Reasons for using swelling ratio in sonographic diagnosis of carpal tunnel syndrome and a reliable method for its calculation.

INTRODUCTION: The aim of this study was to investigate factors affecting median nerve cross-sectional area (CSA) and determine a dependable swelling ratio (SR) calculation method. METHODS: Using ultrasonography, median nerve CSAs were measured at the tunnel inlet, midtunnel, and outlet, and at 4 cm and 12 cm proximal to the wrist. We used CSAmax as the largest of the tunnel measurements and calculated swelling ratios (SRs) by using the CSAmax. Sonographic measurements were correlated with electrophysiologic findings. We evaluated the effects of gender, weight, and height on median nerve thickness. RESULTS: We studied 95 wrists of 55 CTS patients and 48 wrists of 27 volunteers. Gender, weight, and height had effects on certain median nerve CSA measurements. CSAmax, SRmax4, and SRmax12 had superior correlations with electrophysiologic findings. The correlation between 4-cm and 12-cm median nerve CSAs was statistically significant (r = 0.879 and P < 0,001). CONCLUSION: We have developed a reliable SR method considering factors affecting median nerve CSA.

Time-resolved MR angiography of the intracranial venous system: an alternative MR venography technique.

OBJECTIVES: To compare time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance angiography (MRA) with two-dimensional time-of-flight (TOF) magnetic resonance venography (MRV), and three-dimensional contrast-enhanced (CE) MRV in the visualisation of normal cerebral veins and dural venous sinuses. METHODS: This prospective study consisted of 35 consecutive patients. All patients were examined with TOF MRV, TRICKS MRA and CE MRV; a single dose of intravenous contrast material was administered for the last two sequences. The image quality of these techniques was assessed and compared qualitatively (by a semiquantitative scoring system) and quantitatively (by calculating signal-to-noise ratios [SNRs] and contrast-to-noise ratios [CNRs]). RESULTS: Left transverse sinus, left sigmoid sinus, bilateral thalamostriate veins and Trolard veins were better visualised by TRICKS MRA and CE MRV compared with TOF MRV (P < 0.05). For left thalamostriate vein visualisation, TRICKS MRA was inferior to CE MRV (P < 0.05). With quantitative analysis the SNRs and CNRs were highest at TRICKS MRA, which was followed by CE MRV and TOF MRV (P < 0.05). CONCLUSIONS: Despite its limited spatial resolution, TRICKS MRA is comparable to static CE MRV and better than TOF MRV in the visualisation of normal dural sinuses and cerebral veins. KEY POINTS: • Time resolved magnetic resonance angiography can image the intracranial venous system dynamically • It seems comparable to contrast-enhanced MRV techniques in venous visualisation • The optimal phase for venous structures can be chosen from the dynamic data set • The diagnostic performance in venous thrombosis requires further research.

Follow-up sonographic results for Graf type 2A hips: association with risk factors for developmental dysplasia of the hip and instability.

OBJECTIVES: The purpose of the study was to evaluate the association of sonographic worsening in type 2a hips with risk factors of developmental dysplasia of the hip, stability of the hip, and initial sonographic findings. METHODS: Among infants who were referred for hip sonography between 2007 and 2009, 3450 were included in this study. Sonographic examinations were performed by combining the static Graf technique and the dynamic Harcke technique. The rate of sonographic worsening in type 2a hips and the relationship between sonographic worsening and risk factors for developmental dysplasia, instability of the hip, lateralization (right or left) of immaturity, and the presence of unilateral and bilateral immature hips were evaluated. RESULTS: Type 2a hips were observed in 529 infants (15.3%; 780 hips [11.3%]). Of these, in 36 cases (6.8%; 44 hips [5.6%]), the sonographic results worsened. Twenty-five of these 36 cases (32 of 44 hips) were diagnosed as type 2 b; in others, the dysplasia worsened, and 6 cases (7 hips) were classified as type 2 c, 3 cases (3 hips) as type D, and 2 cases (2 hips) as type 3. Instability, unilateral type 2a hips, and associated central nervous system anomalies were found to be independent predictors of sonographic worsening in type 2a hips. CONCLUSIONS: Type 2a hips may worsen sonographically at a rate of 5.6%; hence, sonographic follow-up is needed. Instability, central nervous system anomalies, and unilateral type 2a hips were found to be independent predictors of sonographic worsening. Our study shows that cases with these risk factors should be followed more carefully.

