Edema of the upper extremity on the unaffected side in unilateral breast cancer patients.

Breast cancer-related lymphedema (BCRL) occurs usually on the affected side, and its cause and pathophysiology are well known. However, the cause of edema of the upper extremity on the unaffected side is barely known. It is often considered to be chemotherapy-induced general edema, and clinical evaluation is rarely performed in these patients. This study aimed to present the clinical characteristics of unilateral breast cancer patients with edema of upper extremity on the unaffected side, and to emphasize the importance of early diagnosis and medical interventions. This study retrospectively analyzed the medical records of unilateral breast cancer patients complaining edema of upper extremity on the unaffected side, from January 2020 to May 2021. Lymphoscintigraphy was used to assist in confirming the diagnosis of lymphedema, and Doppler ultrasonography or 3D computed tomography angiography were performed to differentiate vascular problems. Fourteen patients were enrolled in the study. Seven, 3, and 4 patients had edema of both upper extremities, edema of the upper extremity on the unaffected side only, and edema of all extremities, respectively. None of the 4 patients with edema of all extremities showed abnormal findings on examination. In patients with edema in the upper extremity on the unaffected side alone, lymphatic flow dysfunction was seen in 2 patients, and deep vein thrombosis (DVT) was diagnosed in 1. In patients with edema of both upper extremities, lymphatic flow dysfunction was seen in 2 patients, and DVT was diagnosed in 3. One patient had DVT and accompanying lymphatic flow dysfunction. Lymphedema and DVT were diagnosed in a number of patients with edema of the upper extremity on the unaffected side, and lymphedema can occur without direct injury to the lymphatic flow system. Therefore, clinicians should not overlook the fact that diseases that require early diagnosis and treatment can occur in patients with edema of the unaffected upper extremity.

Regional Distribution of Extracellular Volume Quantified by Cardiac CT in Aortic Stenosis: Insights Into Disease Mechanisms and Impact on Outcomes.

BACKGROUND: Extracellular volume fraction (ECV) is a marker for myocardial fibrosis and infiltration, can be quantified using cardiac computed tomography (ECVCT), and has prognostic utility in several diseases. This study aims to map out regional differences in ECVCT to obtain greater insights into the pathophysiological mechanisms of ECV expansion and its clinical implications. METHODS: Three prospective cohorts were included: patients with aortic stenosis (AS) and coexisting AS and transthyretin cardiac amyloidosis were referred for a transcatheter aortic valve replacement and had ECG-gated CT angiography and Technetium-99m-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy to differentiate between the 2 cohorts. Controls had CT angiography and cardiac magnetic resonance demonstrating no significant coronary artery disease or infarction. Global and regional ECVCT was analyzed, and its association with mortality was assessed for patients with AS. RESULTS: In 199 patients, controls (n=65; 66% male), AS (n=115), and coexisting AS and transthyretin cardiac amyloidosis (n=19) had a global ECVCT of 26.1 (25.0-27.8%) versus 29.1 (27.5-31.1%) versus 37.4 (32.5-46.6%), respectively; P<0.001. Across cohorts, ECVCT was higher at the base (versus apex), the inferoseptum (versus anterolateral wall), and the subendocardium (versus subepicardium); P<0.05 for all. Among patients with AS, epicardial ECVCT, rather than any other regional value or global ECVCT, was the strongest predictor of mortality at a median of 3.9 (max 6.3) years (adjusted hazard ratio, 1.21 [95% CI, 1.08-1.36]; P=0.002). CONCLUSIONS: Regional differences in ECVCT suggest a predilection for fibrosis and amyloid infiltration at the base, subendocardium, inferior wall, and septum more than the anterior and lateral myocardium. ECVCT can predict long-term mortality with the subepicardium demonstrating the strongest discriminatory power. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03029026 and NCT03094143.

Correlations between the peripheral coronary fat attenuation index based on computed tomography images, high-risk plaque and degree of coronary artery stenosis in patients with coronary atherosclerosis.

