Use of Chest Imaging in the Diagnosis and Management of COVID-19: A WHO Rapid Advice Guide.

The World Health Organization (WHO) undertook the development of a rapid guide on the use of chest imaging in the diagnosis and management of coronavirus disease 2019 (COVID-19). The rapid guide was developed over 2 months by using standard WHO processes, except for the use of "rapid reviews" and online meetings of the panel. The evidence review was supplemented by a survey of stakeholders regarding their views on the acceptability, feasibility, impact on equity, and resource use of the relevant chest imaging modalities (chest radiography, chest CT, and lung US). The guideline development group had broad expertise and country representation. The rapid guide includes three diagnosis recommendations and four management recommendations. The recommendations cover patients with confirmed or who are suspected of having COVID-19 with different levels of disease severity, throughout the care pathway from outpatient facility or hospital entry to home discharge. All recommendations are conditional and are based on low certainty evidence (n = 2), very low certainty evidence (n = 2), or expert opinion (n = 3). The remarks accompanying the recommendations suggest which patients are likely to benefit from chest imaging and what factors should be considered when choosing the specific imaging modality. The guidance offers considerations about implementation, monitoring, and evaluation, and also identifies research needs. Published under a CC BY 4.0 license. Online supplemental material is available for this article.

Early experience with the AMPLATZER vascular plug IV for the occlusion of pulmonary arteriovenous malformations.

The recent generation of AMPLATZER Vascular Plug (AVP; ie, the AVP IV) was used for the occlusion of eight pulmonary arteriovenous malformations (PAVMs) in five patients. A treatment was considered successful when there was a reduction or disappearance of the aneurysmal sac. At a mean follow-up of 20.1 months, no recanalization of PAVMs was observed on multidetector computed tomographic angiography. This shows the AVP IV to be safe and effective as an embolic device to occlude PAVMs.

MDCT findings after hepatic chemoembolization with DC-beads: what the radiologist needs to know.

Transcatheter arterial chemoembolization with drug-eluting beads (TACE-DC-beads) is a new local treatment for primary or metastatic liver tumors. Despite technical efforts to achieve highly selective embolization of the tumor-supplying vessels, small, or large insults to the non-tumorous parenchyma are inevitably induced by the embolic materials or procedure itself. Parenchymal changes following TACE-DC-beads include bile duct injuries (bile duct dilatation, periportal edema, and bilomas), obliteration of intrahepatic portal vein branches, hypodense ill-defined areas, and perilesional parenchymal enhancement. The radiologist must be familiar with the changes induced by this treatment in order to distinguish therapeutic effect and collateral findings from complications and residual or recurrent tumor.

New surgical strategy to induce liver hypertrophy: role of MDCT-volumetry to monitor and predict liver growth.

BACKGROUND/AIMS: To describe the role of MDCT-volumetry to monitor and predict liver hypertrophy in a recently introduced surgical technique in patients needing hepatectomy. METHODOLOGY: This prospective study was approved by the local research and ethics committee and patient informed consent was obtained. Twelve consecutive patients were selected for associating liver partition and portal vein ligation for staged-hepatectomy procedure. The mean absolute the future-liver-remnant (FLR) and FLR/total liver volume (TLV) ratio was calculated before and after surgery to determine the degree of hypertrophy. Six days after surgery a new CT-examination was performed to determine the FLR-volume and FLR/TLV. If the enlargement of the FLR was the expected a second-step surgery was performed. Continuous variables are expressed as mean (range). A p<0.05 was considered significant. RESULTS: The mean pre-operative FLR-volume was 402 mL and the FLR/TLV was 27%. The mean post-operative FLR-volume 6 days after the first step was 702 mL (range 521-1030 mL) being the mean difference between preoperative and postoperative FLR volume 303 mL (p<0.0001). The mean volume increase was 80% ranged from 21-139%. At day six, FLR/TLV was 46.5% (range 33.5-67.7), morbidity was 41% and mortality 0%. CONCLUSIONS: MDCT-volumetry has a key role in decision-making, monitoring and predicting liver hypertrophy pre- and postoperatively.

