Calcium score: semiautomatic calculation using different vendors versus fully automatic software.

OBJECTIVES: Recent advances in technology have resulted in a multitude of cardiac imaging postprocessing software products from vendors unrelated to the scanner on which the cardiac study was initially performed. A fully automatic calcium score software has also become available. We assess the intervendor variability of calcium score measurement using the semiautomatic software provided by the scanner vendor versus an unrelated vendor versus fully automatic software. METHODS: All consecutive patients who had a calcium score performed from March 2007 to January 2008 were included in this study. The studies were performed on two 64-slice computed tomographic scanners from 2 different vendors. The allocation of the patient to the specific scanner was done according to scanner and technologist availability. The studies were read twice by a cardiac radiologist and a general radiologist with at least 3 months' interval at a workstation specified by the computed tomographic scanner vendor and then at an unrelated workstation, with semiautomatic software. Calcium score was also independently performed by the fully automatic software, blinded to the results of previous readings. Agreement was tested with Pearson correlation coefficient, Bland-Altman graphs, and the Fleiss κ test. RESULTS: The study population included 101 patients: 70 patients scanned at 1 scanner and 31 at a different scanner. Intervendor variability for the 2 groups had κ = 0.98 ± 0.01 and κ = 0.96 ± 0.02; interobserver variability had κ = 1. Semiautomatic versus automatic variability showed κ = 0.88 to 0.94. CONCLUSIONS: Because of very strong agreement between the calcium score measurements obtained by semiautomatic and fully automatic software by different vendors, calcium score measurements can be performed robustly at vendor-specific software, nonrelated software, or fully automatic software.

Deep sedation during pneumatic reduction of intussusception.

BACKGROUND: Pneumatic reduction of intussusception under fluoroscopic guidance is a routine procedure. The unsedated child may resist the procedure, which may lengthen its duration and increase the radiation dose. We use deep sedation during the procedure to overcome these difficulties. OBJECTIVE: The purpose of this study was to summarize our experience with deep sedation during fluoroscopic reduction of intussusception and assess the added value and complication rate of deep sedation. MATERIALS AND METHODS: All children with intussusception who underwent pneumatic reduction in our hospital between January 2004 and June 2011 were included in this retrospective study. Anesthetists sedated the children using propofol. The fluoroscopic studies, ultrasound (US) studies and the childrens' charts were reviewed. RESULTS: One hundred thirty-one attempted reductions were performed in 119 children, of which 121 (92%) were successful and 10 (8%) failed. Two perforations (1.5%) occurred during attempted reduction. Average fluoroscopic time was 1.5 minutes. No complication to sedation was recorded. CONCLUSIONS: Deep sedation with propofol did not add any complication to the pneumatic reduction. The fluoroscopic time was short. The success rate of reduction was high,raising the possibility that sedation is beneficial, possibly by smooth muscle relaxation.

CT multiplanar reconstructions (MPR) for shrapnel injury trajectory.

We report our experience in implementing CT multiplanar reformats (MPRs) to demonstrate the trajectory of penetrating trauma. It is an easily learned tool that can be conveniently and speedily applied in the fragments injury. We describe the detailed technique of performing MPRs, depicted by various examples. Furthermore, benefits and limitations of the technique (such as numerous fragments, change in position and respiratory phase, and embolization of fragments) are presented. We conclude that MPRs in the fragments trajectory can be helpful for accurate and fast diagnosis of injury. In addition, MPRs serve as a vivid presentation of injured and spared organs.

Classification of breast cancer precursors through exhaled breath.

Certain benign breast diseases are considered to be precursors of invasive breast cancer. Currently available techniques for diagnosing benign breast conditions lack accuracy. The purpose of this study was to deliver a proof-of-concept for a novel method that is based on breath testing to identify breast cancer precursors. Within this context, the authors explored the possibility of using exhaled alveolar breath to identify and distinguish between benign breast conditions, malignant lesions, and healthy states, using a small-scale, case-controlled, cross-sectional clinical trial. Breath samples were collected from 36 volunteers and were analyzed using a tailor-made nanoscale artificial NOSE (NA-NOSE). The NA-NOSE signals were analyzed using two independent methods: (i) principal component analysis, ANOVA and Student's t-test and (ii) support vector machine analysis to detect statistically significant differences between the sub-populations. The NA-NOSE could distinguish between all studied test populations. Breath testing with a NA-NOSE holds future potential as a cost-effective, fast, and reliable diagnostic test for breast cancer risk factors and precursors, with possible future potential as screening method.

