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Everything you need to know about Computed Tomography (CT) & CT Scanning

January 2019 Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ January 2019

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Cardiac

    • “Coronary angiography is the current gold standard in providing anatomical information regarding the extent and severity of coronary artery disease. Access site practice has changed in a number of European and Asian countries from mainly being transfemoral (TFA) to transradial (TRA) in view of less access site related bleeding complications, mortality and shorter hospital stay associated with TRA. For instance, in the United Kingdom use of radial access has increased from 14% to 80% between 2005 and 2014 in patients undergoing percutaneous coronary intervention (PCI) and it is estimated that this practice change has saved an estimated 450 lives nationally.”
      Hand dysfunction after transradial artery catheterization for coronary procedures
      Muhammad Ayyaz Ul Haq et al.
      World J Cardiol. 2017 Jul 26; 9(7): 609–619.
    • “Nevertheless, despite of its clear advantages over TFA, TRA is not without limitations and is associated with longer operator learning curve, increased radiation exposure in individual operators at the start of their learning curves and higher case radial proportion to translate the better results of randomized trials into clinical practice. Moreover, vascular complications such as RAO and radial artery spasm are not uncommon and very recently concerns have been raised that patients undergoing TRA PCI may encounter hand dysfunction.”
      Hand dysfunction after transradial artery catheterization for coronary procedures
      Muhammad Ayyaz Ul Haq et al.
      World J Cardiol. 2017 Jul 26; 9(7): 609–619.
    • “In conclusion, hand dysfunction is an exceedingly rare complication post TRA. There is significant heterogeneity in the methodology and reporting of the studies investigating hand function after TRA. Patients may develop non-specific sensory symptoms or muscle weakness but majority of these symptoms resolve over time. Future studies should be focused around assessing such complications using robust methodology and more importantly reporting on the clinical relevance of hand function. Given the reductions in mortality, MACE and major bleeding complications associated with use of TRA in high risk groups undergoing PCI, TRA should remain the default access site for PCI in such high risk groups of patients at risk of bleeding complications, in line with international guidelines and consensus statements.”
      Hand dysfunction after transradial artery catheterization for coronary procedures
      Muhammad Ayyaz Ul Haq et al.
      World J Cardiol. 2017 Jul 26; 9(7): 609–619.
    • “Coronary artery calcium is a highly specific marker for atherosclerosis and represents an integration of all the risk factors over the lifetime of an individual. Coronary artery calcium is a robust predictor of future cardiovascular events, independent of the traditional markers such as the Framingham risk score (FRS).”
      Coronary Artery Calcium Scoring: Current Status and Review of Literature
      Malguria N, Zimmerman S, Fishman EK
      J Comput Assist Tomogr 2018;42: 887–897
    • ”Agatston score is the most commonly used scoring method and defines CAC as any calcium within the coronary arterial system 130 HU or higher, occupying at least 2 to 3 adjacent pixels. The score is determined by summation of the product of the total plaque area and a cofactor determined by the maximum calcium density within the plaque; 1 for lesions with a maximum density of 130 to 199 HU, 2 for lesions with a maximum density of 200 to 299 HU, 3 for lesions with a maximum density of 300 to 399 HU, and 4 for lesions with a density of 400 HU and higher.”
      Coronary Artery Calcium Scoring: Current Status and Review of Literature
      Malguria N, Zimmerman S, Fishman EK
      J Comput Assist Tomogr 2018;42: 887–897
    • Calcium Score Calculation Errors
      a. Inclusion of mitral annular calcification, mistaken as circumflex calcium, which can cause very high false calcium score
      b. Mistaking aortic root calcium for coronary calcium. We exclude ostial calcium to ensure that aortic root calcium is not included in the score.
      c. Motion related beam hardening artifacts may cause overestimation of score
      d. Inclusion of coronary stents results in inappropriately high scores.
    • “The current paradigm of preventive cardiology is future cardiovascular risk prediction, which is performed using cardiovascular risk scores in asymptomatic patients with no known coronary artery disease. Based on the risk allocation, patients are prescribed statins or aspirin, with a goal toward absolute or percentage improvement in low-density lipoprotein cholesterol levels, cholesterol ratio, and systolic blood pressure.”
      Coronary Artery Calcium Scoring: Current Status and Review of Literature
      Malguria N, Zimmerman S, Fishman EK
      J Comput Assist Tomogr 2018;42: 887–897
    • “A 2017 consensus state- ment of the SCCT recommended performing CAC testing in the context of shared decision making for asymptomatic individuals aged 40 to 75 years of age without clinical ASCVD who are in the 5% to 20% 10-year ASCVD risk group (intermediate risk) and selectively in individuals who are in the less than 5% (low risk) 10-year ASCVD, such as those with a family history of pre- mature coronary artery disease.”
      Coronary Artery Calcium Scoring: Current Status and Review of Literature
      Malguria N, Zimmerman S, Fishman EK
      J Comput Assist Tomogr 2018;42: 887–897
    • The presence of calcium on routine noncontrast ungated chest CT is associated with future cardiovascular risk and is currently recommended to be reported on every NCCT, with visual scoring methods demonstrating good correlation with Agatston score categories.
      Coronary Artery Calcium Scoring: Current Status and Review of Literature
      Malguria N, Zimmerman S, Fishman EK
      J Comput Assist Tomogr 2018;42: 887–897
    • “The strong relationship between zero calcium score and very low cardiovascular event rate applies only to asymptomatic individuals. In a study of 133 symptomatic (chest pain) high-risk patients, the median CAC was 66 and 19% of patients had a negative CAC scan. Of symptomatic patients with CAC = 0, 32% patients showed a significant stenosis on invasive angiography . In this scenario other factors come into play like a much higher pre-test probability and the pathophysiological issues of plaque rupture, non- calcified plaque and thrombotic occlusions, none of which are detected by the calcium score. Therefore, a negative CAC scan cannot be used to rule out relevant obstruction in the setting of symptomatic patients.”
