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3D and Workflow: Misdiagnosis and Use of 3D Imaging Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ 3D and Workflow ❯ Misdiagnosis and Use of 3D Imaging

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  • “Medicine exists as a public trust, with the expectation that the profession will self-regulate. Today, in the wake of all harmful errors, bioethical principles require that clinicians and health care organizations demonstrate transparency, compassion, and accountability and proactively meet patient needs. These steps can not only increase trust in the health care system, but also help it improve.”
    Responding to Medical Errors — Implementing the Modern Ethical Paradigm
    Thomas H. Gallagher, M.D., and Allen Kachalia
    N engl j med 390;3 nejm.org January 18, 2024
  • “Several factors initiated a paradigm shift. In the early 2000s, reports from the Institute of Medicine transformed the way the health care profession conceptualized patient safety.1 The imperative became creating cultures of safety that encouraged everyone to report errors to enable learning and foster more reliable systems. Transparency assumed greater importance, since you cannot fix problems you don’t know about. The ethical imperative for openness was further supported when rising consumerism made it clear that patients expected responses to harm to include disclosure of what happened, an apology, reconciliation, and organizational learning.”
    Responding to Medical Errors — Implementing the Modern Ethical Paradigm
    Thomas H. Gallagher, M.D., and Allen Kachalia
    N engl j med 390;3 nejm.org January 18, 2024
  • “Recent advances in 3-dimensional visualization of volumetric computed tomography data have led to the novel technique of cinematic rendering (CR), which provides photorealistic images with enhanced surface detail and realistic shadowing effects that are generally not possible with older methods such as volume rendering. The emergence of CR coincides with the increasingly widespread availability of virtual reality (VR)/ augmented reality (AR) interfaces including wearable headsets. The intersection of these technologies suggests many potential advances, including the ability of interpreting radiologists to look at photorealistic images of patient pathology in real time with surgeons and other referring providers, so long as VR/AR headsets are deployed and readily available. In this article, we will present our initial experience with viewing and manipulating CR images in the context of a VR/AR headset. We include a description of key aspects of the software and user interface, and provide relevant pictorial examples that may help potential adopters understand the initial steps of using this exciting convergence of technologies. Ultimately, trials evaluating the added value of the combination of CR with VR/AR will be necessary to understand the potential impact of these methods on medical practice.”
    Augmented Reality With Cinematic Rendered 3-Dimensional Images From Volumetric Computed Tomography Data
    Steven P. Rowe, MD, PhD,* Robert Schneider, PhD,† Sebastian Krueger, PhD,† Valerie Pryde, RT, CIIP,* Linda C. Chu, MD,* and Elliot K. Fishman, MD*
    J Comput Assist Tomogr • (in press) 2022
  • “In parallel to the development of CR, virtual reality (VR)/ augmented reality (AR) has also been increasingly incorporated intomedical imaging The combination of photorealistic CR images with a VR/AR interface can facilitate real-time discussions between imaging specialists and clinicians and allow multiple individuals from an interdisciplinary team to see and manipulate the CR images. Photorealistic images are necessary to create the proper depth and immersion to best leverage VR/AR emerging technology. In this article, we will describe our initial experience with the HoloLens headset as a display for CR images and offer observations on the interface and its potential future applications.”
    Augmented Reality With Cinematic Rendered 3-Dimensional Images From Volumetric Computed Tomography Data
    Steven P. Rowe, MD, PhD,* Robert Schneider, PhD,† Sebastian Krueger, PhD,† Valerie Pryde, RT, CIIP,* Linda C. Chu, MD,* and Elliot K. Fishman, MD*
    J Comput Assist Tomogr • (in press) 2022I
  • “With the CR image projected into AR, the user can make a brief squeezing motion with his/her hand and outline the image. A white cube surrounds the CR image, and the user can either manipulate the image from the corners of the cube (pinching a corner and moving in or out will zoom the image) or, with another hand motion, covert the cube to have linear projections from the middle of the sides, which permit the user to spin the image or apply cut-planes. Please note that in capturing images for the figures in this article, it was difficult to film the cube, hence this feature of the software is not shown. The user can also walk around the CR hologram to see obscured anatomy or pathology, although this should be done with caution in an area cleared of trip hazards, because the user's vision is restricted by the headset and the projected CR hologram.”
