Society of Chest Imaging and Interventions Consensus Guidelines for the Interventional Radiology Management of Hemoptysis.

The recommendations from the Society of Chest Imaging and Interventions expert group comprehensively cover all the aspects of management of hemoptysis, highlighting the role of diagnostic and interventional radiology. The diversity existing in etiopathology, imaging findings, and management of hemoptysis has been addressed. The management algorithm recommends the options for effective treatment while minimizing the chances of recurrence, based on the best evidence available and opinion from the experts.

ABPA sans asthma: an entity to remember.

A male patient in his 20s presented with a cough and a small volume of haemoptysis that lasted a year. He had no other constitutional symptoms and a respiratory examination was suggestive of a consolidation. A chronic infection, such as tuberculosis, was suspected. The routine evaluation showed peripheral eosinophilia with raised serum total IgE. Sputum examination for tuberculosis was negative; hence, a high-resolution CT of the thorax was performed, which revealed bilateral bronchiectasis with high-attenuation mucus plugging. The imaging and blood profiles were in favour of allergic bronchopulmonary aspergillosis, but there was no history suggestive of asthma, and the pulmonary function test was normal. The patient underwent a skin prick test and an allergen-specific IgE test for Aspergillus fumigatus, and both were positive. His bronchoalveolar lavage cultures also grew A. fumigatus, and he responded well to antifungal therapy. This case illustrates the presentation of a rare entity-allergic bronchopulmonary aspergillosis sans asthma.

Can epicardial and pericardial adipose tissue volume predict the presence and severity of coronary artery disease?

Purpose: Excessive accumulation of free fatty acids in the coronary arteries can lead to coronary artery disease (CAD). Quantification of epicardial adipose tissue (EAT) and pericardial adipose tissue (PAT) is beneficial to understand its relationship with CAD, hypertension (HT), and diabetes. Material and methods: This retrospective study included 54 patients who underwent CT coronary angiogram using a multidetector row CT scanner. The EAT and PAT volumes from cardiac images were quantified using Image J software. The severity of CAD was graded using the CAD-RADS score. Results: Twenty-nine patients had no CAD, 21 patients had significant CAD, and 4 patients had insignificant CAD. Out of 21 patients with significant CAD, 14 had involvement of multiple coronary arteries. The EAT and PAT volumes were higher in patients with HT, DM, CAD-present group and significant-CAD-present group, but this was not statistically significant except the PAT volume with respect to diabetes. Significant correlation was found between EAT volume and calcium score (p = 0.035) and between EAT volume and total cholesterol level (p = 0.017). Significant differences in the EAT volumes were found in different CAD-RADS categories in the right coronary artery (RCA). From the threshold values, it was observed that CAD can develop in LAD even at lower of EAT and PAT volumes. Conclusions: Quantification of EAT and PAT volumes is beneficial in understanding its relationship with the presence and severity of coronary artery disease and its risk factors.

Prospective Clinical Trial Comparing IV Esmolol to IV Metoprolol in CT Coronary Angiography: Effect on Hemodynamic, Technical Parameters and Cost.

BACKGROUND: Intravenous [IV] esmolol, an alternative to IV metoprolol for coronary computed tomography angiography [CCTA], has shorter half-life that decreases the risk of prolonged hypotension. The primary aim was to prospectively compare IV esmolol alone to IV metoprolol alone for effectiveness in achieving heart rate [HR] of 60 beats per minute[bpm] during CCTA. The secondary aim was to compare hemodynamic response, image quality, radiation dose and cost. MATERIALS AND METHODS: Institutional Review Board approved prospective randomized study of 28 CCTA patients medicated in a 1:1 blinded match with IV esmolol or IV metoprolol to achieve HR of 60 bpm. Serial hemodynamic response was measured at 6 specified times. Two cardiac radiologists independently scored the image quality. RESULTS: Both IV esmolol and IV metoprolol achieved the target HR. IV esmolol resulted in significantly less profound and shorter duration of reduction in systolic blood pressure [BP] than IV metoprolol with a difference of -10, -14 and -9 mm Hg compared to -20, -26 and -25 mmHg at 2, 15 & 30 min respectively. No significant difference in HR at image acquisition, exposure window, radiation dose and image quality. Although IV esmolol was expensive, the overall cost of care was comparable to IV metoprolol due to shortened post CCTA observation period consequent to faster restoration of hemodynamic status. CONCLUSION: Comparison of IV esmolol and IV metoprolol demonstrate that both are effective in achieving the target HR but significantly faster recovery of HR and BP in patients who receive IV esmolol was found.

