A visual marker for early atrophy of the supraspinatus muscle on conventional MRI: introduction of the blackbird sign.

OBJECTIVES: The aim of this study was to introduce the blackbird sign as a fast, qualitative measure of early supraspinatus (SSP) muscle atrophy and to correlate the sign with quantitatively assessed muscle volume and intramuscular fat fraction (FF) in patients with full-thickness SSP tears. MATERIALS AND METHODS: The blackbird sign describes the asymmetric pattern of early SSP atrophy: on sagittal MR images, the supero-posterior contour of the muscle becomes concave, resembling the shape of a blackbird. MRIs of patients with full-thickness SSP tears were retrospectively reviewed for the presence of the blackbird and tangent signs. Patients were then divided into group 1: negative tangent sign and negative blackbird sign (n = 67), group 2: negative tangent sign and positive blackbird sign (n = 31), and group 3: positive tangent sign (n = 32). A 2-point Dixon sequence was acquired in all patients from which quantitative FF and muscle volumes were calculated. RESULTS: In total 130 patients (mean age 67 ± 11 years) were included. Mean SSP volume was significantly smaller in group 3 (15.8 ± 8.1 cm3) compared to group 2 (23.9 ± 7.0 cm3, p = 0.01) and group 1 (29.7 ± 9.1 cm3, p < 0.01). Significantly lower muscle volumes were also found in group 2 compared to group 1 (p = 0.02), confirming that the blackbird sign is able to identify early SSP atrophy. Mean FF in the SSP was significantly higher in group 3 (18.5 ± 4.4%) compared to group 2 (10.9 ± 4.7%, p < 0.01) and group 1 (6.1 ± 2.6%, p < 0.01). CONCLUSION: Visual assessment of early muscle atrophy of the SSP is feasible and reproducible using the blackbird sign, allowing the diagnosis of early SSP atrophy. CLINICAL RELEVANCE STATEMENT: In routine clinical practice, the blackbird sign may be a useful tool for assessing early muscle degeneration before the risk of postoperative rotator cuff re-tears increases with progressive muscle atrophy and fatty infiltration. KEY POINTS: Quantitative measurements of rotator cuff injuries require time, limiting clinical practicality. The proposed blackbird sign is able to identify early SSP atrophy. Reader agreement for the blackbird sign was substantial, demonstrating reproducibility and ease of implementation in the clinical routine.

Photon-Counting Detector CT Versus Energy-Integrating Detector CT of the Lumbar Spine: Comparison of Radiation Dose and Image Quality.

BACKGROUND. Photon-counting detector (PCD) CT could be useful to help address the typically high radiation doses of conventional energy-integrating detector (EID) CT of the lumbar spine. OBJECTIVE. The purpose of our study was to compare PCD CT and EID CT of the lumbar spine, both performed using tin filtration, in terms of radiation dose and image quality. METHODS. This study included a prospective sample of 39 patients (22 men, 17 women; mean age, 27.2 years) who underwent investigational PCD CT of the lumbar spine as part of a separate study and a retrospective sample of 39 patients (22 men, 17 women; mean age, 34.9 years) who underwent clinically indicated EID CT of the lumbar spine. In both groups, all examinations were performed using unenhanced technique with tin prefiltration between June 2022 and January 2023. Patients were matched between groups using age, sex, and BMI. A custom gaussian curve-fitting algorithm was used to automatically calculate image noise, SNR, and CNR for each examination, on the basis of all voxels within the image set. Three radiologists independently reviewed examinations to perform a subjective visual assessment of visualization of trabecular architecture, cortical bone, neuroforaminal content, paraspinal muscles, and intervertebral disk, as well as overall image quality, using a 4-point Likert scale (1 = poor, 4 = excellent). PCD CT and EID CT examinations were compared. RESULTS. Mean CTDIvol was 4.4 ± 1.0 (SD) mGy for PCD CT versus 11.1 ± 1.9 mGy for EID CT (p < .001). Mean size-specific dose estimate (SSDE) was 6.2 ± 1.0 (SD) mGy for PCD CT versus 14.2 ± 1.8 mGy for EID CT (p < .001). PCD CT and EID CT examinations were not significantly different in terms of image noise or SNR (both p > .05). PCD CT, in comparison with EID CT, showed significantly higher CNR (mean ± SD, 33.6 ± 3.3 vs 29.3 ± 4.1; p < .001). For all three readers, the median score for overall image quality was 4 (range, 3-4) for both PCD CT and EID CT. PCD CT and EID CT examinations showed no significant difference in terms of any qualitative measure for any reader (all p > .05). CONCLUSION. PCD CT, in comparison with EID CT, yielded significantly lower radiation dose with preserved image quality. CLINICAL IMPACT. The findings support expanded use of PCD CT for lumbar spine evaluation.

