Inflammation has been implicated as a secondary injury mechanism following ischemia and stroke. A variety of experimental models, including thromboembolic stroke, focal and global ischemia, have been ...used to evaluate the importance of inflammation. The vasculature endothelium promotes inflammation through the upregulation of adhesion molecules such as ICAM, E-selectin, and P-selectin that bind to circulating leukocytes and facilitate their migration into the CNS. Once in the CNS, the production of cytotoxic molecules may facilitate cell death. The macrophage and microglial response to injury may either be beneficial by scavenging necrotic debris or detrimental by facilitating cell death in neurons that would otherwise recover. While many studies have tested these hypotheses, the importance of inflammation in these models is inconclusive. This review summarizes data regarding the role of the vasculature, leukocytes, blood-brain barrier, macrophages, and microglia after experimental and clinical stroke.
Use of whole-body CT scan (WBCT) is widespread in the evaluation of traumatically injured patients and may be associated with improved survival. WBCT protocols include the use of IV contrast unless ...there is a contraindication. This study tests the hypothesis that using plain WBCT scan during the global contrast shortage would result in greater need for repeat contrast-enhanced CT, but would not impact mortality, missed injuries, or rates of acute kidney injury (AKI).
All trauma encounters at an academic level-I trauma center between March 1, 2022 and June 24, 2022, excluding burns and prehospital cardiac arrests, were reviewed. Imaging practices and outcomes before and during contrast shortage (beginning May 3, 2022) were compared.
The study population included 1,109 consecutive patients (72% male), with 890 (80%) blunt and 219 (20%) penetrating traumas. Overall, 53% of patients underwent WBCT and contrast was administered to 73%. The overall rate of AKI was 6% and the rate of renal replacement therapy (RRT) was 1%. Contrast usage in WBCT was 99% before and 40% during the shortage (p < 0.001). There was no difference in the rate of repeat CT scans, missed injuries, AKI, RRT, or mortality.
Trauma imaging practices at our center changed during the global contrast shortage; the use of contrast decreased despite the frequency of trauma WBCT scans remaining the same. The rates of AKI and RRT did not change, suggesting that WBCT with contrast is insufficient to cause AKI. The missed injury rate was equivalent. Our data suggest similar outcomes can be achieved with selective IV contrast use during WBCT.
We present a case report of the successful use of thoracic epidural analgesia for the surgical resection of a large recurrent desmoid tumor and forequarter amputation in an adolescent male. Spinal ...anesthesia has been reported for intra-operative management of desmoid tumor resection, however, there are no reported cases of thoracic epidural analgesia for this tumor. Thoracic epidural should be used with caution in this patient population due to risk of de novo tumor creation but can be useful adjuvant to multi-modal analgesia to decrease post-operative opioid requirement.
To (a) determine the diagnostic performance of 64-section multidetector computed tomography (CT) trajectography for penetrating diaphragmatic injury (PDI), (b) determine the diagnostic performance of ...classic signs of diaphragmatic injury at 64-section multidetector CT, and (c) compare the performance of these signs with that of trajectography.
This HIPAA-compliant retrospective study had institutional review board approval, with a waiver of the informed consent requirement. All patients who had experienced penetrating thoracoabdominal trauma, who had undergone preoperative 64-section multidetector CT of the chest and abdomen, and who had surgical confirmation of findings during a 2.5-year period were included in this study (25 male patients, two female patients; mean age, 32.6 years). After a training session, four trauma radiologists unaware of the surgical outcome independently reviewed all CT studies and scored the probability of PDI on a six-point scale. Collar sign, dependent viscera sign, herniation, contiguous injury on both sides of the diaphragm, discontinuous diaphragm sign, and transdiaphragmatic trajectory were evaluated for sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Accuracies were determined and receiver operating characteristic curves were analyzed.
Sensitivities for detection of PDI by using 64-section multidetector CT with postprocessing software ranged from 73% to 100%, specificities ranged from 50% to 92%, NPVs ranged from 71% to 100%, PPVs ranged from 68% to 92%, and accuracies ranged from 70% to 89%. Discontinuous diaphragm, herniation, collar, and dependent viscera signs were highly specific (92%-100%) but nonsensitive (0%-60%). Contiguous injury was generally more sensitive (80%-93% vs 73%-100%) but less specific (50%-67% vs 83%-92%) than transdiaphragmatic trajectory when patients with multiple entry wounds were included in the analysis. Transdiaphragmatic trajectory was a much more sensitive sign of PDI than previously reported (73%-100% vs 36%), with NPVs ranging from 71% to 100% and PPVs ranging from 85% to 92%.
Sixty-four-section multidetector CT trajectography facilitates the identification of transdiaphragmatic trajectory, which accurately rules in PDI when identified. Contiguous injury remains a highly sensitive sign, even when patients with multiple injuries are considered, and is useful for excluding PDI.
Introduction
Empty sella in MRI is an important finding associated with idiopathic intracranial hypertension (IIH). This study assesses the sensitivity and reproducibility of several morphological ...measures of the sella and pituitary gland to indentify the measure that best differentiates IIH from controls. Additionally, the study assesses reversal in gland compression following treatment.
