non-traumatic subarachnoid hemorrhage (SAH). MATERIAL AND METHODS: Between 2005 and 2011, CTA and digital subtraction angiography (DSA) were performed in 326 patients with non-traumatic SAH. Sensitivity and specificity for aneurysm detection were evaluated per patient, per aneurysm, and per ruptured aneurysm. The image quality of CTA was evaluated by arterial attenuation measurements (mean Hounsfield units [HU]) in the internal carotid artery (ICA). RESULTS: In all, 285 aneurysms in 235 patients were detected by DSA, 19 aneurysms were missed on CTA, and 223 aneurysms were classified as ruptured. In 91 patients, no aneurysm was found. Correct diagnosis with CTA was made in 28 patients with perimesencephalic hemorrhage. Sensitivity and specificity (95% confidence interval) calculated per patient were 91.6% (87.3-94.9) and 87.9% (79.8-93.6), respectively, per aneurysm 93.3% (89.7-95.9) and 88% (79.9-93.6), and per ruptured aneurysm 94.9% (91.3-97.3) and 96.7% (90.7-99.3). Arterial attenuation (in HU) in CTA revealing true positive ruptured aneurysms and true negative aneurysms (mean 535 ± 110 HU) differed significantly (P = 0.02) from false negative ruptured aneurysms (mean 424 ± 30 HU). CONCLUSION: CTA has high sensitivity and specificity for the detection of ruptured aneurysms. The sensitivity is related to arterial attenuation in the ICA.

Emergency room decision-making for urgent cranial computed tomography: selection criteria for subsets of non-trauma patients.

BACKGROUND: Computed tomography (CT) of the brain is used extensively in the urgent work-up of patients with a suspicion of intracranial pathology, but is often normal. Previously proposed selection criteria aim at limiting the ordering of urgent cranial CT in the non-trauma population, while maintaining high sensitivity for diagnoses demanding immediate attention. PURPOSE: To retrospectively evaluate these selection criteria in a general non-trauma population from a Swedish tertiary hospital, as well as in a nested subgroup that lacks guidelines at present, namely where the chief complaint was not headache, symptoms clearly indicating stroke, seizures, or vertigo. MATERIAL AND METHODS: Medical records of 346 patients (114 in the nested group) who had undergone urgent cranial CT were reviewed. Selection criteria as proposed by Rothrock (patient age ≥60 years, presence of new onset focal neurologic deficit, headache with vomiting, or altered mental status) were used. Acute cerebral infarction, intracranial hemorrhage, malignancy, infection, cerebral edema, or hydrocephalus were considered significant findings. RESULTS: The prevalence of significant findings was 10.1%. The Rothrock criteria had a sensitivity of 97.1% (identifying 34 of 35 significant findings) among all 346 patients and 100% (10/10) among the 114 patients in the subgroup and resulted in a potential scan reduction rate of 22.8% and 11.4%, respectively. In the patient with significant pathology, that was not selected for CT, focal neurological symptoms were not described as newly onset. CONCLUSION: Although 100% sensitivity was not achieved, our results may contribute to the evidence that in the absence of focal neurologic deficit, headache with vomiting or altered mental status in patients aged <60 years cranial tomography can be refrained from, in the general population as well as in the subgroup defined above. Further research might validate patient history as a parameter.

Hybrid iterative reconstruction algorithm in brain CT: a radiation dose reduction and image quality assessment study.

BACKGROUND: Iterative reconstruction (IR) algorithms improve image quality and allow for radiation dose reduction in CT. Dose reduction is particularly challenging in brain CT where good low-contrast resolution is essential. Ideally, evaluation of image quality combines objective measurements and subjective assessment of clinically relevant quality criteria. Subjective assessment is associated with various pitfalls and biases. PURPOSE: To evaluate the potential of the hybrid IR algorithm iDOSE(4) to preserve image quality in phantom and clinical brain CT acquired with 30% reduced radiation dose, and to discuss the image quality assessment methods. MATERIAL AND METHODS: Forty patients underwent two consecutive brain CTs with normal radiation dose (ND) and 30% reduced dose (RD). Both ND and RD were reconstructed with FBP. In addition the reduced dose CTs were reconstructed with two levels of IR (ID2, ID4). Three image quality criteria (grey-white-matter discrimination, basal ganglia delineation, general image quality) were graded and ranked by six neuroradiologists. Noise levels and contrast-to-noise ratios (CNR) were measured in clinical data. Noise, signal-to-noise ratio (SNR), spatial resolution, and noise-power spectrum (NPS) were also assessed in a phantom. RESULTS: Subjective image quality was considered adequate for clinical use for all reconstructions, graded good or excellent in 93% of cases for ND, 83% for ID4, 79% for ID2, and 67% for RD. For all quality parameters, ID4 and ID2 were graded better than RD (P < 0.0055 and P < 0.035), but worse than ND (P < 0.001). In clinical images, objective measurements showed lower noise and significantly higher CNR in ID4 compared with ND and RD (P < 0.001). CNR was similar for ID2 and ND. In the phantom, IR reduced noise while maintaining spatial resolution and NPS. CONCLUSION: The IR algorithm improves image quality of reduced dose CTs and consistently delivers sufficient image quality for clinical purposes. Pitfalls related to subjective assessment can be addressed with careful study design.