    Augmented Reality With Cinematic Rendered 3-Dimensional Images From Volumetric Computed Tomography Data
    Steven P. Rowe, MD, PhD,* Robert Schneider, PhD,† Sebastian Krueger, PhD,† Valerie Pryde, RT, CIIP,* Linda C. Chu, MD,* and Elliot K. Fishman, MD*
    J Comput Assist Tomogr • (in press) 2022I
  • “There are other potential advantages of the combination of CR and AR/VR. The rise of artificial intelligence (AI) as a driving force in the future of radiology suggests that new visualization methods for volumetric data may be important as data inputs for graphical processing unit–driven AI workstations. Adding AR/ VR to CR visualizations may allow nonradiologists to have input into the images that are sent to the picture archiving and communication system and facilitate the incorporation of clinical data into ensemble AI algorithms.”
    Augmented Reality With Cinematic Rendered 3-Dimensional Images From Volumetric Computed Tomography Data
    Steven P. Rowe, MD, PhD,* Robert Schneider, PhD,† Sebastian Krueger, PhD,† Valerie Pryde, RT, CIIP,* Linda C. Chu, MD,* and Elliot K. Fishman, MD*
    J Comput Assist Tomogr • (in press) 2022I
  • “CR of PET/CT data provides a photorealistic means of visualizing complex fusion imaging datasets. Such visualizations may aid anatomic understanding for surgical or procedural applications, may improve teaching of trainees, and may allow improved communication with patients.”
    Photorealistic three‑dimensional visualization of fusion datasets: cinematic rendering of PET/CT
    Steven P. Rowe · Martin G. Pomper · Jeffrey P. Leal · Robert Schneider · Sebastian Krüger · Linda C. Chu · Elliot K. Fishman 
  • The external light used for CR is emitted from a high dynamic range (HDR) lightmap that defines the environment of the rendering. Because CR is based on the enhanced rendering equation, it can support the option that external light can not only be scattered and reflected, but internal light can also be emitted by a volume or a segmentation. In the current algorithm, we added a parameter for the PET dataset that defines how much light is emitted by the PET, which can also be set to zero so that in such a case no internal light is emitted at all. To have more flexibility to influence internal versus external light, we also added a parameter that scales the intensity of the external light emitted from the lightmap.
    Photorealistic three‑dimensional visualization of fusion datasets: cinematic rendering of PET/CT
    Steven P. Rowe · Martin G. Pomper · Jeffrey P. Leal · Robert Schneider · Sebastian Krüger · Linda C. Chu ·Elliot K. Fishman
    Abdominal Radiology (2022) 47:3916–3920 
  • “There are potential limitations of the described technique. The creation of PET/CT CR images may add significant time to the interpretation of cases until the reader develops the necessary experience to quickly utilize presets and adjust those presets as needed. Although there is no specific expertise required for the successful deployment of PET/CT CR images, there is a learning curve and readers may need to make the time to familiarize themselves with the software and develop a facility with the presets and their manual manipulation. Further, key pathology can be obscured by overlapping structures in the CR images, necessitating diligent correlation to the 2D reconstructions and the use of cut planes and multiple presets to ensure important findings are well displayed. Of course, potential applications will need to be studied. Nonetheless, the presented technology is promising. The ultimate utility of this technology will depend upon its widespread availability and acceptance by imaging specialists.”
