Frequency of extracardiac findings on "negative" CT coronary angiography studies.

AIM: To evaluate the prevalence and nature of extracardiac findings identified on computed tomography (CT) coronary angiography (CTCA) in patients with chest pain but without evidence of coronary artery disease (CAD). MATERIALS AND METHODS: CTCA studies in patients referred to the hospital between January 2017 to February 2021 with chest pain and a suspected diagnosis of CAD were reviewed retrospectively for the presence of extracardiac findings. Consensus review of CTCA studies was performed by two experienced thoracic radiologists. The presence and severity of extracardiac findings, together with the likelihood that chest pain might be attributed to these, was recorded. Patient records were reviewed to ascertain the recording of extracardiac findings on initial CTCA reports and, where applicable, the nature of the follow-up. RESULTS: Extracardiac findings (n=210) were present in 110/180 patients (61%) with a mean of 1.9 findings per patient. Extracardiac findings were more prevalent in patients aged ≥65 years compared to those <65 years (p<0.001). At least one extracardiac finding with the potential to cause chest pain was present in 40 patients (22%): degenerative disc disease (n=23 [13%]) and hiatus hernia (n=6 [3.3%]) were the most common extracardiac findings. Only 37.6% (79) of all retrospectively identified findings had been initially reported and, of these, 12.7% (10) required further follow-up. CONCLUSION: Extracardiac findings are common in patients with no evidence of CAD on CTCA. The entire dataset should be evaluated for the presence of extracardiac findings that could explain chest pain symptoms on wide field of view reconstructions.

Contemporary interventional management of pulmonary embolism.

Minimally invasive interventional techniques are being utilised more frequently in the management of acute and chronic pulmonary emboli; however, robust clinical evidence is only emerging for the utilisation of these techniques. Hence, there is a need for a robust mechanism of patient selection and careful consideration of the benefits and risks of the interventions. In this review, we discuss the risk stratification mechanisms; the role of the multidisciplinary pulmonary embolism response team to support decision-making; and describe the various commonly used interventional techniques and how these can be integrated into treatment strategies for the benefit of our patients.

Radiological-pathological correlation of negative CT biopsy results enables high negative predictive value for thoracic malignancy.

AIM: To evaluate multidisciplinary team (MDT) practice of radiological-pathological correlation of non-malignant biopsy results to examine the additive effect on the predictive values of computed tomography (CT) biopsy for malignancy and their subsequent management and outcomes. MATERIALS AND METHODS: A service evaluation of the MDT management of non-malignant lung biopsy results (May 2014- May 2017) was undertaken. RESULTS: Sixty patients had a non-malignant diagnosis on initial CT biopsy. Five patients were lost to follow-up leaving 55 in the final cohort. Forty-eight of the 55 patients had biopsy results classified as potentially non-specific, of which 26 were classified as concordant with radiology (e.g., organising pneumonia with compatible CT features), and 22 were classified as discordant (e.g., non-specific inflammation and yet sufficiently suspicious CT features). Patients with concordant negative pathology showed resolution (n=19) or stability (n=6) on imaging follow-up. One lesion demonstrated growth and was proven malignant on surgical resection. Discordant lesions were managed with repeat biopsy (n=8) or surgical resection (n=13), with 12 final benign diagnoses and nine malignancies. The negative predictive value of CT biopsy alone was 44/55 (80%), following repeat biopsy was 44/50 (88%), and following radiological-pathological assessment was 32/33 (97%). No patients underwent a shift in stage from time of biopsy to resection. CONCLUSION: Combining radiological-pathological interpretation of negative biopsy results offers superior negative predictive value for lung malignancy without delayed diagnosis of lung cancer.

Massive paediatric pulmonary haemorrhage in Dieulafoy's disease: Roles of CT angiography, embolisation and bronchoscopy.

Acute, major pulmonary haemorrhage in children, is rare, may be life-threatening and at times presents atypically. Dieulafoy's disease of the bronchus presenting with recurrent or massive hemoptysis was first described in adults. Prior to reviewing the literature, we report an illustrative case of bronchial Dieulafoy's disease (BDD) in a child presenting unusually with massive apparent hematemesis. The source of bleeding is a bronchial artery that fails to taper as it terminates within the bronchial submucosa. A high index of suspicion is required to identify such lesions via radiological imaging and the role of bronchial artery embolisation is highlighted with video images of angiography included.

Current and future approaches to large airways imaging in adults and children.

