Prótesis mitral mecánica disfuncionante: cuando el trombo sobre pannus dificulta el diagnóstico / Dysfunctioning mechanical mitral valve prosthesis: When thrombus over pannus makes hinders diagnosis

La obstrucción de una válvula protésica es una complicación rara pero que puede ser letal. Las causas más frecuentes son la formación de trombos y pannus, en ausencia de datos infecciosos. El diagnóstico no siempre es sencillo recurriendo a la realización de tomografía computarizada (TC) cardiaca, y en el 46-85% de los casos coexisten trombo y pannus, por lo que el diagnóstico se complica. Un diagnóstico rápido es esencial para evitar un desenlace fatal de esta patología, cuya mortalidad, a pesar de un tratamiento correcto, es elevada.(AU)

Prosthetic valve obstruction is a rare but potentially lethal complication. The most frequent causes are thrombus and pannus formation, in the absence of infectious data. Diagnosis is not always easy using cardiac CT scanning and in 46-85% of cases thrombus and pannus coexist, complicating the diagnosis. A rapid diagnosis is essential to avoid a fatal outcome of this pathology whose mortality, despite correct treatment, is high.(AU)

Herramientas para el tamizaje de aneurisma de aorta abdominal / Tools for abdominal aortic aneurysm screening

Introducción. El aneurisma de la aorta abdominal (AAA) es la dilatación de la aorta abdominal mayor de 1,5 veces el diámetro esperado. Su prevalencia es variable, con tasas reportadas de hasta el 12,5 %. Se considera como causa de muerte de más de 10.000 personas al año en los Estados Unidos. El objetivo de esta revisión de la literatura fue describir los factores de riesgo y las herramientas de tamizaje de AAA. Métodos. Se realizó una búsqueda de la literatura utilizando dos ecuaciones en bases de datos electrónicas, empleando términos seleccionados de "Medical Subject Heading" (MeSH) y "Descriptores en Ciencias de la Salud" (DeCS). Se evaluó la calidad de los estudios con la herramienta STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Resultados. Se recolectaron 40 artículos y a partir de ellos se construyó el texto de revisión, identificando en estos, los factores de riesgo asociados al desarrollo de AAA, tales como sexo masculino, tabaquismo, hipertensión arterial, antecedente familiar y obesidad, entre otros. La diabetes mellitus parece actuar como factor protector. Dentro de los instrumentos de tamizaje, el ultrasonido abdominal es uno de los más usados. Conclusión. El AAA es una patología multifactorial. En la actualidad la ultrasonografía de aorta es el método de elección para el tamizaje, permitiendo la detección precoz. El tamizaje de AAA con métodos no invasivos, como el ultrasonido, es útil sobre todo en zonas con prevalencia alta de la patología y en pacientes con determinados factores de riesgo.

Introduction. Abdominal aortic aneurysm (AAA) is a dilation of the abdominal aorta greater than 1.5 times the expected diameter. Its prevalence is variable, with reported rates of up to 12.5%. It is considered the cause of death of more than 10,000 people a year in the United States. The objective of this literature review was to describe risk factors and screening tools for AAA. Methods. A literature search was conducted using two equations in electronic databases, using terms selected from "Medical Subject Heading" (MeSH) and "Descriptors in Health Sciences" (DeCS). The quality of the studies was evaluated with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) tool. Results. Forty articles were collected and from them the review text was constructed, identifying the risk factors associated with the development of AAA, such as male sex, smoking, high blood pressure, family history and obesity, among others. Diabetes mellitus seems to act as a protective factor. Among the screening instruments, abdominal ultrasound is one of the most used. Conclusion. AAA is a multifactorial pathology. Currently, aortic ultrasonography is the method of choice for screening, allowing early detection. Screening for AAA with non-invasive methods, such as ultrasound, is useful especially in areas with a high prevalence of this pathology and in patients with certain risk factors.

Dysfunctioning mechanical mitral valve prosthesis: When thrombus over pannus makes hinders diagnosis.

Prosthetic valve obstruction is a rare but potentially lethal complication. The most frequent causes are thrombus and pannus formation, in the absence of infectious data. Diagnosis is not always easy using cardiac CT scanning and in 46%-85% of cases thrombus and pannus coexist, complicating the diagnosis. A rapid diagnosis is essential to avoid a fatal outcome of this pathology whose mortality, despite correct treatment, is high.

