3D and Workflow

• “ Quality control  does not negatively affect productivity. Performance monitoring and echnologist mentoring are essential for quality assurance and result in considerable improvement.”
  Quality Improvement in 3D Imaging
  Pierce L et al.
  AJR 2012:198;150-155

Cardiac

• Cardiac Tamponade: Causes
  - Malignant pericardial effusion
  - Free wall aortic rupture following a myocardial infarction
  - Rupture of a coronary artery aneurysm
  - Complications of endocarditis
  - Cardiac neoplasms
  - Dressler syndrome
  - Trauma
• Cardiac Tamponade: Causes
  - Aortic dissection
  - Aneurysm rupture
  - Lung cancer
  - Esophageal cancer
• Cardiac Tamponade: CT Findings
  - Enlargement of the SVC with a diameter similar to or greater than that of the adjacent thoracic aorta
  - Enlargement of the IVC with a diameter or greater than twice that of adjacent abdominal aorta
  - Periportal lymphedema
  - Reflux of contrast material within the IVC
  - Reflux of contrast material within the azygous vein
  - Enlargement of hepatic and renal veins
• “ Cardiac tamponade is a hemodynamic state that results from the slow or rapid accumulation of fluid, pus, blood, gas, or benign or malignant neoplastic tissue within the pericardial cavity.”
  Imaging Findings in Cardiac Tamponade with Emphasis on CT
  Restrepo CS et al.
  RadioGraphics 2007; 27:1595-1610
• “ Radiologists should be aware of the clinical significance and the varied appearance of bicuspid valve at cardiac MDCT and cardiovascular MRI.”
  Bicuspid Aortic Valve: Spectrum of Imaging Findings at Cardiac MDCT and Cardiovascular MRI
  Ko SM et al.
  AJR 2012; 198:89-97
• Bicuspid Aortic Valve: Complications
  - Aortic stenosis
  - Aortic regurgitation
  - Infective endocarditis
  - Dilated ascending aorta
  - Aneurysm of the ascending aorta
  - Dissection of the ascending aorta
• Bicuspid Valve Classiciation
  There are 3 key characteristics
  - The number of raphes (type)
  - The spatial position of the cusps and raphe
  - The functional status of the valve
• “ Coronary artery dissection with aortic extension can be a fatal although infrequent complication. he coronary artery entry point is usually stented in the catherization laboratory. Thereafter, CT is the imaging modality of choice for immediate confirmation of the presence or residual iatrogenic dissection and evaluation of its extent and later noninvasive follow-up.”
  Catheter Induced Aortic Dissection After Invasive Coronary Angiography: Evaluation With MDCT
  Tanasie C et al.
  AJR 2011;197:1335-1340
• “ MDCT is a useful alternative to MRO in the evaluation of cardiac and paracardiac masses, particularly in those patients with contraindications to MRI. MDCT has high spatial and temporal resolutions and is sensitive for the presence of calcification and fat.”
  Computed Tomography of Cardiac and Pericardiac Masses
  Rajiah P et al.
  J Cardiovasc Computed Tomogr (2011) 5, 16-29
• Primary Cardiac Neoplasms: Facts
  - Prevalence of 0.002%-0.3% at autopsy and 0.15% in echocardiography series
  - Metastases are 20-40 times as common as primary cardiac neoplasms
  - In an AFIP series of primary tumors and cysts of the heart and pericardium, 60% were benign tumors, 23% were malignant tumors and 17% were cysts
• Cardiac Masses: Benign
  - Myxoma
  - Lipoma
  - Papillary fibroelastoma
  - Hemangioma
  - Paraganglioma
  - Rhabdomyoma
  - Fibroma
  - Teratoma
• Cardiac Masses: Malignant
  - Metastases
  - Lymphoma
  - Sarcoma (spindle cell, angiosarcoma, undifferentiated sarcoma, liposarcoma, MFH)
  - Malignant teratoma
  - Mesothelioma
• Cardiac Masses: Nontumoral
  - Lipomatous hypertrophy of the interatrial septum
  - Thrombus
  - Pericardial cyst
  - Bronchognic cyst
  - Caseous mairal annuar calcification
  - Hiatal hernia
  
  
  

