Split-bolus pancreas CTA protocol for local staging of pancreatic cancer and detection and characterization of liver lesions.

PURPOSE: To validate the use of a split-bolus pancreas CTA protocol for local staging of pancreatic cancer and to evaluate its ability to detect and characterize liver lesions. METHODS: Consecutive patients with pancreatic cancer who underwent split-bolus pancreas CTA between 12/2015 and 12/2016 were included in this IRB-approved HIPAA-compliant retrospective study. Objective evaluation of the abdominal vessels, the pancreas, the liver, and lesions, if present, was performed with attenuation measurements and tumor conspicuity and contrast-to-noise ratio (CNR) calculations. An abdominal radiologist with 20 years of experience performed subjective evaluation of image quality and blindly detected and characterized liver lesions. Any inconclusive findings or grading scores were evaluated in consensus with another abdominal radiologist with 7 years of experience. Liver findings were validated using a composite reference standard to assess accuracy. RESULTS: There were 82 pancreatic cancer patients with a total of 91 liver findings. Tumor conspicuity and CNR were 60.8 ± 35.1 HU and 8.0 ± 5.8 for the pancreatic lesions and 58 ± 34.7 HU and 9.7 ± 6.3 for the liver lesions, respectively. The accuracy, sensitivity, and specificity of the split-bolus protocol for the hepatic findings were correspondingly 89/91 (97.8%, 95% CI 92.3-99.4), 58/60 (96.7%, 95% CI 88.6-99.1), and 33/33 (100%, 95% CI 89.6-100). The subjective image quality ratings were optimal in more than 89% of the cases for various structures, with no non-diagnostic ratings. CONCLUSION: Split-bolus pancreas CTA protocol allows for detection and staging of pancreatic cancer, both for the primary tumor and detection and characterization of liver lesions.

Split-Bolus Injection Producing Simultaneous Late Arterial and Portal Venous Phases in CT Enterography: Preliminary Results.

OBJECTIVE: The purpose of this article is to evaluate the image quality and added value of split-bolus contrast agent injection combining late arterial and portal venous phases compared with single-bolus contrast agent injection late arterial phase CT enterography. MATERIALS AND METHODS: Consecutive patients who underwent CT enterography before and after implementation of a single-bolus CT enterography protocol were included. Attenuation and contrast-to-noise ratio (CNR) were assessed by ROI measurements of the bowel wall and arterial and venous structures. Subjective enhancement of the bowel wall (1, arterial; 2, mucosal; 3, transmural; 4, transmural with mucosal hyperenhancement) and bowel abnormalities were assessed by two independent readers. MR enterography examinations, endoscopy reports, and surgery reports within 30 days after CT enterography were used to produce a composite outcome. RESULTS: Sixty-six patients were included in our study: 33 (mean [± SD] age, 46.0 ± 19.8 years) who underwent split-bolus CT enterography and 33 (mean age, 49.9 ± 19.0 years) who underwent single-bolus CT enterography. Bowel wall attenuation and CNR were higher for split-bolus CT enterography than for single-bolus CT enterography at 120 kVp (enhancement, 98.7 ± 23.1 HU vs 85.1 ± 23.3 HU; CNR, 6.4 ± 2.5 vs 4.4 ± 2.3; p < 0.01). Subjective ratings of bowel wall enhancement were higher with the split-bolus CT enterography than the single-bolus CT enterography (2.6 ± 0.8 vs 2.3 ± 0.6; p < 0.001). Split-bolus CT enterography led to a higher detection rate of mucosal hyperenhancement than did single-bolus CT enterography in patients with active inflammatory bowel disease (100.0% [7/7; 95% CI, 59.0-100.0%] vs 33.3% [2/6; 95% CI, 4.3-77.7%]; p = 0.02), whereas both protocols had a specificity of 100.0% (9/9). CONCLUSION: Split-bolus CT enterography led to improved CNR (47%) compared with single-bolus CT enterography and significantly increased the detection rate of mucosal hyperenhancement in patients with active inflammatory bowel disease.

Split-bolus intravenous contrast material injection vs. single-bolus injection in patients following endovascular abdominal aortic repair (EVAR).