Integrated SPECT/CT for assessment of haemodynamically significant coronary artery lesions in patients with acute coronary syndrome.

PURPOSE: Early risk stratification in patients with non-ST elevation acute coronary syndromes (NSTE-ACS) is important since the benefit from more aggressive and costly treatment strategies is proportional to the risk of adverse clinical events. In the present study we assessed whether hybrid single photon emission computed tomography (SPECT)/coronary computed tomography angiography (CCTA) technology could be an appropriate tool in stratifying patients with NSTE-ACS. METHODS: SPECT/CCTA was performed in 90 consecutive patients with NSTE-ACS. The Thrombolysis in Myocardial Infarction risk score (TIMI-RS) was used to classify patients as low- or high-risk. Imaging was performed using SPECT/CCTA to identify haemodynamically significant lesions defined as >50% stenosis on CCTA with a reversible perfusion defect on SPECT in the corresponding territory. RESULTS: CCTA demonstrated at least one lesion with >50% stenosis in 35 of 40 high-risk patients (87%) as compared to 14 of 50 low-risk patients (35%; TIMI-RS<3; p<.0001). Of the 40 high-risk and 50 (16%) low-risk TIMI-RS patients, 16 (40%) and 8 (16%), respectively, had haemodynamically significant lesions (p=0.01). Patients defined as high-risk by a high TIMI-RS, a positive CCTA scan or both (n=45) resulted in a sensitivity of 95%, specificity of 49%, PPV of 35% and NPV of 97% for having haemodynamically significant coronary lesions. Those with normal perfusion were spared revascularization procedures, regardless of their TIMI-RS. CONCLUSION: Noninvasive assessment of coronary artery disease by SPECT/CCTA may play an important role in risk stratification of patients with NSTE-ACS by better identifying the subgroup requiring intervention.

Multidetector CT angiography in the evaluation of acute mesenteric ischemia.

The aim of this study was to determine the accuracy of multidetector row CT angiography in the diagnosis of acute mesenteric ischemia. Ninety-three consecutive studies on 91 patients with clinically suspected acute mesenteric ischemia underwent abdominal CT angiography as the first, and usually the sole, diagnostic procedure. CT was performed with a multidetector 16-row CT system from the level of the diaphragm to the pelvis in two phases: early arterial and late portal phase. CT examinations were reviewed by the duty radiologist. Final diagnosis was established by a senior radiologist. CTA was diagnostic in 92 studies. Mesenteric ischemia was diagnosed in 18 patients, 14 of them were of the thromboembolic type and four from the nonocclusive type. Positive CTA findings were confirmed by surgery in 13 patients and by clinical follow-up in three cases. Other reasons for abdominal pain were diagnosed by CT in 38 patients out of the remaining 74. There were two false positive and two false negative CT results, resulting in an overall accuracy of 95.6%. Multidetector CT angiography is a fast and accurate investigation for the diagnosis of acute mesenteric ischemia and in most cases can be used as the sole diagnostic procedure.

Pseudopancreatitis in trauma patients.

OBJECTIVE: The purpose of our study was to review the significance of intra- and peripancreatic fluid in trauma patients who have no other signs of pancreatic injury. CONCLUSION: We propose that intra- and peripancreatic fluid may be the consequence of hypovolemic shock treated with hyperhydration when there is significant delay between injury and imaging.

Coping with war mass casualties in a hospital under fire: the radiology experience.