Photon-Counting Detector CT With Denoising for Imaging of the Osseous Pelvis at Low Radiation Doses: A Phantom Study.

BACKGROUND. Photon-counting detector (PCD) CT may allow lower radiation doses than used for conventional energy-integrating detector (EID) CT, with preserved image quality. OBJECTIVE. The purpose of this study was to compare PCD CT and EID CT, reconstructed with and without a denoising tool, in terms of image quality of the osseous pelvis in a phantom, with attention to low radiation doses. METHODS. A pelvic phantom comprising human bones in acrylic material mimicking soft tissue underwent PCD CT and EID CT at various tube potentials and radiation doses ranging from 0.05 to 5.00 mGy. Additional denoised reconstructions were generated using a commercial tool. Noise was measured in the acrylic material. Two readers performed independent qualitative assessments that entailed determining the denoised EID CT reconstruction with the lowest acceptable dose and then comparing this reference reconstruction with PCD CT reconstructions without and with denoising, using subjective Likert scales. RESULTS. Noise was lower for PCD CT than for EID CT. For instance, at 0.05 mGy and 100 kV with tin filter, noise was 38.4 HU for PCD CT versus 48.8 HU for EID CT. Denoising further reduced noise; for example, for PCD CT at 100 kV with tin filter at 0.25 mGy, noise was 19.9 HU without denoising versus 9.7 HU with denoising. For both readers, lowest acceptable dose for EID CT was 0.10 mGy (total score, 11 of 15 for both readers). Both readers somewhat agreed that PCD CT without denoising at 0.10 mGy (reflecting reference reconstruction dose) was relatively better than the reference reconstruction in terms of osseous structures, artifacts, and image quality. Both readers also somewhat agreed that denoised PCD CT reconstructions at 0.10 mGy and 0.05 mGy (reflecting matched and lower doses, respectively, with respect to reference reconstruction dose) were relatively better than the reference reconstruction for the image quality measures. CONCLUSION. PCD CT showed better-quality images than EID CT when performed at the lowest acceptable radiation dose for EID CT. PCD CT with denoising yielded better-quality images at a dose lower than lowest acceptable dose for EID CT. CLINICAL IMPACT. PCD CT with denoising could facilitate lower radiation doses for pelvic imaging.

How accurate is MRI for diagnosing tarsal coalitions? A retrospective diagnostic accuracy study.

OBJECTIVES: This study aimed to evaluate the diagnostic accuracy, inter-reader agreement, and associated pathologies on MR images of patients with confirmed TC. METHODS AND MATERIALS: In this retrospective study, 168 ankle MRI exams were included, consisting of 56 patients with clinically or surgically confirmed TC and 112 controls without TC, matched for age and sex. Images were analyzed independently by three radiologists blinded to clinical information. The evaluation criteria included the presence, type, and location of TC, as well as associated pathologies. After calculating diagnostic accuracy and the odds ratio of demographic data and anatomic coalition type for associated pathologies, inter-reader agreement was assessed using kappa statistics. RESULTS: The majority of TCs were non-osseous (91.1%) and located at the calcaneonavicular (33.9%) or talocalcaneal joint (66.1%). Associated pathologies included adjacent and distant bone marrow edema (57.1% and 25.0%), osteochondral defect of the talar dome (OCD, 19.6%), and joint effusion (10.7%) and accessory anterolateral talar facet (17.9%). Talar OCD was associated with increased patient age (p = 0.03). MRI exhibited a cumulative sensitivity and specificity of 95.8% and 94.3% with almost perfect inter-reader agreement (κ = 0.895). CONCLUSION: MRI is a reliable method for detecting tarsal coalition and identifying commonly associated pathologies. Therefore, we recommend the routine use of MRI in the diagnostic workup of patients with foot pain and suspected tarsal coalition. CLINICAL RELEVANCE STATEMENT: MRI is an accurate and reliable modality for diagnosing tarsal coalitions and detecting associated pathologies, while improving patient safety compared to computed tomography by avoiding radiation exposure. KEY POINTS: • Despite the technological progress in magnetic resonance imaging (MRI), computed tomography (CT) is still regarded as the gold standard for diagnosing tarsal coalition (TC). • MRI had a cumulative sensitivity of 95.8% and specificity of 94.3% for detecting tarsal coalition with an almost perfect inter-reader agreement. • MRI demonstrates high accuracy and reliability in diagnosing tarsal coalitions and is useful for identifying associated pathologies, while also improving patient safety by avoiding radiation exposure.