PURPOSE: To investigate the feasibility and accuracy of a split-bolus contrast injection CTA (SB-CTA) compared to a single-bolus injection CTA (SI-CTA) protocol of post-EVAR patients. MATERIALS AND METHODS: In this IRB-approved study, patients who underwent SB-CTA and SI-CTA after EVAR were evaluated. Attenuation and contrast-to-noise ratio (CNR) of vessels and parenchymal organs were assessed. Subjective enhancement of vessels, quality of 3D reconstructions, and enhancement phase of parenchymal organs were assessed by two independent readers. Endoleak visibility and incidental findings were evaluated. RESULTS: Fifty-six patients with SB-CTA and SI-CTA at two different time points after EVAR were included in the study (112 imaging studies, mean age 75 ± 9 years). There was no difference in attenuation and CNR for aorta between SB-CTA and SI-CTA (310 ± 87 vs. 311 ± 80 HU, p = 0.88; 31.1 ± 12.6 vs. 29.0 ± 12.2, p = 0.20), although both were improved in the venous structures and parenchymal organs with SB-CTA (portal vein: 149 ± 33 vs. 88 ± 32 HU, 11.6 ± 5.6 vs. 4.3 ± 3.4; liver: 91 ± 19 vs. 68 ± 20 HU, 4.4 ± 2.8 vs. 2.1 ± 2.0; pancreas: 108 ± 27 vs. 82 ± 23 HU, 6.4 ± 3.1 vs. 3.6 ± 2.4; p < 0.0001). Subjectively, enhancement of veins, liver, spleen, bowel, and kidneys was improved (p < 0.001), while there was no difference for the aorta (p = 0.46) and 3D reconstructions (p = 0.58). None of the 18/56 (32.1%) endoleaks was missed with the SB-CTA. More incidental findings were detected with SB-CTA (158/56) compared to SI-CTA (135/56), p < 0.001. SB-CTA was able to adequately characterize 7/15 (47%) of the findings that needed further evaluation in SI-CTA. 4/15 (26%) incidental findings that were missed with SI-CTA but seen with SB-CTA required further evaluation. CONCLUSION: Split-bolus injection CTA in the follow-up of EVAR patients allows reliable visualization of endoleaks with improved subjective and objective image quality.

Metal implants on CT: comparison of iterative reconstruction algorithms for reduction of metal artifacts with single energy and spectral CT scanning in a phantom model.

PURPOSE: To assess single energy metal artifact reduction (SEMAR) and spectral energy metal artifact reduction (MARS) algorithms in reducing artifacts generated by different metal implants. MATERIALS AND METHOD: Phantom was scanned with and without SEMAR (Aquilion One, Toshiba) and MARS (Discovery CT750 HD, GE), with various metal implants. Images were evaluated objectively by measuring standard deviation in regions of interests and subjectively by two independent reviewers grading on a scale of 0 (no artifact) to 4 (severe artifact). Reviewers also graded new artifacts introduced by metal artifact reduction algorithms. RESULTS: SEMAR and MARS significantly decreased variability of the density measurement adjacent to the metal implant, with median SD (standard deviation of density measurement) of 52.1 HU without SEMAR, vs. 12.3 HU with SEMAR, p < 0.001. Median SD without MARS of 63.1 HU decreased to 25.9 HU with MARS, p < 0.001. Median SD with SEMAR is significantly lower than median SD with MARS (p = 0.0011). SEMAR improved subjective image quality with reduction in overall artifacts grading from 3.2 ± 0.7 to 1.4 ± 0.9, p < 0.001. Improvement of overall image quality by MARS has not reached statistical significance (3.2 ± 0.6 to 2.6 ± 0.8, p = 0.088). There was a significant introduction of artifacts introduced by metal artifact reduction algorithm for MARS with 2.4 ± 1.0, but minimal with SEMAR 0.4 ± 0.7, p < 0.001. CONCLUSION: CT iterative reconstruction algorithms with single and spectral energy are both effective in reduction of metal artifacts. Single energy-based algorithm provides better overall image quality than spectral CT-based algorithm. Spectral metal artifact reduction algorithm introduces mild to moderate artifacts in the far field.

Dual energy CT angiography: pros and cons of dual-energy metal artifact reduction algorithm in patients after endovascular aortic repair.