OBJECTIVE: We report the role of the imaging department at a level 1 trauma center during the Second Lebanon War (summer 2006). Our institution received 849 military and civilian casualties, an average of 25 war-injured patients per day, 338 with acute traumatic stress disorders and 511 physically injured, coming in waves after a rocket attack or a battle confrontation. About 12 potentially critical physically injured patients per day were referred to the imaging department for sometimes complex imaging procedures. The unpredictable waves of casualties and nature of the injuries forced us to reorganize our routine workflow to provide adequate care to casualties and to nonemergent patients. Our nurses' station was transformed into a small emergency department. The radiology staff was distributed into 12 diagnostic stations, providing 24-hour service. Communication was improved by means of walkie-talkies. Three ultrasound units were placed at the emergency department for immediate focused assessment with sonography for trauma performance enabling initial triage of patients. The site and extent of injuries were accurately diagnosed on CT and CT angiography. Digital angiography allowed definitive vascular diagnosis and interventional procedures. CONCLUSION: Adequate communication, strict workflow, and correct use of imaging protocols ensured optimal triage, diagnosis, and therapy of casualties while maintaining care for nonwar patients.

Diagnosing acute appendicitis in adults: accuracy of color Doppler sonography and MDCT compared with surgery and clinical follow-up.

OBJECTIVE: The objective of our study was to evaluate the accuracy of color Doppler sonography and contrast-enhanced MDCT in the diagnosis of acute appendicitis in adults and their utility as a triage tool in lower abdominal pain. MATERIALS AND METHODS: We reviewed the medical records of 420 consecutive adult patients, 271 women and 149 men, 18 years old or older, referred from the emergency department to sonography examination for clinically suspected acute appendicitis between January 2003 and June 2006. Patients underwent sonography of the right upper abdomen and pelvis followed by graded compression and color Doppler sonography of the right lower quadrant. CT was performed in 132 patients due to inconclusive sonography findings or a discrepancy between the clinical diagnosis and the sonography diagnosis. Sonography and CT reports were compared with surgery or clinical follow-up as the reference standard. Statistical analyses were performed by Pearson's chi-square test and cross-tabulation software. RESULTS: Sonography and CT correctly diagnosed acute appendicitis in 66 of 75 patients and in 38 of 39 patients, respectively, and correctly denied acute appendicitis in 312 of 326 and in 92 of 92 patients. Sonography was inconclusive in 17 of 418 cases and CT, in one of 132 cases. Sonography and CT allowed alternative diagnoses in 82 and 42 patients, respectively. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for sonography were 74.2%, 97%, 88%, 93%, and 92%, respectively, and for CT, 100%, 98.9%, 97.4%, 100%, and 99%. CONCLUSION: Sonography should be the first imaging technique in adult patients for the diagnosis of acute appendicitis and triage of acute abdominal pain. CT should be used as a complementary study for selected cases.

Cardiology consultation as a gatekeeper prior to cardiac multi-detector computed tomography scan.

BACKGROUND: Multi-detector computed tomography has advanced enormously and now enables non-invasive evaluation of coronary arteries as well as cardiac anatomy, function and perfusion. However, the role of cardiac MDCT is not yet determined in the medical community and, consequently, many clinically unnecessary scans are performed solely on a self-referral basis. OBJECTIVES: To prospectively evaluate the role of a cardiologist consultation and recommendation prior to the scan, and the influence on the diagnostic yield of cardiac MDCT. METHODS: In our center a CT service was initiated, but with the prerequisite approval of a cardiologist before performance of the CT. Each individual who wanted and was willing to pay for a cardiac CT was interviewed by an experienced cardiologist who determined whether cardiac MDCT was the most appropriate next test in the cardiovascular evaluation. Subjects were classified into three groups: a) those with a normal or no prior stress test, no typical symptoms and no significant risk factors of coronary artery disease were recommended to perform a stress test or to remain under close clinical follow-up without MDCT; b) those with an equivocal stress test, atypical symptoms and/or significant risk factors were allowed to have cardiac MDCT; and c) those with positive stress test or clinically highly suspected CAD were advised to go directly to invasive coronary angiography. CT findings were categorized as normal CAD (normal calcium score and no narrowings), < 50% and > 50% CAD. RESULTS: A total of 254 people were interviewed, and in only 39 cases did the cardiologist approve the CT. However, 61 of the 215, despite our recommendation not to undergo CT, decided to have the scan. Assessment of the 100 cases that underwent MDCT showed a statistically significant better discrimination of significant CAD, according to the cardiologist's recommendation: MDCT not recommended in 3/54 (6%) vs. MDCT recommended in 12/39 (31%) vs. recommended invasive coronary angiography in 4/7 (57%)(P<0.001). CONCLUSIONS: Detection of coronary calcification, as well as MDCT angiography can provide clinically useful information if applied to suitable patient groups. It is foreseeable that MDCT angiography will become part of the routine workup in some subsets of patients with suspected CAD. Selection of patients undergoing MDCT scans by a cardiologist improves the ability of the test to stratify patients, preventing unnecessary scans in both high and low risk patients.

