CT Marker in Emergency Imaging of Acute Basilar Artery Occlusion: Thrombosis vs. Embolism.

Purpose: Acute basilar artery occlusion, a neurovascular emergency leading to high rates of morbidity and mortality, is usually diagnosed by CT imaging. The outcome is partly dependent on etiology, with a worse outcome in occlusions with underlying basilar artery stenosis. As this occlusion type requires a more complex angiographic therapy, this study aimed to develop new CT markers in emergency admission imaging to rapidly identify underlying stenosis. Methods: A total of 213 consecutive patients (female n = 91, age in years (mean/SD/range): 72/13/28−97), who received endovascular treatment at a single comprehensive stroke center for acute basilar artery occlusion, were included in this study. After applying strict inclusion criteria for imaging analyses, novel CT imaging markers, such as 'absolute density loss' (ADL) and relative thrombus attenuation (CTA-index), that measure perviousness, were assessed for n = 109 patients by use of CT-angiography and correlated to different occlusion patterns (thrombotic vs. embolic). Inter-observer agreement was assessed using an intraclass correlation coefficient for independent measures of a radiologist and a neuroradiologist. Associations between the imaging markers and clinical and interventional parameters were tested. Results: CT markers differ between the subgroups of basilar artery occlusions with and without underlying stenosis (for ADL: 169 vs. 227 HU (p = 0.03), for CTA-index: 0.55 vs. 0.70 (p < 0.001)), indicating a higher perviousness in the case of stenosis. A good inter-rater agreement was observed for ADL and CTA-index measures (ICC 0.92/0.88). For the case of embolic occlusions, a more pervious thrombus correlates to shorter time intervals, longer procedure times, and worse reperfusion success (p-values < 0.05, respectively). Conclusions: ADL and CTA-index are easy to assess in the emergency setting of acute basilar artery occlusion with the use of routinely acquired CT-angiography. They show a high potential to differentiate thrombotic from embolic occlusions, with an impact on therapeutic decisions and angiographic procedures. Measurements can be quickly performed with good reliability, facilitating implementation in clinical practice.

Is It Possible to Replace Conventional Radiography (CR) with a Dose Neutral Computed Tomography (CT) of the Cervical Spine in Emergency Radiology-An Experimental Cadaver Study.

The purpose of this experimental study on recently deceased human cadavers was to investigate whether (I) the radiation exposure of the cervical spine CT can be reduced comparable to a dose level of conventional radiography (CR); and (II) whether and which human body parameters can be predictive for higher dose reduction potential (in this context). MATERIALS AND METHODS: Seventy serial CT scans of the cervical spine of 10 human cadavers undergoing postmortem virtual autopsy were taken using stepwise decreasing upper limits of the tube current (300 mAs, 150 mAs, 110 mAs, 80 mAs, 60 mAs, 40 mAs, and 20 mAs) at 120 kVp. An additional scan acquired at a fixed tube current of 300 mAs served as a reference. Images were reconstructed with filtered back projection and the upper (C1-4) and lower (C4-7) cervical spine were evaluated by three blinded readers for image quality, regarding diagnostic value and resolution of anatomical structures according to a semiquantitative three-point-scale. Dose values and individual physical parameters were recorded. The relationship of diagnostic IQ, dose reduction level, and patients' physical parameters were investigated. The high-contrast resolution of the applied CT protocols was tested in an additional phantom study. RESULTS: The IQ of the upper cervical spine was diagnostic at 1.69 ± 0.58 mGy (CTDI) corresponding to 0.20 ± 0.07 mSv (effective dose) in all cadavers. IQ of the lower cervical spine was diagnostic at 4.77 ± 1.86 mGy corresponding to 0.560 ± 0.21 mSv (effective dose) in seven cadavers and at 2.60 ± 0.93 mGy corresponding to 0.31 ± 0.11 mSv in four cadavers. Significant correlation was detected for BMI (0.8366; p = 0.002548) and the anteroposterior (a.p.) chest diameter (0.8363; p = 0.002566), shoulder positioning (0.79799; p = 0.00995), and radiation exposure. CONCLUSIONS: Conventional radiography can be replaced with a nearly dose-neutral CT scan of the cervical spine.

