Under pressure - Association of the arm position and leading circulatory structure behind the pressure point in cardiopulmonary resuscitation patients.

BACKGROUND: Thoracic computed tomography scans (CT) are used by several study groups to investigate the circulatory structures (heart and vessels) located behind the pressure point for chest compressions. Yet, it remains unclear how the positioning of these structures is influenced by factors such as intubation, the respiratory cycle and arm positioning. METHODS: We retrospectively analyzed data of adult patients with in- or out-of-hospital cardiac arrest who underwent thoracic CT imaging within one year before or up to six months after arrest. A region of interest (ROI) behind the pressure point was defined. The largest structure within this region was defined as "leading circulatory structure", which was the primary outcome. Airway status (intubated versus spontaneous breathing), respiratory cycle (inspiration, expiration, resting expiratory position), and arm position (up over the head versus down beside the trunk) served as covariates in an ordinal regression model. RESULTS: Among 500 initially screened patients, 411 (82.2 %) were included in the analysis. There was a significant association between the arm position and the leading circulatory structure behind the pressure point. However, no association was found with airway status or respiratory cycle. The most frequently identified leading circulatory structure was the left atrium (arms up: 41.8 %, down: 50.7 %), followed by the ascending aorta (up: 23.8 % vs. down: 16.7 %). The left ventricle was the leading structure in only one case (0.2 %, arms down). CONCLUSION: This study shows that arm position is significantly associated with the leading circulatory structure behind the pressure point for chest compressions in cardiac arrest.

Prediction model for leaflet thrombosis in patients undergoing transcatheter aortic valve implantation: the EFFORT study.

BACKGROUND: Leaflet thrombosis (LT) is a multifaceted and underexplored condition that can manifest following transcatheter aortic valve implantation (TAVI). The objective of this study was to formulate a prediction model based on laboratory assessments and clinical parameters, providing additional guidance and insight into this relatively unexplored aspect of post-TAVI complications. METHODS: The present study was an observational prospective hypothesis-generating study, including 101 patients who underwent TAVI and a screening for LT (the primary endpoint) by multidetector computed tomography (MDCT). All images were acquired on a third-generation dual-source CT system. Levels of von Willebrand factor (vWF) activity, hemoglobin (Hb), and lactate dehydrogenase (LDH) were measured among other parameters. A predictive score utilizing binary logistic regression, Kaplan-Meier time-to-event analysis, and receiver operating characteristics (ROC) analysis was established. RESULTS: LT (11 subclinical and 2 clinical) was detected in 13 of 101 patients (13%) after a median time to screening by MDCT of 105 days (IQR, 98-129 days). Elevated levels of vWF activity (> 188%) pre-TAVI, decreased Hb values (< 11.9 g/dL), as well as increased levels of LDH (> 312 U/L) post-TAVI and absence of oral anticoagulation (OAC) were found in patients with subsequent LT formation as compared to patients without LT. The established EFFORT score ranged from - 1 to 3 points, with an increased probability for LT development in patients with ≥ 2 points (85.7% of LT cases) vs < 2 points (14.3% of LT cases; p < 0.001). Achieving an EFFORT score of ≥ 2 points was found to be significantly associated with a 10.8 times higher likelihood of developing an LT (p = 0.001). The EFFORT score has an excellent c-statistic (area under the curve (AUC) = 0.89; 95% CI 0.74-1.00; p = 0.001) and a high negative predictive value (98%). CONCLUSION: An EFFORT score might be a helpful tool to predict LT development and could be used in risk assessment, if validated in confirmatory studies. Therefore, the score has the potential to guide the stratification of individuals for the planning of subsequent MDCT screenings.

Ultra-low-dose CT vs. chest X-ray in non-traumatic emergency department patients - a prospective randomised crossover cohort trial.