Hybrid iterative reconstruction algorithm improves image quality in craniocervical CT angiography.

OBJECTIVE: The purpose of this study was to evaluate the potential of a hybrid iterative reconstruction algorithm for improving image quality in craniocervical CT angiography (CTA) and to assess observer performance. SUBJECTS AND METHODS: Thirty patients (mean age, 58 years; range 16-80 years) underwent standard craniocervical CTA (volume CT dose index, 6.8 mGy, 2.8 mSv). Images were reconstructed using both filtered back projection (FBP) and a hybrid iterative reconstruction algorithm. Five neuroradiologists assessed general image quality and delineation of the vessel lumen in seven arterial segments using a 4-grade scale. Interobserver and intraobserver variability were determined. Mean attenuation and noise were measured and signal-to-noise and contrast-to-noise ratios calculated. Descriptive statistics are presented and data analyzed using linear mixed-effects models. RESULTS: In pooled data, image quality in iterative reconstruction was graded superior to FBP regarding all five quality criteria (p < 0.0001), with the greatest improvement observed in the vertebral arteries. Iterative reconstruction resulted in elimination of arterial segments graded poor. Interobserver percentage agreement was significantly better (p = 0.024) for iterative reconstruction (69%) than for FBP (66%) but worse than intraobserver percentage agreement (mean, 79%). Noise levels, signal-to-noise ratio, and contrast-to-noise ratio were significantly (p < 0.001) improved in iterative reconstruction at all measured levels. CONCLUSION: The iterative reconstruction algorithm significantly improves image quality in craniocervical CT, especially at the thoracic inlet. Despite careful study design, considerable interobserver and intraobserver variability was noted.

CT angiography of intracranial arterial vessels: impact of tube voltage and contrast media concentration on image quality.

BACKGROUND: Computed tomography angiography (CTA) of intracranial arteries has high demands on image quality. Important parameters influencing vessel enhancement are injection rate, concentration of contrast media and tube voltage. PURPOSE: To evaluate the impact of an increase of contrast media concentration from 300 to 400 mg iodine/mL (mgI/mL) and the effect of a decrease of tube voltage from 120 to 90 kVp on vessel attenuation and image quality in CT angiography of intracranial arteries. MATERIAL AND METHODS: Sixty-three patients were included into three protocol groups: Group I, 300 mgI/mL 120 kVp; Group II, 400 mgI/mL 120 kVp; Group III, 400 mgI/mL 90 kVp. Hounsfield units (HU) were measured in the internal carotid artery (ICA) and the M1 and M2 segments of the middle cerebral artery. Image quality grading was performed regarding M1 and M2 segments, volume rendering and general image impression. RESULTS: The difference in mean HU in ICA concerning the effect of contrast media concentration was statistically significant (P = 0.03) in favor of higher concentration. The difference in ICA enhancement due to the effect of tube voltage was statistically significant (P < 0.01) in favor of lower tube voltage. The increase of contrast medium concentration raised the mean enhancement in ICA with 18% and the decrease of tube voltage raised the mean enhancement with 37%. Image quality grading showed a trend towards improved grading for higher contrast concentration and lower tube voltage. Statistically significant better grading was found for the combined effect of both measures except for general impression (P 0.01-0.05). CONCLUSION: The uses of highly concentrated contrast media and low tube voltage are easily performed measures to improve image quality in CTA of intracranial vessel.

Radiation dose reduction in CT of the brain: can advanced noise filtering compensate for loss of image quality?