    Photorealistic three‑dimensional visualization of fusion datasets: cinematic rendering of PET/CT
    Steven P. Rowe · Martin G. Pomper · Jeffrey P. Leal · Robert Schneider · Sebastian Krüger · Linda C. Chu ·Elliot K. Fishman
    Abdominal Radiology (2022) 47:3916–3920 
  • “Augmented and virtual reality devices are being actively investigated and implemented for a wide range of medical uses. However, significant gaps in the evaluation of these medical devices and applications hinder their regulatory evaluation. Addressing these gaps is critical to demonstrating the devices’ safety and effectiveness. We outline the key technical and clinical evaluation challenges discussed during the US Food and Drug Administration’s public workshop, “Medical Extended Reality: Toward Best Evaluation Practices for Virtual and Augmented Reality in Medicine” and future directions for evaluation method development. Evaluation challenges were categorized into several key technical and clinical areas. Finally, we highlight current efforts in the standards communities and illustrate connections between the evaluation challenges and the intended uses of the medical extended reality (MXR) devices. Participants concluded that additional research is needed to assess the safety and effectiveness of MXR devices across the use cases.”
    Evaluation Challenges for the Application of Extended Reality Devices in Medicine
    Ryan Beams et al.  
    Journal of Digital Imaging (2022) 35:1409–1418
  • “In addition to image quality considerations from the hardware components, the software and rendering pipeline also introduce unique challenges for MXR devices. MXR devices often utilize commercial game engines for visualization and rendering. The formatting, bit-depth, voxelization, grayscale, and color properties of the input medical images can be impacted by the rendering process due to the use of shaders, material properties, and graphical performance optimization. This is particularly true for diagnostics and surgery planning using radiographic images that generally utilize the Digital Imaging and Communications in Medicine (DICOM) Grayscale Standard Display Function. The impact of these rendering engines on medical image quality is largely unexplored lacking both standards and evaluation methods. Besides the rendering pipeline, formatting of the saved data including biometrics also presents a challenge from both a data standardization perspective and a data security perspective.”
    Evaluation Challenges for the Application of Extended Reality Devices in Medicine
    Ryan Beams et al.  
    Journal of Digital Imaging (2022) 35:1409–1418
  • “The task and physical environments also impact the usability of MXR devices by adding additional evaluation considerations. For example, a VR device for immersive therapeutics raises different evaluation considerations for usability. Similarly, surgical tasks in interventional suites and operating rooms with bright ambient illumination present unique challenges for the visibility and spatial mapping of AR images, including the visibility of the patient’s anatomy and the virtual medical image overlaid on the patient. In addition to visibility, the perceived accuracy of an image overlaid on a patient also raises usability questions. Different surgical tasks have varying requirements for AR image accuracy, which can influence device design.”
    Evaluation Challenges for the Application of Extended Reality Devices in Medicine
    Ryan Beams et al.  
    Journal of Digital Imaging (2022) 35:1409–1418
  • “The consensus from the public workshop is that significant evaluation challenges for MXR devices persist across use cases. These can be categorized into a variety of technical and clinical challenges, which were summarized in this consensus article. To address these evaluation gaps, additional research is needed to characterize the performance of these devices from technical and medical performance perspectives. The relevant evaluation challenges and the specific assessment gaps primarily are determined by the intended use of a device. Therefore, development of suitable evaluation methods necessitates expertise across the MXR landscape in a precompetitive space to address the needs of the larger community. A number of potential avenues currently being explored would create the needed platforms for collaboration, including proposals to further the research establishing partnerships among industry, academia, and regulators.”
    Evaluation Challenges for the Application of Extended Reality Devices in Medicine
    Ryan Beams et al.
     Journal of Digital Imaging (2022) 35:1409–1418
  • Purpose: To determine the rate and nature of significant discordances between community and subspecialist emergency radiologists’ interpretations of cross-sectional exams performed on patients transferred to our trauma center.
    Methods: Outside hospital CT and MRI exams performed on transfer trauma patients are routinely overread by subspecialist emergency radiologists, specifying either concordance or discordance with the interpretation by the community radiologist. We evaluated the discordant reports for clinical significance, defined as an additional finding or difference in interpretation which was likely to affect patient management. The total rate of significant discordances, rate by modality, rate by body region, and rate per patient transferred were calculated. The most common errors were identified, and the distribution of errors among individual community radiologists was examined.  
    Transfer patient imaging: discordances between community and subspecialist emergency radiologists  
    Michael G. Flowers et al.