Giant cystic pulmonary hamartoma-images.

Hamartoma is the commonest benign tumor of the lung. They usually present as an asymptomatic solitary solid nodule of varying size, located peripherally in the lung parenchyma and picked up incidentally in a chest X-ray. Rarely, they may be intra-bronchial in location. A giant cystic variant of hamartoma is very rare, with only a few cases reported in literature so far. It may be misdiagnosed as any other cystic disease of the lung and thus get mismanaged. We herewith present the images of a patient with a giant cystic pulmonary hamartoma who presented with respiratory distress.

Pulmonary embolism from cardiac hydatids.

Metastatic hydatid disease of the lung may happen when a hydatid cyst (HC) anywhere in the body ruptures into a systemic vein, a right heart chamber or a pulmonary artery (PA), resulting in the embolisation of the cyst's contents into the lungs. We submit herewith, the images of embolised hydatids within the PA, in a patient who had surgery for HC involving the right ventricular (RV) wall in 2014. Despite adequate surgical and medical management, investigations in 2017 revealed multiple embolised cysts within PA branches. Further continued medical therapy resulted only in partial resolution of the disease, indicating probably the inadequacy of the currently available treatment strategies.

Pneumococcal serotypes causing non-invasive pneumonia in adults from a South Indian tertiary care hospital and the impact of the newer conjugate vaccines.

BACKGROUND: Streptococcus pneumoniae is the leading cause of community-acquired pneumonia (CAP) in adults. Ageing, chronic conditions and comorbidities are important risk factors for pneumococcal pneumonia. PURPOSE: There is lack of data on the pneumococcal serotypes causing non-invasive pneumonia in India. This study aims to determine the prevalent pneumococcal serotypes causing non-invasive pneumonia, the associated comorbidities, and the coverage of both the available pneumococcal vaccines in India and conjugate vaccines that are currently undergoing clinical trials. METHODS: A total of 280 subjects (aged >16 years) who had clinical symptoms correlating with radiological findings for non-invasive bacteremic pneumonia and microbiological evidence of S. pneumoniae between 2018 and 2020 were included. The clinical, demographic, radiological and microbiological findings were retrieved from the Hospital Information System (HIS). RESULT: The common serotypes in order of prevalence were 19F, 9V, 23F, 6B, 11A, 13, 34, 10A, 19A and 6A. The predominant non-vaccine serotypes were 13, 34, 35B, 31 and 16F. The associated radiological findings were pneumonic consolidation and multi-lobar involvement. Other coinfected bacterial pathogens included H. influenzae, S. aureus, K. pneumoniae and P. aeruginosa. CONCLUSION: The pneumococcal vaccines: PCV10/GSK, PCV10/SII, PCV13, PCV15, PCV20 and PPSV23 provide an overall serotype coverage of 36, 41, 47, 48, 61 and 69 %, respectively of S. pneumoniae causing non-invasive pneumonia in South India. Increasing catch-up vaccination using PCV10(SII) in pre-school children could have a more significant impact on reducing pneumococcal pneumonia in adults (>50 years) in terms of increased herd immunity at an affordable cost.

Mediastinal teratoma presenting as a cervical tumor: images.

Benign extra-gonadal germ cell tumors, known as teratoma or dermoid cysts, are commonly found in the anterior mediastinum in association with the thymic gland. This association is due to their common site of embryological origins, from the third and the fourth pharyngeal pouches. Since it is not unusual to find normal thymic tissue in the neck, germ cell tumors arising from here will present as a cervical tumor. We submit the typical images of one such tumor in a young adult. Intraoperatively, the tumor was well encapsulated and was connected to the mediastinal thymus by a long pedicle of thymic tissue. It was not related to the thyroid gland unlike a primary cervical teratoma. We present these typical images of a mediastinal dermoid in this unusual cervical location. The differential diagnoses to be considered clinically are primary cervical teratomas, thyroid tumors, lymph nodal pathologies, and branchial cyst.

