Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand.

Background/Aims: Achalasia is a rare esophageal motility disease, for which peroral endoscopic myotomy (POEM) has emerged as a promising treatment option; however, recurrence remains a challenge. Timed barium esophagography (TBE) is a useful diagnostic tool and potential outcome predictor of achalasia. This study aimed to determine predictive tools for recurrence after POEM. Methods: This retrospective study enrolled achalasia patients who underwent POEM between January 2015 and December 2021. Patients were categorized into two groups using the 1-month post-POEM Eckardt scores and TBE: the discordant group (Eckardt score improved >50%, TBE decreased <50%) and the concordant group (both Eckardt score and TBE improved >50%). Recurrence was defined as a reincrease in the Eckardt score to more than three during follow-up. Results: Complete medical records were available in 30 patients who underwent POEM. Seventeen patients (56.7%) were classified into the discordant group, while 13 patients (43.3%) were in the concordant group. The overall recurrence rate was 11.9% at 1-year, increasing to 23.8% during the extended follow-up. The discordant group had a 6.87 fold higher recurrence rate than the concordant group (52.9% vs. 7.7%, p=0.017). Conclusions: These results strongly suggest that combining the Eckardt score with TBE can effectively predict recurrent achalasia after POEM. Patients in the discordant group had an elevated risk.

Potential of Satellite Sign for Prediction of Hematoma Expansion in Small Spontaneous Hematoma within 7 Days' Follow-Up.

Background Hematoma expansion (HE) is the most important modifiable predictor that can change the clinical outcome of intracerebral hemorrhage (ICH) patients. The study aimed to investigate the potential of satellite sign for prediction of HE in spontaneous ICH patients who had follow-up non-contrast computed tomography (NCCT) within 7 days after the initial CT scan. Methods We retrospectively reviewed data and NCCT from 142 ICH patients who were treated at our hospital at Bangkok, Thailand. All included patients were treated conservatively, had baseline NCCT within 12 hours after symptom onset, and had follow-up NCCT within 168 hours after baseline NCCT. HE was initially estimated by two radiologists, and then by image analysis software. Association between satellite sign and HE was evaluated. Results HE occurred in 45 patients (31.7%). Patients with HE had significantly higher activated partial thromboplastin time ( p = 0.001) and baseline hematoma volume ( p = 0.001). The prevalence of satellite sign was 43.7%, and it was significantly independently associated with HE ( p = 0.021). The sensitivity, specificity, and accuracy of satellite sign for predicting HE was 57.8, 62.9, and 61.3%, respectively. From image analysis software, the cutoff of greater than 9% relative growth in hematoma volume on follow-up NCCT had the highest association with satellite sign ( p = 0.024), with a sensitivity of 55%, specificity of 64.6%, and accuracy of 60.5%. Conclusion Satellite sign, a new NCCT predictor, was found to be significantly associated with HE in Thai population. With different context of Thai population, HE was found in smaller baseline hematoma volume. Satellite sign was found more common in lobar hematoma. Further studies to validate satellite sign for predicting HE and to identify an optimal cutoff in Thai population that is correlated with clinical outcomes are warranted.

Association between Aortic Arch Calcification Detected on Plain Chest X-Ray and Myocardial Scarring Detected on Cardiac Magnetic Resonance Imaging in Coronary Heart Disease Patients.

Background: Coronary heart disease requires advanced investigations. However, findings of fundamental investigations are sometimes underused and/or neglected, such as plain chest X-ray (CXR) and electrocardiography (ECG). A previous study found an association between aortic calcification and coronary artery disease, but there are no studies that have investigated association between aortic arch calcification in CXR and coronary artery disease consequences, such as myocardial viability (scarring). Objective: To investigated association between aortic arch calcification detected on plain CXR and myocardial scarring detected on cardiac magnetic resonance imaging (CMRI) in coronary heart disease patients. Material and Method: one hundred eighty-seven eligible patients aged ≥18 years and diagnosed as coronary heart disease by CMRI at Siriraj Hospital between January 2008 and December 2014 study periods were enrolled. We retrospectively reviewed aortic arch calcification from plain CXR, demographic data, hospitalization data, underlying disease, medications used, and CMRI parameters. Results: There was no significant association between aortic arch calcification from CXR and myocardial scar by CMRI. Aortic arch calcification was detected in 86 (45.98%) and 78 (41.70%) of patients with and without myocardial scar by CMRI (p = 0.981). There was no significant correlation between calcium grading and calcium thickness from CXR and the presence or absence of myocardial scar by CMRI. Myocardial scar was detected in 52.2%, 47.8%, 51.4%, and 59.1% in patients with calcium grade 0, 1, 2, and 3 respectively (p = 0.751). Conclusion: There was no association found between aortic arch calcification detected on plain CXR and myocardial scarring detected on CMRI.