The practice of emergency radiology throughout Europe: a survey from the European Society of Emergency Radiology on volume, staffing, equipment, and scheduling.

OBJECTIVES: To obtain information from radiology departments throughout Europe regarding the practice of emergency radiology METHODS: A survey which comprised of 24 questions was developed and made available online. The questionnaire was sent to 1097 chairs of radiology departments throughout Europe using the ESR database. All data were collected and analyzed using IBM SPSS Statistics software, version 20 (IBM). RESULTS: A total of 1097 radiologists were asked to participate, 109 responded to our survey. The response rate was 10%. From our survey, 71.6% of the hospitals had more than 500 beds. Ninety-eight percent of hospitals have an active teaching affiliation. In large trauma centers, emergency radiology was considered a dedicated section. Fifty-three percent of institutions have dedicated emergency radiology sections. Less than 30% had all imaging modalities available. Seventy-nine percent of institutions have 24/7 coverage by staff radiologists. Emergency radiologists interpret cross-sectional body imaging, US scans, and basic CT/MRI neuroimaging in more than 50% of responding institutions. Cardiac imaging examinations/procedures are usually performed by cardiologist in 53% of institutions, while non-cardiac vascular procedures are largely performed and interpreted by interventional radiologists. Most people consider the European Diploma in Emergency Radiology an essential tool to advance the education and the dissemination of information within the specialty of emergency radiology. CONCLUSION: Emergency radiologists have an active role in the emergency medical team. Indeed, based upon our survey, they have to interact with emergency physicians and surgeons in the management of critically ill patients. A broad skillset from ultrasonography and basic neuroimaging is required. KEY POINTS: • At most major trauma centers in Europe, emergency imaging is currently performed by all radiologists in specific units who are designated in the emergency department. • Radiologists in the emergency section at present have a broad skillset, which includes cross-sectional body imaging, ultrasonography, and basic neuroimaging of the brain and spine. • A dedicated curriculum that certifies a subspecialty in emergency radiology with a diploma offered by the European Society of Emergency Radiology demonstrates a great interest by the vast majority of the respondents.

European Society of Emergency Radiology: guideline on radiological polytrauma imaging and service (short version).

BACKGROUND: Although some national recommendations for the role of radiology in a polytrauma service exist, there are no European guidelines to date. Additionally, for many interdisciplinary guidelines, radiology tends to be under-represented. These factors motivated the European Society of Emergency Radiology (ESER) to develop radiologically-centred polytrauma guidelines. RESULTS: Evidence-based decisions were made on 68 individual aspects of polytrauma imaging at two ESER consensus conferences. For severely injured patients, whole-body CT (WBCT) has been shown to significantly reduce mortality when compared to targeted, selective CT. However, this advantage must be balanced against the radiation risk of performing more WBCTs, especially in less severely injured patients. For this reason, we recommend a second lower dose WBCT protocol as an alternative in certain clinical scenarios. The ESER Guideline on Radiological Polytrauma Imaging and Service is published in two versions: a full version (download from the ESER homepage, https://www.eser-society.org ) and a short version also covering all recommendations (this article). CONCLUSIONS: Once a patient has been accurately classified as polytrauma, each institution should be able to choose from at least two WBCT protocols. One protocol should be optimised regarding time and precision, and is already used by most institutions (variant A). The second protocol should be dose reduced and used for clinically stable and oriented patients who nonetheless require a CT because the history suggests possible serious injury (variant B). Reading, interpretation and communication of the report should be structured clinically following the ABCDE format, i.e. diagnose first what kills first.

Dose reduction in 64-row whole-body CT in multiple trauma: an optimized CT protocol with iterative image reconstruction on a gemstone-based scintillator.