BACKGROUND: Computed tomography (CT) of the brain is performed with high local doses due to high demands on low contrast resolution. Advanced algorithms for noise reduction might be able to preserve critical image information when reducing radiation dose. PURPOSE: To evaluate the effect of advanced noise filtering on image quality in brain CT acquired with reduced radiation dose. MATERIAL AND METHODS: Thirty patients referred for non-enhanced CT of the brain were examined with two helical protocols: normal dose (ND, CTDI(vol) 57 mGy) and low dose (LD, CTDI(vol) 40 mGy) implying a 30% radiation dose reduction. Images from the LD examinations were also postprocessed with a noise reduction software with non-linear filters (SharpView CT), creating filtered low dose images (FLD) for each patient. The three image stacks for each patient were presented side by side in randomized order. Five radiologists, blinded for dose level and filtering, ranked these three axial image stacks (ND, LD, FLD) as best to poorest (1 to 3) regarding three image quality criteria. Measurements of mean Hounsfield units (HU) and standard deviation (SD) of the HU were calculated for large region of interest in the centrum semiovale as a measure for noise. RESULTS: Ranking results in pooled data showed that the advanced noise filtering significantly improved the image quality in FLD as compared to LD images for all tested criteria. No significant differences in image quality were found between ND examinations and FLD. However, there was a notable inter-reader spread of the ranking. SD values were 15% higher for LD as compared to ND and FLD. CONCLUSION: The advanced noise filtering clearly improves image quality of CT examinations of the brain. This effect can be used to significantly lower radiation dose.

Method for studying gas composition in the human mastoid cavity by use of laser spectroscopy.

OBJECTIVES: We evaluated a method for gas monitoring in the mastoid cavity using tunable diode laser spectroscopy by comparing it to simultaneously obtained computed tomographic (CT) scans. METHODS: The presented optical technique measures free gases, oxygen (O2), and water vapor (H2O) within human tissue by use of low-power diode lasers. Laser light was sent into the tip of the mastoid process, and the emerging light at the level of the antrum was captured with a detector placed on the skin. The absorption of H2O was used to monitor the probed gas volume of the mastoid cavity, and it was compared to the CT scan-measured volume. The ratio between O2 absorption and H2O absorption estimated the O2 content in the mastoid cavity and thus the ventilation. The parameters were compared to the grading of mastoid cavities based on the CT scans (n = 31). The reproducibility of the technique was investigated by measuring each mastoid cavity 4 times. RESULTS: Both O2 and H2O were detected with good reproducibility. The H2O absorption and the CT volume correlated (r = 0.69). The average ratio between the normalized O2 absorption and the H2O absorption signals was 0.7, indicating a lower O2 content than in surrounding air (expected ratio, 1.0), which is consistent with previous findings made by invasive techniques. All mastoid cavities with radiologic signs of disease were detected. CONCLUSIONS: Laser spectroscopy monitoring appears to be a usable tool for noninvasive investigations of gas composition in the mastoid cavity, providing important clinical information regarding size and ventilation.

Correlation between arterial blood volume obtained by arterial spin labelling and cerebral blood volume in intracranial tumours.

OBJECTIVE: To compare measurements of the arterial blood volume (aBV), a perfusion parameter calculated from arterial spin labelling (ASL), and cerebral blood volume (CBV), calculated from dynamic susceptibility contrast (DSC) MRI. In the clinic, CBV is used for grading of intracranial tumours. MATERIALS AND METHODS: Estimates of aBV from the model-free ASL technique quantitative STAR labelling of arterial regions (QUASAR) experiment and of DSC-CBV were obtained at 3T in ten patients with eleven tumours (three grade III gliomas, four glioblastomas and four meningiomas, two in one patient). Parametric values of aBV and CBV were determined in the tumour as well as in normal grey matter (GM), and tumour-to-GM aBV and CBV ratios were calculated. RESULTS: In a 4-pixel ROI representing maximal tumour values, the coefficient of determination R (2) was 0.61 for the comparison of ASL-based aBV tumour-to-GM ratios and DSC-MRI-based CBV tumour-to-GM ratios and 0.29 for the comparison of parametric values of ASL-aBV and DSC-CBV, under the assumption of proportionality. Both aBV and CBV showed a non-significant tendency to increase when going from grade III gliomas to glioblastomas to meningiomas. CONCLUSION: These results suggest that measurement of aBV is a potential tool for non-invasive assessment of blood volume in intracranial tumours.

Classifications of atherosclerotic plaque components with T1 and T2* mapping in 11.7 T MRI.

