Tip of the iceberg: extracardiac CT findings in infective endocarditis.

Infective endocarditis (IE) is a disease with high morbidity and mortality rate, but diagnosis is confounded by diverse clinical presentations, which mimic other pathologies. A history of illicit intravenous drug use, previous cardiac valve surgery, and indwelling intracardiac devices increases the risk for developing infective endocarditis. The modified Duke criteria serve as the standard diagnostic tool, though its accuracy is reduced in certain cases. Radiologists in the Emergency Room setting reading body CT may be the first to identify the secondary extra-cardiac complications and facilitate expeditious management by considering otherwise unsuspected infective endocarditis. This review highlights common extracardiac complications of IE and their corresponding CT findings in the chest, abdomen, pelvis, and brain. If IE is suspected radiologists should suggest further investigation with echocardiography.

Consumption of trematode parasite infectious stages: from conceptual synthesis to future research agenda.

Given their sheer cumulative biomass and ubiquitous presence, parasites are increasingly recognized as essential components of most food webs. Beyond their influence as consumers of host tissue, many parasites also have free-living infectious stages that may be ingested by non-host organisms, with implications for energy and nutrient transfer, as well as for pathogen transmission and infectious disease dynamics. This has been particularly well-documented for the cercaria free-living stage of digenean trematode parasites within the Phylum Platyhelminthes. Here, we aim to synthesize the current state of knowledge regarding cercariae consumption by examining: (a) approaches for studying cercariae consumption; (b) the range of consumers and trematode prey documented thus far; (c) factors influencing the likelihood of cercariae consumption; (d) consequences of cercariae consumption for individual predators (e.g. their viability as a food source); and (e) implications of cercariae consumption for entire communities and ecosystems (e.g. transmission, nutrient cycling and influences on other prey). We detected 121 unique consumer-by-cercaria combinations that spanned 60 species of consumer and 35 trematode species. Meaningful reductions in transmission were seen for 31 of 36 combinations that considered this; however, separate studies with the same cercaria and consumer sometimes showed different results. Along with addressing knowledge gaps and suggesting future research directions, we highlight how the conceptual and empirical approaches discussed here for consumption of cercariae are relevant for the infectious stages of other parasites and pathogens, illustrating the use of cercariae as a model system to help advance our knowledge regarding the general importance of parasite consumption.

Patterns of Clinostomum marginatum infection in fishes and amphibians: integration of field, genetic, and experimental approaches.

Digenetic trematodes of the genus Clinostomum are cosmopolitan parasites infecting fishes, amphibians, reptiles, and snails as intermediate hosts. Despite the broad geographical distribution of this genus, debate about the number of species and how they vary in host use has persisted. To better understand patterns of infection among host species and across life stages, we used large-scale field surveys and molecular tools to examine five species of amphibians and seven species of fishes from 125 California ponds. Among the 12,360 examined hosts, infection was rare, with an overall prevalence of 1.7% in amphibians and 9.2% in fishes. Molecular evidence indicated that both groups were infected with Clinostomum marginatum. Using generalized linear mixed effects models, host species identity and host life stage had a strong influence on infection status, such that Lepomis cyanellus (green sunfish) (49.3%) and Taricha granulosa (rough skinned newt) (9.2%) supported the highest overall prevalence values, whereas adult amphibians tended to have a higher prevalence of infection relative to juveniles (13.3% and 2.5%, respectively). Experimentally, we tested the susceptibility of two amphibian hosts (Pseudacris regilla [Pacific chorus frog] and Anaxyrus boreas [western toad]) to varying levels of cercariae exposure and measured metacercariae growth over time. Pseudacris regilla was 1.3× more susceptible to infection, while infection success increased with cercariae exposure dose for both species. On average, metacarcariae size increased by 650% over 20 days. Our study highlights the importance of integrating field surveys, genetic tools, and experimental approaches to better understand the ecology of host-parasite interactions.

Development and application of an eDNA method to detect and quantify a pathogenic parasite in aquatic ecosystems.