Esophageal cancer characterization with pneumo-64-MDCT.

Early diagnosis and accurate staging of esophageal cancer are both essential for therapeutic strategy planning. Endoscopic ultrasound, CT, and positron emission tomography have all been used in the preoperative staging of esophageal cancer separately or in various combinations. Each imaging method has its strengths and weaknesses. Depiction of the tumor's anatomic location conditions the surgical strategy. Endoscopic ultrasound and PET have important advantages but neither provides information for surgical planning. CT scans have some limitations for hollow organ assessment in the absence of lumen distension, since the organ wall may be collapsed. Therefore, optimal esophageal distension could be very useful to overcome these limitations. This potential drawback is crucial at the level of the GE junction, a typically difficult region to evaluate. In order to optimize tumor visualization in the esophageal wall and in the GE junction, we developed a technique named pneumo-64-MDCT. We achieve maximum lumen distension, which better highlights the thickened areas in relation to the normal esophageal wall. At the present time, we have performed 200 studies with this technique and it proved useful, safe and accurate to identify esophageal wall thickening and to stage esophageal cancer. The additional stomach distension led to an adequate definition of both the upper and lower borders of the lesion in tumors located in the GE junction, which in turn was helpful to design the surgical approach.

Direct 64-row MDCT venography in the diagnosis of an inferior vena cava leiomyosarcoma.

We report the usefulness of a technique called direct-MDCT venography in the diagnostic workup of a patient with an inferior vena cava leiomyosarcoma. The technique consists in the injection of contrast agent through both lower limbs achieving maximum enhancement in the inferior vena cava. Images are similar to those of the gold standard conventional cavography. To our knowledge, this is the first description of the direct-MDCT imaging appearance of an inferior vena cava leiomyosarcoma.

Prenatal diagnosis of skeletal dysplasias: contribution of three-dimensional computed tomography.

OBJECTIVE: To describe the contribution of 3-dimensional computed tomography (3D-CT) in the prenatal diagnosis of skeletal dysplasias (SD) in a cohort of patients with inconclusive diagnosis by ultrasound (US). METHODS: Between May 2007 and February 2010, six pregnant women with suspected fetal SD on US examination but with no specific diagnosis were studied with 3D-CT. The images were evaluated by a multidisciplinary team who proposed a likely diagnosis. Further postnatal workup included clinical and radiological evaluation in all cases. Prenatal and postnatal diagnoses were compared. RESULTS: The use of 3D-CT provided a precise diagnosis confirmed postnatally in 5/6 patients. These included osteogenesis imperfecta type II (n = 2), osteogenesis imperfecta type III (n = 1), chondrodysplasia punctata (n = 1) and thanatophoric dysplasia type I (n = 1). A precise diagnosis could not be made in 1 case - either pre- or postnatally. CONCLUSION: Prenatal 3D-CT contributed to the diagnosis of the specific fetal SD in the majority of these cases. 3D-CT may have a complementary role to US where fetal SD is suspected, but no specific diagnosis can be made using US alone. Further studies on clinical performance and risk-benefit analysis are needed.

[New method of hepatic regeneration]. / Nuevo Metodo de Regeneracion hepatica.

Postoperative liver failure (PLF) is the most feared and serious complication after extensive liver resections. We present an innovative surgical technique for the treatment of a patient with colorectal cancer and initially unresectable liver metastases. After completing neoadjuvant chemotherapy, it was decided to perform simultaneous surgery. A left hemicolectomy and cleaning of the metastases in the left liver was performed. As the future liver remnant (FLR) was insufficient, it was decided to perform an in situ liver split and a right portal vein ligation. On the 6(th) day after the surgery a volumetric CT showed an increase greater than 40% of the FLR. The right hepatectomy was completed and the patient was discharged on the 11(th) day after surgery. The technique induced a rapid growth of the FLR, exceeding that reported using portal occlusion. If these findings are corroborated in future studies, this revolutionary technique could enable surgery to be performed in two stages on patients with initially unresectable liver disease during the same hospital admission and without PLF.

Esophageal cancer: pneumo-64-MDCT.