Computed tomography angiography versus Agatston score for diagnosis of coronary artery disease in patients with stable chest pain: individual patient data meta-analysis of the international COME-CCT Consortium.

OBJECTIVES: There is conflicting evidence about the comparative diagnostic accuracy of the Agatston score versus computed tomography angiography (CTA) in patients with suspected obstructive coronary artery disease (CAD). PURPOSE: To determine whether CTA is superior to the Agatston score in the diagnosis of CAD. METHODS: In total 2452 patients with stable chest pain and a clinical indication for invasive coronary angiography (ICA) for suspected CAD were included by the Collaborative Meta-analysis of Cardiac CT (COME-CCT) Consortium. An Agatston score of > 400 was considered positive, and obstructive CAD defined as at least 50% coronary diameter stenosis on ICA was used as the reference standard. RESULTS: Obstructive CAD was diagnosed in 44.9% of patients (1100/2452). The median Agatston score was 74. Diagnostic accuracy of CTA for the detection of obstructive CAD (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) was significantly higher than that of the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001). Among patients with an Agatston score of zero, 17% (101/600) had obstructive CAD. Diagnostic accuracy of CTA was not significantly different in patients with low to intermediate (1 to < 100, 100-400) versus moderate to high Agatston scores (401-1000, > 1000). CONCLUSIONS: Results in our international cohort show CTA to have significantly higher diagnostic accuracy than the Agatston score in patients with stable chest pain, suspected CAD, and a clinical indication for ICA. Diagnostic performance of CTA is not affected by a higher Agatston score while an Agatston score of zero does not reliably exclude obstructive CAD. KEY POINTS: • CTA showed significantly higher diagnostic accuracy (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) for diagnosis of coronary artery disease when compared to the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001). • Diagnostic performance of CTA was not affected by increased amount of calcium and was not significantly different in patients with low to intermediate (1 to <100, 100-400) versus moderate to high Agatston scores (401-1000, > 1000). • Seventeen percent of patients with an Agatston score of zero showed obstructive coronary artery disease by invasive angiography showing absence of coronary artery calcium cannot reliably exclude coronary artery disease.

Detection and Characterization of Renal Stones by Using Photon-Counting-based CT.

Purpose To compare a research photon-counting-detector (PCD) CT scanner to a dual-source, dual-energy CT scanner for the detection and characterization of renal stones in human participants with known stones. Materials and Methods Thirty study participants (median age, 61 years; 10 women) underwent a clinical renal stone characterization scan by using dual-energy CT and a subsequent research PCD CT scan by using the same radiation dose (as represented by volumetric CT dose index). Two radiologists were tasked with detection of stones, which were later characterized as uric acid or non-uric acid by using a commercial dual-energy CT analysis package. Stone size and contrast-to-noise ratio were additionally calculated. McNemar odds ratios and Cohen k were calculated separately for all stones and small stones (≤3 mm). Results One-hundred sixty renal stones (91 stones that were ≤ 3 mm in axial length) were visually detected. Compared with 1-mm-thick routine images from dual-energy CT, the odds of detecting a stone at PCD CT were 1.29 (95% confidence interval: 0.48, 3.45) for all stones. Stone segmentation and characterization were successful at PCD CT in 70.0% (112 of 160) of stones versus 54.4% (87 of 160) at dual-energy CT, and was superior for stones 3 mm or smaller at PCD CT (45 vs 25 stones, respectively; P = .002). Stone characterization agreement between scanners for stones of all sizes was substantial (k = 0.65). Conclusion Photon-counting-detector CT is similar to dual-energy CT for helping to detect renal stones and is better able to help characterize small renal stones. © RSNA, 2018.