Approaches based on organismal DNA found in the environment (eDNA) have become increasingly utilized for ecological studies and biodiversity inventories as an alternative to traditional field survey methods. Such DNA-based techniques have largely been used to establish the presence of free-living organisms, but have much potential for detecting and quantifying infectious agents in the environment, which is necessary to evaluate disease risk. We developed an eDNA method to examine the distribution and abundance of the trematode Ribeiroia ondatrae, a pathogenic parasite known to cause malformations in North American amphibians. In addition to comparing this eDNA approach to classical host necropsy, we examined the detectability of R. ondatrae in water samples subject to different degradation conditions (time and temperature). Our test exhibited high specificity and sensitivity to R. ondatrae, capable of detecting as little as 14 fg (femtograms) of this parasite's DNA (1/2500th of a single infectious stage) from field water samples. Compared to our results from amphibian host necropsy, quantitative PCR was -90% concordant with respect to R. ondatrae detection from 15 field sites and was also a significant predictor of host infection abundance. DNA was still detectable in lab samples after 21 days at 25°C, indicating that our method is robust to field conditions. By comparing the advantages and disadvantages of eDNA vs. traditional survey methods for determining pathogen presence and abundance in the field, we found that the lower cost and effort associated with eDNA approaches provide many advantages. The development of alternative tools is critical for disease ecology, as wildlife management and conservation efforts require reliable establishment and monitoring of pathogens.

Biomphalaria straminea (Mollusca: Planorbidae) as an intermediate host of Ribeiroia sp. (Trematoda: Psilostomidae) in Brazil.

Species of Ribeiroia are trematode parasites of birds and mammals that have acquired notoriety since Ribeiroia ondatrae was identified as a cause of mortality and malformations in North American amphibians. Although species of Ribeiroia have been reported in vertebrate hosts in South America, the snails involved in its transmission remain unknown in Brazil. During malacological studies conducted at Pampulha Reservoir, Belo Horizonte, Minas Gerais, Brazil, between January 2009 and February 2012, in total 14,264 specimens of Biomphalaria straminea were collected, of which 192 (1.35%) were infected with gymnocephalous cercariae. The larvae were used for experimental infection of laboratory-reared guppies ( Poecilia reticulata ); metacercariae obtained in these fishes were orally administered to domestic ducks (Cairina moschata); and adult parasites were obtained from the proventriculus 10 days after infection. Based on morphological and molecular analyses, the parasite was identified as Ribeiroia sp., a species morphologically similar to R. ondatrae , but distinctly different at the molecular level. This is the first report of larvae of Ribeiroia in Brazil and B. straminea as a new intermediate host for this genus.

Diversity, decoys and the dilution effect: how ecological communities affect disease risk.

Growing interest in ecology has recently focused on the hypothesis that community diversity can mediate infection levels and disease ('dilution effect'). In turn, biodiversity loss--a widespread consequence of environmental change--can indirectly promote increases in disease, including those of medical and veterinary importance. While this work has focused primarily on correlational studies involving vector-borne microparasite diseases (e.g. Lyme disease, West Nile virus), we argue that parasites with complex life cycles (e.g. helminths, protists, myxosporeans and many fungi) offer an excellent additional model in which to experimentally address mechanistic questions underlying the dilution effect. Here, we unite recent ecological research on the dilution effect in microparasites with decades of parasitological research on the decoy effect in macroparasites to explore key questions surrounding the relationship between community structure and disease. We find consistent evidence that community diversity significantly alters parasite transmission and pathology under laboratory as well as natural conditions. Empirical examples and simple transmission models highlight the diversity of mechanisms through which such changes occur, typically involving predators, parasite decoys, low competency hosts or other parasites. However, the degree of transmission reduction varies among diluting species, parasite stage, and across spatial scales, challenging efforts to make quantitative, taxon-specific predictions about disease. Taken together, this synthesis highlights the broad link between community structure and disease while underscoring the importance of mitigating ongoing changes in biological communities owing to species introductions and extirpations.

Individuals homozygous for the age-related macular degeneration risk-conferring variant of complement factor H have elevated levels of CRP in the choroid.