BACKGROUND: Coronary artery disease can be quantified by measuring the fat attenuation index (FAI). OBJECTIVE: To explore the correlations between FAI, high-risk plaque and the degree of coronary artery stenosis. METHODS: The clinical data of patients with coronary atherosclerosis who underwent a coronary computed tomography (CT) angiography examination between July 2020 and June 2023 were selected for retrospective analysis. These patients were classified into a high-risk plaque group and non-high-risk plaque group according to the presence of CT high-risk plaque. The diagnostic value of FAI and FAI combined with the degree of stenosis was evaluated for CT high-risk plaque. RESULTS: Differences in age, body mass index, smoking history, FAI and the degree of stenosis between the two groups were statistically significant (all P< 0.05). The results of a binary logistic regression analysis revealed that FAI (odds ratio (OR): 1.131, 95% confidence interval (CI): 1.101-1.173, P< 0.001) and the degree of stenosis (OR: 1.021, 95% CI: 1.012-1.107, P< 0.001) were risk factors for high-risk plaque. CONCLUSION: The FAI can be used to monitor the inflammation level of the coronary artery; the higher the FAI is, the higher the risk of plaque and degree of stenosis.

IV Flat Detector CT Angiography in Flat Detector CT Image-Guided Minimally Invasive Surgery for the Treatment of Intracerebral Hypertensive Hemorrhage.

BACKGROUND AND PURPOSE: Spontaneous intracerebral hemorrhage is a serious stroke subtype with high mortality and morbidity. Minimally invasive surgery plus thrombolysis is a promising treatment option, but it requires accurate catheter placement and real-time monitoring. The authors introduced IV flat detector CT angiography (ivFDCTA) into the minimally invasive surgery procedure for the first time, to provide vascular information and guidance for hematoma evacuation. MATERIALS AND METHODS: Thirty-six patients with hypertensive intracerebral hemorrhage were treated with minimally invasive surgery under the guidance of ivFDCTA and flat detector CT (FDCT) in the angiography suite. The needle path and puncture depth were planned and calculated using software on the DSA workstation. The hematoma volume reduction, operation time, complications, and clinical outcomes were recorded and evaluated. RESULTS: The mean preoperative hematoma volume of 36 patients was 35 (SD, 12) mL, the mean intraoperative volume reduction was 19 (SD, 11) mL, and the mean postoperative residual hematoma volume was 15 (SD, 8) mL. The average operation time was 59 (SD, 22) minutes. One patient had an intraoperative epidural hematoma, which improved after conservative treatment. The mean Glasgow Outcome Scale score at discharge was 4.3 (SD, 0.8), and the mean mRS score at 90 days was 2.4 (SD, 1.1). CONCLUSIONS: The use of ivFDCTA in the evacuation of an intracerebral hemorrhage hematoma could improve the safety and efficiency of minimally invasive surgery and has shown great potential in hemorrhagic stroke management in selected patients.

Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography.

INTRODUCTION: The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS: The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS: The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION: Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

Value of multidetector computed tomography angiography in severe non-variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit.

BACKGROUND: Non-variceal upper gastrointestinal bleeding is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment. As historically played a limited role in the diagnosis of acute non-variceal upper gastrointestinal bleeding, multidetector-row computed tomography angiography is emerging as a promising tool in the diagnosis of non-variceal upper gastrointestinal bleeding, especially for severe cases. However, to date, evidence concerning the role of multidetector-row computed tomography angiography in the non-variceal upper gastrointestinal bleeding diagnosis is still lacking. AIM: The purpose of this study was to retrospectively investigate the diagnostic performance of emergent multidetector-row computed tomography angiography performed prior to any diagnostic modality or following urgent upper endoscopy to identify the status, the site, and the underlying etiology of severe non-variceal upper gastrointestinal bleeding. METHODS: Institutional databases were reviewed in order to identify severe acute non-variceal upper gastrointestinal bleeding patients who were admitted to our bleeding unit and were referred for emergent multidetector-row computed tomography angiography prior to any hemostatic treatment (< 3 h) or following (< 3 h) endoscopy, between December 2019 and October 2022. The study aim was to evaluate the diagnostic performance of multidetector-row computed tomography angiography to detect the status, the site, and the etiology of severe non-variceal upper gastrointestinal bleeding with endoscopy, digital subtraction angiography, surgery, pathology, or a combination of them as reference standards. RESULTS: A total of 68 patients (38 men, median age 69 years [range 25-96]) were enrolled. The overall multidetector-row computed tomography angiography sensitivity, specificity, and accuracy to diagnose bleeding status were 77.8% (95% CI: 65.5-87.3), 40% (95% CI: 5.3-85.3), and 75% (95% CI: 63.0-84.7), respectively. Finally, the overall multidetector-row computed tomography angiography sensitivity to identify the bleeding site and the bleeding etiology were 92.4% (95% CI: 83.2-97.5) and 79% (95% CI: 66.8-88.3), respectively. CONCLUSION: Although esophagogastroduodenoscopy is the mainstay in the diagnosis and treatment of most non-variceal upper gastrointestinal bleeding cases, multidetector-row computed tomography angiography seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute non-variceal upper gastrointestinal bleeding. It may play a crucial role in the management of selected cases of non-variceal upper gastrointestinal bleeding, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of multidetector-row computed tomography angiography in the diagnostic process of acute non-variceal upper gastrointestinal bleeding.