"Large airways disease" is a catch-all phrase encompassing a wide variety of pathology affecting the trachea, main, lobar, segmental, and proximal sub-segmental bronchi. Relevant pathologies can be divided into focal or diffuse processes and many conditions have classic appearances on computed tomography (CT). We provide a review of the imaging specifics of a wide range of large airway pathologies in adult, childhood, and fetal life with examples of common and rare pathologies ranging from well-known entities such as cystic fibrosis and allergic bronchopulmonary aspergillosis to rarities such as Williams-Campbell, primary ciliary dyskinesia, and congenital high-airway obstruction syndrome (CHAOS). Although the spatial and temporal resolution of modern multidetector CT lends itself well to the depiction of small structures such as the peripheral airways, concerns regarding radiation exposure and increasing interest in the role of functional and quantitative imaging have led to a surge in research into dose reduction in CT and both structural and functional airway imaging via magnetic resonance imaging. We discuss the current literature on these emerging techniques along with some exiting near future directions for large airways imaging.

The influence of inspiratory effort and emphysema on pulmonary nodule volumetry reproducibility.

AIM: To evaluate the impact of inspiratory effort and emphysema on reproducibility of pulmonary nodule volumetry. MATERIALS AND METHODS: Eighty-eight nodules in 24 patients with emphysema were studied retrospectively. All patients had undergone volumetric inspiratory and end-expiratory thoracic computed tomography (CT) for consideration of bronchoscopic lung volume reduction. Inspiratory and expiratory nodule volumes were measured using commercially available software. Local emphysema extent was established by analysing a segmentation area extended circumferentially around each nodule (quantified as percent of lung with density of -950 HU or less). Lung volumes were established using the same software. Differences in inspiratory and expiratory nodule volumes were illustrated using the Bland-Altman test. The influences of percentage reduction in lung volume at expiration, local emphysema extent, and nodule size on nodule volume variability were tested with multiple linear regression. RESULTS: The majority of nodules (59/88 [67%]) showed an increased volume at expiration. Mean difference in nodule volume between expiration and inspiration was +7.5% (95% confidence interval: -24.1, 39.1%). No relationships were demonstrated between nodule volume variability and emphysema extent, degree of expiration, or nodule size. CONCLUSION: Expiration causes a modest increase in volumetry-derived nodule volumes; however, the effect is unpredictable. Local emphysema extent had no significant effect on volume variability in the present cohort.

Quality assurance in cardiovascular CT: a practical guide.

Cardiovascular computed tomography (CCT) is a cutting-edge imaging technique providing important, non-invasive, diagnostic information. Concerns exist regarding radiation exposure to patient populations, but achieving optimal image quality at the lowest doses can be challenging. This guide provides practical advice about how quality can be assured in any CCT unit or radiology department. Illustrated by real-world vignettes and data analysis from our own experience, we highlight a multidisciplinary team approach to each stage of the patient journey, the effectiveness of regular dose audit overseen by a CT optimisation group, and the importance of underused systolic scanning techniques, in order to drive significant dose reduction without loss of image quality or clinical confidence.

The safe practice of CT coronary angiography in adult patients in UK imaging departments.

Computed tomography coronary angiography is increasingly used in imaging departments in the investigation of patients with chest pain and suspected coronary artery disease. Due to the routine use of heart rate controlling medication and the potential for very high radiation doses during these scans, there is a need for guidance on best practice for departments performing this examination, so the patient can be assured of a good quality scan and outcome in a safe environment. This article is a summary of the document on 'Standards of practice of computed tomography coronary angiography (CTCA) in adult patients' published by the Royal College of Radiologists (RCR) in December 2014.

Maximizing the clinical benefit of high-pitch, single-heartbeat CT coronary angiography in clinical practice.

AIM: To prospectively analyse the occurrence of right coronary artery (RCA) artefact and assess its relationship with patient heart rate (HR) and HR variability (HRV) in order to determine the most appropriate parameters for high-pitch cardiovascular computed tomography (CT) acquisition, minimize the likelihood of artefact, and maximize the clinical benefit in consecutive clinical high-pitch CT coronary angiography (CA) examinations. MATERIALS AND METHODS: One hundred and seventy-three patients undergoing high-pitch CTCA were prospectively assessed for the presence of RCA artefact. Median and maximum HR and the difference in predicted and actual acquisition HR (HR difference, HRD) were correlated from the electrocardiograms recorded at the time of acquisition. RESULTS: Sixty-six percent of the cohort was male, with a median age of 54 (range 16-84 years). There were 53 cases of RCA artefact (30.6%); 26 (49.1%) of these required further imaging to fully delineate the RCA. Of the 53 cases with artefact, 81.1% affected the distal RCA and 18.9% were more proximal. Gender was not associated with an increased likelihood of the artefact (p = 0.14). RCA artefact decreased by 2% with each year of increasing age (p = 0.04). When compared with a reference HR of >70 beats/min, univariate analysis demonstrated RCA artefact significantly increased with both increasing median and maximum HR, whilst the incidence of RCA artefact increased for all HRD >1, with a greater likelihood of artefact with increasing HRD. CONCLUSION: The present results highlight the importance of optimizing patient HR in order to reduce the likelihood of RCA artefact. In addition to aggressive HR control to a median HR of ≤60 beats/min, the present results suggest limiting high-pitch acquisition to patients with HR variability of <3 beats/min. Therefore, use of beta-blockers is of crucial importance to both reduce HR and HR variability to optimize use of high-pitch single-heartbeat CTCA.