Polymorphisms in the complement factor H gene (CFH) are associated with a significantly increased risk for, or protection against, the development of age-related macular degeneration (AMD). The most documented risk-conferring single-nucleotide polymorphism results in a tyrosine-to-histidine substitution at position 402 (Y402H) of the CFH protein. In this work, we examined the ocular distributions and relative abundance of CFH, several CFH-binding proteins, and abundant serum proteins in the retinal pigmented epithelium (RPE), Bruch's membrane, and choroid (RPE-choroid) in CFH homozygotes possessing either the "at-risk" 402HH or "normal" 402YY variants. Although CFH immunoreactivity is high in the choroid and in drusen, no differences in CFH-labeling patterns between genotypes are apparent. In contrast, at-risk individuals have significantly higher levels of the CFH-binding protein, C-reactive protein (CRP), in the choroidal stroma. Immunoblots confirm that at-risk individuals have approximately 2.5-fold higher levels of CRP in the RPE-choroid; no significant differences in the levels of CFH or other serum proteins are detected. Similarly, we find no differences in CFH transcription levels in the RPE-choroid nor evidence for local ocular CRP transcription. Increased levels of CRP in the choroid may reflect a state of chronic inflammation that is a by-product of attenuated CFH complement-inhibitory activity in those who possess the CFH at-risk allele. Because the CRP-binding site in CFH lies within the domain containing the Y402H polymorphism, it is also possible that the AMD risk-conferring allele alters the binding properties of CFH, thereby leading to choroidal CRP deposition, contributing to AMD pathogenesis.

Intraoperative sonographic localization of breast masses: success with specimen sonography and surgical bed sonography to confirm excision.

OBJECTIVE: To assess the use of intraoperative sonography for localization of breast masses at excisional biopsy, with specimen and surgical bed sonography to confirm excision. METHODS: A computer search of the 5-year period from January 1993 through January 1998 revealed 138 consecutive women referred for sonographically guided excisional biopsy of 148 masses; 35 masses were excluded because they had no postoperative mammograms. One hundred thirteen masses constituted the study group. Specimen sonography (n = 60) or surgical bed sonography (n = 53) was performed as the initial evaluation to confirm excision, but ultimately, surgical bed sonography may have been necessary after specimen sonography, and specimen sonography may have been necessary after surgical bed sonography. The miss rates determined by postoperative imaging were calculated for each group and compared with those of mammographically guided needle localization series from the literature. RESULTS: Follow-up physical examination and mammography showed no residual mass in the region of surgery in any patient. However, follow-up sonography had 1 miss in the initial specimen sonogram group (1 [1.7%] of 60) and 1 miss in the initial surgical bed group (1 [1.9%] of 53). As shown by the Fisher exact test, there was no significant difference between the miss rates of the 2 initial methods of confirming lesion excision or between the miss rates of these initial methods, both groups combined, and 6 mammographic localization series from the literature. CONCLUSION: Intraoperative breast sonography, using specimen sonography and scanning the surgical bed, has miss rates comparable with those of mammographic needle localization. Follow-up sonography must be performed if there is any doubt of complete excision.

Sonographically guided renal mass biopsy: indications and efficacy.

PURPOSE: To review the clinical indications, pathologic results, and success rate of all our sonographically guided solid renal mass biopsies over a 5-year period. METHODS: Between 1993 and 1998, 44 consecutive patients underwent sonographically guided percutaneous biopsy of a solid renal mass. Indications included prior history of nonrenal malignancy, metastatic disease of unknown primary origin, previous contralateral nephrectomy for a renal cell neoplasm, a renal transplant mass, suspected renal lymphoma, history of tuberous sclerosis, and poor surgical candidacy. Aspiration biopsies were initially performed with 22- to 18-gauge spinal needles. If the initial cytologic evaluation findings were nondiagnostic, core biopsies were then performed with 20- to 18-gauge core biopsy guns. Dictated sonographic reports of the biopsies were reviewed to determine the following: indication for biopsy, location and size of the renal mass, needle gauge and type, number of needle passes, and complications. Final cytologic and surgical pathologic records were reviewed. RESULTS: Thirty-six (82%) of the 44 biopsy specimens were diagnostic. Aspirated smears were diagnostic in 24 (67%) of these cases, with the diagnosis made on the basis of cell block alone in an additional 2 (6%). A definitive diagnosis came from core biopsy alone in 10 cases (28%). The 18-gauge core needle yielded diagnostic results more reliably than the 20-gauge core needle, and a significant correlation was seen between core biopsy needle size and the rate of diagnostic core samples (P = .017). Pathologic diagnoses included renal cell carcinoma (n = 18), lymphoma (n = 4), oncocytic neoplasm (n = 4), transitional cell carcinoma (n = 2), angiomyolipoma (n = 1), papillary cortical neoplasm (n = 1), and metastatic carcinoma (n = 6). Complications were seen in 4 (9%) of 44 cases; all were treated conservatively. CONCLUSIONS: For specific clinical indications, sonographically guided fine-needle aspiration and core biopsy of a solid renal mass can be performed safely. In many cases, a definitive diagnosis can be made on the basis of fine-needle aspiration alone. However, diagnosis may ultimately require core biopsy, for which 18-gauge core needles would be more reliably diagnostic than 20-gauge needles.

