Tricuspid annular plane systolic excursion for the evaluation of right ventricular function in functional cardiac CT compared to MRI.

AIM: To compare ejection fraction estimated by tricuspid annular plane systolic excursion (TAPSE) using cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) to the non-invasive reference standard, volumetric quantification of right ventricular ejection fraction (RVEF) by cardiac magnetic resonance imaging (MRI). MATERIALS AND METHODS: Thirty-one patients, who had undergone functional cardiac CT angiogram and cardiac MRI within 12 months, were evaluated retrospectively. Right ventricular (RV) volumes were processed using automated cardiac analysis software for CT, and manually processed by Simpson's method for MRI. MR-TAPSE was defined as the difference in length between two separate reference lines drawn at end diastole and end systole from the lateral tricuspid annulus to the right ventricular apex measured on four-chamber CINE images. CT-TAPSE was determined in an analogous manner on four-chamber reformatted images. RESULTS: MR-TAPSE correlated moderately with MR-RVEF, (r=0.57, p<0.001). CT-TAPSE was found to correlate moderately well with MR-RVEF (r=0.58, p<0.001) and CT-RVEF (r=0.63, p<0.001). Bland-Altman analysis repeated with various multiplication factors for CT-TAPSE and MR-RVEF, determined a multiplication factor of 2.7 resulted in the lowest bias (0.74%). CONCLUSION: CT-TAPSE is an easily obtainable parameter of RV function and is correlated with CT-RVEF and MR-RVEF. It can function as a quick check to rapidly validate CT right volumetry and estimate MR-RVEF.

High pitch, low voltage dual source CT pulmonary angiography: assessment of image quality and diagnostic acceptability with hybrid iterative reconstruction.

Increased use of CT Pulmonary angiography in suspected pulmonary embolism (PE) has driven research to minimize radiation dose while maintaining image quality and diagnostic accuracy. Following institutional review board approval, we performed a retrospective comparison study in patients with suspected PE. Patients were scanned using an ultra high pitch dual source technique (pitch = 2.6) using 120 kV (SVCTPA) (n = 54) or 100 kV (RV-CTPA) (n = 52). SV-CTPA images were reconstructed using filtered back projection (SV-wFBP) and RV-CTPA images were reconstructed using both FBP (RV-wFBP) and Iterative Reconstruction (RV-IR). Comparison of radiation dose, diagnostic ability, subjective image noise, quality, and sharpness, diagnostic agreement, signal to noise (SNR) and contrast to noise ratios (CNR) were performed. Mean effective dose was 2.56 ± 0.19 mSv for the RV protocol compared to 5.36 ± 0.60 mSv for the SV. The RV-CTPA protocol resulted in a mean DLP reduction of 52 % and mean CTDI reduction of 51 %. Pulmonary artery SNR and CNR were significantly higher on RV-IR images than SV-wFBP (p = 0.007, p = 0.003). Mean subjective image noise, quality and sharpness scores did not differ significantly between the SV-wFBP and RVIR images (p > 0.05). Subjective quality scores were significantly better for the RV-IR group compared to the RV-wFBP group (p < 0.001). Agreement between readers for presence or absence of pulmonary emboli on RV-IR images was almost perfect (κ = 0.891, p < 0.001). Iterative reconstruction complements ultra high pitch dual source CTPA examinations acquired using a reduced voltage resulting in higher mean pulmonary artery SNR and CNR when compared to both RV-wFBP and SV-CTPA.

Intense hypoxic cycle exercise does not alter lung density in competitive male cyclists.