      CT calcium scoring. History, current status and outlook
      V. Sandfort, D.A. Bluemke
      Diagnostic and Interventional Imaging (2017) 98, 3—10
    • “The strong relationship between zero calcium score and very low cardiovascular event rate applies only to asymp- tomatic individuals. In a study of 133 symptomatic (chest pain) high-risk patients, the median CAC was 66 and 19% of patients had a negative CAC scan. Of symptomatic patients with CAC = 0, 32% patients showed a significant stenosis on invasive angiography . In this scenario other factors come into play like a much higher pre-test probability and the pathophysiological issues of plaque rupture, non- calcified plaque and thrombotic occlusions, none of which are detected by the calcium score.”
      CT calcium scoring. History, current status and outlook
      V. Sandfort, D.A. Bluemke
      Diagnostic and Interventional Imaging (2017) 98, 3—10
    • “In a study of 133 symptomatic (chest pain) high-risk patients, the median CAC was 66 and 19% of patients had a negative CAC scan. Of symptomatic patients with CAC = 0, 32% patients showed a significant stenosis on invasive angiography . In this scenario other factors come into play like a much higher pre-test probability and the pathophysiological issues of plaque rupture, non- calcified plaque and thrombotic occlusions, none of which are detected by the calcium score. Therefore, a negative CAC scan cannot be used to rule out relevant obstruction in the setting of symptomatic patients.”
      CT calcium scoring. History, current status and outlook
      V. Sandfort, D.A. Bluemke
      Diagnostic and Interventional Imaging (2017) 98, 3—10
    • “In summary, physicians need to be aware of elevated cardiac risk with higher absolute calcium scores. At the same time, a subject with low calcium score but a high percentile rank compared to his peers likely still has an elevated long term risk. This dual approach is also reflected in the 2013 ACC/AHA guidelines by specifying an absolute and a relative cutoff for CAC risk assessment (≥ 300 or ≥ 75th percentile).”
      CT calcium scoring. History, current status and outlook
      V. Sandfort, D.A. Bluemke
      Diagnostic and Interventional Imaging (2017) 98, 3—10
    • ”In summary, repeat calcium scoring in patients with a positive CAC has not been shown to help in treatment decisions. Due to the increase of CAC in relationship to age, multiple CAC scoring sessions may lead to unjustified concerns in patients and possibly unnecessary downstream testing. At this time, repeat CAC scoring is not recommended.”
      CT calcium scoring. History, current status and outlook
      V. Sandfort, D.A. Bluemke
      Diagnostic and Interventional Imaging (2017) 98, 3—10
    • ” If coronary calcium has been identified in a patient, is there any value in performing a follow-up scan to evaluate progression? Multiple prospective, randomized statin trials have evaluated repeat CAC testing. In nearly all trials, the calcium score increased over time in both treatment and placebo groups without statistical intergroup differences. Whether calcium progression is a prognostic indicator above the baseline calcium score is unclear. No clinical algorithm for treatment decisions based on calcium progression exists to date.”
      CT calcium scoring. History, current status and outlook
      V. Sandfort, D.A. Bluemke
      Diagnostic and Interventional Imaging (2017) 98, 3—10
    • CR differs from traditional VR in making use of a global lighting model that more realistically takes into account the interactions of propagating photons with the component materials of the imaged volume. As a result, this method enhances surface detail and creates lifelike shadowing effects in order to generate truly photorealistic visualizations from standard CT acquisition volumetric data.”
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • “ While the advantages of this new technique are still under investigation, potential applications include improved visualization of complex anatomic structures that obviates the need for expensive 3D printing, better display of soft tissue texture that may improve detection and characterization of subtle lesions, improved pre-operative planning, and better trainee and patient engagement.”
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • In this case series, we have demonstrated the ability of CR visualizations to effectively convey key anatomic information related to coronary artery aneurysms in patients with history of KD. While the role of imaging in following patients with KD has been previously investigated, this is the first reported experience with the novel CR visualization methodology, and these examples demonstrate the potential of this technique for evaluating such complex vascular pathologic states.
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • “As with other 3D visualization methods, CR would be expected to provide a global overview of the disease process that is not easily appreciated on 2D axial or multi-planar reformatted images. In particular, this may help to identify relatively distal, small caliber sites of aneurysmal enlargement, which stand out with high contrast on the 3D images but can be subtle when only 2D images are viewed.”
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • “Given the anatomic complexity of the mediastinum with many adjacent vascular structures, it may be that CR has intrinsic advantages relative to other 3D methods in being able to accurately display the relative positions of those structures in a manner that may be more intuitively grasped in comparison to less photorealistic depictions. At the same time, the shadowing effects produced by CR can potentially obscure important sites of pathology, so a careful inspection of CR visualizations from multiple viewing angles and with multiple different window settings is necessary.”
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • Coronary Artery to Pulmonary Artery Fistulae Involving both the LAD and RCA
      - cinematic rendering makes use of a more complex lighting model that creates photorealistic images with improved detail and that demonstrate shadowing effects that allow for robust visualization of the relative positions of structures
    • “Cinematic rendering (CR) a new method of 3D computed tomography (CT) volumetric visualization that produces photorealistic images. As with traditional 3D visualization methods, CR may prove to be of value in providing important information when evaluating regions of complex anatomy such as the heart.”
      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations
      Rowe SP, Johnson PT, Fishman EK
      J Cardiovasc Comput Tomogr. 2018 Jan - Feb;12(1):56-59.
    • “Appropriate selection of window presets using either a ramp (for tissues differing markedly in attenuation such as bone in comparison to adjacent soft tissue) or trapezoid method (for differentiation of similar attenuation structures such as adjacent soft tissues) and slab thickness will allow for appropriate display of pathology and will ensure that a finding of interest is not obscured by an overlying structure.”