OBJECTIVE: Evaluation of potential dose savings by implementing adaptive statistical iterative reconstruction (ASiR) on a gemstone-based scintillator in a clinical 64-row whole-body CT (WBCT) protocol after multiple trauma. METHODS: Dose reports of 152 WBCT scans were analysed for two 64-row multidetector CT scanners (Scanners A and B); the main scanning parameters were kept constant. ASiR and a gemstone-based scintillator were used in Scanner B, and the noise index was adjusted (head: 5.2 vs 6.0; thorax/abdomen: 29.0 vs 46.0). The scan length, CT dose index (CTDI) and dose-length product (DLP) were analysed. The estimated mean effective dose was calculated using normalized conversion factors. Student's t-test was used for statistics. RESULTS: Both the mean CTDI (mGy) (Scanner A: 53.8 ± 2.0, 10.3 ± 2.5, 14.4 ± 3.7; Scanner B: 48.7 ± 2.2, 7.1 ± 2.3, 9.1 ± 3.6; p < 0.001, respectively) and the mean DLP (mGy cm) (Scanner A: 1318.9 ± 167.8, 509.3 ± 134.7, 848.8 ± 254.0; Scanner B: 1190.6 ± 172.6, 354.6 ± 128.3, 561.0 ± 246.7; p < 0.001, respectively) for the head, thorax and abdomen were significantly reduced with Scanner B. There was no relevant difference in scan length. The total mean effective dose (mSv) was significantly decreased with Scanner B (24.4 ± 6.0, 17.2 ± 5.8; p < 0.001). CONCLUSION: The implementation of ASiR and a gemstone-based scintillator allows for significant dose savings in a clinical WBCT protocol. ADVANCES IN KNOWLEDGE: Recent technical developments can significantly reduce radiation dose of WBCT in multiple trauma. Dose reductions of 10-34% can be achieved.

Emergency radiology: straightening of the cervical spine in MDCT after trauma--a sign of injury or normal variant?

OBJECTIVE: To evaluate whether straightening of the cervical spine (C-spine) alignment after trauma can be considered a significant multidetector CT (MDCT) finding. METHODS: 160 consecutive patients after C-spine trauma admitted to a Level 1 trauma centre received MDCT according to Canadian Cervical Spine Rule and National Emergency X-Radiography Utilization Study indication rule; subgroups with and without cervical collar immobilization (CCI +/-) were compared with a control group (n = 20) of non-traumatized patients. Two independent readers evaluated retrospectively the alignment, determined the absolute rotational angle of the posterior surface of C2 and C7 (ARA C2-7) and grouped the results for lordosis (<-13°), straight (-13 to +6°) and kyphosis (>+6°). RESULTS: In the two CCI-/CCI+ study groups, the straight or kyphotic alignment significantly (p = 0.001) predominated over lordosis. The number of patients with straight C-spine alignment was higher in the CCI+ group (CCI+ 69% vs CCI- 49%, p = 0.05). A comparison of the CCI+ group vs the CCI- group revealed a slightly smaller number of kyphotic (10% vs 18%, p = 0.34) and lordotic (21% vs 33%, p = 0.33) alignments. Statistically, however, the differences were of no significance. The control group revealed no significant differences. CONCLUSION: Straightening of the C-spine alone is not a definitive sign of injury but is a biomechanical variation due to CCI and neck positioning during MDCT or active patient control. ADVANCES IN KNOWLEDGE: Straightening of the C-spine alignment in MDCT alone is not a definitive sign of injury. Straightening of the C-spine alignment is related to neck positioning and active patient control. CCI has a straightening effect on the cervical alignment.

Imaging minor head injury (MHI) in emergency radiology: MRI highlights additional intracranial findings after measurement of trauma biomarker S-100B in patients with normal CCT.

OBJECTIVE: To investigate whether MRI in emergency radiology can detect (a) additional trauma-related findings after minor head injury (MHI) or (b) structural, non-trauma-related intracranial lesions when trauma biomarker S-100B concentration is raised, or clinical symptoms are unexplained, or both. METHODS: 41 patients with MHI were included. Concentrations of S-100B in serum were measured and categorized using an established cut-off at 0.1 µg l(-1). Intracerebral trauma-related as well as non-trauma-related chronic structural findings (atrophy, microangiopathy and chronic parenchymal defects) were assessed by cranial CT (CCT) and MRI by two independent radiologists (UL and LLG). All CCT and MRI results were compared with biomarker S-100B. RESULTS: Compared with CCT, MRI detected 10 additional lesions. 5 patients had abnormal MRI with a total of 15 trauma-related lesions and showed elevated S-100B concentrations. Although sensitivity of S-100B was 100%, specificity was only 25%. Patients with structural brain lesions showed significantly higher S-100B serum levels (0.50 and 0.14 µg l(-1), p = 0.01). CONCLUSION: Biomarker S-100B has proven its high negative-predictive value to rule out intracranial bleeding in patients after MHI even if MRI is used as imaging modality. Regarding the low specificity of S-100B, structural lesions of the brain parenchyma not related to the acute trauma may be associated with increased serum concentrations of protein S-100B. ADVANCES IN KNOWLEDGE: Biomarker S-100B has a high negative-predictive value to rule out intracranial bleeding after MHI. Biomarker S-100B's low specificity may be associated with non-traumatic brain parenchyma lesions. MRI is superior to CCT in detecting subtle findings in neuroimaging after MHI. Biomarker S-100B can potentially reduce the large number of normal CCT studies after MHI.