Background: Ultra-low-dose CT (ULDCT) examinations of the chest at only twice the radiation dose of a chest X-ray (CXR) now offer a valuable imaging alternative to CXR. This trial prospectively compares ULDCT and CXR for the detection rate of diagnoses and their clinical relevance in a low-prevalence cohort of non-traumatic emergency department patients. Methods: In this prospective crossover cohort trial, 294 non-traumatic emergency department patients with a clinically indicated CXR were included between May 2nd and November 26th of 2019 (www.clinicaltrials.gov: NCT03922516). All participants received both CXR and ULDCT, and were randomized into two arms with inverse reporting order. The detection rate of CXR was calculated from 'arm CXR' (n = 147; CXR first), and of ULDCT from 'arm ULDCT' (n = 147; ULDCT first). Additional information reported by the second exam in each arm was documented. From all available clinical and imaging data, expert radiologists and emergency physicians built a compound reference standard, including radiologically undetectable diagnoses, and assigned each finding to one of five clinical relevance categories for the respective patient. Findings: Detection rates for main diagnoses by CXR and ULDCT (mean effective dose: 0.22 mSv) were 9.1% (CI [5.2, 15.5]; 11/121) and 20.1% (CI [14.2, 27.7]; 27/134; P = 0.016), respectively. As an additional imaging modality, ULDCT added 9.1% (CI [5.2, 15.5]; 11/121) of main diagnoses to prior CXRs, whereas CXRs did not add a single main diagnosis (0/134; P < 0.001). Notably, ULDCT also offered higher detection rates than CXR for all other clinical relevance categories, including findings clinically irrelevant for the respective emergency department visit with 78.5% (CI [74.0, 82.5]; 278/354) vs. 16.2% (CI [12.7, 20.3]; 58/359) as a primary modality and 68.2% (CI [63.3, 72.8]; 245/359) vs. 2.5% (CI [1.3, 4.7]; 9/354) as an additional imaging modality. Interpretation: In non-traumatic emergency department patients, ULDCT of the chest offered more than twice the detection rate for main diagnoses compared to CXR. Funding: The Department of Biomedical Imaging and Image-guided Therapy of Medical University of Vienna received funding from Siemens Healthineers (Erlangen, Germany) to employ two research assistants for one year.

Three-Dimensional Quantitative Tumor Response and Survival Analysis of Hepatocellular Carcinoma Patients Who Failed Initial Transarterial Chemoembolization: Repeat or Switch Treatment?

OBJECTIVES: The purpose of this study was to assess treatment responses and evaluate survival outcomes between responders and non-responders after each transarterial chemoembolization (TACE) session using the 3D quantitative criteria of the European Association for the Study of the Liver (qEASL) in hepatocellular carcinoma (HCC) patients. METHODS: A total of 94 consecutive patients who underwent MR imaging before and after TACE were retrospectively included. Volumetric tumor enhancement (qEASL) was expressed in cubic centimeters (cm3). The Kaplan-Meier method with the log-rank test was used to calculate the overall survival (OS) for the non-/responders. RESULTS: In total, 28 (29.8%) patients showed a response after the first TACE. These responders demonstrated a clear trend toward longer OS compared with the non-responders (36.7 vs. 21.5 months, p = 0.071). Of the 43 initial non-responders who underwent a second TACE within 3 months and had complete follow-up imaging, 15/43 (34.9%) achieved a response, and their median OS was significantly longer than that of the 28 non-responders to the second TACE (47.8 vs. 13.6 months, p = 0.01). Furthermore, there was no significant difference in OS between the 28 patients who achieved a response after the first TACE and the 15 initial non-responders who achieved a response after the second TACE (36.7 vs. 47.8 months, p = 0.701). The difference in OS between the responders and non-responders after the third TACE was not significant (11.4 months vs. 13.5 months, p = 0.986). CONCLUSION: Our study quantitatively demonstrated that a second TACE can be beneficial in terms of tumor response and survival for HCC patients who do not initially respond to TACE.

Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure.

OBJECTIVES: Investigate long-term effects of repeated transarterial chemoembolization (TACE) on portal venous pressure (PVP) using non-invasive surrogate markers of portal hypertension. METHODS: Retrospective, Institutional Review Board-approved study. 99 patients [hepatocellular carcinoma (HCC) group (n=57); liver metastasis group (n=42)] who underwent 279TACEs and had longitudinal pre-/post-therapy contrast-enhanced-MRI (n=388) and complete blood work were included. Outcomes of interest were platelet count (PC), spleen volume, ascites and portosystemic collaterals. Variables included TACE type/number, tumor type, microcatheter location, Child-Pugh, baseline tumor burden (tumor number/total/largest size), vessel invasion, alpha-fetoprotein, Eastern Cooperative Oncology Group (ECOG) performance status, and Model for End-Stage Liver Disease (MELD) score. Generalized Estimating Equations assessed the associations between TACE and outcomes. Power analysis determined the sample size was sufficient. RESULTS: No significant change in PC over time was observed in either groups, regardless of liver function (P>0.05). Baseline spleen volume was 226 cm3 for metastatic group, and was larger by 204 cm3 for HCC group (P<0.001). Spleen volume increased by 20 cm3 (95%CI: 8-32; P=0.001) for both groups after 1stTACE and by 16cm3/TACE (P=0.099) over the full follow-up (up to 9TACEs). Spleen volume also tended to increase by 23cm3 (95%CI: -1-48; P=0.064) with higher tumor burden. Odds of developing moderate/severe ascites for metastatic patients was decreased by 0.5 (95%CI: 0.3-0.9; P=0.014), regardless of the Child-Pugh, and increased by 1.5 (95%CI: 1.2-1.9; P<0.001) among HCC patients with unstable Child-Pugh, whereas no change was noted with stable Child-Pugh. HCC patients with unstable Child-Pugh demonstrated a significant increase in portosystemic collaterals number over time (P=0.008). PVP-related complications such as variceal bleeding post-TACE were low (0.4%). CONCLUSION: Repeated TACEs did seem to have an impact on PVP. However, the increase in PVP had marginal effects with low portal hypertension-related complications.