Chest

• What is the role of CAD in CT today?
  - Virtual colonoscopy
  - Coronary artery stenosis detection
  - Lung nodule detection
  - Pulmonary embolism detection
• “ At the expense of increased reading time, CAD has the potential to increase reader sensitivity for detecting segmental and subsegmental PE without significant loss of specificity.”
  Acute Pulmonary Embolism: Effect of a Computer-assited Detection Prototype on Diagnosis-An Observer Study
  Wittenberg R et al.
  Radiology 2012; 262:305-313
• “ In summary we conclude from our results that CAD has the potential to increase reader sensitivity for the detection of segmental and subsegmental pulmonary emboli and to strengthen reader confidence for the diagnosis of PE without significant loss of specificity. For clinical application of CAD, the number of false positive candidate lesions has to be further decreased.”
  Acute Pulmonary Embolism: Effect of a Computer-assited Detection Prototype on Diagnosis-An Observer Study
  Wittenberg R et al.
  Radiology 2012; 262:305-313
• “ In summary we conclude from o
  ur results that CAD has the potential to increase reader sensitivity for the detection of segmental and subsegmental pulmonary emboli and to strengthen reader confidence for the diagnosis of PE without significant loss of specificity.”
  Acute Pulmonary Embolism: Effect of a Computer-assited Detection Prototype on Diagnosis-An Observer Study
  Wittenberg R et al.
  Radiology 2012; 262:305-313
• “ For clinical application of CAD, the number of false positive candidate lesions has to be further decreased.”
  Acute Pulmonary Embolism: Effect of a Computer-assisted Detection Prototype on Diagnosis-An Observer Study
  Wittenberg R et al.
  Radiology 2012; 262:305-313
• Pulmonary Embolism in Pregnancy: Facts
  - Estimated incidence of 10.6 per 100,000
  - Risk is highest in the post partum period
  - Prevalence of PE in pregnant woman presenting with clinical symptoms is in the 3-6% range
  - CT is a challenge in the pregnant patient due to physiologic changes including increased cardiac output and blood volume that result in decreased opacification
• “ Pulmonary embolism (PE) is a leading cause of maternal mortality in the developed world. Along with appropriate prophylaxis and therapy, prevention of deaths from PE in pregnancy requires a high index of clinical suspicion followed by a timely and accurate diagnostic approach.”
  American Thoracic Society Documents: An Official American Thoracic Society/Sociey of Thoracic radiology Clinical Practice Guideline-Evaluation of Suspected Pulmonary Embolism in Pregnancy
  Leung AN et al.
  Radiology 2012; 262:635-646
• Fetal and Maternal Doses Associated with Diagnostic Tests for PE
  Executive Summary: Seven Recommendations
  - “ In pregnant woman with suspected PE we suggest that D-dimer not be used to exclude PE.” (weak recommendation, very low quality evidence)
  - “ In pregnant woman with suspected PE, we recommend a CXR as the first radiation associated procedure in the imaging workup.” (strong recommendation, low quality evidence)
  - “ In pregnant woman with suspected PE and a normal CXR, we recommend lung scintigraphy as the next imaging test rather than CTPA.” (strong recommendation, low quality evidence)
• Executive Summary: Seven Recommendations
  - “ In pregnant woman with suspected PE and a nondiagnostic V/Q scan we suggest further diagnostic testing rather than clinical management alone (weak recommendation, low quality evidence). In patients with a nondiagnostic V/Q scan in whom a decision is made to further investigate, we recommend CTPA rather than DSA (strong recommendation, very low quality evidence)”
  - “In pregnant woman with suspected PE and an abnormal CXR, we suggest CTPA as the next imaging test rather than lung scintigraphy (weak recommendation, very low qualiry evidence.”
• Some Explanations for the Decision Process
  - “ In pregnant woman with suspected PE and a normal CXR, we recommend lung scintigraphy as the next imaging test rather than CTPA.” (strong recommendation, low quality evidence)
  - “ The recommendation puts a high value on minimizing radiation dose to the mother. It puts a lower value on rapidity of the diagnostic test and the possibility of alternate diagnoses afforded by CTPA.”
  -  “ In pregnant woman with suspected PE and a nondiagnostic V/Q scan we suggest further diagnostic testing rather than clinical management alone (weak recommendation, low quality evidence). In patients with a nondiagnostic V/Q scan in whom a decision is made to further investigate, we recommend CTPA rather than DSA (strong recommendation, very low quality evidence)”
  - "This recommendation puts a high value on diagnostic certainty given the potential morbid consequences if PE is undiagnosed due to a nondiagnostic V/Q scan.”