      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations
      Rowe SP, Johnson PT, Fishman EK
      J Cardiovasc Comput Tomogr. 2018 Jan - Feb;12(1):56-59.
    • “While the shadowing effects that arise from the global lighting model that is used contribute to the photorealistic quality of the images, shadowing can also potentially obscure important pathology.”
      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations
      Rowe SP, Johnson PT, Fishman EK
      J Cardiovasc Comput Tomogr. 2018 Jan - Feb;12(1):56-59.
    • “Furthermore, three-dimensional volume-rendered CT angiograms facilitate accurate assessment of the complex anatomy of CAFs, including their origin, drainage site, and complexity and the number and size of fistulous tracts. Knowledge of these characteristics is crucial for therapeutic planning.”
      Coronary Artery Fistulas: Pathophysiology, Imaging Findings, and Management
      Yum G, Nam Th, Chun EJ
      RadioGraphics 2018; 38:688–703
    • “Although CAFs historically have been evaluated with conventional invasive angiography,electrocardiographically gated cardiac computed tomographic (CT) angiography has emerged as the noninvasive alternative modality of choice owing to the high spatial and temporal resolution and short acquisition time. Furthermore, three-dimensional volume-rendered CT angiograms facilitate accurate assessment of the complex anatomy of CAFs, including their origin, drainage site, and complexity and the number and size of fistulous tracts. Knowledge of these characteristics is crucial for therapeutic planning.”
      Coronary Artery Fistulas: Pathophysiology, Imaging Findings, and Management
      Yum G, Nam Th, Chun EJ
      RadioGraphics 2018; 38:688–703
    • Coronary Artery Fistulae: Clinical Presentation
      - Incidental finding
      - myocardial ischemia
      - heart failure
      - arrhythmia
      - infective endocarditis in adults
    • “A coronary artery fistula (CAF) or coronary arteriovenous fistula is a congenital or acquired abnormal vascular communication of coronary arteries with cardiac chambers or any segment of the systemic or pulmonary circulation, without an intervening capillary network.”
      Coronary Artery Fistulas: Pathophysiology, Imaging Findings, and Management
      Yum G, Nam Th, Chun EJ
      RadioGraphics 2018; 38:688–703
    • “The drainage site of a CAF is more important clinically than the origin. A shunt to low-pressure structures may dilate the coronary arteries and sometimes lead to aneurysm formation.”
      Coronary Artery Fistulas: Pathophysiology, Imaging Findings, and Management
      Yum G, Nam Th, Chun EJ
      RadioGraphics 2018; 38:688–703
    • Coronary Artery Fistulae: Etiology
      - Congenital (90%)
      - Acquired (10%)
      -- coronary stent placement
      -- coronary bypass surgery
      -- trauma
      -- chest irradiation
      -- myocardial infarction
    • Coronary Artery Fistulae: Facts
      - The right coronary artery (RCA) is the most common origin site of CAFs, accounting for 50%–55% of cases.
      - The left anterior descending artery (LAD), accounting for about 35%–40% of cases
      - left circumflex artery, accounting for 5%–20% cases
    • Coronary Artery Fistulae: Facts
      - The drainage site of CAFs is more important clinically than the origin and is classified into two fistula categories: coronary cameral fistulas, with which coronary arteries drain into the cardiac chamber, and coronary arteriovenous fistulas, with which coronary arteries drain into any segments of the pulmonary or systemic circulation
    • Coronary Artery Fistulae: Facts
      - Coronary cameral fistula, defined as the entry of a coronary artery into any of the cardiac chambers, is considered the most common type of CAF detected with coronary angiography. Coronary cameral fistulas commonly originate from the RCA (55%), the LAD (35%), or both of these arteries.The most commonly involved chamber is the right ventricle (41%), followed by the right atrium (26%) and the left atrium and left ventricle (3%–5%)
    • Coronary Artery Fistulae: Facts
      - The incidence of coronary-to-pulmonary artery fistulas has increased as cardiac CT angiography has become widely used, with these fistulas accounting for 15%–30% of all CAFs
      - results of a recent systematic review (41) showed the LCA to be the most common origin site (84% of cases), followed by the RCA (38% of cases). The majority (89%) of CAFs drain into the pulmonary trunk rather than into other segmental pulmonary arteries.
    • Coronary Artery Fistulae: Management
      - Percutaneous transcatheter closure
      -- Proximal fistula origin
      -- Single drain site
      -- Nontortuous vessel with distal portion of fistula accessible with the closure device
      -- Extra-anatomic termination of fistula away from normal coronary arteries
      -- Older patients with high risk of perioperative complications
      -- Absence of concomitant cardiac disorders
    • Coronary Artery Fistulae: Management
      - Surgical ligation
      -- Large symptomatic fistula with high fistula blood flow
      -- Multiple communications and drainage sites
      -- Tortuous and aneurysmal fistulous arteries
      -- Need for simultaneous distal bypass
      -- Large vascular branches that can be accidentally embolized
    • “A CAF is a rare anomaly with a variable clinical course, from no symptoms to serious complications that include heart failure and myocardial infarction—depending on the extent of the shunt. ECG-gated CT angiography with 3D reconstruction can be used to accurately assess the complex anatomy of CAFs, including the site and number of origins and drainage sites, and the associated anomalies. This information is essential for therapeutic planning.”
      Coronary Artery Fistulas: Pathophysiology, Imaging Findings, and Management
      Yum G, Nam Th, Chun EJ
      RadioGraphics 2018; 38:688–703
    • “Coronary–pulmonary artery fistula in adults was found more often than in previous studies. CAF commonly originates from LCA or both LCA and RCA in adults. DSCT is a robust tool for investigating the origin, course and drainage site of CAF and coexistent abnormalities.”
      Coronary artery fistula in adults: evaluation with dual- source CT coronary angiography
      ZHOU K et al.