An arcade in the heart: Multimodality imaging.

Congenital mitral stenosis (MS) is a spectrum of anomalies that result in functional and anatomic obstruction of inflow into the left ventricle. Mitral arcade is one of the varieties of congenital MS where there is an abnormal development of chordae tendineae, resulting in stenosis, regurgitation, or both. Here, we describe the case of a mitral arcade in a child, which was diagnosed on echocardiography and confirmed with other imaging modalities.

Organising pneumonia in Rhupus syndrome.

Interstitial lung disease (ILD) is seen in 17% of patients with Rhupus syndrome. Organising pneumonia (OP), a subtype of connective tissue disease-associated ILD, is rare but associated with good outcomes. Here, we present a patient with Rhupus who developed OP.

Correlation of quantitative and qualitative parameters of high-resolution computed tomography with pulmonary function test for diagnosing and assessing the severity of obstructive pulmonary disease.

PURPOSE: The aim of the study was to evaluate the role of high-resolution computed tomography (HRCT) in the prediction of presence and severity of chronic obstructive pulmonary disease (COPD), based on the pulmonary function test (PFT), to correlate the various quantitative and qualitative indices of COPD in HRCT with PFT values, and to derive at the threshold values for various quantitative HRCT indices of COPD. MATERIAL AND METHODS: A one-year retrospective and prospective evaluation of the HRCTs of 90 cases and 38 controls was performed. Quantitative and qualitative parameters of COPD were assessed in HRCT and were correlated with PFT. RESULTS: Among the qualitative parameters, significant correlation with spirometry was found with the qualitative scoring for emphysema and presence and inhomogeneous attenuation. Among the quantitative indices, anterior junction line length, thoracic cage ratio at both aortic arch and inferior pulmonary vein level, thoracic cross-sectional area/[height]² at the aortic arch were found to have good correlation with spirometry. There was significant strong correlation of anterior junction line length and tracheal index with residual volume/total lung capacity (RV/TLC). The threshold values of chest X-ray and HRCT quantitative parameters were calculated and were found to be lower than those of the western population. CONCLUSION: HRCT has a definite role in the diagnosis of COPD and can be used to predict the severity of emphysema.

Magnetic resonance imaging as an adjunct to computed tomography in the diagnosis of pulmonary Hydatid cysts.

INTRODUCTION: Although pulmonary hydatid cysts can be diagnosed on computed tomography (CT), sometimes findings can be atypical. Other hypodense infective or neoplastic lesions may mimic hydatid cysts. We proposed that magnetic resonance imaging (MRI) may act as a problem-solving tool, aiding the definite diagnosis of hydatid cysts and differentiating it from its mimics. The aim of this study is to assess the findings of pulmonary hydatid cysts on CT and MRI and the additional contribution of MRI in doubtful cases. MATERIALS AND METHODS: This is a retrospective study of 90 patients with suspected hydatid cysts. CT and MRI findings were noted and role of MRI in diagnosing hydatid cysts and its mimics was studied. Descriptive statistics for CT findings and sensitivity and specificity of MRI were calculated using surgery or histopathology as gold standard. RESULTS: Of the 90 patients with suspected pulmonary hydatid cysts, there were 52 true-positive and 7 false-positive cases on CT. Commonest CT finding was unilocular thick-walled cyst. In the 26 patients who had additional MRI, based on T2-weighted hypointense rim or folded membranes, accurate preoperative differentiation of 14 patients with hydatid cysts from 10 patients with alternate diagnosis was possible. There was one false-positive and one false-negative case on MRI. CONCLUSION: Although hydatid cyst can be diagnosed on CT on most occasions, sometimes there are challenges with certain mimics and atypical appearances. T2-weighted MRI can act as a problem solving tool to conclusively diagnose hydatid cyst or suggest an alternate diagnosis.

A Retrospective Case-Control Study to Evaluate the Diagnostic Accuracy of Honeycomb Sign in Melioid Liver Abscess.