BACKGROUND AND AIMS: Histopathology is the gold standard for analysis of atherosclerotic plaques but has drawbacks due to the destructive nature of the method. Ex vivo MRI is a non-destructive method to image whole plaques. Our aim was to use quantitative high field ex vivo MRI to classify plaque components, with histology as gold standard. METHODS: Surgically resected carotid plaques from 12 patients with recent TIA or stroke were imaged at 11.7 T MRI. Quantitative T1/T2* mapping sequences and qualitative T1/T2* gradient echo sequences with voxel size of 30 × 30 × 60 µm3 were obtained prior to histological preparation, sectioning and staining for lipids, inflammation, hemorrhage, and fibrous tissue. Regions of interest (ROI) were selected based on the histological staining at multiple levels matched between histology and MRI. The MRI parameters of each ROI were then analyzed with quadratic discriminant analysis (QDA) for classification. RESULTS: A total of 965 ROIs, at 70 levels matched between histology and MRI, were registered based on histological staining. In the nine plaques where three or more plaque components were possible to co-localize with MRI, the mean degree of misclassification by QDA was 16.5 %. One of the plaques contained mostly fibrous tissue and lipids and had no misclassifications, and two plaques mostly contained fibrous tissue. QDA generally showed good classification for fibrous tissue and lipids, whereas plaques with hemorrhage and inflammation had more misclassifications. CONCLUSION: 11.7 T ex vivo high field MRI shows good visual agreement with histology in carotid plaques. T1/T2* maps analyzed with QDA is a promising non-destructive method to classify plaque components, but with a higher degree of misclassifications in plaques with hemorrhage or inflammation.

Can iterative reconstruction algorithms replace tube loading compensation in low kVp hepatic CT? Subjective versus objective image quality.

BACKGROUND: Hepatic computed tomography (CT) with decreased peak kilovoltage (kVp) may be used to reduce contrast medium doses in patients at risk of contrast-induced acute kidney injury (CI-AKI); however, it increases image noise. To preserve image quality, noise has been controlled by X-ray tube loading (mAs) compensation (TLC), i.e. increased mAs. Another option to control image noise would be to use iterative reconstructions (IR) algorithms without TLC (No-TLC). It is unclear whether this may preserve image quality or only reduce image noise. PURPOSE: To evaluate image quality of 80 kVp hepatic CT with TLC and filtered back projection (FBP) compared with 80 kVp with No-TLC and IR algorithms (SAFIRE 3 and 5) in patients with eGFR <45 mL/min. MATERIAL AND METHODS: Forty patients (BMI 18-32 kg/m2) were examined with both protocols following injection of 300 mg I/kg. Hepatic attenuation, image noise, enhancement, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and subjective image quality were evaluated for each patient. RESULTS: Comparing TLC/FBP with No-TLC/IR-S5, there were no significant differences regarding hepatic attenuation, image noise, enhancement, SNR and CNR: 114 vs. 115 HU, 14 vs. 14 HU, 55 vs. 57 HU, 8.0 vs. 8.4, and 3.8 vs. 4.0 in median, respectively. No-TLC/IR-S3 resulted in higher image noise and lower SNR and CNR than TLC/FBP. Subjective image quality scoring with visual grading showed statistically significantly inferior scores for IR-S5 images. CONCLUSION: CT of 80 kVp to reduce contrast medium dose in patients at risk of CI-AKI combined with IR algorithms with unchanged tube loading to control image noise does not provide sufficient diagnostic quality.

Diffusion and perfusion MRI of the brain in comatose patients treated with mild hypothermia after cardiac arrest: a prospective observational study.

BACKGROUND: Outcome for resuscitated cardiac arrest (CA) patients is poor. The 1-year survival rate with favourable neurological outcome (CPC 1-2) after out-of-hospital CA is reported to be 4%. Among resuscitated patients treated within an ICU, approximately 50% regain consciousness, whereas the other 50% remain comatose before they die. Induced hypothermia significantly improves the neurological outcome and survival in patients with primary CA who remain comatose after return of spontaneous circulation. AIM: To evaluate magnetic resonance imaging (MRI) changes in resuscitated CA patients remaining in coma after treatment with hypothermia. METHODS: This prospective, observational study comprised 20 resuscitated CA patients who remained in coma 3 days after being treated with mild hypothermia (32-34 degrees C during 24h). Diffusion and perfusion MRI of the entire brain was performed approximately 5 days after CA. Autopsy was done on two patients. RESULTS: The largest number of diffusion changes on MRI was found in the 16 patients who died. The parietal lobe showed the largest difference in number of acute ischaemic MRI lesions in deceased compared with surviving patients. Perfusion changes, > or = +/-2 SD compared with healthy volunteers from a previously published cerebral perfusion study, were found in seven out of eight patients. The autopsies showed lesions corresponding to the pathologic changes seen on MRI. CONCLUSION: Diffusion and perfusion MRI are potentially helpful tools for the evaluation of ischaemic brain damage in resuscitated comatose patients treated with hypothermia after CA.