Identifying enhancement-based staging markers on baseline MRI in patients with colorectal cancer liver metastases undergoing intra-arterial tumor therapy.

OBJECTIVES: To determine if three-dimensional whole liver and baseline tumor enhancement features on MRI can serve as staging biomarkers and help predict survival of patients with colorectal cancer liver metastases (CRCLM) more accurately than one-dimensional and non-enhancement-based features. METHODS: This retrospective study included 88 patients with CRCLM, treated with transarterial chemoembolization or Y90 transarterial radioembolization between 2001 and 2014. Semi-automated segmentations of up to three dominant lesions were performed on pre-treatment MRI to calculate total tumor volume (TTV) and total liver volumes (TLV). Quantitative 3D analysis was performed to calculate enhancing tumor volume (ETV), enhancing tumor burden (ETB, calculated as ETV/TLV), enhancing liver volume (ELV), and enhancing liver burden (ELB, calculated as ELV/TLV). Overall and enhancing tumor diameters were also measured. A modified Kaplan-Meier method was used to determine appropriate cutoff values for each metric. The predictive value of each parameter was assessed by Kaplan-Meier survival curves and univariable and multivariable cox proportional hazard models. RESULTS: All methods except whole liver (ELB, ELV) and one-dimensional/non-enhancement-based methods were independent predictors of survival. Multivariable analysis showed a HR of 2.1 (95% CI 1.3-3.4, p = 0.004) for enhancing tumor diameter, HR 1.7 (95% CI 1.1-2.8, p = 0.04) for TTV, HR 2.3 (95% CI 1.4-3.9, p < 0.001) for ETV, and HR 2.4 (95% CI 1.4-4.0, p = 0.001) for ETB. CONCLUSIONS: Tumor enhancement of CRCLM on baseline MRI is strongly associated with patient survival after intra-arterial therapy, suggesting that enhancing tumor volume and enhancing tumor burden are better prognostic indicators than non-enhancement-based and one-dimensional-based markers. KEY POINTS: • Tumor enhancement of colorectal cancer liver metastases on MRI prior to treatment with intra-arterial therapies is strongly associated with patient survival. • Three-dimensional, enhancement-based imaging biomarkers such as enhancing tumor volume and enhancing tumor burden may serve as the basis of a novel prognostic staging system for patients with liver-dominant colorectal cancer metastases.

Radiomics of high-resolution computed tomography for the differentiation between cholesteatoma and middle ear inflammation: effects of post-reconstruction methods in a dual-center study.

OBJECTIVES: To evaluate the performance of radiomic features extracted from high-resolution computed tomography (HRCT) for the differentiation between cholesteatoma and middle ear inflammation (MEI), and to investigate the impact of post-reconstruction harmonization and data resampling. METHODS: One hundred patients were included in this retrospective dual-center study: 48 with histology-proven cholesteatoma (center A: 23; center B: 25) and 52 with MEI (A: 27; B: 25). Radiomic features (co-occurrence and run-length matrix, absolute gradient, autoregressive model, Haar wavelet transform) were extracted from manually defined 2D-ROIs. The ten best features for lesion differentiation were selected using probability of error and average correlation coefficients. A multi-layer perceptron feed-forward artificial neural network (MLP-ANN) was used for radiomics-based classification, with histopathology serving as the reference standard (70% of cases for training, 30% for validation). The analysis was performed five times each on (a) unmodified data and on data that were (b) resampled to the same matrix size, and (c) corrected for acquisition protocol differences using ComBat harmonization. RESULTS: Using unmodified data, the MLP-ANN classification yielded an overall median area under the receiver operating characteristic curve (AUC) of 0.78 (0.72-0.84). Using original data from center A and resampled data from center B, an overall median AUC of 0.88 (0.82-0.99) was yielded, while using ComBat harmonized data, an overall median AUC of 0.89 (0.79-0.92) was revealed. CONCLUSION: Radiomic features extracted from HRCT differentiate between cholesteatoma and MEI. When using multi-centric data obtained with differences in CT acquisition parameters, data resampling and ComBat post-reconstruction harmonization clearly improve radiomics-based lesion classification. KEY POINTS: • Unenhanced high-resolution CT coupled with radiomics analysis may be useful for the differentiation between cholesteatoma and middle ear inflammation. • Pooling of data extracted from inhomogeneous CT datasets does not appear meaningful without further post-processing. • When using multi-centric CT data obtained with differences in acquisition parameters, post-reconstruction harmonization and data resampling clearly improve radiomics-based soft-tissue differentiation.