      Br J Radiol 2015;88:20140754.
    • “DSCT could provide motion-free high-resolution images by using an electrocardiographically gated technique, especially for coronary CTA with complex vascular anatomy, despite the limited haemodynamic information. The multiplanar reformation can clearly demonstrate the sites of origin and termination of abnormal blood vessels, and the volume-rendered images acquired from three-dimensional CT data sets can provide an overview of the heart as well as its vascular anatomy and help surgeons to understand the anatomical complexity before surgery.”
      Coronary artery fistula in adults: evaluation with dual- source CT coronary angiography
      ZHOU K et al.
      Br J Radiol 2015;88:20140754.
    • Coronary Artery Fistulae: Associated Findings
      - tetralogy of Fallot,
      - atrial septal defects,
      - patent ductus arteriosus
      - ventricular septal defects
      - pulmonary atresia with an intact ventricular septum
    • “With advances in technology, computed tomography coronary angiography (CTCA) can be developed as a low-radiation imaging paradigm for children with KD.7-10 Advantages over echocardiography include the ability to visualize middle and distal coronary segments with little or no interobserver variability. Unlike catheter angiography, CTCA is noninvasive and clearly delineates intramural abnormalities. Besides, the measurements of coronary artery abnormalities (CAA) on catheter angiography.”
      Computed Tomography Coronary Angiography for Evaluation of Children With Kawasaki Disease
      Manphool Singhal et al.
      Current Problems in Diagnostic Radiology 47 (2018) 238–244
    • "In KD, any segment of coronary arteries and their major branches can be involved, although the majority of aneurysms occur in proximal segments. On echocardiography, it is difficult to evaluate middle and distal segments of coronary arteries, particularly in older children. Besides, CTCA is superior to echocardiography in In KD, any segment of coronary arteries and their major branches can be involved, although the majority of aneurysms occur in proximal segments. On echocardiography, it is difficult to evaluate middle and distal segments of coronary arteries, particularly in older children. Besides, CTCA is superior to echocar- diography in the assessment of coronary stenoses and calcifications.”
      Computed Tomography Coronary Angiography for Evaluation of Children With Kawasaki Disease
      Manphool Singhal et al.
      Current Problems in Diagnostic Radiology 47 (2018) 238–244
    • “In conclusion, high-risk patients with histories of KD had nonobstructive and obstructive CAD not visualized by other noninvasive imaging tests. In properly selected high-risk patients with KD, coronary CTA may identify a subset at increased risk for future coronary pathology who may benefit from medical therapy.”
      Coronary Computed Tomographic Angiographic Findings in Patients With Kawasaki Disease
      Kelly Han B, Lesser A, Rosenthal K et al.
      Am J Cardiol 2014;114:1676e1681
    • “We identified obstructive and nonobstructive CAD by coronary CTA in a highly select group of patients with KD with acute-phase coronary artery dilatation, resolved coronary aneurysms, or persistent coronary aneurysms. Coronary disease was present at the time of coronary CTA, with and without persistent coronary aneurysms. Stress imaging studies rarely suggested the presence of physiologically important CAD in those with or without obstruction.”
      Coronary Computed Tomographic Angiographic Findings in Patients With Kawasaki Disease
      Kelly Han B, Lesser A, Rosenthal K et al.
      Am J Cardiol 2014;114:1676e1681
    • Coronary Artery Aneurysms: Facts
      - Hereditary connective tissue disorders like Marfan syndrome and Ehlers–Danlos disease can also result in CAAs.
      - Bacterial, mycobacterial, fungal, syphilitic, Lyme, septic emboli, mycotic aneurysm, and HIV infections are also different CAA etiologies.
    • “The management of CAAs remains a clinical challenge and should be tailored to each patient based on a comprehensive clinical evaluation that encompasses the patient’s cardiovascular risk factors, comorbidities, and the nature and anatomy of the CAA to enable a patient-specific treatment plan. Certainly, as the understanding of the pathophysiology and etiology of CAAs develops, the treatment and prognosis of CAAs will improve.”
      Coronary Artery Aneurysms: A Review of the epidemiology, Pathophysiology, Diagnosis, and Treatment
      Sherif SA et al.
      Frontiers in Cardiovascular Medicine May 2017 Vol 4; 1-12
    • “The management of CAAs remains a clinical challenge and should be tailored to each patient based on a comprehensive clinical evaluation that encompasses the patient’s cardiovascular risk factors, comorbidities, and the nature and anatomy of the CAA to enable a patient-specific treatment plan. Certainly, as the understanding of the pathophysiology and etiology of CAAs develops, the treatment and prognosis of CAAs will improve.”
      Coronary Artery Aneurysms: A Review of the epidemiology, Pathophysiology, Diagnosis, and Treatment
      Sherif SA et al.
      Frontiers in Cardiovascular Medicine May 2017 Vol 4; 1-12
    • Coronary Artery Aneurysms: Etiologies
      - Atherosclerosis,
      - Takayasu arteritis,
      - Congenital disorders,
      - Kawasaki disease (KD)
      - Percutaneous coronary intervention
      - Trauma
      - Ehlers Danlos Syndrome
      - Marfans Syndrome
    • Coronary Artery Aneurysms: Facts
      - Incidence higher in men than in woman (2.2% vs 0.5%)
      - Right coronary artery most commonly affected and is involved in 40-70% of cases
      - most common cause of CAAs is atherosclerosis, which has been linked to 50% of CAAs diagnosed in adults
    • Coronary Artery Aneurysms: Facts
      Kawasaki disease is the most common cause of CAAs in childhood and is the second most common cause in adults. KD is an acute inflammatory syndrome that may result in acute vasculitis of the coronary arteries and subsequent coronary artery dilatation and aneurysm formation; CAAs occur in around 10–15% of patients during the acute phase of the disease
    • “Kawasaki’s disease (KD) is a vasculitis that predominantly affects children and can lead to the development of coronary artery aneurysms. These aneurysms can subsequently thrombose and occlude, which may lead to chest pain and other signs and symptoms of acute coronary syndrome in young patients. Coronary CT angiography, including 3D visualization techniques, is a common modality used in the follow-up of KD patients.”