PURPOSE: To evaluate the value of metal artifact reduction (MAR) post-processing and iodine MD images in fast kV-switching dual-energy computed tomography (DECT) in patients after endovascular aortic repair (EVAR). MATERIALS AND METHODS: Twenty-four consecutive EVAR patients (age 76 ± 9 years, 7/24 (29%) with coils, 9/24 (37.5%) with 10 endoleaks) who underwent DECT angiography were included in this HIPAA-compliant, IRB-approved retrospective study. Monochromatic reconstructions included 55, 60, 65, 70, and 75 keV with and without MAR and iodine MD images. Near field, far field, and vessel artifacts were assessed subjectively (1 = none; 5 = severe) and objectively by measuring noise and contrast-to-noise ratio. Visibility of endoleak was evaluated (1 = optimal; 5 = not visible). RESULTS: MAR objectively decreased artifacts from EVAR stents in the near field (60.7 ± 25.4 HU vs. 70.1 ± 34.2; p = .002) and subjectively increased near field (3.2 ± 0.9 vs. 2.8 ± 0.6; p < .001), far field (2.2 ± 0.6 vs. 1.6 ± 0.6; p < .001), and vessel (3.1 ± 1.1 vs. 2.5 ± 0.9; p < .001) artifacts. Near-field artifacts from coils were reduced by the MAR objectively (72.4 ± 24.8 vs. 182.7 ± 57.3 HU; p < .001) and subjectively (4.5 ± 0.5 vs. 4.9 ± 0.4; p = .02). CNR of standard reconstructions was optimal at 60 keV (38.3 ± 16.8). Reconstructions without MAR and iodine MD images provided improved endoleak visualization in 6/10 (60%) of cases (median 1 for both) compared to MAR (median 3) (p < 0.001). However, MAR improved visualization in 1/10 (10%) cases due to endoleak location adjacent to a coil. CONCLUSION: DECT with MAR reduced artifacts from coils and improved endoleak visualization in 1/10 (10%) cases due to location adjacent to a coil. However, MAR impaired endoleak visualization in 6/10 (60%) cases and should be reviewed combined with 60 keV standard reconstructions and iodine MD images.

Diagnostic yield and clinical impact of microbiologic diagnosis from CT-guided drainage in patients previously treated with empiric antibiotics.

PURPOSE: The purpose of the study was to evaluate diagnostic yield and the added value of culture results on the clinical management of patients empirically treated with antibiotics prior to CT-guided drainage. METHODS: This retrospective, HIPAA-compliant, IRB-approved study reviewed records of 300 consecutive patients who underwent CT-guided aspiration or drainage for suspected infected fluid collection while on empiric antibiotics (11/2011 to 9/2013) at a single institution. Patient imaging and clinical characteristics were evaluated by an abdominal imaging fellow and culture results, and patient management were evaluated by an infectious diseases fellow. RESULTS: After exclusion of 14/300 (4.6%) patients who were not on empiric antibiotics and 8/300 (2.6%) patients in which no culture was acquired, 278 patients (average age 55 ± 16 years; M:F ratio 54:46) constituted the final study cohort. Leukocytosis was present in 163/278 (59%), and fever in 65/278 (24%). The average collection size was 8.5 ± 4.2 cm with gas present in 140/278 (50%) of collections; median amount drained was 35 mL, and visibly purulent material was obtained in 172/278 (63%). 236/278 (85%) received drains and the remainder were aspirated only. Average time between initiation of antibiotics and start of the drainage procedure was 4.1 ± 6.4 days (median 1.7 days). Cultures were positive in 205/278 (74%) patients with a resulting change in management in 181/278 (65%) cases. The change in management included change of antibiotics in 71/278 (26%), narrowing the antibiotic regimen in 94/278 (34%), and cessation of antibiotics in 16/278 (6%). Multidrug-resistant bacteria were cultured in 53/278 (19%). Several factors were found to be statistically significant predictors of positive cultures: patient leukocytosis (sens 62%, spec 53%), gas in the collection on CT (sens 59%, spec 77%), purulent material aspiration (sens 76%, spec 76%), and presence of polymorphonuclear cells in the specimen. CONCLUSIONS: Despite predrainage antibiotic therapy, CT-guided drainage demonstrates a high yield of positive cultures and influences clinical management in the majority of patients.

MDCT vs. MRI for incidental pancreatic cysts: measurement variability and impact on clinical management.