Optimisation of contrast medium volume and injection-related factors in CT pulmonary angiography: 64-slice CT study.

OBJECTIVE: To compare the image quality of computed tomography pulmonary angiography (CTPA) obtained with the injection of various low doses of contrast medium (CM) with different injection-related factors. METHODS: A total of 90 patients (42 females, 48 males; 54.3 +/- 18.6 years) undergoing CTPA were included. Three CM protocols, each containing 30 patients, were created. Protocols 1, 2 and 3 consisted of a CM of 60 ml, 55 ml and 50 ml, and a bolus trigger level of 120 HU, 90 HU and 75 HU, respectively. Injection was uniphasic for protocols 1 and 2 (flow rate 5 ml/s), and biphasic for protocol 3 (flow rates 5 and 4 ml/s); with saline flushing afterwards. Enhancement was measured in three central and six peripheral pulmonary arteries. RESULTS: The mean attenuation value for pulmonary arteries was over 250 HU for all protocols. There was no difference between the attenuation levels with the protocols (p > 0.05). The percentage of pulmonary arteries exceeding optimal attenuation (> or =250 HU) showed that protocols 2 and 3 were 90-100% successful (p < 0.05). CONCLUSION: The use of proper injection-related factors during CTPA, such as a low trigger level and a high flow rate with saline injection following a decreased CM volume (55 ml or 50 ml), will enable adequate pulmonary artery contrast enhancement.

The effects of copper contraceptive intrauterine device on the uterine blood flow: A prospective transvaginal Doppler study.

PURPOSE: To evaluate the hemodynamic changes by transvaginal color Doppler sonography (CDS) in the uterine vascular bed after the insertion of a contraceptive intrauterine device (CIUD) and to investigate whether those CDS findings could predict potential side effects, such as dysmenorrhea and abnormal bleeding. METHOD: Pulsatility index (PI), resistance index, and systole/diastole ratio (S/D) were measured in the uterine artery and its myometrial branches on 28 patients before and after the insertion of copper IUD, and a correlation with dysmenorrhea and abnormal bleeding was investigated. RESULT: PI and S/D values in the uterine artery increased significantly after the insertion of the CIUD (p < 0.05). Patients with increased bleeding scores after insertion of CIUD had significantly lower uterine artery PI compared with those without increased bleeding scores (p < 0.05). No statistically significant difference was detected in the Doppler flow parameters regarding dysmenorrhea scores. CONCLUSION: Low uterine artery PI values recorded in the early phase of the menstrual cycle in patients with a CIUD were associated with an increased bleeding risk.

Does the presence of a mesh have an effect on the testicular blood flow after surgical repair of indirect inguinal hernia?

PURPOSE: Modern treatment of inguinal hernias includes prosthetic mesh repairs. However, direct contact of the mesh to the vessels in the inguinal canal and perimesh fibrosis may have a negative impact on testicular flow. The aim of this prospective study was to evaluate the effect of mesh implantation/perimesh fibrosis on testicular flow after repair of indirect inguinal hernias (IIHs). METHOD: Forty-eight male patients with unilateral IIH were included. Both testicular parenchyma were assessed using gray-scale sonography, and color/spectral Doppler sonography was performed to evaluate testicular arterial impedance, perfusion, and venous flow. Measurements were made bilaterally at the level of the inguinal canal 1 day before and at the end of the 2nd month after the operation. RESULTS: There was no difference in testicular and echotexture perfusion between the hernia and the control sides pre- and postoperatively. No venous thrombosis was found. In all groups, resistance index and pulsatility index, measured at 4 levels, were highest in the proximal inguinal canal and lowest at the extratesticular-intrascrotal level (p < 0.05). For all Doppler parameters there was no significant difference between the pre- and postoperative measurements on both the hernia and the control sides. CONCLUSION: Mesh implantation/perimesh fibrosis does not adversely affect ipsilateral testicular flow. Mesh application is still a safe procedure in male patients in whom testicular function is important.

Bilateral internal carotid artery hypoplasia and multiple posterior circulation aneurysms. Importance of 3DCTA for the diagnosis.