Growth Rate of Aortic Diameter in Post Treatment of Aortic Dissection.

OBJECTIVE: To evaluate growth rate of aortic diameter true lumen, and false lumen in post endovascular aortic repair of aortic dissection. MATERIAL AND METHOD: Between January 2005 and September 2010, 48 consecutive patients with aortic dissection were followed with computed tomographic angiography (CTA), including 18 post-surgical repaired type A patients and 30 type B (14 conservative treatment and 16 post stent-grafting therapy). CTA were performed with a mean of 5.2 scans per patient, and a meanfollow-up of 37.08 months. The diameter ofthe aorta, true lumen, andfalse lumen were measured by axial scan images and multi-planar reformatting (MPR). RESULTS: In medically managed patients with type B aortic dissection, the aortic diameter increased over time at mean rate 1.49 mm/year at proximal descending aorta with greater increased in size ofthe false lumen diameters than the true lumen diameter. In post-surgical repaired type A and post stent-grafting therapy type B aortic dissection, aortic diameter did not change over time. In addition, 12 of 16 patients (75%)patients with post stent-grafting therapy type B dissection hadpartial thrombosed in false lumen and 4 of 16 patients (25%) had complete resolution offalse lumen. CONCLUSION: In post-surgical repaired type A and post stent-grafting therapy type B aortic dissection, aortic diameter did not change over time. Type B aortic dissection with medical treatment had minimal increased in aortic diameter over time. The results suggested that uncomplicated type B aortic dissection requires on-going medical treatment.

64-slice MDCT angiography of upper extremity in assessment of native hemodialysis access.

OBJECTIVE: To compare multidetector row computed tomographic (MDCT) angiography with conventional digital subtraction angiography (DSA) in the evaluation of vascular access stenoses in hemodialysis patients. MATERIALS AND METHODS: Twenty-one consecutive patients were imaged with MDCT angiography and subsequent DSA. The superficial vein of leg was used as the route for intravenous administration. The vascular stenosis was assessed in not significant (<50% stenosis), moderate stenosis (50%-74% stenosis), severe stenosis (75%-99%), and total occlusion (100%). The accuracy, sensitivity, specificity, positive, and negative predictive values were calculated for significant vascular stenosis using DSA as the standard reference. RESULTS: The sensitivity and specificity of MDCT angiography for the detection of significant hemodialysis vascular access were 100% (95% CI, 89.3%-100%) and 94.8% (95% CI, 89.1%-97.6%), respectively. The positive and negative predictive values were 84.2% (95% CI, 68.1%-93.4%) and 100% (95% CI, 95.8%-100%), respectively. The accuracy of MDCT angiography for detection of significant stenoses was 95.9% (95% CI, 91.4%-97.0%). CONCLUSIONS: MDCT angiography provides excellent correlation in vascular stenosis as compared with DSA in hemodialysis access. Complete assessment of entire vascular segments could be performing with MDCT angiography in planning before endovascular intervention or surgical correction.

Computed tomography of aortic intramural hematoma and thrombosed dissection.

A retrospective study was undertaken to evaluate the appearance of the aortic wall on computed tomography for the purpose of developing criteria for differentiating acute aortic intramural hematoma from thrombosed false lumen seen in aortic dissection. Computed tomography angiography findings of the thoracoabdominal aorta in 23 patients with suspected intramural hematoma and 25 with thrombosed false lumen were reviewed. The more common features of an intramural hematoma were hyperattenuation of the aortic wall, wall thickness less than a quarter of the aortic diameter, intrinsic wall calcification, a lesion extending around the entire aortic circumference, and ulcer-like projections that may be precursors of intramural hematoma. Wall thickness less than a quarter of the aortic diameter, lesion extending around the entire aortic circumference, and ulcer-like projections were the most useful indicators for distinguishing intramural hematoma from the thrombosed false lumen in aortic dissection.