PURPOSE: To investigate incidental pancreatic cysts (IPCs) size discrepancy in a cohort of patients receiving both computed tomography (CT) and magnetic resonance imaging (MRI) and its impact on clinical management based on the 2010 American College of Radiology (ACR) guidelines. METHODS: This was a HIPAA-compliant, retrospective, IRB-approved study. Informed consent was waived. Patients with known IPCs and at least one case-pair, consisting of an abdominal CT and MRI examination within 180 days between 05/1999 and 12/2011, were included. Maximum diameter of cysts was measured in both the CT and MR examinations. A subset of 30 patients was measured by three radiologists independently to assess inter-observer variability. Absolute difference in diameter measurements between CT and MRI was calculated. Influence of cyst size, cyst location, and patient characteristics such as weight, height, and body mass index (BMI) on variability of size measurements were evaluated. Clinical impact in terms of current ACR guidelines was assessed. RESULTS: Overall, 267 case-pairs of cysts in 113 patients were included in this study. 59/267 cysts were visualized on MRI but not on CT (22.1%, 95% CI 17.1%-27.1%; 32 patients, 64.6 ± 11.7 years, BMI 28.5 ± 4.8 kg/m2), with a median MRI cyst size of 7.8 mm, IQR 6.0-9.0 mm, range 2-17.8 mm. 208 case-pairs in 113 patients with a mean BMI of 26.9 ± 5.1 kg/m2 (range 16.9-39.5 kg/m2) and mean cysts size of 13.4 ± 8.1 mm (range 3-49 mm) were seen in both CT and MRI. The mean absolute size difference for IPCs measured on MRI and CT was 2.1 ± 1.8 mm (median 1.5 mm, IQR 0.9-2.9 mm, range 0-9 mm). Absolute size difference between CT and MRI measurements increased with size of the cyst (r = 0.31, p < 0.001), whereas location of the cyst did not influence the absolute difference between CT and MRI measurements (p = 0.44). Patient weight and BMI had a negative correlation with the difference in cyst size between CT and MRI (weight r = -0.17, p = 0.023; BMI r = -0.17, p = 0.027), with cyst measurements being larger on MRI in thin patients and on CT in obese patients. Inter-reader variability was excellent (ICC = 0.99). In 12/208 (5.7%, 95% CI 2.7%-9.1%), variability between CT and MRI would have changed ACR-based follow-up recommendation. CONCLUSION: There was a median difference of 1.5 mm between measurements of IPCs on CT vs. MRI. If imaging modality was switched during follow-up, variability of measurements may lead to inappropriate change of follow-up regimen in 6% of all cases. A single follow-up CT for incidental IPCs does not seem sufficient due to a high number (22%) of missed IPCs on CT.

Limited added utility of performing follow-up contrast-enhanced CT in patients undergoing initial non-enhanced CT for evaluation of flank pain in the emergency department.

In our emergency department (ED), patients with flank pain often undergo non-enhanced computed tomography (NECT) to assess for nephroureteral (NU) stone. After immediate image review, decision is made regarding need for subsequent contrast-enhanced CT (CECT) to help assess for other causes of pain. This study aimed to review the experience of a single institution with this protocol and to assess the utility of CECT. Over a 6 month period, we performed a retrospective analysis on ED patients presenting with flank pain undergoing CT for a clinical diagnosis of nephroureterolithiasis. Patients initially underwent abdominopelvic NECT. The interpreting radiologist immediately decided whether to obtain a CECT to evaluate for another etiology of pain. Medical records, CT reports and images, and 7-day ED return were reviewed. CT diagnoses on NECT and CECT were compared. Additional information from CECT and changes in management as documented in the patient's medical record were noted. Three hundred twenty-two patients underwent NECT for obstructing NU stones during the study period. Renal or ureteral calculi were detected in 143/322 (44.4 %). One hundred fifty-four patients (47.8 %) underwent CECT. CECT added information in 17/322 cases (5.3 %) but only changed management in 6/322 patients (1.9 %). In four of these patients with final diagnosis of renal infarct, splenic infarct, pyelonephritis and early acute appendicitis in a thin patient, there was no abnormality on the NECT (4/322 patients, 1.2 %). In the remaining 2 patients, an abnormality was visible on the NECT. In patients presenting with flank pain with a clinical suspicion of nephroureterolithiasis, CECT may not be indicated. While CECT provided better delineation of an abnormality in 5.3 % of cases, changes in management after CECT occurred only in 2 %. This included 1 % of patients in whom a diagnosis of organ infarct, pyelonephritis or acute appendicitis in a thin patient could only be made on CECT.