Clinical validation of dual-source dual-energy computed tomography (DECT) for coronary and valve imaging in patients undergoing trans-catheter aortic valve implantation (TAVI).

AIM: To assess the validity of virtual non-contrast (VNC) reconstructions for coronary artery calcium (CACS) and aortic valve calcium scoring (AVCS) in patients undergoing trans-catheter aortic valve implantation (TAVI). MATERIALS AND METHODS: Twenty-three consecutive TAVI patients underwent a three-step computed tomography (CCT) acquisition: (1) traditional CACS; (2) dual-energy (DE) CT coronary angiogram (CTCA); and (3) DE whole-body angiogram. Linear regression was used to model calcium scores generated from VNC images with traditional scores to derive a conversion factor [2.2 (95% CI: 1.97-2.58)]. The effective radiation dose for the TAVI protocol was compared to a standard control group. Bland-Altman analysis and weighted k-statistic were used to assess inter-method agreement for absolute score and risk centiles. RESULTS: CACS and AVCS from VNC reconstructions correlated well with traditional scores (r = 0.94 and r = 0.86; both p < 0.0001). There was excellent agreement between VNC and non-contrast coronary calcium scores [mean difference -71.8 (95% limits of agreement -588.7 to 445.1)], with excellent risk stratification into risk centiles (k = 0.99). However, the agreement was weaker for the aortic valve [mean difference -210.6 (95% limits of agreement -1233.2 to 812)]. Interobserver variability was excellent for VNC CACS [mean difference of 6 (95% limits of agreement 134.1-122.1)], and AVCS [mean difference of -16.4 (95% limits of agreement 576 to -608.7)]. The effective doses for the DE TAVI protocol was 16.4% higher than standard TAVI protocol (22.7 versus 19.5 mSv, respectively) accounted for by the DE CTCA dose being 47.8% higher than that for a standard CTCA [9.9 (5.6-14.35) versus 6.7 (1.17-13.72) mSv; p < 0.01). CONCLUSIONS: CACS and AVCS can be accurately quantified, and patients can be risk stratified using DECT VNC reconstructions. However, the dose from DE CTCA is significantly greater than the standard single-energy CTCA precluding the use of this technology in routine clinical practice.

CT and histopathological correlation of congenital cystic pulmonary lesions: a common pathogenesis?

AIM: To determine whether similarities exist in both the imaging and histopathological features of congenital cystic lung lesions and whether a more appropriate classification would be to adopt the theory of "malinosculation". MATERIAL AND METHODS: From the histopathology and computed tomography (CT) database, 24 patients (16 male, median age 3 years) with congenital cystic lung lesions were identified. CT studies were reviewed for site and characteristics of the lesions, parenchymal features, bronchial anatomy, and the presence of a feeding systemic vessel. Individual histopathological parameters were also correlated with CT data. RESULTS: There were five type 1 congenital cystic adenomatoid malformations (CCAMs), six type 2 CCAMs, one type 4 CCAM, one bronchial atresia, four pleuropulmonary blastomas (PPBs), and seven sequestrations. CCAMs (types 1, 2 and 4), sequestrations and PPBs appeared as cystic lesions, with cyst size less than 2 cm in type 2 CCAMs. Sequestrations were distinguished radiologically from CCAMs by systemic vessels. Reduced pulmonary attenuation was seen in bronchial atresia, type 2 CCAMs and in sequestrations. Histopathology showed an overlap in entities with sequestrations demonstrating CCAM type 2 histology and segmental atresia noted in both type 2 CCAMs and sequestrations. PPBs showed histological and imaging overlap with type 4 CCAMs and were distinguished on histology by the presence of blastematous proliferation. CONCLUSIONS: This study demonstrates overlap in the CT appearances of congenital cystic lesions. The similarity in CT and histopathology findings across the spectrum of developmental lesions supports the hypothesis of a common aetiology.