CT angiography evaluation of endoleak after thoracic endovascularaortic repair in thoracic aortic aneurysm.

OBJECTIVE: Analyze the incidence and findings of endoleak after thoracic endovascular aortic repair by using CT angiography MATERIAL AND METHOD: Between August 2006 and December 2008, 68 patients diagnosed with thoracic aortic aneurysm underwent thoracic endovascular aortic repair and were included in the present study. The patients were 47 men and 21 women, with a mean age of 69 +/- 9.4 years old. Thoraco-abdominal CT angiographic images (64-slice MDCT) after operation of 68 patients were retrospectively reviewed to evaluate incidence of endoleak and classify findings of endoleak. RESULTS: Endoleaks were detected in 26 patients (38.2%). There were type I endoleaks in three cases (11.5%), type II endoleaks in 22 cases (84.6%), and type III endoleaks in one case (3.9%). Type II endoleaks were detected as peritubular collection, mostly located at periphery of the aneurysm. Eleven cases (50%) of type II endoleaks were supplied by left subclavian artery. Twenty patients who had completed 1, 3, and 6 months follow-up CT angiography were selected for further evaluation of changing in size of aneurysm. The measurement of the thoracic aneurysm showed no decreasing of the maximum length of diameter and volume of the aneurysmal sac in endoleak group. CONCLUSION: Follow-up CT angiography is useful for detection and characterization of endoleak after endovascular aortic repair of thoracic aneurysm. Most of type II endoleaks show peritubular (collection) shape and locate at the periphery. Patients with endoleak after thoracic endovascular aortic repair tend to continue to have sac expansion.

Optimization of the table speed of lower extremity CT angiography protocols in different patient age groups.

BACKGROUND: Scanning with 64-slice multidetector row CT (MDCT) is usually faster than blood flow in peripheral arteries of the lower extremities, and the distal arteries of lower extremities are difficult to visualize, particularly in elderly patients. Thus, the optimal table speed for CT angiography (CTA) studies should be adjusted for appropriate patient age groups. OBJECTIVE: We evaluated the relative efficacy of different table speeds in several age groups of patients with suspected peripheral arterial occlusive disease (PAOD) undergoing CTA of lower extremity arteries, as a guideline for routine use. METHODS: This retrospective study reviewed routine CTA of the lower extremity arteries of 107 patients with suspected PAOD to evaluate vascular opacification in each vascular segment of 5 age groups: < or =40 years (group 1), 41-60 years (group 2), 61-70 years (group 3), 71-75 years (group 4), and > or =76 years (group 5). Adequate vascular opacification was measured for attenuation in the suprarenal and infrarenal abdominal aorta and in the arteries of the lower extremity. Venous contamination was also measured. RESULTS: Adequate vascular opacification from the suprarenal aorta to the level of the mid-popliteal artery was shown in all patients. Arterial opacification at the dorsalis pedis or plantar arteries was visualized in 85.7%-91.7% of patients and at the plantar arch arteries in 84.1%-91.7%. Minimal venous contamination was also shown adjacent to arterial enhancement, ranging from 0% to 28.6%. CONCLUSION: Performing CTA of the lower extremities with 64-slice MDCT could reduce the table speed to allow adequate arterial opacification and minimal venous contamination.

Preoperative localization of Adamkiewicz arteries and their origins by using MDCT angiography.