Radiation dose reduction capabilities of a new C-arm system with optimized hard- and software.

PURPOSE: To assess the radiation dose reduction capabilities and the image quality of a new C-arm system in comparison to a standard C-arm system. METHOD: Prospective, randomized, IRB approved two-arm trial design. 49 consecutive patients with primary or secondary liver cancer were treated with transarterial chemoembolization (TACE) on two different angiography units. 28 patients were treated on a conventional angiography unit B, 21 patients on unit A which provides improved hardware and optimized image processing algorithms. Dose area product (DAP) and fluoroscopy time were recorded. DSA image quality of all procedures was assessed on a four-rank-scale by two independent and blinded readers. RESULTS: Both cohorts showed no significant differences with regard to patient characteristics, tumor burden and fluoroscopy time. The new system resulted in a statistically significant reduction of cumulative DAP of 72% compared to the old platform (median 76 vs. 269 Gy*cm2). Individually, Fluoro-DAP and DSA-DAP decreased by 48% and 77% (p = 0.012 and p < 0.01), respectively. No statistically significant differences in DSA image quality were found between the two imaging platforms. CONCLUSIONS: The new C-arm system significantly reduced radiation exposure for TACE procedures without increased radiation time or negative impact on DSA image quality. The combination of optimized hardware and software yields the highest radiation dose reduction and is of utmost importance for patients and interventionalists.

Characteristics of a New X-Ray Imaging System for Interventional Procedures: Improved Image Quality and Reduced Radiation Dose.

PURPOSE: To compare image quality and radiation exposure between a new angiographic imaging system and the preceding generation system during uterine artery embolization (UAE). MATERIALS AND METHODS: In this retrospective, IRB-approved two-arm study, 54 patients with symptomatic uterine fibroids were treated with UAE on two different angiographic imaging systems. The new system includes optimized acquisition parameters and real-time image processing algorithms. Air kerma (AK), dose area product (DAP) and acquisition time for digital fluoroscopy (DF) and digital subtraction angiography (DSA) were recorded. Body mass index was noted as well. DF image quality was assessed objectively by image noise measurements. DSA image quality was rated by two blinded, independent readers on a four-rank scale. Statistical differences were assessed with unpaired t tests and Wilcoxon rank-sum tests. RESULTS: There was no significant difference between the patients treated on the new (n = 36) and the old system (n = 18) regarding age (p = 0.10), BMI (p = 0.18), DF time (p = 0.35) and DSA time (p = 0.17). The new system significantly reduced the cumulative AK and DAP by 64 and 72%, respectively (median 0.58 Gy and 145.9 Gy*cm2 vs. 1.62 Gy and 526.8 Gy*cm2, p < 0.01 for both). Specifically, DAP for DF and DSA decreased by 59% (75.3 vs. 181.9 Gy*cm2, p < 0.01) and 78% (67.6 vs. 312.2 Gy*cm2, p < 0.01), respectively. The new system achieved a significant decrease in DF image noise (p < 0.01) and a significantly better DSA image quality (p < 0.01). CONCLUSIONS: The new angiographic imaging system significantly improved image quality and reduced radiation exposure during UAE procedures.

Multipath Curved Planar Reformations of Peripheral CT Angiography: Diagnostic Accuracy and Time Efficiency.

OBJECTIVES: To compare diagnostic performance and time efficiency between 3D multipath curved planar reformations (mpCPRs) and axial images of CT angiography for the pre-interventional assessment of peripheral arterial disease (PAD), with digital subtraction angiography as the standard of reference. METHODS: Forty patients (10 females, mean age 72 years), referred to CTA prior to endovascular treatment of PAD, were prospectively included and underwent peripheral CT angiography. A semiautomated toolbox was used to render mpCPRs. Twenty-one arterial segments were defined in each leg; for each segment, the presence of stenosis > 70% was assessed on mpCPRs and axial images by two readers, independently, with digital subtraction angiography as gold standard. RESULTS: Both readers reached lower sensitivity (Reader 1: 91 vs. 94%, p = 0.08; Reader 2: 89 vs. 93%, p = 0.03) but significantly higher specificity (Reader 1: 94 vs. 89%, p < 0.01; Reader 2: 96 vs. 95%, p = 0.01) with mpCPRs than with axial images. Reader 1 achieved significantly higher accuracy with mpCPRs (93 vs. 91%, p = 0.02), and Reader 2 had similar overall accuracy in both evaluations (94 vs. 94%, p = 0.96). Both readers read mpCPRs significantly faster than axial images (Reader 1: 5'45″ based on mpCPRs vs. 7'40″ based on axial images; Reader 2: 4'41″ based on mpCPRs vs. 6'57″ based on axial images; p < 0.01). CONCLUSIONS: mpCPRs are a promising 3D reformation technique that facilitates a fast assessment of PAD with high diagnostic accuracy.