Prosthetic vascular graft infection: the role of 18F-FDG PET/CT.

UNLABELLED: Graft infection after prosthetic vascular reconstruction is an uncommon but severe complication. The clinical presentation is often subtle and nonspecific and may occur long after surgery. Although defining a prosthetic vascular graft infection can be difficult, early diagnosis and treatment are important because of the relatively high rates of amputation and death. The present study assessed the role of PET/CT using 18F-FDG for the diagnosis of vascular graft infections. METHODS: Thirty-nine patients (35 men and 4 women; age range, 44-82 y) with suspected vascular graft infection underwent 18F-FDG PET/CT. The performance of PET/CT for the diagnosis of an infectious process and its localization to the graft or soft tissues was assessed. The final diagnosis was based on histopathologic findings and microbiologic assays obtained at surgery or on clinical and imaging follow-up. RESULTS: PET/CT detected foci of increased 18F-FDG uptake suspected as infection in 27 patients and localized these findings to the graft in 16 patients. Vascular graft infection was confirmed in 14 of these patients (88%). PET/CT excluded graft involvement in 11 patients, and in 10 (91%) of these 11, long-term follow-up further confirmed that the infectious process was limited to surrounding soft tissues only. No abnormal 18F-FDG uptake was found in any of the 12 patients with no further evidence of infection. PET/CT had a sensitivity of 93%, specificity of 91%, positive predictive value of 88%, and negative predictive value of 96% for the diagnosis of vascular graft infection. CONCLUSION: 18F-FDG PET/CT is a reliable noninvasive imaging modality for the diagnosis of vascular graft-related infection. The precise anatomic localization of increased 18F-FDG uptake provided by PET/CT enables accurate differentiation between graft and soft-tissue infection.

Hemorrhagic complications of minimally invasive urological surgeries, treated with selective endovascular embolization.

Minimally invasive urological procedures have gained in popularity and replaced open surgery in various urological procedures. Although considered minimally invasive, these procedures are not free from complications, and life-threatening hemorrhage may occur. Herein we describe 3 case series of patients who underwent minimally invasive urological surgeries that were complicated with bleeding. In all 3 patients we used super selective angiographic embolization to stop hemorrhage. Minimally invasive urological surgeries carry the risk of hemorrhage, and patients should be informed about this possibility. In hemodynnmic stable patients endovascular embolization allowed bleeding cessation with maximal preservation of the bleeding kidney tissue.

SPECT/CT using 67Ga and 111In-labeled leukocyte scintigraphy for diagnosis of infection.

UNLABELLED: The present study evaluated the role of SPECT/CT as an adjunct to (67)Ga (GS) or (111)In-labeled white blood cell (WBC) scintigraphy for diagnosis or localization of infection. METHODS: Eighty-two patients (56 male and 26 female; mean age, 62 y) assessed for known or suspected infectious processes underwent 88 SPECT/CT studies. Forty-seven patients underwent GS SPECT/CT (13 with fever of unknown origin, 21 with suspected osteomyelitis, and 13 with suspected soft-tissue infection), and 35 patients underwent WBC SPECT/CT (24 with suspected vascular graft infection, and 11 with suspected osteomyelitis). Ninety-eight suggestive sites were identified (52 on GS and 46 on WBC). Additional information provided by SPECT/CT for diagnosis or localization of infection, as compared with planar and SPECT scintigraphy, was recorded. The SPECT/CT contribution was analyzed on a patient and site basis and was compared for the 2 tracers and clinical indications. RESULTS: SPECT/CT provided additional information for infection diagnosis and localization in 39 (48%) of 82 patients and in 47 (48%) of 98 sites. SPECT/CT defined the extent of infection in 35 patients (43%) in 43 sites (44%) and excluded infection in 4 suggestive sites defined as physiologic bowel uptake on GS. SPECT/CT was incorrect in 2 suggestive sites (1 GS and 1 WBC). The contribution of SPECT/CT was significantly higher for WBC than for GS (P < 0.05)--in 63% versus 36% of patients, respectively, and in 61% versus 36% of sites, respectively. CONCLUSION: SPECT/CT made an incremental contribution to GS and WBC in 48% of patients with suspected infections, by improving diagnosis, localization, and definition of extent of disease. SPECT/CT has an important role mainly with highly specific, low-background infection-seeking tracers such as WBC.