Contrast

• Should you place IV contrast in a warmer prior to using it?
  - Yes
  - No
  - Not sure
• Why would you not warm iodinated contrast?
  - Cost and record keeping is needed
  - Purchase warmer
  - Keep log and monitor the warmer for correct temperature daily (Joint Commission rule)
  - Need to label bottles with 30 day expiration date (Joint Commission rule)
• “ Extrinsic warming (to 37° C) does not appear to affect adverse event rates for intravenous injections of iopamidol 300 of less than 6 ml/sec but is associated with a significant reduction in extravasation and overall adverse event rates for the more viscous iopamidol 370.”
  Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C
  Davenport MS et al.
  Radiology 2012; 262:475-484
• “Discontinuation of extrinsic warming (to 37° C) did not appear to affect adverse event rates for intravenous injections of iopamidol 300 of less than 6 ml/sec but was associated with an approximate tripling of  extravasation and overall adverse event rates for the more viscous iopamidol 370.”
  Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C
  Davenport MS et al.
  Radiology 2012; 262:475-484

Liver

• “ Recent advances in pathology and cytogenetics have thrown fresh light on the pathogenesis of hepatic adenomas leading to classification of HCAs into 3 distinct subgroups, each with a characteristic epidemiology, histopathology, oncogenesis and imaging findings.”
  Hepatocellular Adenomas: Current Update on Genertics, Taxonomy and Management
  Shanbhogue A et al.
  J Comput Assist Tomogra March/April 2011; Volume 35:2; pp159-166
• Hepatic Adenomas: 3 Subtypes
  - Hepatocyte nuclear factor-1α (HNF-1α)-mutated HCAs (HNF-HCAs)
  - β- catenin mutations
  - Inflammatory HCAs (I-HCAs) due to mutations involving interleukin-6 signal transducer (IL-6)
• Hepatic Adenomas: facts
  - More common in woman (1.8-1)
  - Mean age of 41 years
  - Strong relationship between long term oral contraceptive use and hepatic adenoma (usually greater than 2 years)
  - Increased risk with anabolic androgen steroid intake as well as metabolic liver disease such as glycogen storage disease, tyrosinemia, staetohepatits and hemochromatosis
• Hepatic Adenomas: facts
  - Usually solitary
  - May be multiple in adenomatosis (>10 lesion in liver)
  - Size range 1-20 cm
  

Practice Management

• “ The federal government has the authority, precedents, and mechanisms to address CT safety concerns through comprehensive regulatory schemes. Federal activities to date, namely imaging facility accreditation under MIPPA and increased FDA oversight, signify important steps aimed at eliminating the risk of accidental radiation overdoses.”
  The Federal Government’s Oversight of CT Safety: Regulatory Possibilities
  Harvey HB, Pandharipande PV
  Radiology 2012; 262;391-398
• “ However, alone these measures only partially address the CT safety problem as defined by experts in Congressional testimony. Working together with states and the radiologic community, the federal government could further leverage its authority to provide more comprehensive regulatory solutions that attend to overutilization and dose optimization.”
  The Federal Government’s Oversight of CT Safety: Regulatory Possibilities
  Harvey HB, Pandharipande PV
  Radiology 2012; 262;391-398
• Pulmonary Embolism in Pregnancy: Facts
  - Estimated incidence of 10.6 per 100,000
  - Risk is highest in the post partum period
  - Prevalence of PE in pregnant woman presenting with clinical symptoms is in the 3-6% range
  - CT is a challenge in the pregnant patient due to physiologic changes including increased cardiac output and blood volume that result in decreased opacification
• “ Pulmonary embolism (PE) is a leading cause of maternal mortality in the developed world. Along with appropriate prophylaxis and therapy, prevention of deaths from PE in pregnancy requires a high index of clinical suspicion followed by a timely and accurate diagnostic approach.”
  American Thoracic Society Documents: An Official American Thoracic Society/Sociey of Thoracic radiology Clinical Practice Guideline-Evaluation of Suspected Pulmonary Embolism in Pregnancy
  Leung AN et al.
  Radiology 2012; 262:635-646
• Fetal and Maternal Doses Associated with Diagnostic Tests for PE
• Some Explanations for the Decision Process
  - “ In pregnant woman with suspected PE and a normal CXR, we recommend lung scintigraphy as the next imaging test rather than CTPA.” (strong recommendation, low quality evidence)
  - “ The recommendation puts a high value on minimizing radiation dose to the mother. It puts a lower value on rapidity of the diagnostic test and the possibility of alternate diagnoses afforded by CTPA.”
• Some Explanations for the Decision Process
  - “ In pregnant woman with suspected PE and a nondiagnostic V/Q scan we suggest further diagnostic testing rather than clinical management alone (weak recommendation, low quality evidence). In patients with a nondiagnostic V/Q scan in whom a decision is made to further investigate, we recommend CTPA rather than DSA (strong recommendation, very low quality evidence)”
  - “ This recommendation puts a high value on diagnostic certainty given the potential morbid consequences if PE is undiagnosed due to a nondiagnostic V/Q scan.”
• Should you place IV contrast in a warmer prior to using it?
  - Yes
  - No
  - Not sure
• Why would you not warm iodinated contrast?
  - Cost and record keeping is needed
  - Purchase warmer
  - Keep log and monitor the warmer for correct temperature daily (Joint Commission rule)
  - Need to label bottles with 30 day expiration date (Joint Commission rule)
• “ Extrinsic warming (to 37° C) does not appear to affect adverse event rates for intravenous injections of iopamidol 300 of less than 6 ml/sec but is associated with a significant reduction in extravasation and overall adverse event rates for the more viscous iopamidol 370.”
  Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C
  Davenport MS et al.
  Radiology 2012; 262:475-484
• 
  “Discontinuation of extrinsic warming (to 37° C) did not appear to affect adverse event rates for intravenous injections of iopamidol 300 of less than 6 ml/sec but was associated with an approximate tripling of  extravasation and overall adverse event rates for the more viscous iopamidol 370.”
  Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C
  Davenport MS et al.
  Radiology 2012; 262:475-484