We tested the hypothesis that intense short duration hypoxic exercise would result in an increase in extravascular lung water (EVLW), as evidenced by an increase in lung density. Using computed tomography (CT), baseline lung density was obtained in eight highly trained male cyclists (mean +/- SD: age = 28 +/- 8 years; height = 180 +/- 9 cm; mass = 71.6 +/- 8.2 kg; VO2max= 65.0 +/- 5.2 ml kg min(-1)). Subjects then completed an intense hypoxic exercise challenge on a cycle ergometer and metabolic data, HR and %S(p)O2 were recorded throughout. While breathing 15% O2, subjects performed five 3 km cycling intervals (mean power, 286 +/- 20 W; HR = 91 +/- 4% HRmax) separated by 5 min of recovery. From a resting hypoxic S(p)O2 of 92 +/- 4%, subjects further desaturated during exercise to 76 +/- 3%. CT scans were repeated 76 +/- 10 min (range 63-88 min) following the completion of exercise. There was no change in lung density from pre (0.18 +/- 0.02 g ml(-1)) to post-exercise (0.18 +/- 0.04 g ml(-1)). The substantial reduction in S(p)O2 may be explained by a number of potential mechanisms, including decreased pulmonary diffusion capacity, alveolar hypoventilation, reduced red cell transit time, ventilation/perfusion inequality or a temperature and pH induced rightward-shift in the oxyhaemoglobin dissociation curve. Alternatively, the integrity of the blood gas barrier may have been disrupted without any measurable increase in lung density.

Central line pump infusion and large volume mediastinal contrast extravasation in CT.

The use of multidetector CT scanners for CT angiography requires rapid injection of radiographic contrast media. Central venous catheters are now widely used for this purpose. Several complications may occur while using central venous access for rapid, large volume contrast injection such as catheter rupture and contrast extravasation. We describe a case in which inadvertent malposition of a central venous catheter led to a high volume extravasation of contrast in the mediastinum in a trauma patient.

Bronchiolitis obliterans following lung transplantation: early detection using computed tomographic scanning.

BACKGROUND: Computed tomographic (CT) scanning may enable earlier diagnosis of chronic lung allograft dysfunction than forced expiratory volume in 1 second (FEV1). A study was undertaken to determine intra-observer and inter-observer agreement of composite and air trapping CT scores, to examine the association of FEV1 with the composite and air trapping CT score, and to relate the baseline composite CT score to changes in FEV1 and changes in the composite CT score over 1 year. METHODS: Lung function and baseline CT scans following transplantation and at subsequent annual follow ups were analysed in 38 lung transplant recipients. Scans were randomly scored by two observers for bronchiectasis, mucus plugging, airway wall thickening, consolidation, mosaic pattern, and air trapping, and re-scored after 1 month. CT scores were expressed on a scale of 0-100 and correlated with FEV1 as a percentage of the post-transplant baseline value. RESULTS: The mean (SD) interval between baseline and follow up CT scans was 11.2 (4.7) months. Inter-observer and intra-observer agreement was good for both the composite and air trapping CT scores. There was a significant association between FEV1 and the composite CT score, with each unit of worsening in the baseline composite CT score predicting a 1.55% and 1.37% worsening in FEV1 over the following year (p<0.0001) and a 1.25 and 1.12 unit worsening in the composite CT score (p<0.0001) for observers 1 and 2, respectively. CONCLUSION: These findings indicate a potential role for a composite CT scoring system in the early detection of bronchiolitis obliterans.

Progressive damage on high resolution computed tomography despite stable lung function in cystic fibrosis.

For effective clinical management of cystic fibrosis (CF) lung disease it is important to closely monitor the start and progression of lung damage. The aim of this study was to investigate the ability of high-resolution computed tomography (HRCT) scoring systems and pulmonary function tests (PFT) to detect changes in lung disease. CF children (n=48) had two HRCT scans in combination with two PFT 2 yrs apart. Their scans were scored using five scoring systems (Castile, Brody, Helbich, Santamaria and Bhalla). "Sensitivity" was defined as the ability to detect disease progression. In this group of children, HRCT scores worsened. PFT remained unchanged or improved. Of the HRCT parameters, mucous plugging and the severity, extent and peripheral extension of bronchiectasis worsened significantly. Relationships between changes in HRCT scores and PFT were weak. Substantial structural lung damage was evident in some children who had normal lung function. These data show that high-resolution computed tomography is more sensitive than pulmonary function tests in the detection of early and progressive lung disease, and suggest that high-resolution computed tomography may be useful in the follow up of cystic fibrosis children and as an outcome measure in studies that aim to reduce lung damage.

Pulmonary embolism: comparison of gadolinium-enhanced MR angiography with contrast-enhanced spiral CT in a porcine model.