OBJECTIVE: To evaluate the ability of thoraco-abdominal MDCT angiography to visualize Adamkiewicz arteries for preoperative planning in patients diagnosed with aortic disease. MATERIAL AND METHOD: The present study retrospectively reviewed clinical data from 73 patients who underwent a thoraco-abdominal 64-slice MDCT angiography. The Adamkiewicz artery was evaluated on multiplanar reformation images in each case. The visualization of the Adamkiewicz artery, level of origin, side of origin and continuation from an intercostal artery was investigated. RESULTS: The Adamkiewicz arteries were visualized in 52 of the 73 patients (71.2%), and the total number of the delineated Adamkiewicz arteries was 64. Two Adamkiewicz arteries were found in nine patients (17.3%). Four Adamkiewicz arteries were found in one patient (1.9%). Most of the delineated arteries arose from the T9-L2 levels (89.1%). A left side of origin was found in 41 of 64 arteries (64.1%), and a right side of origin was found in 23 of 64 arteries (35.9%). Only 12 of 64 delineated arteries (18.8%) showed continuity from their origins to the anterior radiculomedullary artery. CONCLUSION: The preoperative detection rate of the Adamkiewicz artery with the routine technique of 64-slice MDCT angiography was 71.2%. The preoperative location of the Adamkiewicz artery may help to reduce the risk of perioperative ischemic changes in the spinal cord.

Uncorrected pink tetralogy of Fallot in an adult patient: incidental CT findings.

Tetralogy of Fallot (TOF), one of the most common congenital heart diseases, has four major components: right ventricular hypertrophy, overriding aorta, membranous ventricular septal defect, and right ventricular outflow tract obstruction. If not already present at birth, cyanosis develops in the first year of life. Survival of the patient depends on the degree of pulmonary obstruction and the pulmonary blood supply. Patients rarely survive after the fourth decade of life. Limitation of blood to the lungs combined with ventricular septal defect results in supply of oxygen-poor blood to the body, causing cyanosis (blue coloration) in the patient. If the pulmonary stenosis is mild and ventricular septal defect is in balance, however, the noncyanotic patient is referred as having "pink tetralogy of Fallot."

Influence of heart rate on image quality to identify the best cardiac phase in 16-slice coronary CT angiography.

OBJECTIVE: To identify the best cardiac phase in different patient's heart rate on 16-slice coronary CT angiography. MATERIAL AND METHOD: The patients who had undergone coronary CT angiography with 16 multi-detector rows CT at Siriraj Hospital between September 2003 and August 2004. For each patient, the image reconstruction based on relative timing was performed placed at center of 35% to 85% of the R-R interval with step increments 10%. The authors created six data sets (35%, 45%, 55%, 65%, 75%, and 85% of R-R interval) throughout the cardiac cycle. The coronary arteries were reviewed based on cross-sectional images and reformat images. The authors inspected all data sets and selected the cardiac phase that contained the best image quality for each coronary artery. RESULTS: Five hundred sixty four vessels were evaluated in the 141 patients (83 men, 58 women). The mean patient age was 63.3 +/- 16.7 years (range 4-89 years). Mean patient heart rate was 65.7 +/- 16.5 beats per minute (bpm), range 46-104 bpm. The most coronary arteries were well demonstrated at center of 75% of R-R interval (66.8%). Ninety-eight patients (69.5%) required one phase that provided best overall image quality and motion free delineation for four coronary arteries. Forty-three patients (30.5%) required combination of data from each phase to achieve motion free images. CONCLUSION: The best cardiac phase of evaluate coronary artery in 16 slices coronary CT angiography in the patient's heart rate below 70 bpm is 75% of cardiac cycle (mid to late diastole). In patients with a heart rate 71-80 bpm, the authors required a combination of images from 45% and 75% of cardiac cycle to completely evaluate all coronary arteries. In patients with a heart rate above 80 bpm, 45% of cardiac cycle (end-systole) is the best phase.

Comparison of image quality of coronary CT angiography between 16 and 64 slices MDCT.

OBJECTIVE: To compare the image quality and visibility of coronary arteries that were performed by 16 slices and 64 slices multidetector row CT (MDCT). STUDY DESIGN: Descriptive analysis. MATERIAL AND METHOD: Twenty-eight patients suspected of hearing coronary artery disease had noninvasive coronary CT angiography performed by 16 slices MDCT and 64 slices MDCT Data were retrospectively analyzed and reviewed by two radiologists. Image quality was assessed by using a grading scale from excellent (4) to non-assessable (0) and the rate of displayed coronary branches was calculated. RESULTS: Four hundred twenty coronary CT angiography segments in 28 patients were evaluated. CONCLUSION: Coronary CT angiography using 64 slices multi-detector row CT provides a significantly higher image quality of coronary arteries and their branches compared with 16 slices multi-detector row CT.