A BMI-adjusted ultra-low-dose CT angiography protocol for the peripheral arteries-Image quality, diagnostic accuracy and radiation exposure.

OBJECTIVES: To investigate radiation exposure, objective image quality, and the diagnostic accuracy of a BMI-adjusted ultra-low-dose CT angiography (CTA) protocol for the assessment of peripheral arterial disease (PAD), with digital subtraction angiography (DSA) as the standard of reference. METHODS: In this prospective, IRB-approved study, 40 PAD patients (30 male, mean age 72 years) underwent CTA on a dual-source CT scanner at 80kV tube voltage. The reference amplitude for tube current modulation was personalized based on the body mass index (BMI) with 120 mAs for [BMI≤25] or 150 mAs for [2570%) was assessed by two readers independently and compared to subsequent DSA. Radiation exposure was assessed with the computed tomography dose index (CTDIvol) and the dosis-length product (DLP). Objective image quality was assessed via contrast- and signal-to-noise ratio (CNR and SNR) measurements. Radiation exposure and image quality were compared between the BMI groups and between the BMI-adjusted ultra-low-dose protocol and the low-dose institutional standard protocol (ISP). RESULTS: The BMI-adjusted ultra-low-dose protocol reached high diagnostic accuracy values of 94% for Reader 1 and 93% for Reader 2. Moreover, in comparison to the ISP, it showed significantly (p<0.001) lower CTDIvol (1.97±0.55mGy vs. 4.18±0.62 mGy) and DLP (256±81mGy x cm vs. 544±83mGy x cm) but similar image quality (p=0.37 for CNR). Furthermore, image quality was similar between BMI groups (p=0.86 for CNR). CONCLUSIONS: A CT protocol that incorporates low kV settings with a personalized (BMI-adjusted) reference amplitude for tube current modulation and iterative reconstruction enables very low radiation exposure CTA, while maintaining good image quality and high diagnostic accuracy in the assessment of PAD.

Imaging Biomarkers of Tumor Response in Neuroendocrine Liver Metastases Treated with Transarterial Chemoembolization: Can Enhancing Tumor Burden of the Whole Liver Help Predict Patient Survival?

Purpose To investigate whether whole-liver enhancing tumor burden [ETB] can serve as an imaging biomarker and help predict survival better than World Health Organization (WHO), Response Evaluation Criteria in Solid Tumors (RECIST), modified RECIST (mRECIST), and European Association for the Study of the Liver (EASL) methods in patients with multifocal, bilobar neuroendocrine liver metastases (NELM) after the first transarterial chemoembolization (TACE) procedure. Materials and Methods This HIPAA-compliant, institutional review board-approved retrospective study included 51 patients (mean age, 57.8 years ± 13.2; range, 13.5-85.8 years) with multifocal, bilobar NELM treated with TACE. The largest area (WHO), longest diameter (RECIST), longest enhancing diameter (mRECIST), largest enhancing area (EASL), and largest enhancing volume (ETB) were measured at baseline and after the first TACE on contrast material-enhanced magnetic resonance images. With three-dimensional software, ETB was measured as more than 2 standard deviations the signal intensity of a region of interest in normal liver. Response was assessed with WHO, RECIST, mRECIST, and EASL methods according to their respective criteria. For ETB response, a decrease in enhancement of at least 30%, 50%, and 65% was analyzed by using the Akaike information criterion. Survival analysis included Kaplan-Meier curves and Cox regressions. Results Treatment response occurred in 5.9% (WHO criteria), 2.0% (RECIST), 25.5% (mRECIST), and 23.5% (EASL criteria) of patients. With 30%, 50%, and 65% cutoffs, ETB response was seen in 60.8%, 39.2%, and 21.6% of patients, respectively, and was the only biomarker associated with a survival difference between responders and nonresponders (45.0 months vs 10.0 months, 84.3 months vs 16.7 months, and 85.2 months vs 21.2 months, respectively; P < .01 for all). The 50% cutoff provided the best survival model (hazard ratio [HR]: 0.2; 95% confidence interval [CI]: 0.1, 0.4). At multivariate analysis, ETB response was an independent predictor of survival (HR: 0.2; 95% CI: 0.1, 0.6). Conclusion Volumetric ETB is an early treatment response biomarker and surrogate for survival in patients with multifocal, bilobar NELM after the first TACE procedure. © RSNA, 2016.