RATIONALE AND OBJECTIVES: The purpose of this study was to compare gadolinium-enhanced magnetic resonance (MR) angiography with contrast material-enhanced computed tomography (CT) for the detection of small (4-5-mm) pulmonary emboli (PE), with a methacrylate cast of the porcine pulmonary vasculature used as the diagnostic standard. MATERIALS AND METHODS: In 15 anesthetized juvenile pigs, colored methacrylate beads (5.2 and 3.8 mm diameter-the size of segmental and subsegmental emboli in humans) were injected via the left external jugular vein. After embolization, MR angiographic and CT images were obtained. The pigs were killed, and the pulmonary arterial tree was cast in clear methacrylate, allowing direct visualization of emboli. Three readers reviewed CT and MR angiographic images independently and in random order. RESULTS: Forty-nine separate embolic sites were included in the statistical analysis. The mean sensitivity (and 95% confidence intervals) for CT and MR angiography, respectively, were 76% (68%-82%) and 82% (75%-88%) (P > .05); the mean positive predictive values, 92% (85%-96%) and 94% (88%-97%) (P > .05). In this porcine model, PE were usually seen as parenchymal perfusion defects (98%) with MR angiography and as occlusive emboli (100%) with CT. CONCLUSION: MR angiography is as sensitive as CT for the detection of small PE in a porcine model.

Scintigraphic and MR perfusion imaging in preoperative evaluation for lung volume reduction surgery: pilot study results.

PURPOSE: To compare MR perfusion imaging with perfusion scintigraphy in the evaluation of patients with pulmonary emphysema being considered for lung volume reduction surgery. PATIENTS AND METHODS: Six patients with pulmonary emphysema and two normal individuals were evaluated by MR perfusion imaging, perfusion scintigraphy, and selective bilateral pulmonary angiography. MR images were obtained with an enhanced fast gradient recalled echo with three-dimensional Fourier transformation technique (efgre 3D) (6.3/1.3; flip angle, 30 degrees; field of view, 45-48 cm; matrix, 256 x 160). The presence or absence of perfusion defects in each segment was evaluated by two independent observers. RESULTS: Using angiography as the gold standard, the sensitivity, specificity, and accuracy of MR perfusion imaging in detecting focal perfusion abnormalities were 90%, 87%, and 89%, respectively, while those of perfusion scintigraphy were 71%, 76%, and 71%, respectively. The diagnostic accuracy of MR perfusion imaging was significantly higher than that of scintigraphy (p<0.001, McNemar test). There was good agreement between two observers for MR perfusion imaging (kappa statistic, 0.66) and only moderate agreement for perfusion scintigraphy (kappa statistic, 0.51). CONCLUSION: MR perfusion imaging is superior to perfusion scintigraphy in the evaluation of pulmonary parenchymal perfusion in patients with pulmonary emphysema.

MR imaging of pulmonary parenchyma.

Poor image quality has severely limited the clinical effectiveness of MR imaging of lung parenchyma. Recent improvements in imaging gradients and the introduction of phased-array receiver coils have improved image quality and should allow the diagnostic advantages inherent in MR imaging to be applied for images of lung parenchyma. The recent introduction of MR ventilation imaging should also provide further insights into airways diseases, including chronic obstructive lung disease (COLD), asthma, and bronchiolitis obliterans. The continuing research in MR imaging of lung parenchyma attests to the difficulty of obtaining good images and to the potential power of this technology.

Spiral computed tomography is comparable to angiography for the diagnosis of pulmonary embolism.

The use of spiral computed tomography (CT) for the diagnosis of pulmonary embolism has been compared to angiography, the current gold standard. However, the accuracy of pulmonary angiography has never been evaluated against an independent gold standard. The aim of this study was to compare contrast-enhanced spiral CT to pulmonary angiography for the detection of subsegmental-sized pulmonary emboli by using a methacrylate cast of porcine pulmonary vessels as an independent gold standard. We studied 16 anesthetized, juvenile pigs and injected colored methacrylate beads (3.8 mm, small; 4.2 mm, large) via the jugular vein. After embolization spiral CT (3 mm and 1 mm collimation), and pulmonary angiography were performed. Pigs were killed and the pulmonary arterial tree was cast using methacrylate. Spiral CT and angiography were interpreted independently by two radiologists. Sensitivity and 95% confidence intervals for 3 mm and 1 mm collimation CT and angiography, respectively, were: 82% (73 to 88%), 87% (79 to 93%), 87% (79 to 93%) (p = 0.42). Positive predictive values and 95% confidence intervals for 3 mm and 1 mm collimation CT and angiography, respectively, were: 94% (86 to 94%), 81% (73 to 88%), and 88% (80 to 93%). There was no difference between spiral CT and angiography for detection of subsegmental-sized pulmonary emboli. We conclude that spiral CT is comparable to angiography for detection of pulmonary emboli.