We present a case with bilateral internal carotid artery hypoplasia and multiple posterior circulation aneurysms who was diagnosed following a subarachnoid hemorrhage. The patient was admitted to our clinic with a history of sudden and severe headache with short-term loss of consciousness and being unable to open the right eyelid five days ago. Nuchal rigidity and right partial ophthalmoplegia were found during the examination. Computed tomography revealed a subarachnoid hemorrhage. Digital subtraction angiography showed bilateral internal carotid artery hypoplasia while three-dimensional computed tomographic angiography showed bilateral internal carotid artery hypoplasia and multiple posterior circulation aneurysms. The aneurysms arising from the right posterior cerebral artery (P1 segment) and left superior cerebellar artery region were clipped using the right modified pterional approach. Asymptomatic unilateral or bilateral internal carotid artery hypoplasia may not be an important problem. However, other concurrent anomalies may be potentially life-threatening. These aneurysms must be treated due to the marked hemodynamic stress even if they have not ruptured and are asymptomatic. It may not be possible to see the aneurysm with digital subtraction angiography in these cases due to superimposition. Three-dimensional computed tomographic angiography provides more detailed diagnostic information.

Ultrasonographic evaluation of hand and foot tendons in Behçet's disease.

BACKGROUND: There have been few studies in the literature evaluating the effect of Behçet's disease (BD) on tendons. Thus, we planned to search for the involvement of hand and foot tendons in BD by using ultrasonography and to determine the relation of tendon involvement with clinical measurements. METHODS: The study consisted of 33 randomly selected BD patients and 36 voluntary healthy controls matched by age and body mass index. Sonographic evaluations were performed from hands (flexor digitorum süperficialis (2-5), flexor digitorum profundus (2-5), flexor carpi radialis) and Achilles tendons of the nondominant extremities using an 8-10 MHz linear array probe. Grip strength and crepitation were also measured on the nondominant side. RESULTS: Mean hand and foot tendon thickness values of BD patients were significantly higher than in control group (p=0.00). Disease duration, age, and presence of crepitation were not correlated with tendon thickness in the BD group (all p values>0.05). Grip strength values were lower in the BD group than in control group but the difference was not statistically significant (p=0.344). Grip strength values were not correlated with hand tendon thicknesses in BD groups (all p values>0.05). CONCLUSION: Because tendons tears and thicknesses are associated with inflammation, awareness of tendon pathologies is very important in rheumatic diseases. It would be of value to investigate this relationship in future studies in order to determine if this increment in tendon thickness is an indicator of disease activity and affects prognosis. The physician should be on alert about tendon involvement even if the patient has no complaints.

Pineal gland calcification, lumbar intervertebral disc degeneration and abdominal aorta calcifying atherosclerosis correlate in low back pain subjects: A cross-sectional observational CT study.

The goal of this cross-sectional observational study was to assess the possible impact of pineal gland calcification upon the intervertebral disc degeneration and abdominal aorta atherosclerosis in subjects with low back pain, and to investigate the course of these processes with aging. The study was carried out on 81 (66 women and 15 men) subjects: younger than 45 years (group X, n=22), 45-65 years of age (group Y, n=45), and older than 65 years (group Z, n=14). In addition to clinical data, computed tomography (CT) scan of the brain as well as X-ray and CT examination of the lumbar spine were recorded in this study. The degree of disc degeneration and calcification rates of aortic wall and pineal gland were independently determined by two radiologists. Both ratio of calcified pineal gland and density of pineal calcification increased progressively with aging. Also, both the degree of aortic wall calcification and disc degeneration score increased with advancing age. On CT scan, a positive correlation between degree of aortic wall calcification and disc degeneration score was found (r=0.306, p<0.01). Importantly, there was a positive association between calcification of the pineal gland and degenerative disc disease in X-ray or CT study (r=0.378 and r=0.295, p<0.005 and p<0.01, respectively), as well as between abdominal aorta atherosclerosis and pineal calcification (r=0.634, p<0.001). Our findings suggest that there is a significant interaction between pineal gland calcification and lumbar intervertebral disc degeneration and also abdominal aorta atherosclerosis. However, further studies with a larger subject cohorts are needed.

Age-related changes in the incidence of pineal gland calcification in Turkey: A prospective multicenter CT study.