Dynamic CT myocardial perfusion imaging: performance of 3D semi-automated evaluation software.

OBJECTIVES: To evaluate the performance of three-dimensional semi-automated evaluation software for the assessment of myocardial blood flow (MBF) and blood volume (MBV) at dynamic myocardial perfusion computed tomography (CT). METHODS: Volume-based software relying on marginal space learning and probabilistic boosting tree-based contour fitting was applied to CT myocardial perfusion imaging data of 37 subjects. In addition, all image data were analysed manually and both approaches were compared with SPECT findings. Study endpoints included time of analysis and conventional measures of diagnostic accuracy. RESULTS: Of 592 analysable segments, 42 showed perfusion defects on SPECT. Average analysis times for the manual and software-based approaches were 49.1 ± 11.2 and 16.5 ± 3.7 min respectively (P < 0.01). There was strong agreement between the two measures of interest (MBF, ICC = 0.91, and MBV, ICC = 0.88, both P < 0.01) and no significant difference in MBF/MBV with respect to diagnostic accuracy between the two approaches for both MBF and MBV for manual versus software-based approach; respectively; all comparisons P > 0.05. CONCLUSIONS: Three-dimensional semi-automated evaluation of dynamic myocardial perfusion CT data provides similar measures and diagnostic accuracy to manual evaluation, albeit with substantially reduced analysis times. This capability may aid the integration of this test into clinical workflows. KEY POINTS: • Myocardial perfusion CT is attractive for comprehensive coronary heart disease assessment. • Traditional image analysis methods are cumbersome and time-consuming. • Automated 3D perfusion software shortens analysis times. • Automated 3D perfusion software increases standardisation of myocardial perfusion CT. • Automated, standardised analysis fosters myocardial perfusion CT integration into clinical practice.

Global quantification of left ventricular myocardial perfusion at dynamic CT: feasibility in a multicenter patient population.

OBJECTIVE: The purpose of this study was to determine the feasibility of global quantitative measurements of left ventricular myocardial perfusion derived from stress dynamic CT myocardial perfusion imaging. MATERIALS AND METHODS: The coronary CT angiographic and CT myocardial perfusion imaging datasets of 146 patients were visually evaluated for the presence of coronary artery stenosis and perfusion defects. For the quantitative analysis, volumes of interest were defined over the entire left ventricular myocardium to obtain global myocardial blood flow (MBF), myocardial blood volume (MBV), and volume transfer constant (K(trans)). RESULTS: In patients without anatomically significant coronary stenosis or perfusion defects, the mean value of global MBF was 137.9 ± 28.8 mL/100 mL/min; MBV, 19.5 ± 2.3 mL/100 mL; and K(trans), 85.8 ± 15.2 mL/100 mL/min. In patients with perfusion defects in one, two, or three vessels, the mean global MBF values were 132.6 ± 29.2, 117.4 ± 4.9, and 92.5 ± 11.2 mL/100 mL/min; MBV, 17.9 ± 3.2, 16.1 ± 3.1, and 12.8 ± 1.7 mL/100 mL; and K(trans), 80.4 ± 12.9, 76.6 ± 13.8, and 72.6 ± 15.5 mL/100 mL/min. In patients with significant (> 50%) stenosis in one, two, or three vessels at coronary CT angiography, the mean global MBF values were 129.2 ± 28.3, 120.5 ± 24.2, and 119.4 ± 33.5 mL/100 mL/min; MBV, 17.8 ± 3.3, 17.2 ± 3.2, and 14.7 ± 4.1 mL/100 mL; and K(trans), 80.3 ± 12.9, 76.0 ± 14.7, and 77.6 ± 13.2 mL/100 mL/min. CONCLUSION: Global quantitative assessment of left ventricular perfusion with stress dynamic CT myocardial perfusion imaging is feasible, and the findings correlate with the visual assessment of perfusion and the presence of coronary artery stenosis at coronary CT angiography. The potential clinical utility of this technique as a diagnostic tool for differentiating normal from globally reduced myocardial perfusion or as a prognostic marker merits further investigation.

Fat Fractions of the Rotator Cuff Muscles Acquired With 2-Point Dixon MRI: Predicting Outcome After Arthroscopic Rotator Cuff Repair.