Effect of site and rate of contrast material injection on pulmonary vascular distention.

RATIONALE AND OBJECTIVES: The authors performed this study to determine if there were differences in vascular caliber measured on angiograms obtained with the injection protocol used for spiral computed tomography (CT) versus that used for pulmonary angiography. MATERIALS AND METHODS: The authors studied seven juvenile anesthetized pigs by using a prospective repeated measures experimental design. All pigs received injections of nonionic contrast material via catheters in the brachial vein, superior vena cava, main pulmonary artery, and left pulmonary artery. Weight-adjusted injection rates and volumes ranged from 0.05 mL/kg/sec (3.5 mL/sec, spiral CT protocol) to 0.56 mL/kg/sec (40 mL/sec, pulmonary angiography protocol). Heart rate and pulmonary artery and systemic artery pressures were recorded. During each injection, identically positioned pulmonary angiograms were obtained at full inspiration. Vessel diameters were measured at identical locations after each injection by two observers. The relationship between vessel diameter and hemodynamic parameters and injection site and rate was assessed with analysis of variance. RESULTS: At suspended full inspiration, no statistically significant difference (P > .05) in vessel diameter or hemodynamic parameters was found between the different injection sites or rates. There was no difference in vascular caliber between systole and diastole. CONCLUSION: The improved detection of subsegmental pulmonary emboli at pulmonary angiography compared with contrast material-enhanced spiral CT is not due to differences in vascular distention.

Clinically suspected pulmonary embolism: utility of spiral CT.

PURPOSE: To prospectively determine the utility of contrast material-enhanced spiral computed tomography (CT) in the examination of patients clinically suspected of having pulmonary embolism (PE). MATERIALS AND METHODS: One hundred ten patients clinically suspected of having PE were examined with contrast-enhanced spinal CT and at least one other imaging modality: ventilation-perfusion scintigraphy, Doppler ultrasonography of deep leg veins, or pulmonary angiography. Chart review or telephone contact with the referring clinician was used to evaluate the contribution of spiral CT to the final clinical diagnosis. RESULTS: Spiral CT helped correctly identify 23 of 25 patients with PE (sensitivity, 92%). In 57 (67%) of the 85 patients without PE, spiral CT provided additional information that suggested or confirmed the alternate clinical diagnosis: pneumonia (n = 14), cardiovascular disease (n = 10), pulmonary fibrosis (n = 7), trauma (n = 6), malignancy (n = 5), pleural disease (n = 4), postoperative changes (n = 4), and other (n = 7). In the remaining 28 patients, spiral CT scans were normal (n = 12), failed to produce findings supportive of the final clinical diagnosis (n = 13), or were false-positive for PE (n = 3; specificity, 96%). CONCLUSION: Spiral CT has good sensitivity and specificity for the diagnosis of PE. In the majority of patients who do not have PE, it also provides important ancillary information for the final diagnosis.

Transfemoral venous liver biopsy: common problems and complications.

Liver biopsy is still most commonly done via the percutaneous route; however, increasingly, transvascular venous liver biopsy has been used in patients with bleeding disorders. Although the jugular route is now generally favoured, a transfemoral route can be a useful alternative technique when the jugular route is not available. We describe the transfemoral technique and outline a number of commonly encountered problems and complications and suggested methods of addressing them.

Acute pulmonary embolism: ancillary findings at spiral CT.