Radiological mass casualty incident (MCI) workflow analysis: single-centre data of a mid-scale exercise.

OBJECTIVE: The aim of the study was to analyse and interpret radiological mass casualty incident workflow data. METHODS: In a mid-scale mass casualty incident exercise, the on-site triage assigned 12 cases to the investigated institution (11 included in the study). Two out of five institutional multislice-CT-scanners were used and the whole CT workflow and radiological service process chain were simulated as close to realistic as possible. The respective time intervals for reaching defined milestones were measured. RESULTS: The average CT in-room time, i.e. from entering to leaving the CT room was 9.43 min [(standard deviation) SD: 2.27 min; 95% (confidence interval) CI: 7.90-10.95 min]. Time spent on CT table was 6.75 min (SD: 1.67; CI: 5.63-7.87), and the pure scan time was 4.22 min (SD: 0.64; CI: 3.79-4.65). The first images after entering the CT room were available at a dedicated CT workstation after 5.85 min (SD: 2.20; CI: 4.37-7.32) and institution wide via picture archiving system (PACS) after 7.85 min (SD: 1.27; CI: 7.00-8.71). However, the PACS archiving process, that is, transfer of standard reconstruction set of CT images into the PACS was finished after 20.85 min (SD: 2.97; CI: 18.85-22.84). CONCLUSION: Up to six patients may be served per hour and per CT scanner by using a standard whole body CT polytrauma protocol. Dedicated CT triage protocols may even increase this number. The time portion until images were available at end points was relatively long. A solution has to be developed in order to avoid scenarios of patients being faster at end points than their images.

Use of computed tomography and mechanical CPR in cardiac arrest to confirm pulmonary embolism: a case study.

Precise therapeutic decision-making is vital in managing out-of-hospital cardiac arrest. We present an interesting approach where suspected pulmonary embolism could be confirmed by early computed tomography in cardiac arrest. Chest compressions were performed automatically by mechanical devices also during the acquisition of computed tomography data and subsequent thrombolysis.

The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology.

Trauma causes greater losses of life years and it is the most common cause of death for people under the age of 45. Time is one of the most relevant factors for the survival of injured patients, particularly the time elapsed from trauma until the resuscitation procedures. As a member of the trauma team, the radiologist contributes to the rapid diagnosis of traumatic disorders, with appropriate imaging modalities. Based on the evidence, the most appropriate diagnostic tool for severe/multiple trauma is computed tomography (CT). With the advent of multidetector CT (MDCT), radiologists are able to more effectively characterize life-threatening traumatic disorders within a few seconds in stable or stabilized patients. Considering the diagnostic potential of MDCT, conventional radiographs could be virtually abandoned in the diagnostic algorithms for adult polytraumatized patients. The radiologist helps to facilitate triage and to assess the optimal individual treatment for polytrauma patients, thus contributing to the improvement of patient outcomes. In this article, the indications for MDCT in the polytrauma setting are discussed.

Polytrauma: optimal imaging and evaluation algorithm.

Traumatic injuries are the leading cause of death in adults < 45 years of age. Musculoskeletal trauma accounts for a substantial number of injuries in patients sustaining polytrauma. The diagnostic work-up of those patients is challenging, complex, and requires a structured and interdisciplinary workflow. Multidetector CT (MDCT) is considered the imaging modality of choice due to remarkable technical developments in recent years. Besides the evaluation of cranial, chest, and abdominal injuries, MDCT allows for integrated imaging of musculoskeletal trauma within a single CT examination. In this context, CT angiography facilitates the detection of coexisting vascular injuries after trauma of the skeleton. In addition, recent technologies (e.g., dual-energy CT) provide promising applications such as metal artifact reduction. This article summarizes the basic principles of interdisciplinary management of polytrauma patients, reviews recent advances of CT technology that have enabled comprehensive trauma imaging, provides appropriate scan protocols, and discusses the radiologic evaluation of musculoskeletal findings.