Morphometry of the Middle Cerebral Arteries: A Radio-Anatomical Study Based on Computed Tomography Angiography Findings / Morfometría de las Arterias Cerebrales Medias: Un Estudio Anátomo-Radiológico Basado en los Hallazgos de la Angiografía por Tomografía Computada

SUMMARY: Middle cerebral artery (MCA), which has the largest irrigation area of the arteries that feed the brain, is an important artery whose microanatomy should be well known because of its vascular variation. In pathologies which are known to affect the cerebrovascular system such as type 2 diabetes mellitus (T2DM) and hypertension, morphometric characteristics of MCA gain importance. The aim of this study is to compare the morphometric characteristics of M1 segment of MCA in T2DM and hypertensive patients with those of healthy control group by using computed tomographic angiography (CTA). The study was carried out with retrospective morphometric analysis of CTA images of 200 individuals between 40 and 65 years of age. The individuals were grouped in four as hypertensive patients (group 1), patients with T2DM (group 2), patients with hypertension and T2DM (group 3) and healthy control group (group 4). Length and diameter measurements of M1 segment were performed and recorded by using 3D CTA images. While statistically significant difference was found between bilateral M1 segment diameters of both women and men (p0.05). As a result of the post hoc analysis performed, it was concluded that right and left M1 segment diameter of group 1, group 2 and group 3 was found to be different from group 4 in both sexes (p<0.05). We believe that this study will both be a guide in radio-anatomic assessments to be performed and also increase microanatomic level of information in the surgical treatment of the artery by showing the morphometric changes that occur in M1 segment of MCA in T2DM diseases.

La arteria cerebral media (ACM), que otorga la mayor área de irrigación de las arterias que alimentan el cerebro, es un vaso importante cuya microanatomía debe ser bien conocida por su variación vascular. En patologías que afectan al sistema cerebrovascular, como la diabetes mellitus tipo 2 (DM2) y la hipertensión, las características morfométricas de la ACM cobran importancia. El objetivo de este estudio fue comparar las características morfométricas del segmento M1 de la ACM en pacientes con DM2 e hipertensos con las del grupo control sano mediante el uso de angiografía por tomografía computada (TC). El estudio fue realizado através de análisis morfométrico retrospectivo de imágenes de TC de 200 individuos entre 40 y 65 años de edad. Los individuos fueron divididos en cuatro grupos, como pacientes hipertensos (grupo 1), pacientes con DM2 (grupo 2), pacientes con hipertensión y DM2 (grupo 3) y grupo control sano (grupo 4). Las mediciones de longitud y diámetro del segmento M1 se realizaron y registraron utilizando imágenes 3D TC. Si bien se encontraron diferencias estadísticamente significativas entre los diámetros bilaterales de los segmentos M1 de mujeres y hombres (p0,05). Como resultado del análisis post hoc realizado, se concluyó que el diámetro de los segmentos M1 derecho e izquierdo del grupo 1, grupo 2 y grupo 3 fue diferente del grupo 4 en ambos sexos (p<0.05). Creemos que este estudio será una guía en las evaluaciones anátomo-radiológicas y también mejorará el nivel de información microanatómica en el tratamiento quirúrgico al mostrar los cambios morfométricos que ocurren en el segmento M1 de la ACM en las enfermedades con DM2.

Tomografía computarizada coronaria en urgencias: importancia de la experiencia del radiólogo / Coronary computed tomography in emergencies: the importance of the radiologist's experience

Introducción: La incorporación de la angiografía coronaria por tomografía computarizada (ACTC) a la atención sanitaria en las urgencias hospitalarias hace necesaria una adecuada capacitación para la interpretación de esta prueba de imagen. Esta capacitación puede afectar al grado de concordancia interobservador de los radiólogos que evalúan dichos estudios. Objetivo: Evaluar la concordancia interobservador en función de la experiencia en la interpretación de ACTC realizadas a pacientes que acuden a urgencias por dolor torácico agudo (DTA) con probabilidad baja-intermedia de síndrome coronario agudo (SCA). Materiales y método: Estudio de concordancia interobservador en la evaluación de ACTC realizadas en contexto urgente utilizando CAD-RADS como registro de resultados. Se crearon parejas de observadores entre un total de 8 evaluadores (4 staff y 4 en formación). Se estimó el grado de concordancia global y entre subgrupos de acuerdo con su experiencia mediante el coeficiente kappa. Resultados: La concordancia fue sustancial entre radiólogos experimentados y en formación (k= 0,627; IC95%: 0,436-0,826), así como para todas las parejas de evaluadores (k=0,661; IC95%: 0,506-0,823) para todas las categorías CAD-RADS en conjunto. El grado de acuerdo del grupo de radiólogos experimentados fue superior al de los radiólogos en formación en todos los análisis realizados. La concordancia fue excelente para CAD-RADS global (k= 0,950; IC95%: 0,896-1) y para CAD-RADS ≥ 4 (k = 1), observando un menor acuerdo para CAD-RADS ≥ 3 (k= 0,754; IC95%: 0,246-1,255). Los valores del personal en formación para estas categorías fueron k= 0,623, k= 0,596 y k= 0,473, respectivamente. Conclusión: La concordancia entre radiólogos staff en la evaluación de ACTC realizadas a pacientes en el contexto de urgencias es excelente. El grado de acuerdo es menor cuando el personal inexperto forma parte de las parejas analizadas...(AU)