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • “The most important potential complication of KD is in- flammatory damage to the coronary arteries, which classically leads to the formation of coronary artery aneurysms. These aneurysms will often undergo vascular remodeling and partial thrombosis in order to produce a psuedonormal vascular lumen. However, progressive thrombosis and other stenotic processes such as fibrosis can, over time, precipitate cardiac ischemia that can lead to emergency room presentations for chest pain or other signs of acute coronary syndrome and necessitate invasive and/or surgical interventions.”
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
Chest

    • “Thymic neoplasms are rare tumors that account for less than 1% of all adult malignancies, with reported incidences of one to five cases per 1 million people per year.The primary epithelial neoplasms of the thymus are thymoma and thymic carcinoma, with thymoma being more common. Thymic carcinoma is a more aggressive disease that is often diagnosed with needle biopsy before treatment planning; it has been discussed elsewhere.”
      Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma
      Benveniste MFK et al.
      RadioGraphics 2011; 31:1847–1861
    • Thymomas typically occur in patients older than 40 years of age, are rare in children, and affect men and women equally. Most thymomas are solid neoplasms that are encapsulated and localized to the thymus. Approximately one-third exhibit necrosis, hemorrhage, or cystic components, and approximately one-third invade the tumor capsule and the surrounding structures.
      Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma
      Benveniste MFK et al.
      RadioGraphics 2011; 31:1847–1861
    • “Thymomas are slow-growing neoplasms that may exhibit aggressive behavior such as invasion of adjacent structures and involvement of the pleura and pericardium, but distant metastases are rare”.
      Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma
      Benveniste MFK et al.
      RadioGraphics 2011; 31:1847–1861
    • “Myasthenia gravis associated with thymoma occurs most frequently in women. Between 30% and 50% of patients with a thymoma have myasthenia gravis, whereas 10%–15% of patients with myasthenia gravis have a thymoma.Ten percent of patients with a thymoma have hypogammaglobulinemia, whereas 5% have pure red cell aplasia.Thymomas are also associated with various autoimmune disorders such as systemic lupus erythematosus, polymyositis, and myocarditis”.
      Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma
      Benveniste MFK et al.
      RadioGraphics 2011; 31:1847–1861
    • “The role of imaging is to initially diagnose and properly stage thymoma, with emphasis on the detection of local invasion and distant spread of disease, to identify candidates for preoperative neoadjuvant therapy (ie, those with stage III or IV disease). Imaging of treated patients is di- rected at identifying resectable recurrent disease, since patients with completely resected recurrent disease have similar outcomes as those without recurrence.
      Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma
      Benveniste MFK et al.
      RadioGraphics 2011; 31:1847–1861
    • Thymomas may result in vascular invasion , pleural involvement, or pericardial dis- semination. Direct signs of vascular involvement include (a) an irregular vessel lumen contour, (b) vascular encasement or obliteration, and(c) endoluminal soft tissue, which may extend into cardiac chambers (3). Pleural dissemination (“drop metastases”) manifests at CT as one or more pleural nodules or masses, which can be smooth, nodular, or diffuse and are almost always ipsilateral to the anterior mediastinal tumor.
      Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma
      Benveniste MFK et al.
      RadioGraphics 2011; 31:1847–1861
    • “The differential diagnosis for anterior mediastinal tumors includes other primary thymic malignancies (eg, thymic carcinoma, thymic carcinoid tumor), nonthymic tumors (eg, lymphoma, germ cell tumor, small-cell lung cancer), and mediastinal metastasis.”.
      Role of Imaging in the Diagnosis, Staging, and Treatment of Thymoma
      Benveniste MFK et al.
      RadioGraphics 2011; 31:1847–1861
Kidney

    • Renal Vein Thrombosis: Facts
      - may be accompanied in 15–20 % of patients by nephrotic syndrome
      - RVT is associated with abdominal surgery, including laparoscopic cholecystectomy, trauma, tumor invasion of the renal vein or invasion by primary retroperitoneal diseases.
    • “CT is currently the imaging method of choice for diagnosing RVT, as it is non-invasive, is somewhat less expensive than other methods, can be performed quickly, and has a high diagnostic accuracy. CT scans have shown high sensitivity (92 %) and specificity (100 %) in diagnosing these lesions and is therefore recommended as an initial diagnostic tool .”
      Renal vein thrombosis mimicking urinary calculus: a dilemma of diagnosis
      Yimin Wang et al.
      BMC Urol. 2015; 15: 61
    • RVT may be diagnosed incorrectly as renal colic or renal cell carcinoma on abdominal ultrasonography. Results in our patients showed that a calcified RVT may mimic a urinary calculus on conventional ultrasonography, abdominal plain film and noncontrast CT. Renal stones may also resemble paragonimus calcified oval, renal artery aneurysms and acute renal infarctions. Thus, awareness of the conditions that could mimic those observed during the generation of a urinary calculus is important, particularly if a percutaneous procedure is considered. Ultrasonography alone is not sufficient to rule out RVT in these patients, suggesting the need for CT angiography in evaluating our patients.
      Renal vein thrombosis mimicking urinary calculus: a dilemma of diagnosis
      Yimin Wang et al.