Assessment of liver fat in an obese patient population using noncontrast CT fat percent index.

OBJECTIVE: To develop a simplified method to quantify liver fat using computed tomography (CT) fat % index (CTFPI) compared to liver spleen method (CTL/S, CTL-S). METHODS: Noncontrast CT of the liver was performed in 89 patients (overweight, obese, severely obese) to quantify fat, using the following: CTFPI=[(65-patient HU)/65]×100, normal live r=65 HU. RESULTS: There was a strong linear correlation between CTFPI and the standard method of assessing liver fat using CTL/S (r=-0.901), CTL-S (r=-0.911). Hepatic HU and CTFPI were significantly different in the severely obese group compared to other two groups (P<.05). CONCLUSION: Significant correlation indicates equal diagnostic accuracy of the two methods in appropriately calibrated scanners.

Split-bolus spectral multidetector CT of the pancreas: assessment of radiation dose and tumor conspicuity.

PURPOSE: To assess tumor conspicuity and radiation dose with a new multidetector computed tomography (CT) protocol for pancreatic imaging that combines spectral CT and split-bolus injection. MATERIALS AND METHODS: This study was approved by the institutional review board and compliant with HIPAA. The requirement for informed consent was waived. One hundred sixty-three consecutive patients referred for possible pancreatic mass underwent CT with either a standard or split-bolus spectral CT protocol depending on scanner availability. Split-bolus spectral CT (CT unit with spectral imaging) combines pancreatic and portal venous phases in a single scan: 70 seconds before CT, 100 mL of contrast material is injected for the portal venous phase followed approximately 35 seconds later by injection of 40 mL of contrast material to boost the pancreatic phase. Bolus tracking after the second bolus initiates scanning 15 seconds after aorta enhancement reaches 280 HU. Images were reconstructed at 60 and 77 keV. The standard protocol (64-detector row unit) included unenhanced and pancreatic and portal venous phase imaging, with a single contrast material injection timed with bolus tracking 15 seconds after aortic enhancement of 300 HU for the pancreatic phase and 32 seconds later for the portal venous phase. Tumor conspicuity (difference in attenuation between tumor and pancreatic parenchyma) and contrast-to-noise ratio (CNR) were determined. Attenuation of aorta, main portal vein, and liver were measured. Patient size and per-examination radiation dose were recorded. The heteroscedastic t test, Fisher exact test, and Mann-Whitney test were used for statistical analysis. RESULTS: There were no significant differences in age, weight, and body mass index between patients in the standard CT (46 of 80 patients had lesions) and split-bolus spectral CT (39 of 83 patients had lesions) groups; however, there were significantly more women in the split-bolus group (P = .02). Tumor conspicuity and CNR were higher with the 60-keV split-bolus protocol (89.1 HU ± 56.6 and 8.8 ± 6.2, respectively) than with the pancreatic or portal venous phase of the standard protocol (43.5 HU ± 28.4 and 4.5 ± 3.0, and 51.5 HU ± 30.3 and 5.6 ± 4.0, respectively; P < .01 for all comparisons). Dose-length product was 1112 mGy · cm ± 437 with the standard protocol and 633 mGy · cm ± 105 with the split-bolus protocol (P < .001). CONCLUSION: Split-bolus spectral multidetector CT resulted in vascular, liver, and pancreatic attenuation and tumor conspicuity equal to or greater than that with multiphase CT, with a 43% reduction in radiation dose.

Spectral CT with metal artifacts reduction software for improvement of tumor visibility in the vicinity of gold fiducial markers.