Developmental patterns of protein expression in photoreceptors implicate distinct environmental versus cell-intrinsic mechanisms.

The present study has examined the spatial and temporal expression patterns of various proteins associated with the structure and function of mature photoreceptor outer segments in the developing ferret's retina using immunocytochemistry and RT-PCR. One set of proteins, including rod opsin, arrestin, and recoverin, was detected progressively in photoreceptors as they became postmitotic, being expressed well before the differentiation of outer segments. A second set of proteins, including beta- and gamma-transducin, cGMP-phosphodiesterase, phosducin, rhodopsin kinase, rod cGMP-gated cation channel protein, and peripherin, displayed a contrasting temporal onset and pattern of spatial emergence. These latter proteins first became detectable either shortly before or coincident with outer segment formation, and were expressed simultaneously in both older and younger photoreceptor cells. A third set, the short wavelength-sensitive (SWS) and medium wavelength-sensitive (MWS) cone opsin proteins, was the last to be detected, but materialized in a spatio-temporal pattern reminiscent of the neurogenetic gradient of the cones. These different spatial and temporal patterns indicate that cellular maturation must play a primary role in regulating the onset of expression of some of these proteins, while extrinsic signals must act to coordinate the expression of other proteins across photoreceptors of different ages.

Disruption of transient photoreceptor targeting within the inner plexiform layer following early ablation of cholinergic amacrine cells in the ferret.

Photoreceptors in the ferret's retina have been shown to project transiently to the inner plexiform layer (IPL) prior to their differentiation of an outer segment. On postnatal day 15 (P-15), when this projection achieves maximal density, the photoreceptors projecting into the IPL extend primarily to one of two depths, coincident with the processes of cholinergic amacrine cells. The present study has used an excitotoxic approach employing subcutaneous injections of L-glutamate to ablate these cholinergic amacrine cells on P-7, in order to see whether their elimination alters this targeting of photoreceptor terminals within the IPL. The near-complete elimination of cholinergic amacrine cells at P-15 was confirmed, although the population of retinal ganglion cells was also affected, being depleted by roughly 50%. The rod opsin-immunopositive terminals in such treated ferrets no longer showed a stratified distribution, being found throughout the depth of the IPL, as well as extending into the ganglion cell layer. This effect should not be due to the partial loss of retinal ganglion cells, however, since optic nerve transection at P-2, which eliminates the ganglion cells entirely while leaving the cholinergic amacrine cell population intact, was shown not to affect the stratification pattern of the photoreceptors within the IPL. These results strongly suggest that the targeting of the photoreceptor terminals to discrete strata within the IPL is dependent upon the cholinergic amacrine cell processes.

Development of cholinergic amacrine cell stratification in the ferret retina and the effects of early excitotoxic ablation.