Cross-sectional angle prediction of lipid-rich and calcified tissue on computed tomography angiography images.

PURPOSE: The assessment of vulnerable plaque characteristics and distribution is important to stratify cardiovascular risk in a patient. Computed tomography angiography (CTA) offers a promising alternative to invasive imaging but is limited by the fact that the range of Hounsfield units (HU) in lipid-rich areas overlaps with the HU range in fibrotic tissue and that the HU range of calcified plaques overlaps with the contrast within the contrast-filled lumen. This paper is to investigate whether lipid-rich and calcified plaques can be detected more accurately on cross-sectional CTA images using deep learning methodology. METHODS: Two deep learning (DL) approaches are proposed, a 2.5D Dense U-Net and 2.5D Mask-RCNN, which separately perform the cross-sectional plaque detection in the Cartesian and polar domain. The spread-out view is used to evaluate and show the prediction result of the plaque regions. The accuracy and F1-score are calculated on a lesion level for the DL and conventional plaque detection methods. RESULTS: For the lipid-rich plaques, the median and mean values of the F1-score calculated by the two proposed DL methods on 91 lesions were approximately 6 and 3 times higher than those of the conventional method. For the calcified plaques, the F1-score of the proposed methods was comparable to those of the conventional method. The median F1-score of the Dense U-Net-based method was 3% higher than that of the conventional method. CONCLUSION: The two methods proposed in this paper contribute to finer cross-sectional predictions of lipid-rich and calcified plaques compared to studies focusing only on longitudinal prediction. The angular prediction performance of the proposed methods outperforms the convincing conventional method for lipid-rich plaque and is comparable for calcified plaque.

[The application of setting tube voltage and iodine delivery rate in weight-grouped for reducing the radiation and contrast medium dose in coronary CT angiography].

Objective: To evaluate the application value of reducing tube voltage and iodine delivery rate according to body weight in coronary CT angiography (CCTA). Methods: A prospective randomized controlled study. A total of 297 subjects, 172 males and 125 females, aged [M (Q1, Q3)]60.0 (50.0, 68.0) years, who underwent CCTA examination in Peking University Third Hospital due to clinically suspected coronary heart disease from May to December 2022 were included. According to the odd or even visit dates, the subjects were randomly divided into test group (n=156) and control group (n=141). The subjects in both groups were divided into four sub-groups according to body weight: 50-59 group, 60-69 kg group, 70-79 kg group and 80-89 kg group, respectively. The CCTA images were reconstructed with hybrid iterative algorithm(KARL 3D) with levels of 6 and 8, respectively. 100 kVp and iodine flow rate 1.1, 1.3, 1.4 and 1.5 gI/s recommended by the domestic CCTA application guidelines were used in the control group, while the tube voltage and iodine flow rate were reduced in the test group based on the guidelines and body weight:70 kVp and 0.8 g I/s in 50~59 kg group, 80 kVp and 1.0 gI/s in 60~69 kg group, 80 kVp and 1.1 gI/s in70~79 kg group, and 100 kVp and 1.5 gI/s in 80~89 kg group, respectively. The CT values and standard deviation (SD) of aortic root, proximal left anterior descending branch (LAD) and distal right coronary artery (RCA) luminal CCTA, the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of coronary artery CT images, subjective coronary scores and effective radiation dose (ED) were compared between the both groups. One-way ANOVA or Wilcoxon test was used to analyze the differences of above indicators between the groups to evaluate the application value of low voltage and low iodine flow rate based on weight in coronary CCTA. Results: CT values of aortic root, LAD proximal CT values and SD values of aortic root [411.4 (377.2, 439.8) HU, (366.3±42.9) HU, 26.5±2.3] in the test group were all higher than those in the control group [379.00 (335.2, 415.9) HU, (355.0±46.9) HU and 24.8±2.3]. The differences were statistically significant (all P<0.05), and the other parameters were not statistically significant (all P>0.05). The total subjective image quality score in test group were superior to those in the control group (all P<0.05). The total ED and contrast agent dosage [2.07 (1.52, 3.28) mSv and (38.28±9.68) ml] in CCTA examination in the test group were lower than those in the control group [3.30(2.32, 4.44) mSv and (45.31±5.63) ml], and the differences were statistically significant (all P<0.05). The dosage of ED and contrast agent in the test group was decreased by 37.3% and 15.5%, respectively. Conclusion: Combined with KARL 3D,it is feasible to reduce contrast medium and ED by setting the tube voltage and iodine flow rate of CCTA according to the weight of the subject, which can further reduce the radiation dose and contrast agent dosage of CCTA.