Advanced-stage hepatocellular carcinoma with portal vein thrombosis: conventional versus drug-eluting beads transcatheter arterial chemoembolization.

OBJECTIVES: Our study sought to compare the overall survival in patients with hepatocellular carcinoma (HCC) and portal venous thrombosis (PVT), treated with either conventional trans-arterial chemoembolization (cTACE) or drug-eluting beads (DEB) TACE. METHODS: This retrospective analysis included a total of 133 patients, treated without cross-over and compared head-to-head by means or propensity score weighting. Mortality was compared using survival analysis upon propensity score weighting. Adverse events and liver toxicity grade ≥3 were recorded and reported for each TACE. In order to compare with historical sorafenib studies, a sub-group analysis was performed and included patients who fulfilled the SHARP inclusion criteria. RESULTS: The median overall survival (MOS) of the entire cohort was 4.53 months (95 % CI, 3.63-6.03). MOS was similar across treatment arms, no significant difference between cTACE (N = 95) and DEB-TACE (N = 38) was observed (MOS of 5.0 vs. 3.33 months, respectively; p = 0.157). The most common adverse events after cTACE and DEB- TACE, respectively, were as follows: post-embolization syndrome [N = 57 (30.0 %) and N = 38 (61.3 %)], diarrhea [N = 3 (1.6 %) and N = 3 (4.8 %)], and encephalopathy [N = 11 (5.8 %) and N = 2 (3.2 %)]. CONCLUSION: Our retrospective study could not reveal a difference in toxicity and efficiency between cTACE and DEB-TACE for treatment of advanced stage HCC with PVT. KEY POINTS: • Conventional TACE (cTACE) and drug-eluting-beads TACE (DEB-TACE) demonstrated equal safety profiles. • Survival rates after TACE are similar to patients treated with sorafenib. • Child-Pugh class and tumor burden are reliable predictors of survival.

Improved Visibility of Metastatic Disease in the Liver During Intra-Arterial Therapy Using Delayed Arterial Phase Cone-Beam CT.

PURPOSE: To compare the visibility of liver metastases on dual-phase cone-beam CT (DP-CBCT) and digital subtraction angiography (DSA), with reference to preinterventional contrast-enhanced magnetic resonance imaging (CE-MRI) of the liver. METHODS: This IRB-approved, retrospective study included 28 patients with neuroendocrine (NELM), colorectal (CRCLM), or sarcoma (SLM) liver metastases who underwent DP-CBCT during intra-arterial therapy (IAT) between 01/2010 and 10/2014. DP-CBCT was acquired after a single contrast agent injection in the tumor-feeding arteries at early and delayed arterial phases (EAP and DAP). The visibility of each lesion was graded by two radiologists in consensus on a three-rank scale (complete, partial, none) on DP-CBCT and DSA images using CE-MRI as reference. RESULTS: 47 NELM, 43 CRCLM, and 16 SLM were included. On DSA 85.1, 44.1, and 37.5 % of NELM, CRCLM, and SLM, were at least partially depicted, respectively. EAP-CBCT yielded significantly higher sensitivities of 88.3 and 87.5 % for CRCLM and SLM, respectively (p < 0.01), but not for NELM (89.4 %; p = 1.0). On DAP-CBCT all NELM, CRCLM, and SLM were visible (p < 0.001). Complete depiction was achieved on DSA for 59.6, 16.3, and 18.8 % of NELM, CRCLM, and SLM, respectively. The complete depiction rate on EAP-CBCT was significantly higher for CRCLM (46.5 %; p < 0.001), lower for NELM (40.4 %; p = 0.592), and similar for SLM (25 %, p = 0.399). On DAP-CBCT however, the highest rates of complete depiction were found-NELM (97.8 %; p = 0.008), CRCLM (95.3 %; p = 0.008), and SLM (100 %; p < 0.001). CONCLUSION: DAP-CBCT substantially improved the visibility of liver metastases during IAT. Future studies need to evaluate the clinical impact.

Is ECG triggering for motion artefact reduction in dual-source CT angiography of the ascending aorta still required with high-pitch scanning? The role of ECG-gating in high-pitch dual-source CT of the ascending aorta.