Introduction: Incorporating coronary computed tomography angiography (CTA) in the hospital workup for suspected acute coronary syndrome requires appropriate skills for interpreting this imaging test. Radiologists’ skills can affect the interobserver agreement in evaluating these studies. Objective: To determine the interobserver agreement according to radiologists’ experience in the interpretation of coronary CTA studies done in patients who present at the emergency department with acute chest pain and low-to-intermediate probability of acute coronary syndrome. Materials and methods: We studied the interobserver agreement in the urgent evaluation of coronary CTA studies in which CAD-RADS was used to register the findings. We created pairs of observers among a total of 8 assessors (4 attending radiologists and 4 radiology residents). We used the kappa coefficient to estimate the overall concordance and the concordance between subgroups according to their experience. Results: The agreement was substantial between experienced radiologists and residents (k = 0.627; 95%CI: 0.436 – 0.826) as well as between all the pairs of observers (k=0.661; 95%CI: 0.506 – 0.823) for all the CAD-RADS together. The degree of agreement within the group of experienced radiologists was greater than that within the group of residents in all the analyses. The agreement was excellent for the overall CAD-RADS (k=0.950; 95% CI: 0.896 – 1) and for CAD-RADS ≥ 4 (k=1); the agreement was lower for CAD-RADS ≥ 3 (k = 0.754; 95% CI: 0.246 – 1.255). The agreement for the residents for these categories was k= 0.623, k=0.596, and k=0.473, respectively. Conclusion: The agreement among attending radiologists regarding the assessment of urgent coronary CTA studies is excellent. The agreement is lower when residents are paired with attending radiologists...(AU)

Coronary computed tomography in emergencies: The importance of the radiologist's experience.

INTRODUCTION: Incorporating coronary computed tomography angiography (CTA) in the hospital workup for suspected acute coronary syndrome requires appropriate skills for interpreting this imaging test. Radiologists' skills can affect the interobserver agreement in evaluating these studies. OBJECTIVE: To determine the interobserver agreement according to radiologists' experience in the interpretation of coronary CTA studies done in patients who present at the emergency department with acute chest pain and low-to-intermediate probability of acute coronary syndrome. MATERIALS AND METHODS: We studied the interobserver agreement in the urgent evaluation of coronary CTA studies in which CAD-RADS was used to register the findings. We created pairs of observers among a total of 8 assessors (4 attending radiologists and 4 radiology residents). We used the kappa coefficient to estimate the overall concordance and the concordance between subgroups according to their experience. RESULTS: The agreement was substantial between experienced radiologists and residents (k=0.627; 95%CI: 0.436-0.826) as well as between all the pairs of observers (k=0.661; 95%CI: 0.506-0.823) for all the CAD-RADS together. The degree of agreement within the group of experienced radiologists was greater than that within the group of residents in all the analyses. The agreement was excellent for the overall CAD-RADS (k=0.950; 95% CI: 0.896-1) and for CAD-RADS ≥ 4 (k=1); the agreement was lower for CAD-RADS ≥ 3 (k=0.754; 95% CI: 0.246-1.255). The agreement for the residents for these categories was k=0.623, k=0.596, and k=0.473, respectively. CONCLUSION: The agreement among attending radiologists regarding the assessment of urgent coronary CTA studies is excellent. The agreement is lower when residents are paired with attending radiologists. These findings should be taken into consideration when implementing coronary CTA in emergency departments and in the organisation of radiological staff for interpreting and reporting this imaging test.

Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism.

OBJECTIVE: This study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. MATERIALS AND METHODS: In the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. RESULTS: PAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). CONCLUSIONS: PAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

Índice de obstrucción de la arteria pulmonar, diámetro de la arteria pulmonar y strain del ventrículo derecho como hallazgos pronósticos de la tomografía computarizada en el paciente con embolia pulmonar aguda / Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism

Objetivo: Este estudio fue diseñado para determinar los predictores de la hipertensión pulmonar y los signos de disfunción cardíaca derecha causados por la embolia pulmonar (EP) que pueden conducir a la detección temprana de los pacientes de alto riesgo. Por lo tanto, se evaluó el valor predictivo del índice de obstrucción de la arteria pulmonar (IOAP), medido mediante angiografía pulmonar por TC (APTC) en el contexto agudo, para predecir los pacientes susceptibles de sufrir complicaciones cardíacas por EP. También se investigaron otros dos índices de APTC, el diámetro de la arteria pulmonar (DAP) y el strain del ventrículo derecho (VD), en estos pacientes y se demostró su valor predictivo de las complicaciones cardíacas en la ecocardiografía de seguimiento. Materiales y métodos: En el estudio fueron incluidos 120 pacientes con diagnóstico definitivo de EP. El IOAP, el DAP y el strain del VD se midieron mediante APTC en el momento del diagnóstico inicial. Se realizó una ecocardiografía transtorácica 6 meses después del diagnóstico de EP y se midieron los índices ecocardiográficos del VD. Se utilizó la correlación de Pearson para investigar la correlación entre IOAP, DAP, strain del VD y los signos de disfunción del hemicardio derecho. Resultados: El IOAP estaba fuertemente correlacionado con la presión arterial pulmonar sistólica (PAPS) (r=0,83), la presión sistólica del VD (r=0,78) y el grosor de la pared del VD (r=0,61) en la ecocardiografía de seguimiento a largo plazo. Se detectó una mayor tasa de disfunción del VD y de dilatación del VD entre los pacientes con mayor IOAP (p<0,001). Un IOAP≥18 fue claramente predictivo del desarrollo de la disfunción del VD. También la evolución de la hipertensión pulmonar, la hipertensión sistólica del VD, la dilatación del VD, la disfunción del VD y la hipertrofia del VD fueron significativamente más frecuentes entre los pacientes con mayor DAP y strain del VD (p<0,001)...(AU)