Interaction of AI-Enabled Quantitative Coronary Plaque Volumes on Coronary CT Angiography, FFRCT, and Clinical Outcomes: A Retrospective Analysis of the ADVANCE Registry.

BACKGROUND: Luminal stenosis, computed tomography-derived fractional-flow reserve (FFRCT), and high-risk plaque features on coronary computed tomography angiography are all known to be associated with adverse clinical outcomes. The interactions between these variables, patient outcomes, and quantitative plaque volumes have not been previously described. METHODS: Patients with coronary computed tomography angiography (n=4430) and one-year outcome data from the international ADVANCE (Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care) registry underwent artificial intelligence-enabled quantitative coronary plaque analysis. Optimal cutoffs for coronary total plaque volume and each plaque subtype were derived using receiver-operator characteristic curve analysis. The resulting plaque volumes were adjusted for age, sex, hypertension, smoking status, type 2 diabetes, hyperlipidemia, luminal stenosis, distal FFRCT, and translesional delta-FFRCT. Median plaque volumes and optimal cutoffs for these adjusted variables were compared with major adverse cardiac events, late revascularization, a composite of the two, and cardiovascular death and myocardial infarction. RESULTS: At one year, 55 patients (1.2%) had experienced major adverse cardiac events, and 123 (2.8%) had undergone late revascularization (>90 days). Following adjustment for age, sex, risk factors, stenosis, and FFRCT, total plaque volume above the receiver-operator characteristic curve-derived optimal cutoff (total plaque volume >564 mm3) was associated with the major adverse cardiac event/late revascularization composite (adjusted hazard ratio, 1.515 [95% CI, 1.093-2.099]; P=0.0126), and both components. Total percent atheroma volume greater than the optimal cutoff was associated with both major adverse cardiac event/late revascularization (total percent atheroma volume >24.4%; hazard ratio, 2.046 [95% CI, 1.474-2.839]; P<0.0001) and cardiovascular death/myocardial infarction (total percent atheroma volume >37.17%, hazard ratio, 4.53 [95% CI, 1.943-10.576]; P=0.0005). Calcified, noncalcified, and low-attenuation percentage atheroma volumes above the optimal cutoff were associated with all adverse outcomes, although this relationship was not maintained for cardiovascular death/myocardial infarction in analyses stratified by median plaque volumes. CONCLUSIONS: Analysis of the ADVANCE registry using artificial intelligence-enabled quantitative plaque analysis shows that total plaque volume is associated with one-year adverse clinical events, with incremental predictive value over luminal stenosis or abnormal physiology by FFRCT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02499679.

Hipertensión pulmonar y leiomiomas uterinos, ¿existe relación causal? Serie de casos y revisión fisiopatológica / Pulmonary Hypertension and Uterine Leiomyomas, Is there a Causal Relationship? Case Series and Pathophysiological Review

Introducción: Los leiomiomas uterinos son un tipo de neoplasia benigna de frecuente aparición en mujeres de edad reproductiva, relacionados con enfermedad tromboem- bólica venosa. Este vínculo surge del efecto producido por la compresión de fibromas que genera estasis venosa en la región pelviana. Sin embargo, este pareciera no ser el único factor que lo relaciona con el desarrollo posterior de hipertensión pulmonar, sino que su presencia es gatillo de una serie de fenómenos que influyen sobre la vasculatu - ra pulmonar y también a nivel sistémico. Método: Revisión de una serie de casos (seis) atendidos en nuestra unidad, seguido de una revisión sobre la relación entre leiomio- mas y distintas formas de hipertensión pulmonar con una revisión desde la fisiopatología. Resultado y conclusiones: Encontramos sustento bibliográfico en los múltiples caminos fisiopatológicos que relacionan los mediadores vasculares comunes, que parecieran ser el punto clave en la relación entre estas dos patologías.