OBJECTIVES: The aim of this study was to quantify and compare fat fraction (FF) and muscle volume between patients with failed and intact rotator cuff (RC) repair as well as a control group with nonsurgical conservative treatment to define FF cutoff values for predicting the outcome of RC repair. MATERIALS AND METHODS: Patients with full-thickness RC tears who received magnetic resonance imaging (MRI) before and after RC repair including a 2-point Dixon sequence were retrospectively screened. Patients with retear of 1 or more tendons diagnosed on MRI (Sugaya IV-V) were enrolled and matched to patients with intact RC repair (Sugaya I-II) and to a third group with conservatively treated RC tears. Two radiologists evaluated morphological features (Cofield, Patte, and Goutallier), as well as the integrity of the RC after repair (Sugaya). Fat fractions were calculated from the 2-point Dixon sequence, and the RC muscles were segmented semiautomatically to calculate FFs and volume for each muscle. Receiver operator characteristics curves were used to determine FF cutoff values that best predict RC retears. RESULTS: In total, 136 patients were enrolled, consisting of 3 groups: 41 patients had a failed RC repair (58 ± 7 years, 16 women), 50 patients matched into the intact RC repair group, and 45 patients were matched into the conservative treatment group. Receiver operator characteristics curves showed reliable preoperative FF cutoff values for predicting retears at 6.0% for the supraspinatus muscle (0.83 area under the curve [AUC]), 7.4% for the infraspinatus muscle (AUC 0.82), and 8.3% for the subscapularis muscle (0.94 AUC). CONCLUSIONS: Preoperative quantitative FF calculated from 2-point Dixon MRI can be used to predict the risk of retear after arthroscopic RC repair with cutoff values between 6% and 8.3%.

Photon-Counting Detector CT: Clinical Utility of Virtual Monoenergetic Imaging Combined With Tin Prefiltration to Reduce Metal Artifacts in the Postoperative Ankle.

OBJECTIVES: The aim of this study was to compare the effectiveness and clinical utility of virtual monoenergetic image (VMI) reconstructions in computed tomography (CT) scans with and without tin prefiltration on a photon-counting detector (PCD) CT system to reduce metal implant artifacts in the postoperative ankle. MATERIALS AND METHODS: This retrospective study included patients with internal fixation of the ankle scanned with and without tin prefiltration (Sn) on a PCD CT scanner between March and October 2023. Virtual monoenergetic images between 60 and 190 keV were reconstructed with a 10-keV increment in a bone kernel for both acquisitions (VMI Sn and VMI Std , respectively). Noise measurements assessed artifact reduction in the most prominent near-metal image distortions and were compared between acquisitions modes as well as between polychromatic images and VMIs. Three readers assessed the visibility of osseous healing along with interpretability and artifact extent for 5 reconstruction levels. RESULTS: A total of 48 patients (21 females, 27 males; mean age, 55.1 ± 19.4 years) were included in this study. Tin-prefiltered acquisitions (n = 30) had a lower artifact level for polychromatic images and VMIs compared with non-tin-prefiltered acquisitions (n = 18; P ≤ 0.043). A significant reduction of metal artifacts was observed for VMI Sn ≥120 keV compared with polychromatic images (hyperdense artifacts: 40.2 HU [interquartile range (IQR) 39.8] vs 14.0 HU [IQR 11.1]; P ≤ 0.01 and hypodense artifacts: 91.2 HU [IQR 82.4] vs 29.7 HU [IQR 39.6]; P ≤ 0.001). For VMI Std , this applied to reconstructions ≥100 keV (hyperdense artifacts: 57.7 HU [IQR 33.4] vs 19.4 HU [IQR 27.6]; P ≤ 0.001 and hypodense artifacts: 106.9 HU [IQR 76.1] vs 57.4 HU [IQR 55.7]; P ≤ 0.021). For visibility of osseous healing, VMI Sn at 120 keV yielded higher ratings compared with polychromatic images ( P ≤ 0.001), whereas image interpretability was rated better ( P = 0.023), and artifact extent was rated lower ( P ≤ 0.001) compared with polychromatic images. CONCLUSIONS: Tin-prefiltered VMI at 120 keV showed a significant reduction in metal artifacts compared with polychromatic images, whereas visibility of osseous healing and image interpretability was improved. Therefore, tin-prefiltration PCD CT with VMI reconstructions may be a helpful complement to postsurgical CT imaging of the ankle in patients with metal implants.