Objective: This study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. Materials and methods: In the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. Results: PAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). Conclusions: PAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.(AU)

Recommendations on the use of computed tomography in the stroke code: Consensus document SENR, SERAU, GEECV-SEN, SERAM.

The Spanish Society of Emergency Radiology (SERAU), the Spanish Society of Neuroradiology (SENR), the Spanish Society of Neurology through its Cerebrovascular Diseases Study Group (GEECV-SEN) and the Spanish Society of Medical Radiology (SERAM) have met to draft this consensus document that will review the use of computed tomography in the stroke code patients, focusing on its indications, the technique for its correct acquisition and the possible interpretation mistakes.

Recomendaciones sobre el uso de la tomografía computarizada en el código ictus: Documento de consenso SENR, SERAU, GEECV-SEN, SERAM / Recommendations on the use of computed tomography in the stroke code: Consensus document SENR, SERAU, GEECV-SEN, SERAM

La Sociedad Española de Radiología de Urgencias (SERAU), la Sociedad Española de Neurorradiología (SENR), la Sociedad Española de Neurología a través de su Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV-SEN) y la Sociedad Española de Radiología Médica (SERAM) se han reunido para redactar este documento de consenso que repasará el uso de la tomografía computarizada en el código ictus, centrándose en sus indicaciones, la técnica para su correcta adquisición y las posibles causas de error en su interpretación (AU)

The Spanish Society of Emergency Radiology (SERAU), the Spanish Society of Neuroradiology (SENR), the Spanish Society of Neurology through its Cerebrovascular Diseases Study Group (GEECV-SEN) and the Spanish Society of Medical Radiology (SERAM) have met to draft this consensus document that will review the use of computed tomography in the stroke code patients, focusing on its indications, the technique for its correct acquisition and the possible interpretation mistakes (AU)

Influence of contrast enhancement at the contrast injection location for the arm or leg in neonatal and infant patients during cardiac computed tomography.

INTRODUCTION AND OBJECTIVES: Obtaining CCTA images with optimal injection location such as the arm or leg is important to avoid the artifacts caused by the CM. This study compares the computed tomography (CT) numbers and visualization scores of the three-dimensional (3D) images of the lumens of the blood vessels in the arm or leg during cardiac computed tomography angiography (CCTA) in neonatal and infant patients. PATIENTS OR MATERIALS AND METHODS: Between January 2017 and January 2020, 253 consecutive patients were considered for inclusion. We used the estimated propensity scores as a function of the demographic data, including age, body weight, and injection location (right or left side) in the arm (n = 58) and leg (n = 58) of neonatal and infant patients. We compared the mean CT numbers of the pulmonary artery, ascending aorta, and left superior vena cava; contrast-noise ratios (CNR); and visualization scores between the arm and leg as the injection locations. RESULTS: The mean CT numbers during CCTA for the arm and leg were 479.4 and 461.3 HU in the ascending aorta, 464.2 and 448.1 HU in the pulmonary artery, and 232.8 and 220.1 HU in the left superior vena cava, respectively. The mean image noise (SD) and CNR values, respectively, were 38.9 HU and 12.1 for the arm as the injection location and 39.1 HU and 12.3 for the leg as the injection location. The median visualization scores of volume rendering of the 3D images were 3.0 and 3.0 for the arm and leg injection sites, respectively. There were no significant differences in the mean CT numbers of the ascending aorta, pulmonary artery, and left superior vena cava; SD value; CNR; and visualization scores between the arm and leg injection locations. CONCLUSIONS: The CT numbers of the lumen of the blood vessel and visualization scores of the 3D images of the arm and leg injection locations are equal during CCTA in neonatal and infant patients with congenital heart disease.