PURPOSE: To determine the value of parenchymal findings at contrast material-enhanced spiral computed tomography (CT) in patients suspected to have pulmonary embolism (PE). MATERIALS AND METHODS: Eighty-eight patients suspected to have PE underwent contrast-enhanced spiral CT and ventilation-perfusion scintigraphy. Concordance between CT and scintigraphic results was used to diagnose or exclude PE. Pulmonary angiography was attempted in all patients with discordant CT and scintigraphic results or indeterminate scans. Parenchymal CT scans were assessed by two radiologists who were not aware of the diagnosis and who had access only to lung window images. RESULTS: Twenty-six patients had PE; 62 did not. Wedge-shaped pleural-based consolidation was seen in 16 patients with PE (62%) and 17 patients without PE (27%) (P < .05) (sensitivity, 62%; specificity, 73%). Linear bands were seen in 12 patients with PE (46%) and 13 patients without PE (21%) (P < .05) (sensitivity, 46%; specificity, 79%). There was no statistically significant difference in the frequency of non-wedge-shaped consolidation, areas of decreased attenuation, or atelectasis. Central and lower-lobe segmental pulmonary arteries that contained emboli were enlarged (P < .05). CONCLUSION: Parenchymal findings may suggest further investigations when results of spiral CT are inconclusive in diagnosis of PE.

Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy.

PURPOSE: To compare prospectively the accuracy of spiral computed tomography (CT) with that of ventilation-perfusion scintigraphy for diagnosing pulmonary embolism. MATERIALS AND METHODS: Within 48 hours of presentation, 142 patients suspected of having pulmonary embolism underwent spiral CT, scintigraphy, and (when indicated) pulmonary angiography. Pulmonary angiography was attempted if interpretations of spiral CT scans and of scintigrams were discordant or indeterminate and intermediate-probability, respectively. RESULTS: In the 139 patients who completed the study, interpretations of spiral CT scans and of scintigrams were concordant in 103 patients (29 with embolism, 74 without). In 20 patients, intermediate-probability scintigrams were interpreted (six with embolism at angiography, 14 without); diagnosis with spiral CT was correct in 16. Interpretations of spiral CT scans and those of scintigrams were discordant in 12 cases; diagnosis with spiral CT was correct in 11 cases and that with scintigraphy was correct in one. Spiral CT and scintigraphic scans of four patients with embolism did not show embolism. Sensitivities, specificities, and kappa values with spiral CT and scintigraphy were 87%, 95%, and 0.85 and 65%, 94%, and 0.61, respectively. CONCLUSION: In cases of pulmonary embolism, sensitivity of spiral CT is greater than that of scintigraphy. Interobserver agreement is better with spiral CT.

Quantification of idiopathic pulmonary fibrosis using computed tomography and histology.

We used computed tomography (CT) and histologic analysis to quantify lung structure in idiopathic pulmonary fibrosis (IPF). CT scans were obtained from IPF and control patients and lung volumes were estimated from measurements of voxel size, and X-ray attenuation values of each voxel. Quantitative estimates of lung structure were obtained from biopsies obtained from diseased and normal CT regions using stereologic methods. CT density was used to calculate the proportion of tissue and air, and this value was used to correct the biopsy specimens to the level of inflation during the CT scan. The data show that IPF is associated with a reduction in airspace volume with no change in tissue volume or weight compared with control lungs. Lung surface area decreased two-thirds (p < 0.001) and mean parenchymal thickness increased tenfold (p < 0.001). An exudate of fluid and cells was present in the airspace of the diseased lung regions and the number of inflammatory cells, collagen, and proteoglycans was increased per 100 g of tissue in IPF. We conclude that IPF reorganized lung tissue content causing a loss of airspace and surface area without increasing the total lung tissue.

Simulated dose reduction in conventional chest CT: validation study.

PURPOSE: To validate a technique of computer-simulated dose reduction for conventional chest computed tomography (CT). MATERIALS AND METHODS: In 27 patients, CT scans were obtained at 200, 100, and 40 mAs at two levels. The raw data from the 200-mAs scan were modified on a computer workstation to simulate the increased noise present on 100- and 40-mAs scans. Real and simulated 100- and 40-mAs images were independently assessed in random order for overall image quality and radiologic findings by four subspecialty-trained chest radiologists who were blinded to the technique. The four observers were given paired real and simulated images. They were asked to identify the real image and note any difference in diagnostic quality. RESULTS: No difference was seen in overall image quality or radiologic findings between real and simulated images (P > .05). In the paired comparison, 433 of 864 (50.1%) real images were correctly identified. CONCLUSION: Computer modification of 200-mAs raw scan data to simulate 100- and 40-mAs noise levels produces reconstructed images indistinguishable from real 100- and 40-mAs scans. This technique provides realistic reduced-dose images without patient radiation exposure and with identical image registration and motion artifact.