The goal of this cross-sectional observational study was to determine the incidence of pineal gland calcification (PGC), to investigate the interaction of PGC and aging, and to compare the incidence of PGC among the populations living in Turkey. In a prospective study the rate of PGC on CT scans of 1376 individuals in six referral centers from different regions of Turkey was investigated, with emphasis on effects of climatological parameters and aging on PGC. It was found that the incidence of PGC increased rapidly after first decade and the increase remains gradual thereafter, higher in males than in females for all age groups. There was a significant difference for incidence and degree of PGC between different clinics and between both sexes (p<0.001). In addition, there was a significant difference for the degree of PGC between the clinics in low altitude group and those in high altitude group (p<0.001 for each). Logistic regression analysis revealed that age, sex, altitude and intensity of sunlight exposure significantly affected the risk of PGC (odds ratios (OR) 1.335, 95% confidence intervals (CI) 1.261-1.414, p<0.001; OR 1.900, 95% CI 1.486-2.428, p<0.001; OR 0.715, 95% CI 0.517-0.990, p<0.05; OR 0.997, 95% CI 0.994-0.999, p<0.01, respectively). Furthermore, by multiple linear regression analysis, high altitude and increased intensity of sunlight exposure were found to affect the degree of PGC (beta=0.003, p<0.001). It is concluded that there is a close relationship between PGC and the aforementioned parameters, supporting a link between the development of PGC and these. This study provides some reference data for new clinical studies on the putative role of pineal gland in future.

Carotid atherosclerosis and cardiovascular risk factors in hemodialysis and peritoneal dialysis patients.

BACKGROUND: Cardiovascular diseases are important factors in mortality and morbidity of dialysis patients. Cardiovascular risk assessment is important in order to arrange the treatment strategies. The aim of the study was to investigate the relationship between carotid atherosclerosis and various CVD risk factors in dialysis patients. METHODS: 22 HD and 54 PD patients were included in the study. Carotid artery intima media thickness (IMT) and plaque score (PS) were obtained by B-mode ultrasonography for each participant. Uric acid, albumin, bilirubin, lipid profile, apolipoprotein A-l (apo A-l), apolipoprotein B (apo B), lipoprotein(a) [Lp(a)], high-sensitivity CRP (hs-CRP), homocysteine (Hcy), vitamin A, vitamin E, sialic acid (SA) and thiobarbituric acid-reactive substances (TBARS) were determined. The differences of the cardiovascular risk factors between the patients according to the treatment modality and the comparison of the risk factors as indicators of IMT and PS were investigated. RESULTS: There was no significant difference in IMT and PS between the two groups. SA, TBARS, hs-CRP, total, HDL- and LDL-cholesterol, white blood cell (WBC) and erythrocyte sedimentation rate (ESR) levels were significantly higher; albumin levels were significantly lower in PD group. In multiple regression analysis, only bilirubin for IMT and SA for PS were independent predictors. CONCLUSIONS: SA can be a superior marker to hs-CRP in PD patients; however, hs-CRP seems to be a more valuable marker than SA in HD patients according to the correlation analysis. This study provides information and opportunity for comparison of relatively new cardiovascular risk markers in hemodialysis and peritoneal dialysis patients using carotid atherosclerosis as an objective assessment criterion.

Unusual imaging characteristics of complicated hydatid disease.

Hydatid disease, a worldwide zoonosis, is caused by the larval stage of the Echinococcus tapeworm. Although the liver and the lungs are the most frequently involved organs in the body, hydatid cysts of other organs are unusual. Radiologically, they usually demonstrate typical imaging findings, but unusual imaging characteristics of complicated cyst of hydatid disease, associated with high morbidity and mortality, are rarely described in the literature. The purpose of this study is to review the general features of hydatidosis and to discuss atypical imaging characteristics of the complicated hydatid disease in the human, with an emphasis on structure and rupture of the cystic lesion as well as ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) features of the disease. In our study, the available literature and images of the cases with complicated hydatidosis involving liver, lung, brain, spine and orbit were reviewed retrospectively. In hydatid disease, there are many potential local and systemic complications due to secondary involvement in almost any anatomic location in humans. Radiologically, in addition to the presence of atypical findings such as perifocal edema, non-homogenous contrast enhancement, multiplicity or septations and calcification, various unusual manifestations due to rupture or infection of the cyst have been observed in our cases with complicated hydatid disease. To prevent subsequent acute catastrophic results and the development of recurrences in various organs, it should be kept in mind that complicated hydatid cysts can cause unusual USG, CT, and MRI findings, in addition to typical ones, in endemic areas. Therefore, familiarity with atypical radiological appearances of complicated hydatid disease may be valuable in making a correct diagnosis and treatment.