Influencia del realce de contraste al inyectar un medio de contraste en el brazo o la pierna en pacientes neonatos y lactantes durante la angiografía por cardiotomografía / Influence of Contrast Enhancement at the Contrast Injection Location for the Arm or Leg in Neonatal and Infant Patients during Cardiac Computed Tomography

Introducción y objetivos: En la obtención de imágenes de angiografía por cardiotomografía (ACT) es importante escoger una ubicación adecuada para inyectar el medio de contraste (p. ej., el brazo o la pierna) a fin de evitar la formación de artefactos que este provoca. En este estudio se comparan los valores de tomografía computarizada (TC) y las puntuaciones de visualización de las imágenes tridimensionales (3D) de los lúmenes de los vasos sanguíneos del brazo y la pierna durante la ACT en pacientes neonatos y lactantes. Pacientes o materiales y métodos: Entre los meses de enero de 2017 y enero de 2020 se evaluaron 253 pacientes de forma consecutiva para determinar su inclusión en el estudio. Se utilizaron las puntuaciones de propensión estimadas en función de los datos demográficos, incluidos la edad, el peso corporal y la ubicación de la inyección (lado derecho o izquierdo) en el brazo (n=58) y la pierna (n=58) de los pacientes neonatos y lactantes. A continuación, se compararon los valores medios de TC de la arteria pulmonar, la aorta ascendente y la vena cava superior izquierda; las relaciones contraste-ruido (RCR); y las puntuaciones de visualización del brazo y la pierna como lugares de inyección. Resultados: Los valores medios de TC durante la ACT para el brazo y la pierna fueron de 479,4 y 461,3 UH en la aorta ascendente, de 464,2 y 448,1 UH en la arteria pulmonar y de 232,8 y 220,1 UH en la vena cava superior izquierda, respectivamente. Los valores medios de ruido de la imagen (DE) y de RCR fueron, respectivamente, de 38,9 y 12,1 UH para el brazo y de 39,1 y 12,3 UH para la pierna. Las puntuaciones medias de visualización de la representación del volumen de las imágenes 3D fueron de 3,0 y 3,0 para los lugares de inyección del brazo y la pierna, respectivamente.(AU)

Introduction and Objectives: Obtaining CCTA images with optimal injection location such as the arm or leg is important to avoid the artifacts caused by the CM. This study compares the computed tomography (CT) numbers and visualization scores of the three-dimensional (3D) images of the lumens of the blood vessels in the arm or leg during cardiac computed tomography angiography (CCTA) in neonatal and infant patients. Patients or Materials and Methods: Between January 2017 and January 2020, 253 consecutive patients were considered for inclusion. We used the estimated propensity scores as a function of the demographic data, including age, body weight, and injection location (right or left side) in the arm (n=58) and leg (n=58) of neonatal and infant patients. We compared the mean CT numbers of the pulmonary artery, ascending aorta, and left superior vena cava; contrast–noise ratios (CNR); and visualization scores between the arm and leg as the injection locations. Results: The mean CT numbers during CCTA for the arm and leg were 479.4 and 461.3 HU in the ascending aorta, 464.2 and 448.1 HU in the pulmonary artery, and 232.8 and 220.1 HU in the left superior vena cava, respectively. The mean image noise (SD) and CNR values, respectively, were 38.9 HU and 12.1 for the arm as the injection location and 39.1 HU and 12.3 for the leg as the injection location. The median visualization scores of volume rendering of the 3D images were 3.0 and 3.0 for the arm and leg injection sites, respectively. There were no significant differences in the mean CT numbers of the ascending aorta, pulmonary artery, and left superior vena cava; SD value; CNR; and visualization scores between the arm and leg injection locations. Conclusions: The CT numbers of the lumen of the blood vessel and visualization scores of the 3D images of the arm and leg injection locations are equal during CCTA in neonatal and infant patients with congenital heart disease.(AU)

Acute pulmonary embolism: Appropriateness of emergency department management according to clinical guidelines.

BACKGROUND AND AIMS: To evaluate the frequency of acute pulmonary embolism, the use of clinical probability scores, and the appropriateness of the management of patients for whom computed tomography angiography (CTA) was requested from the emergency department for suspected acute pulmonary embolism. MATERIALS AND METHODS: This was a retrospective observational study of CTA studies requested from the emergency department to rule out acute pulmonary embolism. We analyzed clinical variables and the explicit use of clinical probability scores. We determined the appropriateness of management according to the Wells Score and Geneva Score and the simplified versions of these two scores, calculated retrospectively. RESULTS: We included 534 patients (52.8% women; mean age, 73 years). The frequency of acute pulmonary embolism was 23.0% and the Wells Score was explicitly used in 15.2%. The appropriateness of the management varied depending on the clinical probability score used to assess it (54.5%-75.8%) and on whether the standard d-dimer or age-adjusted d-dimer was used. CONCLUSIONS: The failure to use the Wells Scores in all cases does not necessarily imply inappropriate management, and the performance of global clinical judgment can be similar to that of clinical probability scores; however, specific studies are necessary to confirm this hypothesis.