PURPOSE: To evaluate spectral computed tomography (CT) with metal artifacts reduction software (MARS) for reduction of metal artifacts associated with gold fiducial seeds. MATERIALS AND METHODS: Thirteen consecutive patients with 37 fiducial seeds implanted for radiation therapy of abdominal lesions were included in this HIPAA-compliant, institutional review board-approved prospective study. Six patients were women (46%) and seven were men (54%). The mean age was 61.1 years (median, 58 years; range, 29-78 years). Spectral imaging was used for arterial phase CT. Images were reconstructed with and without MARS in axial, coronal, and sagittal planes. Two radiologists independently reviewed reconstructions and selected the best image, graded the visibility of the tumor, and assessed the amount of artifacts in all planes. A linear-weighted κ statistic and Wilcoxon signed-rank test were used to assess interobserver variability. Histogram analysis with the Kolmogorov-Smirnov test was used for objective evaluation of artifacts reduction. RESULTS: Fiducial seeds were placed in pancreas (n = 5), liver (n = 7), periportal lymph nodes (n = 1), and gallbladder bed (n = 1). MARS-reconstructed images received a better grade than those with standard reconstruction in 60% and 65% of patients by the first and second radiologist, respectively. Tumor visibility was graded higher with standard versus MARS reconstruction (grade, 3.7 ± 1.0 vs 2.8 ± 1.1; P = .001). Reduction of blooming was noted on MARS-reconstructed images (P = .01). Amount of artifacts, for both any and near field, was significantly smaller on sagittal and coronal MARS-reconstructed images than on standard reconstructions (P < .001 for all comparisons). Far-field artifacts were more prominent on axial MARS-reconstructed images than on standard reconstructions (P < .01). Linear-weighted κ statistic showed moderate to perfect agreement between radiologists. CT number distribution was narrower with MARS than with standard reconstruction in 35 of 37 patients (P < .001). CONCLUSION: Spectral CT with use of MARS improved tumor visibility in the vicinity of gold fiducial seeds.

Female breast, lung, and pelvic organ radiation from dose-reduced 64-MDCT thoracic examination protocols: a phantom study.

OBJECTIVE: We compared phantom organ doses delivered to breast, lung, and pelvis by five protocols using current dose reduction methods for routine chest CT and pulmonary CT angiography. MATERIALS AND METHODS: We measured the radiation dose to an anthropomorphic phantom using 64-MDCT with metal oxide semiconductor field effect transistor (MOSFET) detectors in the breast (skin and parenchyma), the lungs, and the pelvis (upper and lower). We compared the following five protocols: protocol 1, 120 kVp, automatic dose modulation, 120-320 mA; protocol 2, 120 kVp, automatic dose modulation, 60-200 mA; protocol 3, 100 kVp and fixed dose of 200 mA; protocol 4, 120 kVp, automatic dose modulation, 200-394 mA; and protocol 5, 80 kVp and fixed dose of 120 mA. Organ doses in milligrays and as a percentage of the volume CT dose index (CTDI(vol)) were compared using the analysis of variance for repeated measurements. RESULTS: Protocol 1 delivered the highest breast dose (mean ± SD, 15.8 ± 1.8 mGy; 110.5% of CTDI(vol)). A decrease in breast radiation of more than 50% was achieved with protocol 3 (4.8 ± 1.8 mGy; 91.7% of CTDI(vol)) compared with protocol 4 (13.1 ± 5.5 mGy; 87.0% of CTDI(vol)) (p = 0.003). The lung received the highest organ dose regardless of the protocol (protocol 4: 21.5 ± 1.7 mGy; 142.5% of CTDI(vol)). Pelvic radiation was low regardless of protocol and did not exceed 0.2 mGy (up to 3.7% of CTDI(vol); p = 0.118-0.999). CONCLUSION: The results of this anthropomorphic phantom study showed substantial and significant variation in radiation doses to the breast and lungs depending on the scanning protocol used with the potential for over threefold dose reduction.

Incidence of contrast-induced nephropathy in patients with multiple myeloma undergoing contrast-enhanced CT.

OBJECTIVE: The purpose of this article is to evaluate the incidence of contrast-induced nephropathy (CIN) and the effects of associated risk factors in patients with multiple myeloma undergoing contrast-enhanced CT (CECT) with IV administration of nonionic iodinated contrast agent. MATERIALS AND METHODS: This retrospective review of medical records identified patients with a diagnosis of myeloma who underwent a CECT examination of the chest, abdomen, or pelvis between January 1, 2005, and December 1, 2008. Analysis for CIN, as defined by an increase in creatinine level after the CECT examination of 25% or more, or of 0.5 mg/dL, compared with the level before the CECT examination, both within 48 hours and within 7 days, was performed. Statistical correlations between the development of CIN and creatinine level before CECT examination, patient location, type and amount of contrast agent, blood urea nitrogen-creatinine ratio, history of diabetes, hypercalcemia, Bence Jones proteinuria, ß(2)-microglobulin level, albumin level, International Myeloma Staging System stage, and history of myeloma provided at the time the CT examination was ordered were calculated. RESULTS: Forty-six patients who completed 80 unique examinations were included; their average creatinine level before CECT examination was 0.97 mg/dL. There was no significant difference in the average creatinine levels before CT examination between patients without and those with CIN. Four (5%) and 12 (15%) patients developed CIN within 48 hours and 7 days, respectively. Only serum ß(2)-microglobulin level showed a statistically significant (p = 0.03) correlation with the development of CIN. CONCLUSION: The incidence of CIN in patients with multiple myeloma with a normal creatinine level is low and correlates with ß(2)-microglobulin levels. The administration of contrast agent in this patient population is safe but should be based on the potential benefit of the examination and the expected low risk of developing CIN.