Introduction: Uterine leiomyomas are a type of benign neoplasm that frequently appears in women of reproductive age, related to venous thromboembolic disease. This link arises from the effect produced by the compression of fibroids, which generates venous stasis in the pelvic region. However, this seems not to be the only factor that re- lates it to the subsequent development of pulmonary hypertension, but rather its presence is a trigger for a series of phenomena that influence the pulmonary vasculature and also at a systemic level. Method: Review of a series of cases (six) cared for in our unit, followed by a review on the relationship between leiomyomas and different forms of pulmonary hypertension with a review from the pathophysiology. Result and conclusions: We found bibliographic support in the multiple pathophysiological paths that relate the common vascular mediators, which appear to be the key point in the relationship between these two pathologies.

Risk Factors for Contrast Media Extravasation in Intravenous Contrast-Enhanced Computed Tomography: An Observational Cohort Study.

RATIONALE AND OBJECTIVES: To identify the risk factors for contrast media (CM) extravasation and provide effective guidance for reducing its incidence. MATERIALS AND METHODS: We observed adult inpatients (n = 38 281) who underwent intravenous contrast-enhanced computed tomography between January 1, 2018, and December 31, 2022. Risk factors for CM extravasation were evaluated using univariate and multivariate logistic regression. RESULTS: Among the 38 281 inpatients who underwent enhanced computed tomography angiography, 3885 received peripherally inserted central venous catheters (PICCs) and 34 396 received peripheral short catheters. In 3885 cases of PICCs, no CM extravasation occurred, but in five cases, ordinary PICCs that are unable to withstand high pressure were mistakenly used; three of those patients experienced catheter rupture, and eventually, all five patients underwent unplanned extubation. Among 34 396 cases of peripheral short catheters, 224 (0.65%) had CM extravasation. Female sex (odds ratio [OR]=1.541, 95% confidence interval [CI]: 1.111-2.137), diabetes (OR=2.265, 95% CI: 1.549-3.314), venous thrombosis (OR=2.157, 95% CI: 1.039-4.478), multi-site angiography (OR=9.757, CI: 6.803-13.994), and injection rate ≥ 3 mL/s (OR=6.073, 95% CI: 4.349-8.481) were independent risk factors for CM extravasation. Due to peripheral vascular protection measures in patients with malignant tumor, there was a low incidence of CM extravasation (OR=0.394, 95% CI: 0.272-0.570). CONCLUSION: Main risk factors for CM extravasation are female, diabetes, venous thrombosis, multi-site angiography, and injection rate ≥ 3 mL/s. However, patients with malignant tumor have a low incidence of CM extravasation. CLINICAL IMPACT: Analysis of these risk factors can help reduce the incidence of CM extravasation.

Sex Differences in Coronary Inflammation and Atherosclerosis Phenotypes in Response to Imaging Marker of Stress-Related Neural Activity.

BACKGROUND: Sex-specific differences in coronary phenotypes in response to stress have not been elucidated. This study investigated the sex-specific differences in the coronary computed tomography angiography-assessed coronary response to mental stress. METHODS: This retrospective study included patients with coronary artery disease and without cancer who underwent resting 18F-fluorodexoyglucose positron emission tomography/computed tomography and coronary computed tomography angiography within 3 months. 18F-flourodeoxyglucose resting amygdalar uptake, an imaging biomarker of stress-related neural activity, coronary inflammation (fat attenuation index), and high-risk plaque characteristics were assessed by coronary computed tomography angiography. Their correlation and prognostic values were assessed according to sex. RESULTS: A total of 364 participants (27.7% women and 72.3% men) were enrolled. Among those with heightened stress-related neural activity, women were more likely to have a higher fat attenuation index (43.0% versus 24.0%; P=0.004), while men had a higher frequency of high-risk plaques (53.7% versus 39.3%; P=0.036). High amygdalar 18F-flourodeoxyglucose uptake (B-coefficient [SE], 3.62 [0.21]; P<0.001) was selected as the strongest predictor of fat attenuation index in a fully adjusted linear regression model in women, and the first-order interaction term consisting of sex and stress-related neural activity was significant (P<0.001). Those with enhanced imaging biomarkers of stress-related neural activity showed increased risk of major adverse cardiovascular event both in women (24.5% versus 5.1%; adjusted hazard ratio, 3.62 [95% CI, 1.14-17.14]; P=0.039) and men (17.2% versus 6.9%; adjusted hazard ratio, 2.72 [95% CI, 1.10-6.69]; P=0.030). CONCLUSIONS: Imaging-assessed stress-related neural activity carried prognostic values irrespective of sex; however, a sex-specific mechanism linking psychological stress to coronary plaque phenotypes existed in the current hypothesis-generating study. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05545618.