Follow-up of intracranial aneurysms treated with detachable coils: comparison of 3D inflow MRA at 3T and 1.5T and contrast-enhanced MRA at 3T with DSA.

INTRODUCTION: The purpose of this prospective study was to compare 3T and 1.5T magnetic resonance angiography (MRA) with digital subtraction angiography (DSA) for the follow-up of endovascular treated intracranial aneurysms to assess the grade of occlusion. MATERIALS AND METHODS: Thirty-seven patients with 41 aneurysms who had undergone endovascular treatment with detachable coils were included. MRA was performed on the same day using an eight-channel sensitivity encoding head-coil with 3D axial inflow technique. At 3T, a contrast-enhanced transverse 3D fast gradient echo acquisition was also performed. Most patients underwent DSA the following day. MRA scans and DSA were classified first independently by two neuroradiologists and an interventional neuroradiologist. Secondly, a consensus was done. Source images, maximum intensity projection, multiplanar reconstruction and volume rendering reconstructions were used for MRA evaluations. A modification of the Raymond classification, previously used for DSA evaluation of recanalization, was used. RESULTS: Statistical comparison of the consensus showed that 3T MRA with 3D axial inflow technique had better agreement with DSA (kappa = 0.43) than 1.5T MRA(kappa = 0.21) and contrast-enhanced MRA (CE-MRA) at 3T (kappa = 0.17). The susceptibility artefacts from the coil mesh were significally smaller at 3T (p = 0.002-0.007) than at 1.5T. CONCLUSION: 3T MRA, using a sensitivity encoding head-coil, showed better agreement with DSA than 1.5T and CE-MRA at 3T for evaluation of aneurysms treated with endovascular coiling.

Head computed tomography for prognostication of poor outcome in comatose patients after cardiac arrest and targeted temperature management.

INTRODUCTION: A multimodal approach to prognostication of outcome after cardiac arrest (CA) is recommended. Evidence for combinations of methods is low. In this post-hoc analysis we described findings on head computed tomography (CT) after CA. We also examined whether generalised oedema on CT alone or together with the biomarker Neuron-specific enolase (NSE) could predict poor outcome. METHODS: Patients participating in the Target Temperature Management after out-of-hospital-cardiac-arrest-trial underwent CT based on clinical indications. Findings were divided into pre-specified categories according to local radiologists descriptions. Generalised oedema alone and in combination with peak NSE at either 48h or 72h was correlated with poor outcome at 6 months follow-up using the Cerebral Performance Category (CPC 3-5). RESULTS: 356/939 (37.9%) of patients underwent head CT. Initial CT≤24h after CA was normal in 174/218 (79.8%), whilst generalised oedema was diagnosed in 21/218 (9.6%). Between days 1-7, generalised oedema was seen in 65/143 (45.5%), acute/subacute infarction in 27/143 (18.9%) and bleeding in 9/143 (6.3%). Overall, generalised oedema predicted poor outcome with 33.6% sensitivity (95%CI:28.1-39.5) and 98.4% specificity (95%CI:94.3-99.6), whilst peak NSE demonstrated sensitivities of 61.5-64.8% and specificity 95.7% (95%CI:89.5-98.4). The combination of peak NSE>38ng/l and generalised oedema on CT predicted poor outcome with 46.0% sensitivity (95%CI:36.5-55.8) with no false positives. NSE was significantly higher in patients with generalised oedema. CONCLUSION: In this study, generalised oedema was more common >24h≤7d after CA. The combination of CT and NSE improved sensitivity and specificity compared to CT alone, with no false positives in this limited population.

Imaging of the Lungs in Organ Donors and its Clinical Relevance: A Retrospective Analysis.