Tromboembolismo pulmonar agudo: adecuación del manejo de pacientes según las guías de práctica clínica en el servicio de urgencias / Acute pulmonary embolism: appropriateness of emergency department management according to clinical guidelines

Antecedentes y objetivo: Evaluar la frecuencia de tromboembolismo pulmonar agudo (TEPA), el uso de escalas de probabilidad clínica (EPC) y la adecuación del manejo de los pacientes a los que se solicitó angiografía pulmonar por tomografía computarizada (angio-TC) por sospecha de TEPA desde el servicio de urgencias. Materiales y métodos: Estudio observacional retrospectivo de las angio-TC solicitadas desde el servicio de urgencias para descartar TEPA. Se analizaron variables clínicas y el uso explícito de EPC. Se determinó la adecuación del manejo en función de las escalas de Wells (EW) y Ginebra (EG) y sus versiones simplificadas (EWs y EGs), calculadas retrospectivamente. Resultados: Se incluyeron 534 pacientes (52,8% mujeres, mediana de edad: 73 años). La frecuencia de TEPA fue del 23,0% y el uso explícito de la EW, del 15,2%. La adecuación del manejo fue variable dependiendo de la EPC (54,5-75,8%) y del dímero D estándar o ajustado por edad. Conclusiones: La baja utilización explícita de la EW no conlleva un manejo inadecuado, y el juicio clínico global puede ofrecer un rendimiento similar a las EPC, pero es necesario realizar estudios específicos para comprobar esta hipótesis.(AU)

Background and aims: To evaluate the frequency of acute pulmonary embolism, the use of clinical probability scores, and the appropriateness of the management of patients for whom computed tomography angiography (CTA) was requested from the emergency department for suspected acute pulmonary embolism. Materials and methods: This was a retrospective observational study of CTA studies requested from the emergency department to rule out acute pulmonary embolism. We analyzed clinical variables and the explicit use of clinical probability scores. We determined the appropriateness of management according to the Wells Score and Geneva Score and the simplified versions of these two scores, calculated retrospectively. Results: We included 534 patients (52.8% women; mean age, 73 years). The frequency of acute pulmonary embolism was 23.0% and the Wells Score was explicitly used in 15.2%. The appropriateness of the management varied depending on the clinical probability score used to assess it (54.5%-75.8%) and on whether the standard D-dimer or age-adjusted D-dimer was used. Conclusions: The failure to use the Wells Scores in all cases does not necessarily imply inappropriate management, and the performance of global clinical judgment can be similar to that of clinical probability scores; however, specific studies are necessary to confirm this hypothesis.(AU)

Cefalea mortal: aneurisma en espejo a propósito de un caso

Introducción: Los aneurismas intracerebrales son hallazgos incidentales en estudios de imágenes realizado por otros diagnósticos. Reporte de Caso: Paciente femenino de 35 años, que presentó sincope después de cefalea de gran intensidad sin ceder a tratamiento convencional de AINES; con antecedente de cefalea de larga data y tratamiento esporádico. Al examen: neurológico: despierta, asimetría facial, disartria, fuerza muscular disminuida en ambos miembros inferiores, no signos meníngeos; el informe tomográfico cerebral sin contraste indicó: lesiones cerebrales expansivas de etiología a determinar a nivel de ambos lados de diencéfalo: descartar glioma vs aneurismas; Angiotac cerebral con contraste, refleja aneurismas de carótida interna intracraneal bilateral y cerebral media (en espejo). Posteriormente la paciente fue evaluada por neurocirujano de turno, quien indica referir a centro de mayor complejidad, por no contar con instrumental necesario para intervención quirúrgica; paciente fallece camino a centro de referencia. Conclusiones: Al ser una patología poco frecuente, no es considerada como una primera opción de sospecha diagnostica tras un evento de cefalea.

Background: Intracerebral aneurysms are incidental findings in imaging studies performed for other diagnoses. Case Report: 35- year-old female patient, who presented syncope after severe headache without yielding to conventional treatment with NSAIDs; with a history of long-standing headache and sporadic treatment. On examination: neurological: awake, facial asymmetry, dysarthria, decreased muscle strength in both lower limbs, no meningeal signs; the brain tomographic report without contrast indicated: expansive brain lesions of etiology to be determined at both sides of the diencephalon: rule out glioma vs aneurysms; cerebral Angiotac with contrast, reflects bilateral intracranial internal carotid and middle cerebral (mirror) aneurysms. Subsequently the patient was evaluated by the neurosurgeon on duty, who indicated to refer to a center of higher complexity, for not having the necessary instruments for surgery; patient died on the way to the referral center. Conclusions: Being a rare pathology, it is not considered as a first option for diagnostic suspicion after a headache event.

Angiotomografía en la evaluación de arterias perforantes para reconstrucción mediante colgajos: lo que el cirujano quiere saber y el radiólogo debe informar / Computed tomography angiography for perforator flaps: What the surgeon needs to know and the radiologist should inform

Resumen Desde la introducción del concepto de «angiosomas¼ se describieron las arterias perforantes y su potencial para el uso en colgajos. La angiotomografía es un método excelente para la valoración preoperatoria en cirugías reconstructivas y es clave en la valoración prequirúrgica. Es un estudio multidisciplinario en cuyo análisis participan el radiólogo y el cirujano plástico. Es importante incluir en el reporte radiológico el origen de la arteria, detallar su curso, cuantificar el calibre y determinar su emergencia para facilitar al cirujano la planeación prequirúrgica y la realización del procedimiento quirúrgico. Otra de las principales ventajas es que el uso de este método disminuye los tiempos quirúrgicos y las posibles complicaciones de las cirugías reconstructivas. El radiólogo debe estar familiarizado con los tipos de colgajos más comúnmente utilizados, la anatomía de las arterias y sus perforantes para guiar al cirujano en la planeación prequirúrgica y la toma de decisiones.