Incidence of delayed and missed diagnoses in whole-body multidetector CT in patients with multiple injuries after trauma.

BACKGROUND: Whole-body CT (WBCT) is the imaging modality of choice during the initial diagnostic work-up of multiple injured patients in order to identify serious injuries and initiate adequate treatment immediately. However, delayed diagnosed or even missed injuries have been reported frequently ranging from 1.3% to 47%. PURPOSE: To highlight commonly missed lesions in WBCT of patients with multiple injuries. MATERIAL AND METHODS: A total of 375 patients (age 42.8 ± 17.9 years, ISS 26.6 ± 17.0) with a WBCT (head to symphysis) were included. The final CT report was compared with clinical and operation reports. Discrepant findings were recorded and grouped as relevant and non-relevant to further treatment. In both groups, an experienced trauma radiologist read the CT images retrospectively, whether these lesions were missed or truly not detectable. RESULTS: In 336 patients (89.6%), all injuries in the regions examined were diagnosed correctly in the final reports of the initial CT. Forty-eight patients (12.8%) had injuries in regions of the body that were not included in the CT. Fourteen patients (3.7%) had injuries that did not require further treatment. Twenty-five patients (6.7%) had injuries that required further treatment. With secondary interpretation, 85.4% of all missed lesions could be diagnosed in retrospect from the primary CT data-set. Small pancreatic and bowel contusions were identified as truly non-detectable. CONCLUSION: In multiple traumas, only a few missed injuries in initial WBCT reading are clinically relevant. However, as the vast majority of these injuries are detectable, the radiologist has to be alert for commonly missed findings to avoid a delayed diagnosis.

Filtered back projection, adaptive statistical iterative reconstruction, and a model-based iterative reconstruction in abdominal CT: an experimental clinical study.

PURPOSE: To compare objective and subjective image quality parameters of three image reconstruction algorithms of different generations at routine multidetector computed tomographic (CT) examinations of the abdomen. MATERIALS AND METHODS: This institutional review board-approved study included 22 consecutive patients (mean age, 56.1 years ± 15.8 [standard deviation]; mean weight, 79.1 kg ± 14.8) who underwent routine CT examinations of the abdomen. A low-contrast phantom was used for objective quality control. Raw data sets were reconstructed by using filtered back projection (FPB), adaptive statistical iterative reconstruction (ASIR), and a model-based iterative reconstruction (MBIR). Radiologists used a semiquantitative scale (-3 to +3) to rate subjective image quality and artifacts, comparing both FBP and MBIR images with ASIR images. The Wilcoxon test and the intraclass correlation coefficient were used to evaluate the data. Measurements of objective noise and CT numbers of soft tissue structures were compared with analysis of variance. RESULTS: The phantom study revealed an improved detectability of low-contrast targets for MBIR compared with ASIR or FBP. Subjective ratings showed higher image quality for MBIR, with better resolution (median value, 2; range, 1 to 3), lower noise (2; range, 1 to 3), and finer contours (2; range, 1 to 2) compared with ASIR (all P < .001). FBP performed inferiorly (0, range, -2 to 0]; -1 [range, -3 to 0]; 0 [range, -1 to 0], respectively; all, P < .001). Mean interobserver correlation was 0.9 for image perception and 0.7 for artifacts. Objective noise for FBP was 14%-68% higher and for MBIR was 18%-47% lower than that for ASIR (P < .001). CONCLUSION: The MBIR algorithm considerably improved objective and subjective image quality parameters of routine abdominal multidetector CT images compared with those of ASIR and FBP.

Nephron-sparing resection of angiomyolipoma after sirolimus pretreatment in patients with tuberous sclerosis.