PURPOSE: The aim of the study was to retrospectively evaluate the diagnostic imaging that potential lung donors undergo, the reader variability of image interpretation and its relevance for donation, and the potential information gained from imaging studies not primarily intended for lung evaluation but partially including them. MATERIALS AND METHODS: Bedside chest radiography and computed tomography (CT), completely or incompletely including the lungs, of 110 brain-dead potential organ donors in a single institution during 2007 to 2014 were reviewed from a donation perspective. Two chest radiologists in consensus analyzed catheters and cardiovascular, parenchymal, and pleural findings. Clinical reports and study review were compared for substantial differences in findings that could have led to a treatment change, triggered additional examinations such as bronchoscopy, or were considered important for donation. RESULTS: Among 136 bedside chest radiographs, no differences between clinical reports and study reviews were found in 37 (27%), minor differences were found in 28 (21%), and substantial differences were found in 71 (52%) examinations (P<0.0001). In 31 of 42 (74%) complete or incomplete CT examinations, 50 of 74 findings with relevance for lung donation were not primarily reported (P<0.0001). CONCLUSIONS: The majority of donor patients undergo only chest radiography. A targeted imaging review of abnormalities affecting the decision to use donor lungs may be useful in the preoperative stage. With a targeted list, substantial changes were made from initial clinical interpretations. CT can provide valuable information on donor lung pathology, even if the lungs are only partially imaged.

Blood-brain barrier permeability following traumatic brain injury.

BACKGROUND: Brain edema and intracranial hypertension is deleterious after traumatic brain injury (TBI), but the underlying pathophysiology is complex and poorly understood. One major subject of controversy is the time course and extent of blood-brain barrier (BBB) dysfunction following trauma, and previous studies in humans have only provided semi-quantitative data. The objective of the present study was therefore to quantify changes in BBB-permeability in the early course of TBI, when brain edema is still evolving. METHODS: Sixteen non-consecutive brain trauma patients and two controls were included. Following i.v. injection of iohexol and CT perfusion scans, patients were scanned eight times from 4 to 25 minutes. Blood to brain transfer constant (Ki) for iohexol (molecular weight 821 D), reflecting permeability and available area for diffusion, was calculated offline by Patlak plot analysis of the enhancement curves of intracerebral large venous vessels and pericontusional brain parenchyma. RESULTS: In non-ischemic tissue surrounding contusions and hematomas Ki was increased 2- to 10-fold compared to normal tissue, reaching maximal values of 0.5 mL/min/100 g. In non-injured areas and in controls Ki was about 0.06 mL/min/100 g. The increase was more pronounced in the most severely injured patients, and was detectable within 24 hours after trauma and up to five days after. CONCLUSIONS: Our results suggest that traumatic brain injury is associated with early focal increases in small molecular BBB-permeability. The results indicate that in the injured brain, capillary hydrostatic and oncotic pressures may influence edema formation.

Reduced Quality of Life in Patients with Pituitary Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Prospective Longitudinal Study.

OBJECTIVE: Pituitary dysfunction (PD) after aneurysmal subarachnoid hemorrhage (SAH) has been demonstrated in several studies. Given the similarities between psychological symptoms and reduced quality of life (QoL) in patients with PD and fatigue commonly seen in patients after SAH, we investigated the relationship between QoL and PD after SAH. METHODS: There were 51 patients with aneurysmal SAH prospectively recruited and evaluated for health-related QoL using the Psychological General Well-Being Index. Evaluations were conducted 3-6 months (n = 45), 6-12 months (n = 44), and 12-24 months (n = 44) after SAH, with concomitant assessment of endocrine function. The study protocol also included a magnetic resonance imaging examination 3 months after SAH. RESULTS: Mean general well-being scores showed a positive trend from 97.3 at 3-6 months to 104.3 at 12-24 months for all patients. Multiple regression analysis identified age, sex, Hunt and Hess grade, and PD as independent predictors for general well-being. Patients with PD had significantly lower scores compared with patients with normal pituitary function at 3-6 months (85.4 vs. 101.7) and 6-12 months (90.4 vs. 105.3). This result was due to central hypoadrenalism (score 81.6 at 3-6 months and score 82.2 at 6-12 months) but not other types of PD. The extent of magnetic resonance imaging lesions had a significant negative correlation to Glasgow Outcome Scale score at all follow-up evaluations. All patients with hypothalamic magnetic resonance imaging lesions had evidence of PD at some point during the follow-up period. CONCLUSIONS: The results support PD, and central hypoadrenalism in particular, as a contributing factor for impaired health-related QoL in patients after SAH.