Diabetes mellitus: long-term prognostic value of whole-body MR imaging for the occurrence of cardiac and cerebrovascular events.

PURPOSE: To study the predictive value of whole-body magnetic resonance (MR) imaging for the occurrence of cardiac and cerebrovascular events in a cohort of patients with diabetes mellitus (DM). MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board. Informed consent was obtained from all patients before enrollment into the study. The authors followed up 65 patients with DM (types 1 and 2) who underwent a comprehensive, contrast material-enhanced whole-body MR imaging protocol, including brain, cardiac, and vascular sequences at baseline. Follow-up was performed by phone interview. The primary endpoint was a major adverse cardiac and cerebrovascular event (MACCE), which was defined as composite cardiac-cerebrovascular death, myocardial infarction, cerebrovascular event, or revascularization. MR images were assessed for the presence of systemic atherosclerotic vessel changes, white matter lesions, and myocardial changes. Kaplan-Meier survival and Cox regression analyses were performed to determine associations. RESULTS: Follow-up was completed in 61 patients (94%; median age, 67.5 years; 30 women [49%]; median follow-up, 70 months); 14 of the 61 patients (23%) experienced MACCE. Although normal whole-body MR imaging excluded MACCE during the follow-up period (0%; 95% confidence interval [CI]: 0%, 17%), any detectable ischemic and/or atherosclerotic changes at whole-body MR imaging (prevalence, 66%) conferred a cumulative event rate of 20% at 3 years and 35% at 6 years. Whole-body MR imaging summary estimate of disease was strongly predictive for MACCE (one increment of vessel score and each territory with atherosclerotic changes: hazard ratio, 13.2 [95% CI: 4.5, 40.1] and 3.9 [95% CI: 2.2, 7.5], respectively), also beyond clinical characteristics as well as individual cardiac or cerebrovascular MR findings. CONCLUSION: These initial data indicate that disease burden as assessed with whole-body MR imaging confers strong prognostic information in patients with DM. Online supplemental material is available for this article.

Detection of hemodynamically significant coronary artery stenosis: incremental diagnostic value of dynamic CT-based myocardial perfusion imaging.

PURPOSE: To determine the feasibility of computed tomography (CT)-based dynamic myocardial perfusion imaging for the detection of hemodynamically significant coronary artery stenosis, as defined with fractional flow reserve (FFR). MATERIALS AND METHODS: Institutional review board approval and informed patient consent were obtained before patient enrollment in the study. The study was HIPAA compliant. Subjects who were suspected of having or were known to have coronary artery disease underwent electrocardiographically triggered dynamic stress myocardial perfusion imaging. FFR measurement was performed within all main coronary arteries with a luminal narrowing of 50%-85%. Estimated myocardial blood flow (MBF) was derived from CT images by using a model-based parametric deconvolution method for 16 myocardial segments and was related to hemodynamically significant coronary artery stenosis with an FFR of 0.75 or less in a blinded fashion. Conventional measures of diagnostic accuracy were derived, and discriminatory power analysis was performed by using logistic regression analysis. RESULTS: Of 36 enrolled subjects, 33 (mean age, 68.1 years ± 10 [standard deviation]; 25 [76%] men, eight [24%] women) completed the study protocol. An MBF cut point of 75 mL/100 mL/min provided the highest discriminatory power (C statistic, 0.707; P <.001). While the diagnostic accuracy of CT for the detection of anatomically significant coronary artery stenosis (>50%) was high, it was low for the detection of hemodynamically significant stenosis (positive predictive value [PPV] per coronary segment, 49%; 95% confidence interval [CI]: 36%, 60%). With use of estimated MBF to reclassify lesions depicted with CT angiography, 30 of 70 (43%) coronary lesions were graded as not hemodynamically significant, which significantly increased PPV to 78% (95% CI: 61%, 89%; P = .02). The presence of a coronary artery stenosis with a corresponding MBF less than 75 mL/100 mL/min had a high risk for hemodynamic significance (odds ratio, 86.9; 95% CI:17.6, 430.4). CONCLUSION: Dynamic CT-based stress myocardial perfusion imaging may allow detection of hemodynamically significant coronary artery stenosis.

Dynamic computed tomographic assessment of the mitral annulus in patients with and without mitral prolapse.