PURPOSE: Renal angiomyolipoma in patients with tuberous sclerosis can cause life-threatening bleeding. Embolization or resection is recommended, but either intervention may result in substantial loss of renal function. Recently, regression of angiomyolipoma size has also been achieved with mTOR inhibitor therapy, but recurrent lesion growth after treatment cessation has to be expected. This is the first report on a multimodal therapeutic approach facilitating a nephron-sparing, definitive resection. METHODS: Three patients with renal angiomyolipoma not amenable to nephron-sparing surgery were treated with sirolimus aiming trough levels of 4-8 ng/ml. Treatment was well tolerated. RESULTS: mTOR inhibitor treatment resulted in a regression of angiomyolipoma volume by 38-95 %. Thereafter, nephron-sparing angiomyolipoma resection conserved normal renal function. CONCLUSION: Neoadjuvant use of mTOR inhibitor pretreatment may represent a novel approach facilitating nephron-sparing resection.

Prolonged zona glomerulosa insufficiency causing hyperkalemia in primary aldosteronism after adrenalectomy.

CONTEXT: Unilateral adrenalectomy is the therapy of choice in aldosterone-producing adenoma (APA). Zona glomerulosa (ZG) insufficiency causing hyperkalemia after adrenalectomy has been described in case reports. OBJECTIVE: Our aim was to analyze the clinical relevance of ZG insufficiency causing hyperkalemia after adrenalectomy in a large series of patients with APA. DESIGN: This was a retrospective chart review. SETTING: The study was conducted at two tertiary university referral centers in Germany. PATIENTS: Data from 110 patients with confirmed APA adrenalectomized at the centers in Munich and Berlin between 2004 and 2012 were analyzed. MAIN OUTCOME MEASURES: The primary outcome was the incidence of ZG insufficiency causing hyperkalemia after adrenalectomy; the secondary outcome was the identification of risk factors predisposing for hyperkalemia. RESULTS: Eighteen of 110 patients (16%) developed postoperative hyperkalemia. The majority of these patients (n = 14) had undetectable plasma aldosterone levels after adrenalectomy; four had low aldosterone levels. In 12 of these patients, hyperkalemia was documented only once and resumed spontaneously. Prolonged hypoaldosteronism accompanied by hyperkalemia was observed in six patients (5% of total cohort). These patients needed continuous mineralocorticoid replacement therapy for 11-46 months. Mineralocorticoid antagonist treatment for 4 wk prior to surgery did not prevent hyperkalemia. In multivariate analysis, preoperatively decreased glomerular filtration rate and increased serum creatinine as well as increased postoperative creatinine and microalbuminuria remained significant predictors of hyperkalemia. CONCLUSION: Persistent postoperative hypoaldosteronism with hyperkalemia occurs in 5% of adrenalectomized PA patients through prolonged ZG insufficiency, requiring long-term fludrocortisone treatment. Potassium levels after adrenalectomy must be monitored to avoid life-threatening hyperkalemia.

Imaging of acute pulmonary embolism using a dual energy CT system with rapid kVp switching: initial results.

PURPOSE: Computed tomography pulmonary angiography (CTPA) is considered as clinical gold standard for diagnosing pulmonary embolism (PE). Whereas conventional CTPA only offers anatomic information, dual energy CT (DECT) provides functional information on blood volume as surrogate of perfusion by assessing the pulmonary iodine distribution. The purpose of this study was to evaluate the feasibility of lung perfusion imaging using a single-tube DECT scanner with rapid kVp switching. MATERIALS AND METHODS: Fourteen patients with suspicion of acute PE underwent DECT. Two experienced radiologists assessed the CTPA images and lung perfusion maps regarding the presence of PE. The image quality was rated using a semi-quantitative 5-point scale: 1 (=excellent) to 5 (=non-diagnostic). Iodine concentrations were quantified by a ROI analysis. RESULTS: Seventy perfusion defects were identified in 266 lung segments: 13 (19%) were rated as consistent with PE. Five patients had signs of PE at CTPA. All patients with occlusive clots were correctly identified by DECT perfusion maps. On a per patient basis the sensitivity and specificity were 80.0% and 88.9%, respectively, while on a per segment basis it was 40.0% and 97.6%, respectively. None of the patients with a homogeneous perfusion map had an abnormal CTPA. The overall image quality of the perfusion maps was rated with a mean score of 2.6 ± 0.6. There was a significant ventrodorsal gradient of the median iodine concentrations (1.1mg/cm(3) vs. 1.7 mg/cm(3)). CONCLUSION: Lung perfusion imaging on a DE CT-system with fast kVp-switching is feasible. DECT might be a helpful adjunct to assess the clinical severity of PE.