BACKGROUND: Pre-surgical characterization and staging of esophageal cancer with only one imaging method could be useful since gastric invasion determines the scope of resection and the kind of surgery to be performed. Our aim is to demonstrate the usefulness of Pneumo-64-MDCT (PnCT64) in the presurgical characterization of esophageal neoplasms in correlation with surgical findings. MATERIALS AND METHODS: A total of 50 patients with diagnosis of esophageal neoplasm were prospectively studied. A 14 French Foley catheter was used transorally in all patients. Air was instilled through the catheter to achieve esophageal distension. A 64-row MDCT scan was performed and the tumor was characterized according to scope, shape and anatomic location by using multiplanar 3D reconstructions and virtual endoscopy. Wall infiltration and presence of adenopathies were analyzed. RESULTS: Adequate gastroesophageal distension was achieved in all patients. In 44/50 patients, wall thickening was observed, and in 34/50 regional adenopathies were found. In 29/50 patients the lesion was found in the lower third and in the gastroesophageal junction. The surgical correlation for wall infiltration was 85.7%. CONCLUSIONS: PnCT64 proved to be useful and safe for identification of esophageal wall thickening and presurgical characterization. Optimal distension allowed definition of both upper and lower borders of the tumors located in the gastroesophageal junction, of utmost importance to determine the surgical approach.

[Usefulness of Pneumo-64-MDCT in the presurgical evaluation of esophageal cancer]. / Utilidad de la neumotomografia multislice 64 en la evaluación prequirúrgica del cáncer esofágico.

BACKGROUND: Pre-surgical characterization and staging of esophageal and esophagogastric union cancer with only one imaging method could be useful for the therapeutic strategy. OBJECTIVE: 1) To evaluate the sensitivity of Pneumo-64-MSCT (PnCT64) in the diagnosis of esophageal-cardial wall thickening in correlation with anatomopathological and postsurgical findings. 2) To evaluate the usefulness of gastric distension in the presurgical planning of esophageal cancer, especially those located in the gastroesophageal junction. METHODS: Twenty-four patients with endoscopic diagnosis of esophageal and cardial cancer were prospectively studied with PnCT64 before surgery. CT's were performed with a 64 row CT scanner and in order to achieve esophageal distension, CO2 was instilled with an automated insufflator through a Foley catheter. Mural thickening was evaluated as well as its scope, shape and anatomic location by using different type of reconstructions. PnCT64 findings were correlated with anatomopathological staging. RESULTS: In 21 patients an asymmetric wall thickening was observed with a sensitivity of 86.4% in correlation with anatomopathological findings. Adequate gastroesophageal distension defining the limits of the lesions was achieved in all patients. CONCLUSION: PnCT64 showed high sensitivity in the diagnosis of esophageal and cardial thickening. Gastric distension proved to be useful for the presurgical evaluation defining both upper and lower borders of the tumors located in the gastroesophageal junction.

Validation of an informatics tool to assess resident's progress in developing reporting skills.

BACKGROUND: Diagnostic radiology residency programs pursuits as main objectives of the development of diagnostic capabilities and written communication skills to answer clinicians' questions of referring clinicians. There has been also an increasing focus on competencies, rather than just education inputs. Then, to show ongoing professional development is necessary for a system to assess and document resident's competence in these areas. Therefore, we propose the implementation of an informatics tool to objectively assess resident's progress in developing diagnostics and reporting skills. We expect to found decreased preliminary report-final report variability within the course of each year of the residency program. RESULTS: We analyzed 12,162 evaluations from 32 residents (8 residents per year in a 4-year residency program) in a 7-month period. 73.96% of these evaluations belong to 2nd-year residents. We chose two indicators to study the evolution of evaluations: the total of discrepancies over the total of preliminary reports (excluding score 0) and the total of likely to be clinically significant discrepancies (scores 2b, 3b, and 4b) over the total of preliminary reports (excluding score 0). With the analysis of these two indicators over the evaluations of 2nd-year residents, we found a slight decrease in the value of the first indicator and relative stable behavior of the second one. CONCLUSIONS: This tool is useful for objective assessment of reporting skill of radiology residents. It can provide an opportunity for continuing medical education with case-based learning from those cases with clinically significant discrepancies between the preliminary and the final report.