The present study has examined the emergence of cholinergic stratification within the developing inner plexiform layer (IPL), and the effect of ablating the cholinergic amacrine cells on the formation of other stratifications within the IPL. The population of cholinergic amacrine cells in the ferret's retina was identified as early as the day of birth, but their processes did not form discrete strata until the end of the first postnatal week. As development proceeded over the next five postnatal weeks, so the positioning of the cholinergic strata shifted within the IPL toward the outer border, indicative of the greater ingrowth and elaboration of processes within the innermost parts of the IPL. To examine whether these cholinergic strata play an instructive role upon the development of other stratifications which form within the IPL, one-week-old ferrets were treated with L-glutamate in an attempt to ablate the population of cholinergic amacrine cells. Such treatment was shown to be successful, eliminating all of the cholinergic amacrine cells as well as the alpha retinal ganglion cells in the central retina. The remaining ganglion cell classes as well as a few other retinal cell types were partially reduced, while other cell types were not affected, and neither retinal histology nor areal growth was compromised in these ferrets. Despite this early loss of the cholinergic amacrine cells, which are eliminated within 24 h, other stratifications within the IPL formed normally, as they do following early elimination of the entire ganglion cell population. While these cholinergic amacrine cells are present well before other cell types have differentiated, apparently neither they, nor the ganglion cells, play a role in determining the depth of stratification for other retinal cell types.

Safety and efficacy of sonographically guided random core biopsy for diffuse liver disease.

Sonographic guidance is commonly used in the biopsy of focal hepatic lesions, but biopsy for diffuse disease is often non-image-guided. We evaluated the safety and efficacy of real-time sonographically guided random core biopsy in the assessment of diffuse liver disease in 210 patients. The two most common indications for biopsy were viral hepatitis (in 113 patients) and elevated liver function test results of unknown cause (in 54 patients). Ultrasonography and pathology reports were reviewed retrospectively to determine number of needle passes and final diagnoses. Adequate tissue was obtained in all 210 patients, with 259 of 269 (96%) passes having been successful. Specimens were submitted for light microscopy and other tests as indicated. No difference in success rates was found for right and left lobe biopsies. No major complications occurred. Minor complications occurred in 10 of 210 (4.8%) patients and were self-limited. Sonographically guided core liver biopsy is a safe and effective method for the diagnosis of liver disease.

Size of colorectal liver metastases at abdominal CT: comparison of precontrast and postcontrast studies.

PURPOSE: To investigate whether measurements of hepatic metastases from colorectal carcinoma before contrast material administration are significantly different statistically from measurements after contrast material administration. MATERIALS AND METHODS: Twenty-four patients with hepatic metastases from colorectal carcinoma underwent spiral computed tomography (CT) with 7-mm collimation. The liver was imaged before and in the portal-dominant phase after intravenous contrast material administration. For each scan, one to three discrete liver lesions were selected for measurement (n = 49). Three experienced radiologists performed independent measurements of the selected lesions on both pre- and postcontrast images at a computer workstation. A three-way analysis of variance (ANOVA) was performed: subjects by raters (the three independent radiologists) by pre- or postcontrast status. The dependent variable was the product of bidimensional measurements. RESULTS: Sixty-seven percent (33 of 49) of the lesions were measured as larger on precontrast images; 33% (16 of 49), as smaller. There was high interrater reliability, with an intraclass correlation coefficient greater than 0.9 ANOVA showed significant subject, rater, and contrast material effects (P < .001) for the largest lesions in each liver. Contrast material status was a significant factor for all lesion sizes (P < .003). CONCLUSION: On average, hepatic metastases from colorectal carcinoma are significantly smaller after contrast material administration.

Extrinsic modulation of retinal ganglion cell projections: analysis of the albino mutation in pigmentation mosaic mice.

Tyrosinase is a key enzyme involved in the synthesis of melanin in the retinal pigment epithelium (RPE). Mice that are homozygous for the albino allele at the tyrosinase locus have fewer retinal ganglion cells with uncrossed projections at the optic chiasm. To determine the site of the albino gene action we studied the projections of retinal ganglion cells in two types of pigmentation mosaic mice. First, we generated mosaic mice that contain a translocated allele of the wild-type tyrosinase on one X chromosome but that also have the lacZ reporter transgene on the opposite X chromosome. In these lacZ/tyrosinase mice, which are homozygous for the albino allele on chromosome 7, X-inactivation ensures that tyrosinase cannot be functional within 50% of the retinal ganglion cells and that these individual cells can be identified by their expression of the lacZ reporter gene product, beta-galactosidase. The proportion of uncrossed retinal ganglion cells expressing beta-galactosidase was found to be identical to the proportion that did not express it, indicating that the albino mutation associated with axonal behavior at the optic chiasm must affect ganglion cells in a cell-extrinsic manner. Second, to determine whether the RPE is the source of the extrinsic signal, we generated aggregation chimeras between pigmented and albino mice. In these mosaic mice, the extent of the uncrossed projection corresponded with the amount of pigmented cells within the RPE, but did not correspond with the genotypes of neural retinal cells. These studies demonstrate that the albino mutation acts indirectly upon retinal ganglion cells, which in turn respond by making axonal guidance errors at the optic chiasm.