    Emergency Radiology (2022) 29:395–401 
  • Purpose: To determine the rate and nature of significant discordances between community and subspecialist emergency radiologists’ interpretations of cross-sectional exams performed on patients transferred to our trauma center.
    Conclusion: There is frequent discordance between community and emergency radiologists’ interpretations of CT and MRI exams, leading to a change in transferred patient management. Thus, trauma center radiologists provide added value over- reading these patients’ exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams.
    Transfer patient imaging: discordances between community and subspecialist emergency radiologists  
    Michael G. Flowers et al.
    Emergency Radiology (2022) 29:395–401 
  • Results: 9175 exams were reviewed. Significant discordances were encountered in 4.1% of exams: 3.9% for CT and 6.7% for MRI; 5.1% for head and neck exams, 3.3% for spine, 3.8% for torso, and 2.9% for extremities. The discordance rate per patient transferred was 7.7%. The most common discordances involved missing injuries to the cranio-cervical junction, missing or misinterpreting vascular injuries in the neck, and incompletely characterizing facial fractures. Discordances were evenly spread among 220 community radiologists.  
    Conclusion: There is frequent discordance between community and emergency radiologists’ interpretations of CT and MRI exams, leading to a change in transferred patient management. Thus, trauma center radiologists provide added value over- reading these patients’ exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams.  
    Transfer patient imaging: discordances between community and subspecialist emergency radiologists  
    Michael G. Flowers et al.
    Emergency Radiology (2022) 29:395–401 
  • “Allowing for a subjective definition of clinical significance as determined by radiologists, and understanding that our patient population is highly selective, we have identified a relatively frequent rate of discordance between community and subspecialty-trained emergency radiologists when it comes to interpreting cross-sectional exams of trauma patients. Slightly more errors are made on MRI than CT, and while the most common errors involved the head, neck, and spine, errors were distributed throughout the body. Errors were made by a wide number of community radiologists, as opposed to a small number of outliers. These findings suggest that trauma center radiologists provide added value overreading these patients’ exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams.”
    Transfer patient imaging: discordances between community and subspecialist emergency radiologists  
    Michael G. Flowers et al.
    Emergency Radiology (2022) 29:395–401 
  • Errors on CT of the Body in the ER Setting
    Poor patient prep
    Poor selection of scan protocol
    Lack of interaction of the technologists and the Radiologist.
    Mis-reads of CT scans (false positive or negative)
  • “Another common situation that may produce errors is the inadequate flow of intravenously injected contrast material. Consequently, adequate catheter access and a flow rate of intravenous contrast of 3.5 ml/second higher should be established, as such conditions will help for the correct identification of vascular injuries. In fact, in polytrauma patients, the correct characterization of such injuries is crucial; the site of vascular contrast extravasation (blush) must be identified and the nature of the extravasation must be characterized.”
    Errors in imaging patients in the emergency setting.
    Pinto A, Reginelli A, Pinto F et al.
    Br J Radiol 2016; 89: 20150914.
  • “Injuries of the diaphragm are not common and represent 5% of missed injuries, half of which are not recognized in the first 24 h after the traumatic event. Diagnosis of the injured diaphragm is particularly difficult, resulting in a late diagnosis, and some studies have reported that the sensitivity CT examination for the diagnosis of fractures of the diaphragm is relatively low (50–73%).”
    Errors in imaging patients in the emergency setting.
    Pinto A, Reginelli A, Pinto F et al.
    Br J Radiol 2016; 89: 20150914.
  • “Technical parameters of CT scans (region of interest, use of a contrast agent and scanning timing) differ according to the clinical suspected diseases, and if performed under in- appropriate conditions, CT images will not provide appropriate information for diagnosis. Thus, to avoid missing positive CT findings, in addition to careful readings, radiologists need to obtain such patient information from clinicians.”
    Errors in imaging patients in the emergency setting.
    Pinto A, Reginelli A, Pinto F et al.
    Br J Radiol 2016; 89: 20150914.