OBJECTIVES: To obtain 3D CT measurements of mitral annulus throughout cardiac cycle using prototype mitral modeling software, assess interobserver agreement, and compare among patients with mitral prolapse (MP) and control group. BACKGROUND: Pre-procedural imaging is critical for planning of transcatheter mitral valve (MV) replacement. However, there is limited data regarding reliable CT-based measurements to accurately characterize the dynamic geometry of the mitral annulus in patients with MV disease. METHODS: Patients with MP and control subjects without any MV disease who underwent ECG-gated cardiac CT were retrospectively identified. Multiphasic CT data was loaded into a prototype mitral modeling software. Multiple anatomical parameters in 3D space were recorded throughout the cardiac cycle (0-95%): annular circumference, planar-surface-area (PSA), anterior-posterior (A-P) distance, and anterolateral-posteromedial (AL-PM) distance. Comparisons were made among the two groups, with p < 0.05 considered statistically significant. Interobserver agreement was assessed on ten patients using intraclass correlation coefficient (ICC) among 4 experienced readers. RESULTS: A total of 100 subjects were included: 50 with MP and 50 control. Annular dimensions were significantly higher in the MP group than control group, with circumference (144 ± 11 vs. 117±8 mm), PSA (1533 ± 247 vs. 1005 ± 142 mm2), A-P distance (38 ± 4 vs. 32±2 mm), and AL-PM distance (47 ± 4 vs. 39±3 mm) (all p < 0.001). Substantial size changes were observed throughout the cardiac cycle, but with maximal and minimal sizes at different cardiac phases for the two groups. The interobserver agreement was excellent (ICC≥0.75) for annular circumference, PSA, A-P- and AL-PM distance. CONCLUSION: A significant variation in the mitral annular measures between different cardiac phases and two groups was observed with excellent interobserver agreement.

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data.

OBJECTIVE: To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. DESIGN: Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. DATA SOURCES: Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. RESULTS: Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). CONCLUSIONS: In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42012002780.

The evolution of radiation dose over time: Measurement of a patient cohort undergoing whole-body examinations on three computer tomography generations.

OBJECTIVES: To evaluate and compare the radiation dose and image quality of whole-body-CT (WBCT) performed on the 3rd-generation dual-source-CT (DSCT) with 2nd-generation DSCT and 64-slices-Single-Source-CT (SSCT) in a large patient cohort. MATERIAL AND METHODS: Using a monitoring and tracking software 1451, 747 and 1861 patients scanned with a one-spiral-thorax-abdomen-pelvis-CT-examination on a 3rd-, 2nd-generation DSCT and SSCT, respectively, were extracted from the PACS server. For the intra-individual analysis, 203 patients on the 3rd-generation DSCT were identified. Out of those 203 patients, 155 had the same examination on the 2nd-generation DSCT, 91 patients had the same examination on the SSCT and 43 patients had an examination on all three CT-generations. Automatic tube current modulation was active on all three CT-generations, whereas automatic tube voltage selection was only available on both DSCT-generations. Dose was recorded by the size-specific-dose-estimate-method (SSDE); signal-to-noise-ratio (SNR) and contrast-to-noise-ratio (CNR) were calculated placing a ROI on the ascending aorta/liver and the subcutaneous adipose tissue at comparable level. Image quality of axillary and mediastinal lymph nodes and adrenal glands was assessed by two experienced radiologists. RESULTS: Subjective image quality was excellent throughout all three CT-generations (p=0.38-0.98). Quantitative image quality in both DSCT generations was superior to SSCT (p<0.001). SNR and CNR in the liver parenchyma were superior in the 3rd-generation DSCT compared to the 2nd generation DSCT (p<0.001), whereas there was no difference in the aorta. In the inter-individual analysis, CTDIvol was lower by 26.9% and 44.3% in the 3rd-generation DSCT, when compared to the 2nd-generation DSCT and SSCT, respectively; SSDE was lower by 31.5% and 51% in the 3rd-generation DSCT, when compared to the 2nd-generation DSCT and SSCT, respectively. In the intra-individual comparison CTDIVol in the 3rd-generation DSCT was lower by 33% and 45%, when compared to the 2nd-gneration DSCT and the SSCT, respectively. Consequently, SSDE in the 3rd-generation DSCT was lower by 29% and by 43% when compared to the 2nd-generation DSCT and SSCT, respectively. CONCLUSION: State-of-the-art CT-equipment substantially reduce radiation dose without affecting image quality.