      BMC Urol. 2015; 15: 61
    • Renal Vein Thrombosis
    • Acute Renal Infarction: Causes
      Thromboembolism
      - Thrombus in the left side of the heart or aorta
      - Aneurysm of the aorta or renal artery
      - Atherosclerosis
      - Subacute bacterial endocarditis (septic emboli)
      - Transcatheter embolization and other endovascular procedures
      - Dissection of the aorta or renal artery
    • Acute Renal Infarction: Causes
      - Vasculitis
      -- Polyarteritis nodosa
      -- SLE
      -- Drug-induced vasculitis
      - Trauma
      -- Avulsion of the renal artery
      -- Occlusion of the renal artery
      -- Penetrating vascular injury
      - Paraneoplastic syndrome
      - Hypercoagulable state
      - Acute venous occlusion
    • Acute renal infarction is a relatively rare and scarcely reported condition. Contrast enhanced CT scan is essential for diagnosing this condition. The most common etiology of this condition is cardioembolic, however up to 59% of cases could be classified as idiopathic acute renal infarction. Here we present a case of a 41 year-old male who was admitted for acute onset right flank pain with fevers and rigors. A CT abdomen with contrast showed findings concerning for right pyelonephritis or renal infarction. Urinalysis was negative for infection. He did not respond to treatment with intravenous antibiotics and was thus diagnosed with acute renal infarction. Work-up for common etiologies was negative and the renal infarction was presumed to be idiopathic. He was discharged home on Enoxaparin. In conclusion, acute renal infarction is a rare condition which should be suspected in patients presenting with acute flank/abdominal pain in whom the more common etiologies have been ruled out.
      Acute renal infarction: A diagnostic challenge.
      Markabawi D, Singh-Gambhir H
      Am J Emerg Med. 2018 Jul;36(7):1325.e1-1325.e2.
    • “Acute renal infarction is a relatively rare and scarcely reported condition. Contrast enhanced CT scan is essential for diagnosing this condition. The most common etiology of this condition is cardioembolic, however up to 59% of cases could be classified as idiopathic acute renal infarction.”
      Acute renal infarction: A diagnostic challenge.
      Markabawi D, Singh-Gambhir H
      Am J Emerg Med. 2018 Jul;36(7):1325.e1-1325.e2.
    • “Renal infarction occurs in a variety of clinical setting .The most common cause is thromboembolism from cardiovascular disease. The most common clinical manifestation is sudden onset of flank or back pain. Hematuria, proteinuria, fever, and leukocytosis may be present.”
      CT Evaluation of Renovascular Disease
      Akira Kawashima, MD • Carl M. Sandler, MD • Randy D. Ernst, MD Eric P. Tamm, MD • Stanford M. Goldman, MD • Elliot K. Fishman
      RadioGraphics 2000; 20:1321–1340
    • “Acute infarcts typically appear as wedge-shaped areas of decreased attenuation within an otherwise normal-appearing kidney. When large areas of the kidney are involved, an increase in the size of the kidney due to edema can be seen. In global infarction, the entire kidney is enlarged and its reniform configuration remains preserved.”
      CT Evaluation of Renovascular Disease
      Akira Kawashima, MD • Carl M. Sandler, MD • Randy D. Ernst, MD Eric P. Tamm, MD • Stanford M. Goldman, MD • Elliot K. Fishman
      RadioGraphics 2000; 20:1321–1340
    • Acute cortical necrosis, a rare form of acute renal failure, results from ischemic necrosis of the renal cortex with sparing of the renal medulla. The pathophysiology of this condition is complex and has been attributed to ischemia due to vasospasm of small vessels, toxic damage to glomerular cap- illary endothelium, and primary intravascular thrombosis. The process is either multifocal or diffuse; in most cases, it is bilateral.
      CT Evaluation of Renovascular Disease
      Akira Kawashima, MD • Carl M. Sandler, MD • Randy D. Ernst, MD Eric P. Tamm, MD • Stanford M. Goldman, MD • Elliot K. Fishman
      RadioGraphics 2000; 20:1321–1340
    • “This condition is associated with complications of pregnancy, including abruptio placentae and septic abortion. Other causes include sepsis, shock, venomous snake bite, severe dehydration, transfusion reaction, and hemolytic uremic syndrome. Cortical necrosis can result from any condition that produces acute, prolonged shock.”
      CT Evaluation of Renovascular Disease
      Akira Kawashima, MD • Carl M. Sandler, MD • Randy D. Ernst, MD Eric P. Tamm, MD • Stanford M. Goldman, MD • Elliot K. Fishman
      RadioGraphics 2000; 20:1321–1340
    • “Helical CT performed during the arterial phase can show enhancing interlobar and arcuate arteries adjacent to the nonenhancing cortex. Characteristic parenchymal findings include enhancement of the medulla but no en- hancement of the cortex. A rim of subcapsular cortical enhancement is also a characteristic finding because of collateral flow from the capsular vessels.”
      CT Evaluation of Renovascular Disease
      Akira Kawashima, MD • Carl M. Sandler, MD • Randy D. Ernst, MD Eric P. Tamm, MD • Stanford M. Goldman, MD • Elliot K. Fishman
      RadioGraphics 2000; 20:1321–1340
    • Enhancement of the juxtamedullary zone of the cortex may be present. Therefore, the necrotic cortex appears as a hypoattenuating zone circumscribing the kidneys adjacent to the renal capsule. Renal function is usually diminished. The kidneys become progressively smaller over several months. A single thin rim of calcification or “tramline” calcification can form in the renal cortex . The characteristic cortical calcification appears as early as 1–2 months after the event.
      CT Evaluation of Renovascular Disease
      Akira Kawashima, MD • Carl M. Sandler, MD • Randy D. Ernst, MD Eric P. Tamm, MD • Stanford M. Goldman, MD • Elliot K. Fishman
      RadioGraphics 2000; 20:1321–1340
Practice Management

    • “Generation Z is composed of people who are currently 18 to 22 years old and in many ways they have more similar- ities with Generation X than with Millennials. Generation Z tends to be practical and driven, and this is reflected in the top 10 trends for 2018 that I will discuss.”