  • “Liver metastases without sufficient contrast enhancement, those in patients with hepatic steatosis, those in subcapsular locations, and those found at examinations for indications other than to assess for tumors were significantly more likely to be overlooked.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • “CT is often used to image not only liver metastases but also a wide range of potential sites of extrahepatic disease during the same examination. Consequently, CT is recommended as part of the initial workup of many tumors and subsequent surveillance for metastatic disease after a diagnosis of primary cancer. During CT interpretation, however, liver metastases in the early stages are occasionally overlooked, and the best chance to treat them is lost.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • “There are many types of error in diagnostic radiology, but two broad categories have been identified: perceptual errors (those in which an important abnormality is missed on images) and cognitive errors (those in which the abnormality is visually detected but the meaning or importance of the finding is not correctly understood or appreciated). Perceptual errors are also thought to be the main cause of overlooked liver metastases, especially in patients with known malignant tumors.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • “We investigated the imaging character- istics of liver metastases overlooked at contrast-enhanced CT. The results showed that missed lesions were significantly associated with lower CNR, subcapsular location, hepatic steatosis, and examination indication other than assessment of malignant tumors.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • “In this study, missed lesions were significantly associated with subcapsular location. A prior study showed that a common cause of perceptual errors is the location of a finding, and radiologists tend to overlook findings in the periphery of the locations of interest. We may misinterpret subcapsular liver metastases as soft tissue outside the liver because of the thin boundary with background liver. We also may have a tendency to unconsciously focus on the central area of the liver.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • “Missed lesions were significantly associat- ed with examinations performed for indica- tions other than survey of malignant tumors. We may not spend more time and energy to find liver metastases after making the first finding during the examination. This is known as satisfaction of search, the second most common type of diagnostic error.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • “The causes of overlooking metastases, like the causes of missing other lesions, are mul- tifactorial, extremely subjective, and difficult to analyze. They cannot be separated from the interpretation environment of radiologists, such as fatigue, anxiety, and lack of concentration. Knowledge of the specific imaging characteristics that we describe may help radiologists detect liver metastases correctly.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • “In summary, we performed a retrospective study to investigate the imaging characteristics of liver metastases overlooked at contrast-enhanced CT. We conclude that liver metastases without sufficient contrast, those in a subcapsular location, those in patients with hepatic steatosis, and those on scans ob- tained for indications other than survey of malignant tumors may have a tendency to be overlooked. We should keep these points in mind when looking for liver metastases at contrast-enhanced CT.”
    Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT
    Naka H et al.
    AJR 2019; 212:782–787
  • " 3D imaging has matured to become routinely applied in clinical practice. However, despite progress and refinements in organ or structure segmentation, there is a long way to go to obtain fully automatic segmentation of any organ. Although 3D images of bony structures can be obtained by a single mouse click, 3D images of other organs are still time demanding and often require manual adjustments for exact delineation of organs and pathological structures."
    Three-dimensional imaging: Past, present and future
    Fishman EK, Bluemke DA, Soyer P
    Diagnostic and Interventional Imaging
    Volume 97, Issue 3, March 2016, Pages 283-285
  • "With advances in computer hardware especially with advanced graphics processing unit development, the capabilities of low cost post-processing will continue to evolve and 3D imaging has a promising future."
    Three-dimensional imaging: Past, present and future
    Fishman EK, Bluemke DA, Soyer P
    Diagnostic and Interventional Imaging
    Volume 97, Issue 3, March 2016, Pages 283-285
  • "Maximum intensity projection (MIP) imaging involves selecting the highest attenuation voxels in a data set and then incorporating these high-attenuation voxels into a 2D image. MIP imaging is optimized for evaluating vascular anatomy, while volume rendering allows for optimal visualization of the soft tissues, bony structures, and vasculature in a single image and is the most appropriate 3D technique for demonstrating complex relationships between vessels and adjacent organs."