Implementation of iterative metal artifact reduction in the pre-planning-procedure of three-dimensional physical modeling.

BACKGROUND: To assess the impact of metal artifact reduction techniques in 3D printing by evaluating image quality and segmentation time in both phantom and patient studies with dental restorations and/or other metal implants. An acrylic denture apparatus (Kilgore Typodent, Kilgore International, Coldwater, MI) was set in a 20 cm water phantom and scanned on a single-source CT scanner with gantry tilting capacity (SOMATOM Edge, Siemens Healthcare, Forchheim, Germany) under 5 scenerios: (1) Baseline acquisition at 120 kV with no gantry tilt, no jaw spacer, (2) acquisition at 140 kV, (3) acquisition with a gantry tilt at 15°, (4) acquisition with a non-radiopaque jaw spacer and (5) acquisition with a jaw spacer and a gantry tilt at 15°. All acquisitions were reconstructed both with and without a dedicated iterative metal artifact reduction algorithm (MAR). Patients referred for a head-and-neck exam were included into the study. Acquisitions were performed on the same scanner with 120 kV and the images were reconstructed with and without iterative MAR. Segmentation was performed on a dedicated workstation (Materialise Interactive Medical Image Control Systems; Materialise NV, Leuven, Belgium) to quantify volume of metal artifact and segmentation time. RESULTS: In the phantom study, the use of gantry tilt, jaw spacer and increased tube voltage showed no benefit in time or artifact volume reduction. However the jaw spacer allowed easier separation of the upper and lower jaw and a better display of the teeth. The use of dedicated iterative MAR significantly reduced the metal artifact volume and processing time. Same observations were made for the four patients included into the study. CONCLUSION: The use of dedicated iterative MAR and jaw spacer substantially reduced metal artifacts in the head-and-neck CT acquisitions, hence allowing a faster 3D segmentation workflow.

The use of coronary CT angiography for the evaluation of chest pain.

Coronary computed tomography angiography (CCTA) may improve the diagnosis and management of acute and stable chest pain syndromes. The key for caregivers of patients presenting with acute chest pain is the early identification and management of life-threatening conditions, such as acute coronary syndromes, pulmonary embolism, and acute aortic dissection. The main goal in stable chest pain syndromes is to determine the extent and severity of coronary artery disease. This review article will critically evaluate the current literature supporting the evidence for the clinical use of CCTA in acute and stable chest pain syndromes, considering the latest innovations in CCTA technology and their potential impact on patient care.

Feasibility of dynamic CT-based adenosine stress myocardial perfusion imaging to detect and differentiate ischemic and infarcted myocardium in an large experimental porcine animal model.

The purpose of the study is feasibility of dynamic CT perfusion imaging to detect and differentiate ischemic and infarcted myocardium in a large porcine model. 12 Country pigs completed either implantation of a 75 % luminal coronary stenosis in the left anterior descending coronary artery simulating ischemia or balloon-occlusion inducing infarction. Dynamic CT-perfusion imaging (100 kV, 300 mAs), fluorescent microspheres, and histopathology were performed in all models. CT based myocardial blood flow (MBFCT), blood volume (MBVCT) and transit constant (Ktrans), as well as microsphere's based myocardial blood flow (MBFMic) were derived for each myocardial segment. According to histopathology or microsphere measurements, 20 myocardial segments were classified as infarcted and 23 were ischemic (12 and 14 %, respectively). Across all perfusion states, MBFCT strongly predicted MBFMic (ß 0.88 ± 0.12, p < 0.0001). MBFCT, MBVCT, and Ktrans were significantly lower in ischemic/infarcted when compared to reference myocardium (all p < 0.01). Relative differences of all CT parameters between affected and non-affected myocardium were higher for infarcted when compared to ischemic segments under rest (48.4 vs. 22.6 % and 46.1 vs. 22.9 % for MBFCT, MBVCT, respectively). Under stress, MBFCT was significantly lower in infarcted than in ischemic myocardium (67.8 ± 26 vs. 88.2 ± 22 ml/100 ml/min, p = 0.002). In a large animal model, CT-derived parameters of myocardial perfusion may enable detection and differentiation of ischemic and infarcted myocardium.