The value of color doppler ultrasonography combined with computed tomography angiography and magnetic resonance angiography in the preoperative quantification and classification of carotid body tumors: a retrospective analysis.

BACKGROUND: Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) provide accurate vascular imaging information, but their use may be contraindicated. Color Doppler ultrasonography (CDU) provides simple, safe, noninvasive, and reproducible imaging. We therefore investigated the role of preoperative CDU combined with CTA and MRA in the quantification, typing, and diagnosis of carotid body tumors (CBTs). METHODS: We retrospectively analyzed patients with CBTs categorized into group A (type I [n = 1] and type II [n = 10]) or group B (type III [n = 56]) per the intraoperative Shamblin classification. CDU, CTA, and MRA characteristics of CBTs were observed, surgical results were correlated, and the diagnostic threshold of the CBT classification was calculated. RESULTS: CBTs were usually located at the common carotid artery bifurcation, encircling the carotid artery. An increased angle was found between the internal and external carotid arteries. On CDU, CBTs primarily presented as homogeneous hypoechoic masses with clear boundaries, rich flow signals, and a high-speed, low-resistance artery-like flow spectrum. CTA showed uniform or heterogeneous marked enhancement. MRA showed mixed T1 and slightly longer T2 signals and uniform or uneven obvious enhancement. With increases in the lesion size, amount of blood transfused, and operation time, the intraoperative classification level and possibility of skull-base invasion increased. When the maximum diameter of the lesion, the volume of the tumor, the distance between the upper margin of the tumor to the mastoid and the mandibular angle were 3.10 cm, 10.15 cm3, - 3.26 cm, and 0.57 cm, respectively, the largest Youden index was the best diagnostic boundary value for Shamblin type III tumors. CONCLUSIONS: CDU combined with CTA and MRA can accurately evaluate the size and classification of CBTs.

Maternal and Fetal Radiation-Induced Cancer Risk From Computed Tomography Pulmonary Angiography During Pregnancy: A Retrospective Cohort Study Across a Multihospital Integrated Health Care Network.

OBJECTIVE: Computed tomography pulmonary angiogram (CTPA) is important to evaluate suspected pulmonary embolism in pregnancy but has maternal/fetal radiation risks. The objective of this study was to estimate maternal and fetal radiation-induced cancer risk from CTPA during pregnancy. METHODS: Simulation modeling via the National Cancer Institute's Radiation Risk Assessment Tool was used to estimate excess cancer risks from 17 organ doses from CTPA during pregnancy, with doses determined by a radiation dose indexing monitoring system. Organ doses were obtained from a radiation dose indexing monitoring system. Maternal and fetal cancer risks per 100,000 were calculated for male and female fetuses and several maternal ages. RESULTS: The 534 CTPA examinations had top 3 maternal organ doses to the breast, lung, and stomach of 17.34, 15.53, and 9.43 mSv, respectively, with a mean uterine dose of 0.21 mSv. The total maternal excess risks of developing cancer per 100,000 were 181, 151, 121, 107, 94.5, 84, and 74.4, respectively, for a 20-, 25-, 30-, 35-, 40-, 45-, and 50-year-old woman undergoing CTPA, compared with baseline cancer risks of 41,408 for 20-year-old patients. The total fetal excess risks of developing cancer per 100,000 were 12.3 and 7.3 for female and male fetuses, respectively, when compared with baseline cancer risks of 41,227 and 48,291. DISCUSSION: Excess risk of developing cancer from CTPA was small relative to baseline cancer risk for pregnant patients and fetuses, decreased for pregnant patients with increasing maternal age, and was greater for female fetuses than male fetuses.

Minimizing Contrast Media Dose in CT Pulmonary Angiography with Clinical Photon Counting Using High Pitch Technique.