Abstract Since the introduction of the concept of "angiosomes", the perforating arteries and their potential for use in flaps was described. Angiotomography is an excellent imaging modality for preoperative evaluation in reconstructive surgery and is very important in presurgical assessment. This imaging technique requires a multidisciplinary approach in which the radiologist and the plastic surgeon participate. The radiological report must include the origin of the artery, detail it's course, quantify the caliber and determine the position where it emerges through the fascial plane to give the surgeon the possible information in presurgical planning and surgical procedure. The main advantage of this technique is the reduction of surgical timing and possible complications. The radiologist should be familiar with the most commonly used types of flaps, the anatomy of the arteries and their perforators to guide the plastic surgeon in presurgical planning and decision making.

Anomalous location of intracranial vessels in adults.

Anomalous intracranial vessels are not uncommon, and this finding is not always associated with arteriovenous malformations. Other conditions such as anomalous connections between arteries or phlebitc patterns can also present as vessels with abnormal intracranial locations. Noninvasive diagnosis is important to determine whether to do more invasive tests such as cerebral digital subtraction angiography or to estimate the risk of bleeding in arteriovenous malformations and therefore to evaluate the need for endovascular/surgical treatment. In this paper, we present an algorithm for the differential diagnosis of anomalous intracranial vessels according to their location (intra/extra-axial) and function (whether the vessels are arterialized). Moreover, we analyze the important points of the angioarchitecture of the principal arteriovenous malformations with risk of intracranial bleeding, such as pial arteriovenous malformations and dural fistulas.

Vasos intracraneales en localización anómala en adultos / Anomalous location of intracranial vessels in adults

La detección de vasos anómalos a nivel intracraneal no es un hallazgo infrecuente y no siempre está asociada a la presencia de malformaciones arteriovenosas. Otras entidades como las conexiones arterioarteriales o un patrón flebítico también pueden presentarse como unos vasos en localización intracraneal anómala. El diagnóstico mediante pruebas no invasivas es importante para determinar la necesidad de realizar pruebas más cruentas como una angiografía cerebral por sustracción digital o para estimar el riesgo de sangrado en malformaciones arteriovenosas y, por tanto, evaluar la necesidad de tratamiento endovascular/quirúrgico. En este manuscrito presentamos un algoritmo de diagnóstico diferencial de la presencia de vasos anómalos intracraneales de acuerdo con su localización (intra/extraaxiales) y su funcionalidad (arterialización o no de dichos vasos). Asimismo, analizaremos los puntos importantes de la angioarquitectura de las principales malformaciones arteriovenosas con riesgo de sangrado intracraneal, como son las malformaciones arteriovenosas piales y las fístulas durales.(AU)

Anomalous intracranial vessels are not uncommon, and this finding is not always associated with arteriovenous malformations. Other conditions such as anomalous connections between arteries or phlebitc patterns can also present as vessels with abnormal intracranial locations. Noninvasive diagnosis is important to determine whether to do more invasive tests such as cerebral digital subtraction angiography or to estimate the risk of bleeding in arteriovenous malformations and therefore to evaluate the need for endovascular/surgical treatment. In this paper, we present an algorithm for the differential diagnosis of anomalous intracranial vessels according to their location (intra/extra-axial) and function (whether the vessels are arterialized). Moreover, we analyze the important points of the angioarchitecture of the principal arteriovenous malformations with risk of intracranial bleeding, such as pial arteriovenous malformations and dural fistulas.(AU)

Pertinencia de la solicitud del dímero D en pacientes de un servicio de urgencias / Pertinence of D-dimer request in patients in emergency services / Relevância da solicitação de D-dímero em pacientes de um setor de emergência

Introducción. El tromboembolismo pulmonar y la trombosis venosa profunda son urgencias cardiovasculares relativamente comunes, se han descrito diferentes predictores clínicos para la estratificación del riesgo, biomarcadores séricos y pruebas de imagenología. Dentro de los biomarcadores séricos se ha descrito el dímero D. Debido a que la enfermedad tromboembólica venosa es un reto diagnóstico para el clínico, el objetivo del presente estudio fue evaluar la pertinencia de la solicitud del dímero D, en el servicio de urgencias de un centro de tercer nivel en la ciudad de Bogotá durante los años 2018-2019. Metodología. Estudio observacional, descriptivo y transversal retrospectivo de pacientes que consultaron al servicio de urgencias, de una clínica de tercer nivel, de la ciudad de Bogotá, durante el periodo 2018-2019. Resultados. Se revisaron 583 historias clínicas, se excluyeron 107 pacientes, con un total final de 474 (57.3% mujeres y 42.6% hombres). De estos, 21 pacientes presentaron estudios positivos (angiotomografía y Doppler venoso). El dímero D presentó un valor predictivo negativo inferior al 50%. Discusión. A pesar de los resultados y de ser un estudio de un solo centro se evidencian las dificultades que tienen los médicos de los servicios de urgencias al momento de solicitar pruebas diagnósticas. Conclusiones. Este estudio evidencia la dificultad que existe en los servicios de urgencias al momento de la evaluación diagnóstica y cómo la solicitud de los paraclínicos tiene que ser un proceso estandarizado, guiado por los motivos de consulta y hallazgos al examen físico, y así no perder las características operativas de las pruebas diagnósticas y su utilidad al momento de la evaluación clínica.