      Meet Generation Z: Top 10 Trends of 2018
      Tina Wells, Elliot K. Fishman, Karen M. Horton, Steven P. Rowe
      Journal of the American College of Radiology
      Volume 15, Number 12 ,December 2018
    • “The transition to an increased emphasis on spirituality may, in part, reflect the broader trend of adopting lifestyles. Spirituality itself can be a life- style and may be a more liberating mind-set for some because it is less defined than religion but still allows people to have a connection to a power beyond themselves. In health care, we need to be aware that our patients without specific religious affiliations may still have spirituality in their lives. We must also be cognizant that the changing landscape of spirituality and religion may have implications for health care trends such as the opioid crisis.”
      Meet Generation Z: Top 10 Trends of 2018
      Tina Wells, Elliot K. Fishman, Karen M. Horton, Steven P. Rowe
      Journal of the American College of Radiology
      Volume 15, Number 12 ,December 2018
    • “Companies appealing to consumer’s emotions and doing good is nothing new. However, it is now a virtual expectation that companies engage in purposes beyond purely making money. This phenomenon has put the responsibility on companies to adopt and promote purposes. Indeed, many companies now use marketing, particularly online and social media-based marketing, to define what they stand for instead of only focusing on their products.
      Meet Generation Z: Top 10 Trends of 2018
      Tina Wells, Elliot K. Fishman, Karen M. Horton, Steven P. Rowe
      Journal of the American College of Radiology
      Volume 15, Number 12 ,December 2018
    • “In addition to consumers choosing companies with purposes, many members of Generation Z who are entering the workforce are looking for companies that align with their values and passions. Beyond loving their jobs, Generation Z workers also want to love the companies they are working for. The health care industry should naturally be able to appeal to consumers and prospective employees on this basis given the centrality of patient well- being to the health care enterprise.”.
      Meet Generation Z: Top 10 Trends of 2018
      Tina Wells, Elliot K. Fishman, Karen M. Horton, Steven P. Rowe
      Journal of the American College of Radiology
      Volume 15, Number 12 ,December 2018
    • “Travelers have become incredibly reliant on devices. Booking a flight, reserving a room, utilizing ride- sharing apps, and taking and posting photographs during a trip can all now be done from a mobile device. Fewer people are printing boarding passes, and more commuters are listening to podcasts. Technology is striving to decrease the stress that many people feel when they travel. Expect to see an increase in wearable technology with travel applications. Many of the apps that can help make travel more enjoyable may also be useful to patients who are navigating the process of getting to subspecialty care that is in another part of the country or who may be facing a prolonged hospital stay.”
      Meet Generation Z: Top 10 Trends of 2018
      Tina Wells, Elliot K. Fishman, Karen M. Horton, Steven P. Rowe
      Journal of the American College of Radiology
      Volume 15, Number 12 ,December 2018
Syndromes in CT

    • “In VHL, CNS HBs most commonly occur in the cerebellum (44%–72%), followed by the spinal cord and brainstem The mean age of onset is 33 years (range, 9–78 years). Patients with cerebellar HB may develop gait ataxia, dysmetria, headaches, diplopia, vertigo, and emesis .It should be noted that in many patients, the symptoms may be caused by the cyst or syrinx associated with the tumor rather than the tumor itself.”
      Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Com- prehensive State-of-the-Art Review
      Ganeshan D et al.
      RadioGraphics 2018 (in press)
    • Spinal HBs manifest in 13%–50% of cases of VHL. The mean age of onset is 33 years (range, 11–66 years). Although any part of the spinal canal can be affected, spinal HBs are more common in the thoracic and cervical cord. Radiculopathy and myelopathy-associated symptoms predominate in spinal HB, including hyperesthesia, weakness, gait ataxia, hyperreflexia, pain, incontinence, and rarely quadriplegic.
      Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Com- prehensive State-of-the-Art Review
      Ganeshan D et al.
      RadioGraphics 2018 (in press)
    • “The differential diagnosis includes metastasis, ependymoma, meningioma, arteriovenous malformation, or arteriovenous fistula. Surgical resection and γ-knife radiation therapy may be offered as treatment options in the management of these tumors.”
      Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Com- prehensive State-of-the-Art Review
      Ganeshan D et al.
      RadioGraphics 2018 (in press)
    • “Von Hippel–Lindau syndrome (VHL) is a hereditary tumor syndrome, arising owing to germline mutations in the VHL tumor sup- pressor gene, located on the short arm of chromosome 3.VHL is an autosomal dominant disorder, with a prevalence of around one in 36 000 and one in 50 000 live births. Around 80% of patients with VHL inherit the disorder from an affected parent, while it may arise de novo in 20%.The mean age of initial tumor diagnosis in VHL is 26 years (range, 1–70 years).”
      Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Com- prehensive State-of-the-Art Review
      Ganeshan D et al.
      RadioGraphics 2018 (in press)
    • VHL is a highly penetrant disease, with more than 90% of patients developing symptoms by 65 years of age. Patients may develop multiple benign and malignant tumors involving various organ systems, including retinal hemangioblastomas (HBs), central nervous system (CNS) HBs, endolymphatic sac tumors, pancreatic neuroendocrine tumors (NETs), pancreatic cystadeno- mas, pancreatic cysts, clear cell renal cell carcinomas (RCCs), renal cysts, pheochromocytomas, paragangliomas, and epididymal and broad ligament cystadenomas.”
      Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Com- prehensive State-of-the-Art Review
      Ganeshan D et al.
      RadioGraphics 2018 (in press)
Vascular

    • “Coronary angiography is the current gold standard in providing anatomical information regarding the extent and severity of coronary artery disease. Access site practice has changed in a number of European and Asian countries from mainly being transfemoral (TFA) to transradial (TRA) in view of less access site related bleeding complications, mortality and shorter hospital stay associated with TRA. For instance, in the United Kingdom use of radial access has increased from 14% to 80% between 2005 and 2014 in patients undergoing percutaneous coronary intervention (PCI) and it is estimated that this practice change has saved an estimated 450 lives nationally.”