RATIONALE AND OBJECTIVES: To evaluate the potential to reduce the amount of iodinated contrast media (CM) for computer tomographic pulmonary angiography (CTPA) with a novel photon-counting-detector CT (PCCT). MATERIALS AND METHODS: Overall, 105 patients referred for CTPA were retrospectively included in this study. CTPA was performed using bolus tracking and high-pitch dual-source scanning (FLASH mode) on a novel PCCT (Naeotom Alpha, Siemens Healthineers). CM (Accupaque 300, GE Healthcare) dose was lowered stepwise following the introduction of the new CT scanner. Thus, patients could be divided into 3 groups as follows: group 1, n = 29, 35 ml of CM; group 2, n = 62, 45 ml of CM and group 3, n = 14, 60 ml of CM. Four readers independently assessed the image quality (Likert-scale 1-5) and adequate assessment of the segmental pulmonary arteries. Additionally, the pulmonary arterial contrast opacification was measured. RESULTS: The subjective image quality was rated highest in group 1 with 4.6 compared to 4.5 (group 2) and 4.1 (group 3) with a significant difference between groups 1 and 3 (p < 0.001) and between groups 2 and 3 (p = 0.003). In all groups, almost all segmental pulmonary arteries could be assessed adequately without significant differences (18.5 vs. 18.7 vs. 18.4). Mean attenuation in the pulmonary trunk did not differ significantly between groups 321 ± 92 HU versus 345 ± 93 HU versus 347 ± 88 HU (p = 0.69). CONCLUSION: Significant CM dose reduction is possible without a reduction in image quality. PCCT enables diagnostic CTPA with 35 ml of CM.

Saving Contrast Media in Coronary CT Angiography with Photon-Counting Detector CT.

RATIONALE AND OBJECTIVES: To determine the optimal virtual monoenergetic image (VMI) energy level and the potential of contrast-media (CM) reduction for coronary computed tomography angiography (CCTA) with photon-counting detector CT (PCD-CT). MATERIALS AND METHODS: In this institutional review board-approved study, patients who underwent CCTA with dual-source PCD-CT with an identical scan protocol and radiation dose were included. In group 1, CCTA was performed with our standard CM protocol (volume: 72-85.2 mL, 370 mg iodine/mL). VMIs were reconstructed from 40 to 60 keV at 5 keV increments. Objective image quality (IQ) (vascular attenuation, image noise, and contrast-to-noise ratio [CNR]) was measured. Two blinded, independent readers rated subjective IQ (overall IQ, subjective image contrast, and subjective noise using a five-point discrete visual scale). Results of group 1 served to determine the best VMI level for CCTA. In group 2, CM volume was reduced by 20%, and in group 3 by another 20%. RESULTS: A total of 100 patients were enrolled (45 females, mean age 54 ± 13 years). Inter-reader agreement was good-to-excellent for all comparisons (κ > 0.6). In group 1, the best VMI level regarding objective and subjective IQ was 45 keV, which was selected as the reference for groups 2 and 3. For group 2, mean vascular attenuation was 890 Hounsfield units (HU) and mean CNR was 26, with no differences compared to group 1, 45 keV for both objective and subjective IQ. For group 3, mean vascular attenuation was 676 HU and mean CNR was 21, and all patients were rated as diagnostic except one (severe motion artifacts). CONCLUSION: Increased IQ of PCD-CT can be used for considerable CM volume reduction while still maintaining a diagnostic IQ of CCTA.

Non-ECG-gated cardiac CT angiography in acute stroke is feasible and detects sources of embolism.

BACKGROUND: A significant portion of cryptogenic stroke is hypothesized to be secondary to cardiac embolism. However, transthoracic echocardiogram is usually delayed after stroke, and more detailed cardiac imaging is not routinely done. AIMS: This study aimed to determine whether non-ECG-gated cardiac CT angiography (cCTA) during hyperacute stroke would provide diagnostic quality images and act as an adjunct modality of cardiac imaging to detect sources of emboli. METHODS: In this single-center prospective cohort study, modified Code Stroke imaging was implemented with a 64-slice CT scanner, where the longitudinal axis of CT angiography was extended from the carina to the diaphragm. The primary outcomes of image quality, recruitment feasibility, impact on hyperacute time metrics, and additional radiation dose were assessed. Secondary outcomes consisted of detection of high-risk cardiac sources of embolism, mediastinal or lung pathology, and impact on etiologic classification. RESULTS: One hundred and twenty eligible patients were enrolled, of which 105 (87.5%) had good/moderate quality images for motion artifact and 119 (99.2%) for contrast opacification. Total CT time, door-to-needle time, and door-to-groin puncture time were unchanged with the addition of cCTA. Eighty-nine patients received a final diagnosis of ischemic stroke, of which 12/89 (13.5%) had high-risk cardioembolic findings on cCTA. Incidental findings, such as pulmonary embolism (PE) (7/89, 7.9%) and malignancy (6/89, 6.7%), were observed. cCTA led to changes in management for 19/120 (15.8%) of all patients, and reclassification of stroke etiology for 8/89 (9%) of patients. CONCLUSIONS: Non-ECG-gated cCTA can be feasibly incorporated into Code Stroke and provide diagnostic quality images without delays in hyperacute time metrics. It can detect high-risk cardiac sources, and other findings impacting patient care. This may help reclassify a subset of cryptogenic stroke cases and improve secondary prevention.