Rods and cones project to the inner plexiform layer during development.

Mature rod and cone photoreceptor cells extend terminals to the outer plexiform layer (OPL), where they form characteristic spherules or pedicles, synapsing with the second-order neurons of the inner nuclear layer (INL). The present study demonstrates that, prior to the formation of this connectivity, immature rods and cones in the ferret extend processes beyond the level of the horizontal cells and future OPL, reaching the inner plexiform layer (IPL). The number of processes extending to the IPL increases steadily as the population of photoreceptor cells expands postnatally, reaching a maximum 2 weeks after birth. These processes are immunopositive for synaptophysin, and they terminate in two strata occupied by the dendrites of amacrine cells and ganglion cells. The frequency of these processes declines rapidly during the third postnatal week, and they are no longer detectable by the fourth postnatal week. Their loss is neither a consequence of photoreceptor cell death nor is it due to selective protein trafficking mechanisms that render them immunonegative. Rather, these processes retract to the level of the OPL during this period, coincident with the maturation of bipolar and horizontal cell processes. These results demonstrate that, despite the clear presence of environmental signals presaging the formation of the OPL, photoreceptor terminals initially ignore them to grow beyond this level of the retina. Rather, they detect and respond to signals within the IPL during this period, terminating in proximity to the processes of other cells in the inner retina, where they may contribute to transient retinal circuitry during early development.

CT angiography with volume rendering for quantifying vascular stenoses: in vitro validation of accuracy.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of CT angiography with volume rendering for quantifying vascular stenoses in vitro. MATERIALS AND METHODS: Vascular models with three degrees of stenosis (33%, 67%, and 83%) were imaged at three orientations to the axial plane (parallel, perpendicular, or 45 degrees ) using helical CT with 2-mm collimation and two pitches (1 or 2), two reconstruction intervals (1 or 2 mm), and two scan times (.75 or 1 sec). Diameter and percentage of stenosis were measured from volume renderings using full width at half maximum. Images were measured in two planes whenever resolution varied with direction. Statistical analysis was performed using analysis of variance. RESULTS: Mean absolute error of the measured percentage of stenosis was 7% (range, 0-27%). The actual percentage of stenosis and vessel orientation had the most significant effects on accuracy (p < .001). The measured percentage of stenosis was significantly less accurate with phantoms parallel to the axial plane than with other orientations (p < .001). Mean absolute error in the measured percentage of stenosis was 4% when the parallel-to-the-axial-plane orientation was excluded. Overlapping (1-mm) reconstructions were significantly more accurate than 2-mm reconstructions (p < .05) and direction of measurement significantly affected accuracy (p < .05), but these effects were secondary. CONCLUSION: CT angiography with volume rendering can accurately quantify vascular stenoses, but it is less accurate for vessels in the axial plane. With 2-mm collimation, vessel characteristics have greater effects on accuracy than do acquisition parameters.

Pancreatic carcinoma versus chronic pancreatitis: dynamic MR imaging.

PURPOSE: To determine if dynamic gadolinium-enhanced magnetic resonance (MR) imaging can distinguish chronic pancreatitis from pancreatic carcinoma. MATERIALS AND METHODS: A retrospective review of MR and pathology examination findings was performed for 24 patients with pancreatic ductal adenocarcinoma and seven with chronic pancreatitis who underwent dynamic gadolinium-enhanced breath-hold spoiled gradient-echo imaging. Arterial, portal, and delayed phase images were obtained after injection of gadopentatate dimeglumine. The MR images of 14 patients without clinical evidence of pancreatic disease were also reviewed as controls. Signal intensity (SI) was measured on the precontrast (pre) and gadolinium-enhanced (post) images of the area of the pancreas sampled at biopsy and of the nontumorous pancreas. Percentage enhancement was defined as SIpre/SIpost x 100. RESULTS: Normal pancreas showed rapid enhancement that peaked in the arterial or portal phase. For both diseases, T1-weighted images showed hypointense masses with progressive enhancement (differences were significant [P < .05] on only delayed fat-saturated images). Differences in enhancement between either disease state and normal pancreas were significant for at least one phase. Nontumorous pancreas in patients with carcinoma showed gradual enhancement that was significantly different from that of normal pancreas. CONCLUSION: Chronic pancreatitis and pancreatic carcinoma show abnormal pancreatic enhancement, but the two were not distinguished on the basis of degree and time of enhancement.