Introduction. Pulmonary thromboembolisms and deep vein thromboses are relatively common cardiovascular emergencies. Various clinical predictors, serial biomarkers and imaging tests have been described for the stratification of the risk. D-dimer has been described within the serial biomarkers. Since venous thromboembolic disease is a diagnostic challenge for doctors, the objective of this study was to assess the pertinence of the D-dimer request in emergency services in a level three center in Bogotá during 2018-2019. Methodology. An observational, descriptive and cross-sectional retrospective study of patients who resorted to emergency services in a level three clinic in Bogotá during 2018-2019. Results. 583 medical records were reviewed, and 107 patients were excluded, with a final total of 474 patients (57.3% women and 42.6% men). Of these, 21 patients had positive studies (angiotomography and venous doppler ultrasound). D-dimer had a negative predictive value of less than 50%. Discussion. Despite the results and it being a study in a single clinic, the difficulties emergency service doctors experience when requesting diagnostic tests can be observed. Conclusions. This study shows the difficulties in emergency services when performing a diagnosis. The request for complementary tests has to be a standardized process guided by the reasons for the consultation and findings from the physical exam, in order not to lose the operational characteristics of the diagnostic tests and their usefulness during the clinical evaluation.

Introdução. Tromboembolismo pulmonar e trombose venosa profunda são emergências cardiovasculares relativamente comuns. Têm sido descritos diferentes preditores clínicos para estratificação de risco, biomarcadores séricos e testes de imagem. Entre os biomarcadores séricos, foi descrito o D-dímero. Considerando que a doença tromboembólica venosa é um desafio diagnóstico para o clínico, o objetivo deste estudo foi avaliar a relevância da solicitação de D-dímero no serviço de emergência de um centro de terceiro nível na cidade de Bogotá ao longo dos anos 2018-2019. Metodologia. Estudo observacional, descritivo e transversal retrospectivo de pacientes que consultaram o serviço de emergência de uma clínica de terceiro nível na cidade de Bogotá, no período de 2018-2019. Resultados. Foram revisados 583 prontuários, excluídos 107 pacientes, totalizando 474 (57.3% mulheres e 42.6% homens). Destes, 21 pacientes apresentaram estudos positivos (angiotomografia e Doppler venoso). D-dímero apresentou valor preditivo negativo inferior a 50%. Discussão. Apesar dos resultados e do fato de se tratar de um estudo só de um centro, são evidentes as dificuldades que os médicos de emergência apresentam ao solicitarem exames diagnósticos. Conclusões. Este estudo mostra a dificuldade que existe nos serviços de emergência no momento da avaliação diagnóstica e como a solicitação dos testes paraclínicos tem que ser um processo padronizado, orientado pelos motivos da consulta e pelos resultados do exame físico, e assim não perder as características operacionais dos exames diagnósticos e sua utilidade no momento da avaliação clínica.

Tromboembolismo pulmonar que simula síndrome coronario agudo sin elevación del segmento ST

RESUMEN El tromboembolismo pulmonar se produce como consecuencia de la migración de un trombo hacia el árbol vascular pulmonar. Frecuentemente los pacientes refieren dolor torácico que puede simular un síndrome coronario agudo. Se presenta el caso de un paciente de 57 años de edad que acudió al servicio de urgencias con dolor torácico agudo y disnea. Fue diagnosticado como un síndrome coronario agudo sin elevación del segmento ST, debido a los cambios electrocardiográficos que presentaba al ingreso, pero los hallazgos ecocardiográficos demostraron aumento de las presiones pulmonares y la coronariografía, arterias coronarias normales; por lo que se realizó angiografía pulmonar con tomografía multicorte, la cual confirmó el diagnóstico de tromboembolismo pulmonar bilateral.

ABSTRACT Pulmonary embolism takes place as a consequence of the migration of a thrombus towards the pulmonary vascular tree. Patients frequently report chest pain that can mimic an acute coronary syndrome. We present the case of a 57-year-old patient who came to the emergency department with acute chest pain and dyspnea. He was diagnosed as a non-ST segment elevation acute coronary syndrome, due to the electrocardiographic changes that he presented at admission, but the echocardiographic findings showed increased pulmonary pressures, and the invasive coronary angiography, normal coronary arteries; therefore, a pulmonary angiography with multislice tomography was performed, which confirmed the diagnosis of bilateral pulmonary embolism.