Among pyogenic liver abscesses, melioid etiology is considered in endemic regions in the presence of known health or occupational risk factors. "Honeycomb sign," used to describe an abscess with multiple internal septations dividing the abscess cavity into multiple loculations of comparable sizes on imaging, is a sensitive sign for melioid liver abscess. This is a retrospective case-control study investigating incidence, sensitivity, and specificity of "honeycomb sign" in melioid liver abscess, in a cohort of patients with culture-proven melioidosis infection. Abscesses ≥ 2 cm were analyzed for the honeycomb sign. P value < 0.05 was taken as statistically significant. Interobserver agreement was calculated between two radiologists for the presence of the sign, sensitivity, and specificity. A total of 40 abscesses were analyzed. Thirty-four abscesses (85%) manifested the honeycomb sign with interobserver agreement (kappa = 0.70 and 0.92). Sensitivity of the sign is 85% (95% confidence interval [CI]: 70-94%), specificity is 75% (95% CI: 59-87%), positive predictive value is 77% (95% CI: 62-88%), and negative predictive value is 83% (95% CI: 67-94%). If abscess size is ≥ 3 cm, the sensitivity is 91% (95% CI: 77-98%), specificity is 75% (95% CI: 59-87%), positive predictive value is 76% (95% CI: 61-88%), and negative predictive value is 91% (95% CI: 76-98%). Honeycomb sign is a novel imaging marker for melioid liver abscess. Increased awareness and recognition of this imaging feature has the potential to affect patient management.

Non-Invasive and Minimally Invasive Imaging Evaluation of CSF Rhinorrhoea - a Retrospective Study with Review of Literature.

BACKGROUND: Localization of a cerebrospinal fluid [CSF] fistula is a diagnostic challenge. The choice of an optimal imaging technique is necessary to locate the site of CSF leak which is required for surgical/endoscopic repair of the CSF fistula. MATERIAL/METHODS: Retrospective analysis of imaging was performed in 33 patients who presented with symptoms suggestive of CSF rhinorrhoea over a period of two years. Either a bone defect on high resolution CT [HRCT] or CSF column extending extracranially from the subarachnoid space with or without brain/ meningeal herniation on magnetic resonance [MR] cisternography was considered positive for CSF leak. The MR imaging technique included 1-mm heavily T2-weighted [TR 2000 ms; TE-200 ms] fast spin echo study in coronal and sagittal planes. HRCT sections involved 0.625 to 0.8-mm sections in the coronal plane, with or without axial planes, through the paranasal sinuses, reconstructed in a sharp algorithm and acquired with the patient in prone position. Imaging findings were compared with endoscopic findings, being the gold standard for the assessment of CSF rhinorrhea. RESULTS: A total of 25 patients had a combination of HRCT and MR cisternography. The sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] of both MR cisternography and HRCT together were 93%, 100%, 100% and 50% respectively. Two patients underwent only MR cisternography, 5 patients underwent only HRCT and one patient underwent HRCT, MR cisternography and CT cisternography. Though PPV was 100% in the groups with HRCT alone, MR cisternography alone and combined CT cisternography, HRCT and MR cisternography, the results were not statistically significant as the number of patients in those groups was lower. CONCLUSIONS: Combination of MR cisternography and HRCT appears to be complementary, accurate and non-invasive and should be considered as optimal imaging modality for pre-op imaging in the evaluation of CSF rhinorrhoea.

Unilateral Obstructive Emphysema in Infancy due to Mediastinal Bronchogenic Cyst-Diagnostic Challenge and Management.

Bronchogenic cysts are the most common cystic mediastinal lesion in children. Bronchogenic cyst causing unilateral obstructive emphysema is a rare presentation. We report the case of a one and half month old infant who presented with respiratory distress which was initially suspected as left pneumothorax on frontal chest radiograph but was later found to be due to hyperinflated left lung and hence the possibility of congenital lobar emphysema was considered. CT thorax and limited MRI sections revealed a cystic lesion in mediastinum causing obstructive emphysema and mediastinal displacement. He underwent an emergency thoracotomy and excision of the cyst via an extrapleural approach. Post operatively, rapid improvement of the infant was noticed both clinically as well as radiologically. Cross sectional imaging like CT or MR is required for reaching the correct and early diagnosis in paediatric patients with respiratory distress, when there is diagnostic dilemma based on chest radiograph.