    Three-dimensional imaging: Past, present and future
    Fishman EK, Bluemke DA, Soyer P
    Diagnostic and Interventional Imaging
    Volume 97, Issue 3, March 2016, Pages 283-285
  • "Volume rendering requires a more complex computer algorithm. It analyzes the content of each voxel within a data set, assigns a specific color and transparency based on its underlying attenuation, and subsequently presents the data in a 3D display. 3D imaging is now perceived as a valuable adjunct to 2D images for preoperative evaluation of myriad surgical procedures."
    Three-dimensional imaging: Past, present and future
    Fishman EK, Bluemke DA, Soyer P
    Diagnostic and Interventional Imaging
    Volume 97, Issue 3, March 2016, Pages 283-285
  • 1987 and what has changed?
     
  • “Axial and coronal reformations of 64-section multidetector row CT have equal sensitivity and specificity for the diagnosis of acute abdominal pathology. However, coronal reformations improved the diagnostic confidence for all readers but most significantly for the least experienced. Therefore, radiology departments with residents should consider routinely generating coronal images in patients with acute abdominal pain.”
    Acute abdomen: Added diagnostic value of coronal reformations with 64-slice multidetector row computed tomography.
    Zangos S et al.
    Acad Radiol. 2007 Jan;14(1):19-27.
  • “For the most inexperienced reader, the coronal reformations were helpful in 95% of cases, while for the most experienced reader, the coronal reformations were helpful in 35% of the cases. The coronal images were deemed helpful in an average of 62.3% of the cases for the four readers. However, diagnosing subtle pathology in the abdominal wall was difficult on coronal reformations alone. Overall, coronal reformations improved diagnostic confidence and interobserver agreement over axial images alone for visualization of normal abdominal structures and in the diagnosis of abdominal pathology.”
    Acute abdomen: Added diagnostic value of coronal reformations with 64-slice multidetector row computed tomography.
    Zangos S et al.
    Acad Radiol. 2007 Jan;14(1):19-27.
  • “Acute traumatic intracranial abnormality was detected on axial scans in 45 patients. Subtle findings were confirmed on coronal and sagittal CT reformations in ten cases, and these were undetected initially on axial CT. Coronal and sagittal reformations confirmed subtle findings in 18.2% (10/55) of the cases (P = 0.001). Indeterminate neuroimaging findings confirmed by coronal and sagittal CT head reformations include tentorial and interhemispheric fissure subdural hemorrhage, subarachnoid hemorrhage, and inferior frontal and temporal lobe contusions. Coronal and sagittal CT head reformations improve the sensitivity and diagnostic confidence in the clinical setting of acute trauma. Overall, coronal and sagittal reformations improved diagnostic confidence and interobserver agreement over axial images alone for visualization of normal structures and in the diagnosis of acute abnormality.”
    Subtle pathology detection with multidetector row coronal and sagittal CT reformations in acute head trauma.
    Emerg Radiol. 2010 Mar;17(2):97-102
    Zacharia TT, Nguyen DT.
  • “Coronal and sagittal CT head reformations improve the sensitivity and diagnostic confidence in the clinical setting of acute trauma. Overall, coronal and sagittal reformations improved diagnostic confidence and interobserver agreement over axial images alone for visualization of normal structures and in the diagnosis of acute abnormality.”
    Subtle pathology detection with multidetector row coronal and sagittal CT reformations in acute head trauma.
    Emerg Radiol. 2010 Mar;17(2):97-102
    Zacharia TT, Nguyen DT.
  • “Sixteen-section multi-detector row CT transverse and coronal reformations are equally sensitive and specific for diagnosis of appendicitis. Coronal reformations improve confidence in visualization of appendix (whether diseased or normal) and in diagnosis or exclusion of appendicitis.”
    Acute appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multi-detector row CT.
    Paulson EK et al.
    Radiology. 2005 Jun;235(3):879-85.