Absorbed radiation dose in radiosensitive organs during coronary CT angiography using 320-MDCT: effect of maximum tube voltage and heart rate variations.

OBJECTIVE: The purpose of this article is to estimate the absorbed radiation dose in radiosensitive organs during coronary MDCT angiography using 320-MDCT and to determine the effects of tube voltage variation and heart rate (HR) control on absorbed radiation dose. MATERIALS AND METHODS: Semiconductor field effect transistor detectors were used to measure absorbed radiation doses for the thyroid, midbreast, breast, and midlung in an anthropomorphic phantom at 100, 120, and 135 kVp at two different HRs of 60 and 75 beats per minute (bpm) with a scan field of view of 320 mm, 400 mA, 320 × 0.5 mm detectors, and 160 mm collimator width (160 mm range). The paired Student's t test was used for data evaluation. RESULTS: At 60 bpm, absorbed radiation doses for 100, 120, and 135 kVp were 13.41 ± 3.59, 21.7 ± 4.12, and 29.28 ± 5.17 mGy, respectively, for midbreast; 11.76 ± 0.58, 18.86 ± 1.06, and 24.82 ± 1.45 mGy, respectively, for breast; 12.19 ± 2.59, 19.09 ± 3.12, and 26.48 ± 5.0 mGy, respectively, for lung; and 0.37 ± 0.14, 0.69 ± 0.14, and 0.92 ± 0.2 mGy, respectively, for thyroid. Corresponding absorbed radiation doses for 75 bpm were 38.34 ± 2.02, 59.72 ± 3.13, and 77.8 ± 3.67 mGy for midbreast; 26.2 ± 1.74, 44 ± 1.11, and 52.84 ± 4.07 mGy for breast; 38.02 ± 1.58, 58.89 ± 1.68, and 78 ± 2.93 mGy for lung; and 0.79 ± 0.233, 1.04 ± 0.18, and 2.24 ± 0.52 mGy for thyroid. Absorbed radiation dose changes were significant for all organs for both tube voltage reductions as well as for HR control from 75 to 60 bpm at all tube voltage settings (p < 0.05). The absorbed radiation doses for the calcium score protocol were 11.2 ± 1.4 mGy for midbreast, 9.12 ± 0.48 mGy for breast, 10.36 ± 1.3 mGy for lung, and 0.4 ± 0.05 mGy for thyroid. CONCLUSION: CT angiography with 320-MDCT scanners results in absorbed radiation doses in radiosensitive organs that compare favorably to those previously reported. Significant dose reductions can be achieved by tube voltage reductions and HR control.

CT enterography.

Conventional radiologic and endoscopic evaluations of the small bowel are often limited by the length, caliber, and motility of the small bowel loops. The development of new multidetector-row CT scanners, with faster scan times and isotropic spatial resolution, allows high-resolution multiphasic and multiplanar assessment of the bowel, bowel wall, and lumen. CT Enterography (CTE) is a variant of routine abdominal scanning, geared toward more sustained bowel filling with oral contrast material, and the use of multiplanar images, that can enhance gastrointestinal (GI) tract imaging. This article examines the techniques and clinical applications of CTE in comparison with CT enteroclysis, focusing on Crohn disease, obscure GI bleeding, GI tumors, acute abdominal pain, and bowel obstruction.

Escalating computed tomography angiogram (CTA) grade predicts unresectability and margin status for pancreaticobiliary neoplasms.