Spiral CT of acute pulmonary thromboembolism: evaluation of pleuroparenchymal abnormalities.

PURPOSE: The goal of this work was to identify and categorize the spectrum of pulmonary parenchymal and pleural abnormalities identified by CT in patients with acute pulmonary thromboembolism (PE). METHOD: A review of interpretations from 4,715 consecutive contrast-enhanced thoracic CT studies identified 41 examinations in which the diagnosis of PE was reported. Thirty-four studies were available for review, and two radiologists confirmed intraluminal defects in 31 patients. The number of emboli were counted and localized using bronchopulmonary nomenclature. Associated parenchymal and pleural abnormalities were tabulated. RESULTS: Of the 31 patients, 13 underwent confirmatory or correlative studies including angiography, radionuclide study, or autopsy. In addition, deep venous thrombosis was confirmed by ultrasound or MRI in 13 patients. An average of 7.5 emboli per patient was detected. Pleuroparenchymal findings were as follows: Nine patients (29%) had no acute pulmonary parenchymal or pleural abnormality. In the remaining 22 patients, pleural effusion was the most common abnormality, found in 14 of 31 (45%). Ten patients (32%) had peripheral wedge-shaped parenchymal opacities suggestive of pulmonary infarction. Normally enhancing lobar atelectasis was seen in nine patients (29%). Six patients (19%) demonstrated heterogeneous parenchymal enhancement within nonaerated lung, two of whom had pathologically proven pulmonary infarct. Thirteen of 31 patients underwent high resolution CT; a typical mosaic perfusion pattern was seen in only 1 patient. CONCLUSION: Twenty-nine percent of patients with acute PE had no acute lung parenchymal abnormality on CT; thus, the absence of parenchymal abnormality on CT does not exclude PE. High resolution CT mosaic perfusion was not a common feature of acute pulmonary embolism. Regions of decreased enhancement within nonaerated lung, seen in 19%, may prove to be an indicator of pulmonary infarction; however, this is a nonspecific finding.

Renal artery stenosis: CT angiography--comparison of real-time volume-rendering and maximum intensity projection algorithms.

PURPOSE: To compare results of helical computed tomographic (CT) angiography with real-time interactive volume rendering (VR) to CT angiography with maximum intensity projection (MIP) for the detection of renal artery stenosis. MATERIALS AND METHODS: Twenty-five patients underwent both conventional and CT angiography of the renal arteries. Images were blindly reviewed after rendering with MIP and VR algorithms. MIP images were viewed in conjunction with axial CT images; VR models were evaluated in real time at the workstation without CT images. Findings in 50 main and 11 accessory renal arteries were categorized as normal or by degree of stenosis. RESULTS: All arteries depicted on conventional angiograms were visualized on MIP and VR images. Receiver operating characteristic (ROC) analysis for MIP and VIR images demonstrated excellent discrimination for the diagnosis of stenosis of at least 50% (area under the ROC curve, 0.96-0.99). Although sensitivity was not significantly different for VR and MIP (89% vs 94%, P > .1), specificity was greater with VR (99% vs 87%, P = .008 to .08). Stenosis of at least 50% was overestimated with CT angiography in four accessory renal arteries, but three accessory renal arteries not depicted at conventional angiography were depicted at CT angiography. CONCLUSION: In the evaluation of renal artery stenosis, CT angiography with VR is faster and more accurate than CT angiography with MIP. Accessory arteries not depicted with conventional angiography were depicted with both CT angiographic algorithms.