Radiation Dose

• Fetal and Maternal Doses Associated with Diagnostic Tests for PE
• Some Explanations for the Decision Process
  - “ In pregnant woman with suspected PE and a normal CXR, we recommend lung scintigraphy as the next imaging test rather than CTPA.” (strong recommendation, low quality evidence)
  - “ The recommendation puts a high value on minimizing radiation dose to the mother. It puts a lower value on rapidity of the diagnostic test and the possibility of alternate diagnoses afforded by CTPA.”
• Some Explanations for the Decision Process
  - “ In pregnant woman with suspected PE and a nondiagnostic V/Q scan we suggest further diagnostic testing rather than clinical management alone (weak recommendation, low quality evidence). In patients with a nondiagnostic V/Q scan in whom a decision is made to further investigate, we recommend CTPA rather than DSA (strong recommendation, very low quality evidence)”
  - “ This recommendation puts a high value on diagnostic certainty given the potential morbid consequences if PE is undiagnosed due to a nondiagnostic V/Q scan.”
• “ The federal government has the authority, precedents, and mechanisms to address CT safety concerns through comprehensive regulatory schemes. Federal activities to date, namely imaging facility accreditation under MIPPA and increased FDA oversight, signify important steps aimed at eliminating the risk of accidental radiation overdoses.”
  The Federal Government’s Oversight of CT Safety: Regulatory Possibilities
  Harvey HB, Pandharipande PV
  Radiology 2012; 262;391-398
• “ However, alone these measures only partially address the CT safety problem as defined by experts in Congressional testimony. Working together with states and the radiologic community, the federal government could further leverage its authority to provide more comprehensive regulatory solutions that attend to overutilization and dose optimization.”
  The Federal Government’s Oversight of CT Safety: Regulatory Possibilities
  Harvey HB, Pandharipande PV
  Radiology 2012; 262;391-398

Small Bowel

• “ CT angiography performed in the emergency setting in patients with acute lower intestinal bleeding is feasible and correctly depicts the presence and location of active or recent hemorrhage, as well as the potential cause, in the majority of patients.”
  Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography
  Marti M et al.
  Radiology 2012; 262:109-116
• “ CT angiography depicted or helped exclude active or recent bleeding  with an accuracy of 98% (46 of 47 patients).”
  Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography
  Marti M et al.
  Radiology 2012; 262:109-116
• “ CT angiography correctly helped identify the cause of bleeding in 93% (39 of 42) of patients in whom a source of hemorrhage was ultimately established.”
  Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography
  Marti M et al.
  Radiology 2012; 262:109-116
• “ Findings of CT angiography and the standard of reference (angiography, colonoscopy, or surgical findings) were concordant for determining definitive or potential cause of bleeding in 44 of 47 patients (93% accuracy).”
  Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography
  Marti M et al.
  Radiology 2012; 262:109-116
• “ Rather than restricting it to cases where colonoscopy fails initially, in the majority of cases, we propose CT angiography as the first step in diagnostic evaluation of patients with substantial bleeding for confirmation of active or recent hemorrhage and correct identification of the site and cause of bleeding.”
  Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography
  Marti M et al.
  Radiology 2012; 262:109-116
• GI Bleed Scan protocol
  - Non contrast
  - Arterial phase (trigger at 150 HU)
  - Venous phase (at 70 sec post start of injection)
  - Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography
  Marti M et al.
  Radiology 2012; 262:109-116
• Why do a non-contrast CT for GI Bleeding studies?
  - Prevent confusion of high density material in or near bowel with hemorrhage
  - High density material in bowel is considered 60 HU or greater

Vascular

• “ Coronary artery dissection with aortic extension can be a fatal although infrequent complication. he coronary artery entry point is usually stented in the catherization laboratory. Thereafter, CT is the imaging modality of choice for immediate confirmation of the presence or residual iatrogenic dissection and evaluation of its extent and later noninvasive follow-up.”
  Catheter Induced Aortic Dissection After Invasive Coronary Angiography: Evaluation With MDCT
  Tanasie C et al.
  AJR 2011;197:1335-1340