Erectile dysfunction and silent coronary artery disease: abnormal computed tomography coronary angiogram in the presence of normal exercise ECGs.

BACKGROUND: Erectile dysfunction (ED) and coronary artery disease (CAD) frequently coexist. ED may be present in the absence of cardiac symptoms 3-5 years before a coronary event. Exercise electrocardiography may identify flow-limiting CAD but cardiac computed tomography (CT) may identify early non-calcified plaque disease potentially vulnerable to rupture precipitating an acute event. METHODS: Twenty men aged 39-69 years with ED and no cardiac symptoms underwent screening for cardiovascular risk including maximal treadmill exercise testing and CT coronary angiography. ED was confirmed using the Sexual Health Inventory for Men questionnaire. FINDINGS: Eighteen had a low-density lipoprotein cholesterol > 3 mmol/l, none were diabetic and seven were hypertensive controlled on medical therapy. Coronary calcium scores were > 50 in 11 men (range: 54-1234) all of whom had angiographic CAD on CT. Nine of these had normal exercise ECGs. Four men had calcium scores of 6-17 and single plaque disease on CT. Five had normal cardiac CT studies. INTERPRETATION: Erectile dysfunction may be a predictor of subclinical non-flow limiting CAD not detectable on exercise electrocardiography. Men with organic ED and no cardiac symptoms should be considered as 'cardiac equivalents' and aggressive risk reduction therapy initiated.

Delay in the diagnosis of breast cancer: the effect of the introduction of fine needle aspiration cytology to a breast clinic.

Fine needle aspiration cytology (FNAC) was introduced to a District General Hospital Breast Clinic in 1984 and since that time the rate of surgical excision biopsy for benign breast disease has halved. The rate of benign to malignant breast operations fell from 2.0 to 0.7 over a 7-year period from 1982 to 1988. During this period the diagnosis of breast cancer was made at the first clinic appointment in 85% of women. However, a delay in diagnosis of more than 50 days occurred in 33 patients (6.9%) and there was little difference in the annual rate of delayed diagnosis despite the addition of FNAC as an extra diagnostic tool in the later years of the study. Eighty-five per cent of patients with a delayed diagnosis were under the age of 55 (mean and median age 47) years. FNAC is a useful adjunct in the management of patients with diagnostic breast problems, but even in combination with mammography is not always sufficiently sensitive to exclude malignancy, particularly in young women.

Case report: pulmonary oedema secondary to laryngospasm following general anaesthesia.

The development of pulmonary oedema following the relief of upper airway obstruction has been reported in a wide range of conditions including post-anaesthetic laryngospasm. Radiologists should be aware of this condition as a complication of general anaesthesia.

Review article: current indications for high resolution computed tomography scanning of the lungs.

High resolution computed tomography (HRCT) is an effective technique for demonstrating the lung parenchyma in detail and overcomes many of the inadequacies of chest radiography in the diagnosis of diffuse lung disease. This article reviews the role of HRCT in the management of patients with chronic infiltrative lung disease, occupational lung disease, airways disease and acute and sub-acute lung disease.

Portable chest radiography in intensive care: a comparison of computed and conventional radiography.

A prospective study was performed comparing computed and conventional radiography for the detection and visibility of cardiovascular devices in intensive care unit patients. Computed images were obtained using a commercially available 2K x 2K, 12-bit storage phosphor plate system. Image sets from 50 patients were assessed independently by three observers. A significant difference between the types of image was found for the detection of mediastinal drainage tubes and prosthetic valves. Computed images allowed greater confidence in the identification of courses and tips of lines. This advantage was most marked with edge-enhanced computed images.

Assessment of a single lumbar spine radiograph in low back pain.

The lumbosacral spine radiographs of 200 patients with unexplained low back pain and without neurological signs were reviewed. The purpose of the study was to determine whether significant diagnostic information would be lost by replacing the standard three film series with a single radiograph, either in the lateral or antero-posterior projection. The contribution of the coned lumbosacral junction view was also assessed. The results show that a single lateral radiograph is diagnostically satisfactory and would have the added advantages of reducing patient radiation dose and radiographic workload.

The efficacy of a single posteroanterior radiograph in the assessment of metastatic pulmonary melanoma.

Posteroanterior (PA) and lateral chest radiographs are performed as part of the routine staging and follow-up investigation of patients with malignant melanoma. We have assessed the contribution of the lateral chest radiograph in the follow-up of 227 consecutive patients with proven malignant melanoma. In only once case was an abnormality evident on the lateral radiograph which was not previously detected on the PA films. Our department, as a result of this study, has discontinued the routine use of lateral chest radiography in the follow-up of patients with malignant melanoma.