OBJECTIVE:: To compare electrocardiographic (ECG)-triggered high-pitch (HP) dual-source CT angiography (CTA) with non-ECG-triggered HP CTA of the aorta, particularly the ascending aorta, with regard to image quality, motion artefacts, contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) and radiation dose. METHODS:: 59 consecutive patients who had been referred for CTA for known or suspected aortic disease, previous aortic intervention or planned transapical or transfemoral aortic valve implantation were prospectively included. Patients underwent CTAs with HP, using a dual-source CTA system, with [control group (Group A); n = 30] or without (Group B; n = 29) ECG triggering after randomization. For evaluation, image quality and a motion artefact score (MAS) were assessed in a blinded fashion at different predefined anatomic regions. CNR and SNR were measured at the same levels. Radiation dose estimates and contrast enhancement were compared between the two groups. RESULTS:: There were no significant differences for image quality and MAS. The intra-arterial contrast resolution was significantly higher at the level of the aortic arch and descending aorta in the non-triggered group (CNR values, p = 0.002-0.018). No significant differences in the radiation dose were found. CONCLUSION:: Non-triggered HP dual-source CTA provided comparable results with regard to image quality, MAS, CNR, SNR and radiation doses compared with ECG-triggered HP CTA. Therefore, ECG triggering of the ascending aorta might be obviated when HP scanning is available. ADVANCES IN KNOWLEDGE:: HP dual-source CTA might obviate ECG triggering in the ascending aorta. Non-triggered HP CTA of the ascending aorta provides an excellent image quality.

A Novel Inherently Radiopaque Bead for Transarterial Embolization to Treat Liver Cancer - A Pre-clinical Study.

PURPOSE: Embolotherapy using microshperes is currently performed with soluble contrast to aid in visualization. However, administered payload visibility dimishes soon after delivery due to soluble contrast washout, leaving the radiolucent bead's location unknown. The objective of our study was to characterize inherently radiopaque beads (RO Beads) in terms of physicomechanical properties, deliverability and imaging visibility in a rabbit VX2 liver tumor model. MATERIALS AND METHODS: RO Beads, which are based on LC Bead® platform, were compared to LC Bead. Bead size (light microscopy), equilibrium water content (EWC), density, X-ray attenuation and iodine distribution (micro-CT), suspension (settling times), deliverability and in vitro penetration were investigated. Fifteen rabbits were embolized with either LC Bead or RO Beads + soluble contrast (iodixanol-320), or RO Beads+dextrose. Appearance was evaluated with fluoroscopy, X-ray single shot, cone-beam CT (CBCT). RESULTS: Both bead types had a similar size distribution. RO Beads had lower EWC (60-72%) and higher density (1.21-1.36 g/cc) with a homogeneous iodine distribution within the bead's interior. RO Beads suspension time was shorter than LC Bead, with durable suspension (>5 min) in 100% iodixanol. RO Beads ≤300 µm were deliverable through a 2.3-Fr microcatheter. Both bead types showed similar penetration. Soluble contrast could identify target and non-target embolization on fluoroscopy during administration. However, the imaging appearance vanished quickly for LC Bead as contrast washed-out. RO Beads+contrast significantly increased visibility on X-ray single shot compared to LC Bead+contrast in target and non-target arteries (P=0.0043). Similarly, RO beads demonstrated better visibility on CBCT in target arteries (P=0.0238) with a trend in non-target arteries (P=0.0519). RO Beads+dextrose were not sufficiently visible to monitor embolization using fluoroscopy. CONCLUSION: RO Beads provide better conspicuity to determine target and non-target embolization compared to LC Bead which may improve intra-procedural monitoring and post-procedural evaluation of transarterial embolization.

A new angiographic imaging platform reduces radiation exposure for patients with liver cancer treated with transarterial chemoembolization.

OBJECTIVES: To quantify the reduction of radiation liver cancer patients are exposed to during transarterial chemoembolization (TACE), while maintaining diagnostic image quality, using a new C-arm imaging platform. METHODS: In this prospective, HIPAA-compliant, IRB-approved, two-arm trial, 78 consecutive patients with primary or secondary liver cancer were treated with TACE on a C-arm imaging platform before and after an upgrade incorporating optimized acquisition parameters and advanced real-time image processing algorithms. Dose area product (DAP) and radiation time of each digital fluoroscopy (DF), digital subtraction angiography (DSA) and cone beam CT (CBCT) were recorded. DSA image quality was assessed by two blinded and independent readers on a four-rank scale. RESULTS: Both cohorts showed no significant differences with regard to patient characteristics and tumour burden. The new system resulted in a statistically significant reduction of cumulative DAP of 66% compared to the old platform (median 132.9 vs. 395.8 Gy cm(2)). Individually, DAP of DF, DSA and CBCT decreased by 52%, 79% and 15% (p < 0.01, p < 0.01, p = 0.51), respectively. No statistically significant differences in DSA image quality were found between the two imaging platforms. CONCLUSIONS: The new imaging platform significantly reduced radiation exposure for TACE procedures without increased radiation time or negative impact on DSA image quality. KEY POINTS: • The new C-arm system allowed reduction of radiation exposure by two thirds • The procedure's course was not affected by the new platform • No decrease in DSA image quality was observed after the radiation reduction.