Comparison of multidetector computed tomography versus echocardiography for assessing regional left ventricular function.

Multidetector computed tomography (MDCT) of the heart is a rapidly developing technique mainly used to evaluate the coronary arteries. However, it is also capable of evaluating ventricular function. It compares well with magnetic resonance imaging in calculating volumes and ejection fractions, but little has been reported on its ability to assess left ventricular (LV) segmental wall motion (LVSWM). This study compared semiquantitative LVSWM scoring by MDCT with echocardiography as the gold standard. Thirty-nine patients underwent MDCT angiography on a 16-slice scanner. Short- and long-axis LV slices were created at different phases of the cardiac cycle and visually evaluated using cine mode. Echocardiography was performed <48 hours after MDCT for 21 patients after acute myocardial infarctions and <1 month after MDCT for 18 patients without acute myocardial infarctions. Two blinded observers scored the MDCT and echocardiographic examinations according to the 16-segment model, scoring each segment from 1 (normal) to 3 (akinetic). Segmental dysfunction was found in 27 patients by echocardiography and in 24 by MDCT. An identical score was given by the 2 methods in 502 of 616 assessable segments (82%). Using a binary analysis (normal or abnormal), there was 89% agreement (546 of 616 segments). MDCT had a sensitivity of 66% (103 of 155 segments) and a specificity of 96% (443 of 461 segments) compared with echocardiography as the gold standard. Most disagreements occurred in the right coronary artery segments. In conclusion, MDCT can be used to evaluate LVSWM, showing good agreement with echocardiography, except for the right coronary artery segments.

Combined functional and structural evaluation of cancer patients with a hybrid camera-based PET/CT system using (18)F-FDG.

UNLABELLED: Correct diagnosis and definition of the functional and anatomic status of lesions in cancer patients are of clinical importance. The value of hybrid imaging using a gamma camera-based PET/CT and (18)F-FDG in determining the relationship between mass and cancer was assessed. METHODS: Hybrid imaging was performed using a device combining low-dose CT and gamma camera-based PET. Ninety-one patients with histologically proven malignancy and 190 suspected sites of disease were evaluated. Camera-based PET was performed after the injection of 296-370 MBq (18)F-FDG. The presence of organomegaly or an abnormal mass on CT and of abnormal uptake of (18)F-FDG was assessed for each suspected lesion. The presence of malignancy at each site was determined by biopsy, imaging follow-up, or clinical outcome. RESULTS: Five imaging patterns were found. Pattern 1 showed congruent abnormal (18)F-FDG uptake and a mass on CT in 110 of the lesions. One hundred two sites (93%) had active cancer. Pattern 2 showed a mass on CT, larger than the area of abnormal (18)F-FDG uptake, and was found in 5 lesions. Active malignancy was proven in 3 sites (60%). Pattern 3 showed an abnormal mass on CT with no (18)F-FDG uptake and was found in 52 lesions. Thirteen of these lesions (25%) had active tumor. Pattern 4 showing abnormal (18)F-FDG uptake with no mass on CT was found in 23 lesions. Sixteen of these sites (70%) were malignant. Pattern 5 showed normal CT findings and no abnormal (18)F-FDG uptake in 11 patients. Two of these patients (18%) had active disease. Hybrid imaging was of value in establishing the correct relationship between CT and (18)F-FDG findings in 98 of the 190 lesions (52%). CONCLUSION: A range of patterns presenting with or without abnormal (18)F-FDG uptake on camera-based PET and a mass on CT may occur in suspected cancer sites. Both structural changes on CT and increased cell metabolism expressed by abnormal (18)F-FDG uptake should be considered in oncologic imaging. Hybrid imaging, a combined physiologic and anatomic modality, appears to provide new diagnostic opportunities in characterizing function and morphology in malignancies.