A novel parameter by EFOV US for the quantification and the distinction of physiological amount of scrotal fluid and hydrocele: ratio of testis volume/scrotum volume.

OBJECTIVE: To determine the limits for the amount of tunical fluid enough to be termed as hydrocele by using extended-field of view US technology and to define hydrocele for the first time with standard numerical criteria. METHODS: A total of 60 patients were evaluated in this prospective study. Group 1 consisted of 20 patients with unilateral clinical hydrocele. Group 2 included 20 patients referred for scrotal US for reasons other than hydrocele. Group 3 comprised 20 male controls with no scrotal complaints. Testis volume (V(t)), scrotum volume (V(s)) and V(t)/V(s) ratio were calculated for each subject by dimensions measured in longitudinal and tranverse planes. RESULTS: Mean V(t)/V(s) ratio was 0.28 +/- 0.17 (range, 0.07-0.57), 0.69 +/- 0.08 (range, 0.53-0.80) and 0.71 +/- 0.07 (range, 0.61-0.85) for groups 1, 2 and 3, respectively. Mean V(t)/V(s) for group 1 was significantly lower than those for groups 2 and 3, respectively (p<0.001 for each). Based on the ROC curve analysis, 0.55 for V(t)/V(s) ratio was determined as the optimal cut-off point below which the US diagnosis of hydrocele could be made (sensitivity 95.0% and specificity 97.5%). CONCLUSIONS: We propose a novel US parameter of V(t)/V(s) ratio below 0.55 for a standard distinction between hydrocele and physiological amount of scrotal fluid.

Diffuse stylohyoid chain ossification.

Clinical symptoms of stylohyoid chain ossification vary from ear pain to dysphagia. It is usually diagnosed coincidentally. Localized ossification of the chain is common, whereas diffuse ossification is rare. Herein, a case with bilateral diffuse stylohyoid chain ossification diagnosed with computed tomography, which was performed in order to evaluate the patient's temporomandibular joint pain, a rare onset of this condition, is discussed.

Coexistence of trifid and bifid median nerve in a patient with bilateral carpal tunnel syndrome.

Carpal tunnel syndrome is the most common upper extremity neuropathy in the wrist that may be associated with anatomic variations of median nerve. Trifurcation of the median nerve has been very rarely reported in the literature. We report coexistence of bilateral median nerve variation in the wrist and its radiological features. Ultrasonography and magnetic resonance imaging was performed to the patient after Tinel and Phalen tests. There was bifurcation and trifurcation of the median nerve in right and left wrists respectively. Bilateral carpal tunnel syndrome was caused by bilateral median nerve variation in the present case. When a median nerve variation is detected in one wrist, a possible variation at the other side should be kept in mind and hence should be evaluated. A thorough knowledge of the variations of the median nerve is essential in order to avoid surgical complications and to ensure optimal patient outcome. US is an easy and cheap radiological method for diagnosis and it should be the first chosen radiological technique to evaluate median nerve variations in idiopathic CTS patients.

Carotid stenosis evaluation by 64-slice CTA: comparison of NASCET, ECST and CC grading methods.

Purpose is to evaluate the intraobserver and interobserver variability of the North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trial (ECST) and Common Carotid (CC) methods, which are used to measure the degree of ICA stenosis, using 64-slice CT angiography and to compare the measurements made by these three methods. 88 cases (111 carotid arteries) were included in the study. Carotid CTA was performed by a 64 slice scanner (Toshiba, Aqullion 64).Two radiologists measured the degree of carotid stenosis by using NASCET, ECST and CC methods. Intraobserver and interobserver variability of each method was determined by intraclass correlation coefficient (ICC), Bland-Altman plots and kappa and linear weighted kappa statistics. The relation between the measurements was assessed by correlation coefficient (with linear and quadratic methods). Correlation coefficients showed that there is linear correlation between the measurements made by the three methods. The degree of stenosis measured with the NASCET method had the lowest value, while the corresponding values measured with the ECST and CC methods were close to each other. ICC and Bland-Altman plots showed high intra and inter observer agreement for NASCET, ECST and CC methods whereas kappa statistics showed moderate to substantial agreement. CC method had slightly higher agreement when compared with the other two methods. Intra and interobserver agreement is high for NASCET, ECST and CC methods however CC method has a slightly higher reproducibility. There is linear correlation between the measurements made by the three methods.