64-MDCT in mass casualty incidents: volume image reading boosts radiological workflow.

OBJECTIVE: The purpose of this study was to evaluate the impact of the use of 64-MDCT and volume image reading on the radiologic workflow during a mass casualty incident simulation. MATERIALS AND METHODS: For this simulation, casualties were taken to our level I trauma center, and triage was done with whole-body 64-MDCT. The complete raw dataset of thin-section images was sent to a dedicated 3D workstation for further interpretation and simultaneous reformations. This new reading method is called volume image reading. Several time frames were documented to evaluate the workflow: examination time, time needed for image processing, and mean image transfer rates. The results were compared with those of a previous study using a 4-MDCT with axial images only and transfer of data to a PACS. RESULTS: The time for complete image processing (acquisition, reconstruction, and transfer) for 64-MDCT was 4.1 minutes (range, 3.9-4.3 minutes) compared with 9.0 minutes (range, 6.4-10.2 minutes) for 4-MDCT (p ≤ 0.001). The image processing capacity was 14.8 examinations/h for 64-MDCT compared with 6.7 examinations/h for 4-MDCT. The mean number of images was 953 for 64-MDCT compared with 202 for 4-MDCT (p ≤ 0.001). There were no significant differences between 64- and 4-MDCT for the time needed to prepare patients. CONCLUSION: The use of 64-MDCT with volume image reading led to evident advantages in the radiologic trauma workflow compared with 4-MDCT. Reading of the full image set including reformations can be initiated earlier with volume image reading.

Adrenal vein sampling using rapid cortisol assays in primary aldosteronism is useful in centers with low success rates.

OBJECTIVE: Adrenal vein sampling (AVS) is considered the gold standard in the differential diagnosis of primary aldosteronism (PA), but success rates vary between centers. We hypothesized that rapid (intraprocedure) cortisol measurement can improve performance in a center with initially low AVS success rate. DESIGN: We analyzed 46 patients with confirmed PA studied between 2008 and 2010. Forty-seven PA patients studied between 2004 and 2008 identified by retrospective chart review served as controls. All patients were treated at a single tertiary care university hospital. METHODS: Starting in 2008, rapid cortisol assays (RCA) were performed in all patients during the AVS procedure. A cortisol gradient of ≥2.0 between adrenal vein and a femoral vein sample was used as success criterion. Up to two repeat samples were drawn if adrenal vein cortisol was below this threshold. Results During the control period 26 of 47 AVS were successful (55%). After introduction of RCA, 39 out of 46 AVS (85%) were successful (P=0.003). In 21 of the 46 cases (46%) a resampling was necessary. The increase in overall success was due to an increase in successful right AVS (85 vs 62% before introduction of RCA; P=0.02) and a training effect (P=0.024 for trend). CONCLUSION: RCA during AVS are useful in centers with an initially low AVS success rate.

Analysis of responses of radiology personnel to a simulated mass casualty incident after the implementation of an automated alarm system in hospital emergency planning.

The purpose of this study was to evaluate the response to an automated alarm system of a radiology department during a mass casualty incident simulation. An automated alarm system provided by an external telecommunications provider handling up to 480 ISDN lines was used at a level I trauma center. During the exercise, accessibility, availability, and estimated time of arrival (ETA) of the called in staff were recorded. Descriptive methods were used for the statistical analysis. Of the 49 employees, 29 (59%) were accessible, of which 23 (79%) persons declared to be available to come to the department. The ETA was at an average 29 min (SD ±23). Radiologists and residents reported an ETA to their workplace almost two times shorter compared with technicians (19 ± 16 and 22 ± 16 vs. 40 ± 27 min, p > 0.05). Additional staff reserve is crucial for handling mass casualty incidents. An automated alarm procedure might be helpful. However, the real availability of the employees could not be exactly determined because of unpredictable parameters. But our results allow estimation of the manpower reserve and calculation of maximum radiology service capacities.