      Hand dysfunction after transradial artery catheterization for coronary procedures
      Muhammad Ayyaz Ul Haq et al.
      World J Cardiol. 2017 Jul 26; 9(7): 609–619.
    • “Nevertheless, despite of its clear advantages over TFA, TRA is not without limitations and is associated with longer operator learning curve, increased radiation exposure in individual operators at the start of their learning curves and higher case radial proportion to translate the better results of randomized trials into clinical practice. Moreover, vascular complications such as RAO and radial artery spasm are not uncommon and very recently concerns have been raised that patients undergoing TRA PCI may encounter hand dysfunction.”
      Hand dysfunction after transradial artery catheterization for coronary procedures
      Muhammad Ayyaz Ul Haq et al.
      World J Cardiol. 2017 Jul 26; 9(7): 609–619.
    • “In conclusion, hand dysfunction is an exceedingly rare complication post TRA. There is significant heterogeneity in the methodology and reporting of the studies investigating hand function after TRA. Patients may develop non-specific sensory symptoms or muscle weakness but majority of these symptoms resolve over time. Future studies should be focused around assessing such complications using robust methodology and more importantly reporting on the clinical relevance of hand function. Given the reductions in mortality, MACE and major bleeding complications associated with use of TRA in high risk groups undergoing PCI, TRA should remain the default access site for PCI in such high risk groups of patients at risk of bleeding complications, in line with international guidelines and consensus statements.”
      Hand dysfunction after transradial artery catheterization for coronary procedures
      Muhammad Ayyaz Ul Haq et al.
      World J Cardiol. 2017 Jul 26; 9(7): 609–619.
    • Purpose: To compare diagnostic performance of MDCTA vs MRA before endovascular intervention.
      Results: MDCTA and MRA accurately classify disease in the aorto-iliac (accuracy 0.92 for MDCTA and MRA) and femoro-popliteal (MDCTA 0.94, MRA 0.90) segments. MDCTA was more accurate in stratifying disease in the infra- popliteal segments (0.96 vs. 0.9) and in assessing the impairment of runoff arteries (0.92 vs. 0.85) at per-segment analysis. MDCTA showed a higher confidence and a shorter examination time.
      Conclusion: Our results suggest that MDCTA can be considered as a first-line investigation in patients being candidates for endovascular procedures when clinical history or duplex sonographic evaluation are indicative of severe impairment of the infrapopliteal segment.
      Comparison of CT and MR angiography in evaluation of peripheral arterial disease before endovascular intervention
      Cina A et al
      Acta Radiologica 2016, Vol. 57(5) 547–556
    • Purpose: To evaluate the diagnostic performance and effect on therapeutic management of 64-section computed tomographic (CT) angiography in the assessment of steno-occlusive disease in patients with peripheral arterial disease (PAD), with conventional digital subtraction angiography (DSA) as the reference standard.
      Conclusion: The diagnostic performance of 64-section CT angiography is excellent in patients with clinical symptoms of PAD. The results can be used to effectively guide therapeutic decision making in these patients.
      Peripheral Arterial Occlusive Disease: Diagnostic Performance and Effect on Therapeutic Management of 64-Section CT Angiography
      Napoli A et al.
      Radiology 2011; 261:976–986
    • Objective: Preprocedural computed tomography angiography (CTA) assists in evaluating vascular morphology and disease distribution and in treatment planning for patients with lower extremity peripheral artery disease (PAD). The aim of the study was to determine the predictive value of radiographic findings on CTA and technical success of endovascular revascularization of occlusions in the superficial femoral artery-popliteal (SFA-pop) region.
      Conclusions: Analysis of preoperative CTA shows 100% calcification as the best predictor of technical failure of endo- vascular revascularization of occlusions in the SFA-pop region. Further studies are needed to determine the cost-effectiveness of obtaining preoperative CTA for lower extremity PAD.
      Lower extremity computed tomography angiography can help predict technical success of endovascular revascularization in the superficial femoral and popliteal artery
      Itoga NK et al.
      J Vasc Surg 2017;66:835-43
    • “This study demonstrated 100% vessel calcification as the best predictor of technical failure in endovascular treatment of occlusions in the SFA-pop region. As advances in catheter-based technology and noninvasive radiographic imaging continue to evolve, future guidelines may consider noninvasive imaging in the preopera- tive assessment to help guide treatment strategies.”
      Lower extremity computed tomography angiography can help predict technical success of endovascular revascularization in the superficial femoral and popliteal artery
      Itoga NK et al.
      J Vasc Surg 2017;66:835-43
    • Take Home Message: In a study of 540 endovascular procedures, multivariable analysis revealed that 100% calcification on preoperative computed tomography angiography is the only significant predictor of technical failure (odds ratio, 9.0; 95% confidence interval, 1.8-45.8; P 1⁄4 .008).
      Recommendation: The authors suggest that 100% of vessel calcification on preoperative computed tomography angiography is the best predictor of technical failure in revascularization of superficial femoral and popliteal artery occlusions.
      Lower extremity computed tomography angiography can help predict technical success of endovascular revascularization in the superficial femoral and popliteal artery
      Itoga NK et al.
      J Vasc Surg 2017;66:835-43
    • CTA in Clinical Practice: Advantages
      - Less patient compliance needed
      - Study protocols easier to define across and enterprise
      - Lower cost to the patient and health system
      - Better reproducibility across sequential studies
      - Ability to deal with stents and grafts with definition of muscle and soft tissue without special sequences
      - Availability in ER setting 24/7
    • CTA Success is Dependent On;
      - Scan protocols and scanner technology including Dual Energy CT provide flexibility including decreased contrast volumes
      - Delivery of IV contrast (timing and injection protocols)
      - Use of Post Processing Techniques (Curved Planar Reconstrution, MIP, VRT, CR)
© 1999-2019 Elliot K. Fishman, MD, FACR. All rights reserved.