  • “Mean sensitivity and specificity for all three readers together were 96% and 95% for transverse reformations alone and 95% and 94% for combined transverse and coronal reformations (not significant), respectively. Visualization rates for portion or all of appendix were higher for combined transverse and coronal reformations than for transverse reformations alone (higher mean confidence scores: 0.23 higher [P < .009] and 0.51 higher [P < .001], respectively). In patients without appendicitis, transverse and coronal reformations together enhanced confidence in exclusion of wall thickening, distention, and fluid (lower confidence scores: 0.21 lower [P < .001], 0.17 lower [P < .01], 1.00 lower [P < .001], respectively). Combined transverse and coronal reformations enhanced confidence in identification of appendix in mean of 57 patients. Combined transverse and coronal scans helped exclude appendicitis in mean of 38 patients and aided diagnosis of it in 15.”
    Acute appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multi-detector row CT.
    Paulson EK et al.
    Radiology. 2005 Jun;235(3):879-85.
  • “ In patients without appendicitis, transverse and coronal reformations together enhanced confidence in exclusion of wall thickening, distention, and fluid (lower confidence scores: 0.21 lower [P < .001], 0.17 lower [P < .01], 1.00 lower [P < .001], respectively). Combined transverse and coronal reformations enhanced confidence in identification of appendix in mean of 57 patients. Combined transverse and coronal scans helped exclude appendicitis in mean of 38 patients and aided diagnosis of it in 15.”
    Acute appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multi-detector row CT.
    Paulson EK et al.
    Radiology. 2005 Jun;235(3):879-85.
  • “ Acute appendicitis is the most common cause of abdominal pain requiring urgent surgery in the United States. The clinical diagnosis can be difficult in patients with atypical presentations and, over the past several decades, computed tomography (CT) has been increasingly utilized to improve diagnostic accuracy. Helical CT has proven to be an excellent tool in the work-up of acute abdominal pain with a diagnostic accuracy for acute appendicitis of 93-99%. However, occasionally there are equivocal or false positive or negative cases, often due to non-visualization of the appendix. The development of multi-detector row CT and recent advancements in reconstruction software has allowed rapid, high-resolution imaging of the entire abdomen and pelvis resulting in multiplanar reformations (MPR) with a spatial resolution similar to that of the axial plane. This article reviews the utility of CT in suspected acute appendicitis and the potential added diagnostic value of coronal reformations in confirming or excluding the diagnosis.”
  • “Helical CT has proven to be an excellent tool in the work-up of acute abdominal pain with a diagnostic accuracy for acute appendicitis of 93-99%. However, occasionally there are equivocal or false positive or negative cases, often due to non-visualization of the appendix. The development of multi-detector row CT and recent advancements in reconstruction software has allowed rapid, high-resolution imaging of the entire abdomen and pelvis resulting in multiplanar reformations (MPR) with a spatial resolution similar to that of the axial plane. This article reviews the utility of CT in suspected acute appendicitis and the potential added diagnostic value of coronal reformations in confirming or excluding the diagnosis.”
    MDCT of acute appendicitis: value of coronal reformations.
    Neville AM, Paulson EK
    Abdom Imaging. 2009 Jan-Feb;34(1):42-8.
  • “Advancements in MDCT technology and improvements in 3D software have significantly improved our ability to detect and characterize pancreatic pathologic disorders. However, we consistently see avoidable errors made by interpreting CT radiologists. These include failure to identify a mass, misdiagnosis of extrapancreatic structures as pancreatic neoplasms, and mischaracterization of a lesion as malignant when it is in fact benign.”
    MDCT of the Abdomen: Common Misdiagnosis at a Busy Academic Center
    Horton KM, Johnson PT, Fishman EK
    AJR 2010;194:660-667s
  • “All suspected pancreatic lesions should be evaluated using thin collimation arterial and portal venous phase acquisitions, and interpretation requires review with interactive multiplanar reconstruction and 3D rendering, even if no lesion is detected on the axial scans. The 3D imaging is especially useful in distinguishing pancreatic from peripancreatic structures and for detecting subtle lesions, as well as for accurate staging of vascular encasement.”