Recurrent atretic parietal cephalocele in adult and radiological findings.

Atretic parietal cephaloceles are an extremely rare and occult form of congenital herniations that involve the meninges, remnants of glial cells or central nervous system structures. They are detected as subscalp lesions that are covered by skin. In the literature, atretic parietal cephaloceles have been reported in children in 59 cases and in two cases in adults. We present here a case of a recurrent atretic parietal cephalocele that we recently observed in an adult. This case indicates that an atretic parietal cephalocele should always be considered in the differential diagnosis of subscalp lesions. Radiologic diagnosis is a lifesaving measure that can be undertaken before an operation. Additionally, regular follow-up magnetic resonance imaging is recommended for each case with remnant lesions due to the slow growth of these masses.

Assessment of dental caries risk in children based on color Doppler US and the changes in blood perfusion in the salivary glands during salivary stimulation.

PURPOSE: To investigate in otherwise healthy children the association between the caries index, the stimulated salivary flow rate (SFR), and the spectral Doppler findings of the changes in blood perfusion in the salivary glands during the secretion of saliva. MATERIALS AND METHODS: The study group consisted of 38 children with a mean age of 9.47 ± 1.89 years. The caries index was calculated by determining the number of decayed, missing, and filled teeth. Groups A, B, and C represented subjects with low, moderate, and normal SFRs, respectively, calculated by obtaining chewing-stimulated whole saliva. All subjects were examined by color Doppler ultrasonography (CDUS) before and during secretory stimulation with lemon, by which maximum systolic velocity (MSV), pulsatility index (PI), resistive index (RI), and flow volume (FV) were calculated at the external carotid and facial arteries. RESULTS: The differences for spectral indices obtained before and after stimulation were significantly different among Groups A, B, and C at the external carotid artery (P = 0.006 for delta MSV, P = 0.014 for delta PI, P < 0.001 for delta RI, and P = 0.022 for delta FV) and at the facial artery (P = 0.001 for delta MSV, P = 0.004 for delta PI, P < 0.001 for delta RI, and P < 0.001 for delta FV). In addition, significant correlations were calculated between the SFR and the aforementioned delta values. CONCLUSION: CDUS enabled the evaluation of changes in blood perfusion in the salivary glands during salivary stimulation and may be a promising tool for the assessment of caries risk in children.

Prevalence and extent of coronary artery disease determined by 64-slice CTA in patients with zero coronary calcium score.

The purpose of the study was to assess the presence and extent of atherosclerosis determined by 64-slice CTA in patients with 0 coronary calcium score (CACS) and to evaluate the affect of demographic features and risk factors on the atheroma burden of these patients. 883 cases (378 (42.8%) male, 505 (57.2%) female, mean age 51.28) with zero CACS were included in the study. Cases underwent CTA because of carrying risk factors or having chest pain or atypical symptoms. A non-enhanced CT scan was obtained for calcium scoring immediately before CTA in all cases. CT examinations were performed by 64-slice scanner (Toshiba, Aquillon 64, Toshiba Medical Systems, Otowara, Japan). Coronary artery disease (CAD) was graded according to CTA findings and five groups were defined. In 703 cases (79.6%) CTA was normal while 180 (20.4%) cases had positive CTA findings and 43 cases (4.9%) had CTA obstructive lesion. Cases with positive CTA findings were significantly older than those with normal CTA Diabetes was a significant risk factor of CAD in both male and female cases. Dyslipidemia was associated with CAD in males and family history of CAD was a significant risk factor for females with positive CTA findings. This study demonstrated that considerable amount of patients with zero CAC score have positive CTA findings. Age and diabetes are the risk factors, which were associated with positive CTA findings in both sexes. Dyslipidemia was a significant risk factor in males and family history of CAD in females. Especially in patients with risk factors CTA is better than CAC scoring in determining the atheroma burden.