Reduced radiation dose and volume of contrast medium in heart rate-based, one-stop computed tomography angiography of coronary, carotid and cerebrovascular arteries.

BACKGROUND: Computed tomography angiography (CTA) is a reliable, non-invasive screening method for diagnosing panvascular disease. By using low contrast agent volume, CTA imaging enables one-stop multi-organ scanning, thereby minimizing the potential risk of contrast-induced nephropathy in patients with impaired renal function. PURPOSE: To evaluate the feasibility of one-stop CTA following a heart rate (HR)-based protocol using a low volume of contrast medium (CM) for examination of the coronary, carotid and cerebrovascular arteries. MATERIAL AND METHODS: Sixty patients undergoing coronary carotid, and cerebrovascular CTA after a single injection of CM were recruited and randomly divided into two groups. Group A (n = 30) underwent CTA following a traditional protocol. The timing of the scans in Group B (n = 30) was determined according to the patient's HR. RESULTS: The CT values for the thoracic aorta (432.2 ± 104.28 HU), anterior cerebral artery (303.96 ± 99.29 HU), and right coronary artery (366.70 ± 85.10 HU) in Group A did not differ significantly from those in Group B (445.80 ± 106.13, 293.73 ± 75.25 and 344.13 ± 111.04 HU, respectively). The qualities of most of the scanned images for both groups were scored as 3 or 4 (on a five-point scale). The radiation dose and the volume of CM were significantly higher in Group A (303.05 ± 110.95 mGy) (100 mL) than in Group B (239.46 ± 101.12 mGy) (50 mL). CONCLUSION: The radiation dose and volume of CM were significantly reduced in CTA following the HR-based protocol. The personalized administration of CM also simplified the scanning process.

Deep learning-based scan range optimization can reduce radiation exposure in coronary CT angiography.

OBJECTIVES: Cardiac computed tomography (CT) is essential in diagnosing coronary heart disease. However, a disadvantage is the associated radiation exposure to the patient which depends in part on the scan range. This study aimed to develop a deep neural network to optimize the delimitation of scan ranges in CT localizers to reduce the radiation dose. METHODS: On a retrospective training cohort of 1507 CT localizers randomly selected from calcium scoring and angiography scans and acquired between 2010 and 2017, optimized scan ranges were delimited by two radiologists in consensus. A neural network was trained to reproduce the scan ranges and was tested on two randomly selected and independent validation cohorts: an internal cohort of 233 CT localizers (January 2018-June 2020) and an external cohort from a nearby hospital of 298 CT localizers (July 2020-December 2020). Localizers where a bypass surgery was visible were excluded. The effective radiation dose to the patient was simulated using a Monte Carlo simulation. Scan ranges of radiographers, radiologists, and the network were compared using an equivalence test; likewise, the reduction in effective dose was tested using a superior test. RESULTS: The network replicated the radiologists' scan ranges with a Dice score of 96.5 ± 0.02 (p < 0.001, indicating equivalence). The generated scan ranges resulted in an effective dose reduction of 10.0% (p = 0.002) in the internal cohort and 12.6% (p < 0.001) in the external cohort compared to the scan ranges delimited by radiographers in clinical routine. CONCLUSIONS: Automatic delimitation of the scan range can result in a radiation dose reduction to the patient. CLINICAL RELEVANCE STATEMENT: Fully automated delimitation of the scan range using a deep neural network enables a significant reduction in radiation exposure during CT coronary angiography compared to manual examination planning. It can also reduce the workload of the radiographers. KEY POINTS: • Scan range delimitation for coronary computed tomography angiography could be performed with high accuracy by a deep neural network. • Automated scan ranges showed a high agreement of 96.5% with the scan ranges of radiologists. • Using a Monte Carlo simulation, automated scan ranges reduced the effective dose to the patient by up to 12.6% (0.9 mSv) compared to the scan ranges of radiographers in clinical routine.