    MDCT of the Abdomen: Common Misdiagnosis at a Busy Academic Center
    Horton KM, Johnson PT, Fishman EK
    AJR 2010;194:660-667s
  • 3D Imaging
    Common Misdiagnosis in Body CT: Solutions
     - The need to be aware of pitfalls in general helps you avoid those pitfalls
     - Moving to routine review of non-axial plane imaging. Even a cursory look at coronal and sagittal images will be useful
     - New workflow patterns with next generation workflow and software that incorporate “advanced visualization tools” and make them “standard visualization tools”.
  • Common Misdiagnosis in Body CT
     - Unsuspected pulmonary embolism
     - Gastric tumors especially toward the fundus
     - Etiology of biliary tract obstruction (stone)
     - Pancreatic tumor detection
     - Renal tumors especially in the upper/lower pole
     - Small bowel tumor detection
     - Mesenteric vascular pathology
     - Musculoskeletal pathology
  • “ At our busy academic institution, we have noticed repeated examples of certain misdiagnosis, even by experienced abdominal imagers, both in our own department and at outside institutions. This is likely related to many factors. Discussed here are a variety of common diagnostic errors on body CT examinations.”

    MDCT of the Abdomen: Common Misdiagnosis at a Busy Academic Center
    Horton KM, Johnson PT, Fishman EK
    AJR 2010; 194:660-667
  • “ For each diagnostic error, we explore the reasons for the misdiagnosis and provide experience based advise to avoid these mistakes.”

    MDCT of the Abdomen: Common Misdiagnosis at a Busy Academic Center
    Horton KM, Johnson PT, Fishman EK
    AJR 2010; 194:660-667
  • “ At some point, multiplanar reconstructions will become the standard of care, as opposed to a supplemental display technique.”

    MDCT of the Abdomen: Common Misdiagnosis at a Busy Academic Center
    Horton KM, Johnson PT, Fishman EK
    AJR 2010; 194:660-667
  • 3D Imaging

    "Isotropic scanning of the abdomen and pelvis allows creation of reformats with similar image quality as similar slice thickness axial source images. These reformats are of sufficient quality to form the basis of clinical interpretation."

    Isotropic CT Examination of Abdomen and Pelvis: Diagnostic Quality of Reformat
    Sandrasegaran K et al.
    Acad Radiol 2006; 13:1338-1343
  • "These reformats may be used as the basis of routine image interpretation, changing the long established tradition of using only axial images for reporting."

    Isotropic CT Examination of Abdomen and Pelvis: Diagnostic Quality of Reformat
    Sandrasegaran K et al.
    Acad Radiol 2006; 13:1338-1343
  • "The sensitivity for diagnosing appendicitis based on the coronal images alone was 96%, the specificity was 100% and the accuracy was 98%. Coronal reformations decreased the number of images by 19%. CT diagnosis of appendicitis based on the coronal images is accurate."

    MDCT diagnosis of appendicitis using only coronal reformations
    Yaghmai V et al.
    Emerg Radiol (2007) 14:167-172 (4MDCT Scanner)
  • "The sensitivity for diagnosing appendicitis based on the coronal images alone was 96%, the specificity was 100% and the accuracy was 98%. CT diagnosis of appendicitis based on the coronal images is accurate."

    MDCT diagnosis of appendicitis using only coronal reformations
    Yaghmai V et al.
    Emerg Radiol (2007) 14:167-172 (4MDCT Scanner)
  • 3D technology :

    "Unsuspected mesenteric arterial abnormality may elude diagnosis when axial MDCT sections are interpreted without 3D renderings."

    Unsuspected Mesenteric Arterial Abnormality: Comparison of MDCT Axial Sections to Interactive 3D Rendering
    Chen JK, Johnson PT, Horton KM, Fishman EK
    AJR 2007;189:807-813
  • "In the era of isotropic data, perhaps the new standard of care will be to review all MDCT data sets in 3D mode to exclude any unsuspected vascular abnormality."

    Unsuspected Mesenteric Arterial Abnormality: Comparison of MDCT Axial Sections to Interactive 3D Rendering
    Chen JK, Johnson PT, Horton KM, Fishman EK
    AJR 2007;189:807-813

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