BACKGROUND AND AIMS: The Raptopoulos computed tomography (CT) grading system of pancreaticobiliary cancers was conceived to predict resectability based on tumour involvement of critical vasculature. The aim of the present study was to investigate the relationship between CT grade, resectability, margin status and survival after pancreatic resection. METHODS: Patients with presumed pancreaticobiliary malignancy and a pancreas protocol computed tomography angiogram (CTA) who underwent attempted curative resection from October 2001 and August 2008 were identified. The relationship between radiographical involvement of critical vasculature, according to a five-point scale, and ultimate resectability, margin status and survival was assessed. RESULTS: Overall, 276 (70.2%) out of 393 patients were resectable. The proportion of patients who were unresectable at laparotomy increased as CT grade escalated; 41/250 (16.4%) CT Grade 0, 16/55 (29.1%) CT Grade 1, 33/55 (60%) CT Grade 2, 27/33 CT Grade 3, P < 0.001. Local invasion or vascular involvement was the reason for unresectability in 14/41, 12/16, 23/33, 16/27 patients with CT Grade 0-3, respectively. A R0 resection was achieved in 84/131 patients with pancreatic adenocarcinoma and varied significantly by CT grade, P= 0.021. Significant predictors of survival were age (P < 0.0001), resectability (P < 0.0001) and diagnosis (P < 0.009). CONCLUSIONS: Escalating Raptopoulos CT grade is correlated with increasing probability of unresectability and R1 resection.

Combined vascular-excretory phase MDCT angiography in the preoperative evaluation of renal donors.

OBJECTIVE: The objective of our study was to test a dose reduction protocol that uses combined vascular-excretory phase scanning achieved by split IV contrast injection and compare it with conventional multiphase MDCT angiography (MDCTA) in evaluating potential renal donors. MATERIALS AND METHODS: This study is a review of MDCTA examinations of 54 potential renal donors scanned on 16- and 64-MDCT. The IV bolus was split: 50 mL was administered 3 minutes before scanning and a second injection of 70-100 mL was administered at a rate of 4-6 mL/s, with CT angiography started by bolus tracking. The second vascular (venous) phase was acquired 20 seconds later. Two readers reviewed the two phases, assessed vascular and parenchymal anatomy and variants or abnormalities, graded the added value of the venous phase on a 5-point scale, and took attenuation measurements in Hounsfield units. The operative notes of 39 subjects were reviewed as the reference standard for anatomic findings and compared with CT reports. RESULTS: All of the relevant anatomy findings, according to the operative notes, were accurately depicted by MDCTA, and all were well recognized on the arterial phase. The arterial phase combined information from the arterial, venous, parenchymal, and excretory phases. The venous phase was inferior to the arterial phase in assessing the renal arteries without additional venous, parenchymal, or excretory phase information. The mean renal artery attenuation was 355 HU in the first phase versus 173 HU in the second phase (p<0.0001). The mean renal vein attenuation was not significantly different between the two phases. The parenchymal system and excretory system were equally well depicted in both vascular phases. CONCLUSION: Split-bolus contrast injection and combined vascular-excretory phase scanning are adequate for studying potential renal donors and result in a marked decrease in multiphase scanning and, thus, in radiation dose.

Dose reduction in computed tomographic angiography of pregnant patients with suspected acute pulmonary embolism.

PURPOSE: The aim of this study was to quantify the effect of a reduced-dose pulmonary computed tomographic (CT) angiography protocol on radiation dose and image quality in pregnant patients as compared with a standard protocol. MATERIALS AND METHODS: Twenty-six pregnant women with suspected pulmonary embolism underwent reduced-dose CT angiography (200 mA and 100 kV, from the aortic arch to the diaphragm). The matched control group standard protocol was 400 mA, 120 kilovolt (peak), and the entire thorax. The CT dose index, dose-length product, effective dose, image quality, and signal-to-noise ratio were assessed and compared with the Wilcoxon rank sum test result. RESULTS: The CT dose index, mean dose-length product, and calculated effective dose were lower in the pregnancy group than in the controls: mean (SD), 5.21 (1.54) mGy versus 20.86 (5.59) mGy; 105.65 (39.77) mGy cm versus 575.71 (154.86) mGy cm, and 1.79 (0.676) msv versus 9.787 (2.63) msv, respectively (P < 0.0001). Quality scores of segmental (P = 0.266) and subsegmental (P = 0.207) arteries and arterial attenuation (P = 0.443) were similar. CONCLUSIONS: In pregnant patients with suspected pulmonary embolism, combined reduction of kilovoltage and milliampere-second settings and z-axis coverage results in a substantial reduction of radiation dose while maintaining diagnostic imaging quality.