Pneumo-PET-CT: Initial Results of This Novel Technique on the Evaluation of Esophageal and Gastric Tumors with Anatomic-Surgical Correlation.

We present the initial results of a novel hybrid scanning-based technique that combines pneumo-computed tomography (PNCT) with positron emission tomography (PET) using 2-(fluorine-18) fluoro-2-deoxy-D-glucose (FDG). We denominate it pneumo-PET-CT. The focus of our discussion will be on the description of the pneumo-PET-CT technique and the interpretation criteria with emphasis on its benefits and applications in the presurgical and postneoadjuvant therapy evaluation of esophageal, esophagogastric junction (EGJ), and gastric tumors.

Bilateral Anatomic Variation of Anterolateral Thigh Flap in the Same Individual.

BACKGROUND: Anterolateral thigh flap has gained popularity for its use as a soft-tissue flap for reconstruction of regional and distal defects. There is discrepancy between the predominant skin vessels-musculocutaneous or septocutaneous. The purpose of this study was to demonstrate anatomic variation of bilateral anterolateral thigh flap vasculature in the same individual. METHODS: We performed an observational retrospective case series study in 11 patients and an observational prospective study in 7 cadavers to confirm our findings. RESULTS: We found bilateral anatomic variation in the main cutaneous branch of the descendent branch of the lateral circumflex femoral artery between both thighs in the same individual. In 72.2% of cases, we observed that the main cutaneous branch was septocutaneous in 1 thigh and musculocutaneous in the contralateral thigh; in 16.7%, the main cutaneous branches were musculocutaneous in both thighs, and in 11.1%, the main cutaneous branches were septocutaneous in both thighs. CONCLUSIONS: Significant anatomic variation exists between the right and the left cutaneous branches of deep circumflex femoral arteries. Hence, preoperative imaging by computed tomography angiography (CTA) aids in determination of the vascular anatomy of the descending branch of the lateral circumflex femoral artery and in selection of septocutaneous branches, thereby reducing operative time.

Utilidad de la tomografía computarizada multicorte para la estimación de la composición del derrame pericárdico / Usefulness of computed tomography densities to estimate the composition of pericardial effusion

Resumen El derrame pericárdico (DP) es una entidad frecuente en la práctica diaria, que puede ocurrir por un amplio rango de patologías. Los métodos por imágenes constituyen una herramienta diagnóstica clave en la evaluación del pericardio. El ecocardiograma transtorácico (ETT) se considera de primera línea por su costo-efectividad. La tomografía computarizada multicorte (TCMC), por su parte, representa un valioso complemento ante limitaciones del ETT y en la evaluación de urgencia del paciente con sospecha de DP. El objetivo del trabajo es mostrar la utilidad y rol de la TCMC, mediante la medición de densidades, para estimar la etiología del DP, ilustrado con casos de nuestra institución.

Abstract Pericardial effusion (PE) is a common entity in daily practice, which can occur due to a wide range of conditions. Imaging methods are a key diagnostic tool in the evaluation of the pericardium. Transthoracic echocardiogram (TTE) is the first line imaging method because of its cost-effectiveness. Multi-slice Computed Tomography (MSCT), on the other hand, represents a valuable complement to the limitations of TTE and in emergency evaluation of the patient with suspected PE. The objective of this review is to show the usefulness and role of the MSCT —through the measurement of densities— to estimate the etiology of PE, illustrated with cases of our Institution.

Hallazgos posoperatorios esperables en cirugías de aorta torácica ascendente con angiotomografía computada multicorte: todo lo que un médico radiólogo debe conocer / Expected postoperative findings in ascending thoracic aortic surgeries with multislice angiotomography: Everything a radiologist should know

Resumen Para la reconstrucción y el tratamiento de anomalías que comprometen la aorta torácica pueden emplearse diversas técnicas quirúrgicas abiertas, las cuales estarán determinadas por la patología que presente el paciente. La angiotomografía computada multicorte (ATCMC) es el método de elección para su control y seguimiento. El médico radiólogo debe estar familiarizado con las técnicas quirúrgicas empleadas (Wheat, Bentall de Bono, Cabrol, entre otras), con las reparaciones estructurales que se realizan y con los materiales protésicos utilizados con el fin de evitar una interpretación errónea de las imágenes. El fieltro espontáneamente hiperdenso, los conductos protésicos y sus anastomosis, tanto con la aorta como con los grandes vasos, puede generar errores en el informe final y en el diagnóstico.