New hybrid reformations of peripheral CT angiography: do we still need axial images?

PURPOSE: To quantify the detectability of peripheral artery stenosis on hybrid CT angiography (CTA) reformations. METHODS: Hybrid reformations were developed by combining multipath curved planar reformations (mpCPR) and maximum intensity projections (MIP). Fifty peripheral CTAs were evaluated twice: either with MIP, mpCPR and axial images or with hybrid reformations only. Digital subtraction angiography served as gold standard. RESULTS: Using hybrid reformations, two independent readers detected 88.0% and 81.3% of significant stenosis, respectively. However, CTA including axial images detected statistically significant more lesions (98%). CONCLUSION: Peripheral CTA reading including axial images is still recommended. Further improvement of these hybrid reformations is necessary.

Delayed-Phase Cone-Beam CT Improves Detectability of Intrahepatic Cholangiocarcinoma During Conventional Transarterial Chemoembolization.

PURPOSE: To evaluate the detectability of intrahepatic cholangiocarcinoma (ICC) on dual-phase cone-beam CT (DPCBCT) during conventional transarterial chemoembolization (cTACE) compared to that of digital subtraction angiography (DSA) with respect to pre-procedure contrast-enhanced magnetic resonance imaging (CE-MRI) of the liver. METHODS: This retrospective study included 17 consecutive patients (10 male, mean age 64) with ICC who underwent pre-procedure CE-MRI of the liver, and DSA and DPCBCT (early-arterial phase (EAP) and delayed-arterial phase (DAP)) just before cTACE. The visibility of each ICC lesion was graded by two radiologists on a three-rank scale (complete, partial, and none) on DPCBCT and DSA images, and then compared to pre-procedure CE-MRI. RESULTS: Of 61 ICC lesions, only 45.9% were depicted by DSA, whereas EAP- and DAP-CBCT yielded a significantly higher detectability rate of 73.8% and 93.4%, respectively (p < 0.01). Out of the 33 lesions missed on DSA, 18 (54.5%) and 30 (90.9%) were revealed on EAP- and DAP-CBCT images, respectively. DSA depicted only one lesion that was missed by DPCBCT due to streak artifacts caused by a prosthetic mitral valve. DAP-CBCT identified significantly more lesions than EAP-CBCT (p < 0.01). Conversely, EAP-CBCT did not detect lesions missed by DAP-CBCT. For complete lesion visibility, DAP-CBCT yielded significantly higher detectability (78.7%) compared to EAP (31.1%) and DSA (21.3%) (p < 0.01). CONCLUSION: DPCBCT, and especially the DAP-CBCT, significantly improved the detectability of ICC lesions during cTACE compared to DSA. We recommend the routine use of DAP-CBCT in patients with ICC for per-procedure detectability and treatment planning in the setting of TACE.

Texture-based classification of different gastric tumors at contrast-enhanced CT.

PURPOSE: To determine the feasibility of texture analysis for the classification of gastric adenocarcinoma, lymphoma, and gastrointestinal stromal tumors on contrast-enhanced hydrodynamic-MDCT images. MATERIALS AND METHODS: The arterial phase scans of 47 patients with adenocarcinoma (AC) and a histologic tumor grade of [AC-G1, n=4, G1, n=4; AC-G2, n=7; AC-G3, n=16]; GIST, n=15; and lymphoma, n=5, and the venous phase scans of 48 patients with AC-G1, n=3; AC-G2, n=6; AC-G3, n=14; GIST, n=17; lymphoma, n=8, were retrospectively reviewed. Based on regions of interest, texture analysis was performed, and features derived from the gray-level histogram, run-length and co-occurrence matrix, absolute gradient, autoregressive model, and wavelet transform were calculated. Fisher coefficients, probability of classification error, average correlation coefficients, and mutual information coefficients were used to create combinations of texture features that were optimized for tumor differentiation. Linear discriminant analysis in combination with a k-nearest neighbor classifier was used for tumor classification. RESULTS: On arterial-phase scans, texture-based lesion classification was highly successful in differentiating between AC and lymphoma, and GIST and lymphoma, with misclassification rates of 3.1% and 0%, respectively. On venous-phase scans, texture-based classification was slightly less successful for AC vs. lymphoma (9.7% misclassification) and GIST vs. lymphoma (8% misclassification), but enabled the differentiation between AC and GIST (10% misclassification), and between the different grades of AC (4.4% misclassification). No texture feature combination was able to adequately distinguish between all three tumor types. CONCLUSION: Classification of different gastric tumors based on textural information may aid radiologists in establishing the correct diagnosis, at least in cases where the differential diagnosis can be narrowed down to two histological subtypes.