PET/CT using 2-deoxy-2-[18F]fluoro-D-glucose for the evaluation of suspected infected vascular graft.

An infected vascular graft was identified using a combined positron emission tomography (PET) and computerized tomography (CT) system. The fusion of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) PET and CT images, acquired in a single session, allowed for the precise localization of the abnormal FDG uptake to the vascular graft and led to the correct diagnosis of prosthetic infection. This hybrid modality, which provides precise registration of metabolic and structural imaging data, may enhance the potential use of FDG in the diagnosis and management of infected vascular grafts.

Abdominal aortic aneurysm in Behçet's disease: new treatment options for an old and challenging problem.

BACKGROUND: Arterial involvement in Behçet's syndrome is rare. Aneurysms are common among the arterial lesions, affecting various arteries but mostly the abdominal aorta. Surgical interposition graft insertion is the treatment of choice for large aneurysms. However, vasculitis in these patients is the reason for the notorious surgical complications that result in up to 50% false aneurysms in anastomotic sites. Recently, endovascular repair for abdominal aortic aneurysms has been established. OBJECTIVES: To learn more about vascular Behçet's and, specifically, to compare the results of surgical treatment and endovascular repair of AAA in patients with Behçet's syndrome. METHODS: We retrieved the medical records of all 53 patients with Behçet's disease admitted to Rambam Medical Center during the years 1985 and 2001, and analysed the results and follow-up of open surgery versus endovascular repair of AAA in patients with known Behçet's syndrome. RESULTS: Of the 53 patients with Behçet's disease 18 had vascular manifestations (34%). AAAs were encountered in 8 patients (15%) and 5 were treated. Open surgery (group 1), under general anesthesia, lasted less than 3 hours with an average aortic damping time of 34 minutes (range 26-41 min) after which the patients were transferred to the intensive care unit for 24-48 hours. Endovascular treatment (group 2), although lasting about the same time without the need for intensive care, necessitated contrast media and fluoroscopy. The length of hospital stay was considerably shorter for patients after endovascular repair compared to open surgery (3 days vs. 6 days). Combined mortality and morbidity was higher in patients who underwent open surgery compared to endovascular repair (one death, one major amputation and three anastomotic pseudoaneurysms compared to one temporary contrast-induced nephropathy). CONCLUSIONS: Vasculo-Behçet's patients with AAA are better candidates for endovascular treatment than atherosclerotic patients. Combined morbidity (especially anastomotic pseudoaneurysms) and mortality of Behçet's patients after endovascular repair is considerably lower than after open surgery.

Management of combat vascular injuries using modern imaging: are we getting better?

Background. Vascular injuries often result in life threatening hemorrhage or limb loss. When they present with a single entry or exit wound, surgery is immediately indicated. With multiple injuries, however, imaging such as CTA is necessary for diagnosis and choice of treatment. Methods. For all combat-related vascular cases admitted to our medical center during the Lebanon wars in 1982 and 2006, we compiled and compared presenting signs and symptoms, means of diagnosis, treatments, and results. Results. 126 patients with vascular injuries were admitted (87 in 1982, 39 in 2006). 90% were male; mean age of 29 years (range 20-53). All injuries were accompanied by insult to soft tissue, bones, and viscera. 75% presented with injury to arteries in the extremities. 75% of these patients presented with limb ischemia, and 25% sustained massive blood loss. Treatments included venous interposition graft, end-to-end anastomosis, venous patch, endovascular technique (only in 2006), and ligation/observation. Complications included thrombosis and wound infections. Mortality and amputations occurred only in 1982, and this may be attributed to the use of imaging, advanced technique, and shorter average time from injury to hospital (7 hours). Conclusions. We recommend CTA as the first line modality for diagnosis of vascular injuries, as its liberal use allowed for early and appropriate treatment. Treatment outcomes improved with fast and effective resuscitation, liberal use of tourniquets and fasciotomies, and meticulous treatment by a multidisciplinary team.