Abstract Multiple surgical techniques can be used for the reconstruction and treatment of abnormalities that compromise the thoracic aorta, which will be determined by the patient’s pathology. Multislice computed tomography angiography is the method of choice for their control and monitoring. The radiologist should be familiar with the surgical techniques used (Wheat, Bentall de Bono, and Cabrol, among others), as well as with the structural repairs that are performed and the prosthetic materials used in order to avoid an erroneous interpretation of the images. Spontaneously hyperdense felt, the prosthetic ducts and their anastomosis, both with the aorta and the large vessels, can generate pitfalls in the final report and error in the diagnosis.

[Liver evaluation with multidetector CT. Angiotomography, volume determination and virtual hepatectomy]. / Evaluación hepática con TC multidetector. Angiotomografía, determinación volumétrica y hepatectomia virtual.

AIM: to show a new technique of presurgical liver tumor evaluation using multidetector computed tomography (MDCT), determining the usefulness of an-giographic reconstructions, presurgical virtual hepatectomy and 3D liver volume determination, in correlation with surgery findings. METHODS: twenty patients with primary or secondary liver tumors were evaluated with MDCT and then operated on. Dual-phase CT was performed in all patients on a 4-row multidetector CT scanner (Mx8000; Philips Medical Systems) after mechanical injection of 120 ml of iodinated contrast medium. Scanning was performed using a detector configuration of 4 x 2.5 mm. Images were sent to a workstation and they were analysed with the surgeons. The 3D volumes of each lesion, of the total liver and of the segments to be resected were calculated. Vascular reconstructions and virtual hepatectomy were also performed. Correlation of the liver volume between MDCT and surgery was calculated using the Bland and Altman method. RESULTS: virtual liver segmentation allowed to perform the surgery in 100% of the patients in one time and there were no complications. The correlation coefficient was 0.83 (CI 95%: -132.08, 159.78). CONCLUSIONS: presurgical liver hepatectomy is a new application tool of MDCT The angiographic findings and the volume determination are useful to determine the surgical techniquefor each patient and this information allows the surgeons to know if the remnant liver will be enough for the patients to avoid a post-surgical liver insufficiency.

Aortitis: Hallazgos radiológicos en relación a sus diversas etiologías / Aortitis: Radiological Findings in Relation to its Various Etiologies

Resumen La inflamación de la aorta (aortitis) es una patología poco frecuente, con etiología infecciosa (pseudoaneurisma micótico, sífilis) y no infecciosa (arteritis, aortitis idiopática, espondilitis anquilosante, entre otras) de difícil diagnóstico clínico y variable pronóstico. Por esa razón, la utilización de diversos métodos por imágenes, tales como la tomografía computada multidetector (TCMD), la tomografía computada por emisión de positrones (PET-TC), la resonancia magnética (RM) y ultrasonido (US) facilitan la identificación, seguimiento y tratamiento de esa entidad. El siguiente trabajo tiene como objetivo realizar una revisión y actualización bibliográfica acerca de la aortitis y sus diversas etiologías, ejemplificando con casos de nuestra institución.

Abstract Aortic inflammation (aortitis) is a rare pathology, with infectious (fungal pseudoaneurysm, syphilis) and noninfectious etiology (arteritis, idiopathic aortitis, ankylosing spondylitis, among others), it has a difficult clinical diagnosis and a variable prognosis. The use of various imaging methods such as multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT) and ultrasound (US) facilitate the identification, monitoring and treatment of this entity. The following paper aims to perform a literature review and update about aortitis and its various etiologies, exemplifying cases of our institution.