Methods
Sagittal 3D-T1W sequence with 1 mm isotropic resolution was obtained from ten newly diagnosed IIH patients and 11 matched healthy controls. Follow-up MRI scans were obtained from eight patients at 1-week post-lumbar puncture and acetazolamide treatment. 1D and 2D measures of absolute and normalized heights and cross-sectional areas of the gland and sella were obtained to identify the measure that best differentiates IIH patients and controls.
Results
Overall area-based measurements had higher sensitivity than length with
p
< 0.0001 for sella area compared with
p
= 0.004 for normalized gland height. The gland cross-sectional areas were similar in both cohorts (
p
= 0.557), while the sella area was significantly larger in IIH, 200 ± 24 versus 124 ± 25 mm
2
, with the highest sensitivity and specificity, 100 % and 90.9 %, respectively. Absolute gland area was the most sensitive measure for assessing post treatment changes, with 100 % sensitivity and 50 % specificity. Average post-treatment gland area was 18 % larger (
p
= 0.016). Yet, all eight patients remained within the empty sella range based on a normalized gland area threshold of 0.41.
Conclusions
Sellar area is larger in IIH, and it demonstrated highest sensitivity for differentiating IIH from control subjects, while absolute gland area was more sensitive for detecting post treatment changes.
The segmental classification of congenital heart disease, first conceptualized nearly 50 years ago, is now well established. The Van Praagh classification system, in particular, is commonly used ...throughout North America to facilitate communication between physicians from various specialties who are involved in diagnosing and managing congenital cardiovascular abnormalities. In the Van Praagh system, a three-part notation consisting of letters separated by commas and encompassed by a set of braces is used to succinctly describe the visceroatrial situs, the orientation of the ventricular loop, and the position and relation of the great vessels. For example, the notation "{S, D, S}" describes the normal anatomic configuration, in which the morphologic right atrium and largest hepatic lobe are on the patient's right side and the morphologic left atrium, stomach, and spleen are on the left side (situs solitus); the ventricular loop is curved rightward (dextro- or d-loop); and the aorta is posterior to and rightward of the main pulmonary artery (situs solitus). Because the Van Praagh notation imposes on its users a systematic approach to anatomic description, it is a helpful device for structuring the interpretation of imaging studies as well as the reporting of results: First, the morphologic right and left atria and ventricles must be identified; next, the visceroatrial situs and ventricular loop orientation may be determined from the positions of the cardiac chambers; and last, the position and relation of the great vessels (normal, inverted, transposed, or malpositioned) can be established. The article provides concise, step-by-step guidance for applying the Van Praagh system in the radiology reading room.
Ventilator associated pneumonia (VAP) is defined by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) using laboratory findings, pathophysiologic signs/symptoms, and ...imaging criteria. However, many critically ill trauma patients meet the non-specific laboratory and sign/symptom thresholds for VAP, so the TQIP designation of VAP depends heavily upon imaging evidence. We hypothesized that physician opinions widely vary regarding chest radiograph findings significant for VAP.
The TQIP Spring 2021 Benchmark Report (BR) was used to identify 14 patients with VAP at an academic Level 1 Trauma Center. Critically ill trauma patients (n = 7) who spent at least four days intubated and met TQIP's laboratory and sign/symptom thresholds for VAP but did not appear as VAPs on the BR comprised the control group. For each deidentified patient, four successive chest radiographic images were compiled and arranged chronologically. Cases and controls were randomly arranged in digital format. Blinded physicians (n = 27) were asked to identify patients with VAP based solely on imaging evidence.
Radiographic evidence of VAP was highly subjective (Krippendorff α = 0.134). Among physicians of the same job description, inter-rater reliability remained low (α = 0.137 for trauma attending physicians; α = 0.141 for trauma fellows; α = 0.271 for radiologists). When majority judgment was compared to the TQIP BR, there was disagreement between the two tests (Cohen κ =
0.071; sensitivity, 64.3%; specificity, 28.6%).
Current definitions of VAP rely on subjective imaging interpretation and ignore the reality that there are numerous explanations for opacities on CXR. The inconsistency of physicians' imaging interpretation and protean physiologic findings for VAP in trauma patients should preclude the current definition of VAP from being used as a quality improvement metric in TQIP.
Cardiac computed tomography (CT) and magnetic resonance (MR) imaging provide clinicians with important insights into cardiac physiology and pathology. However, not all radiologists understand the ...language and concepts of cardiac physiology that are used daily by cardiologists. This review article covers basic cardiac physiology as it relates to cardiac CT and MR imaging. Topics include a review of the cardiac cycle and left ventricular pressure-volume loops as they relate to different pathologic states, evaluation of cardiac function, and calculation of key parameters such as left ventricular volumes and the ejection fraction. The hemodynamics of cardiac shunts are covered, with an emphasis on factors important to cardiologists, including the ratio of pulmonary flow to systemic flow. Additionally, valvular physiologic function is reexamined, with a focus on understanding pressure gradients within the heart and also the changes associated with valvular pathologic conditions, including measurement of regurgitant fractions in patients with valvular insufficiency. Understanding these basic concepts will help radiologists tailor the reporting of cardiac studies to clinically relevant information.
Imaging of Foreign Bodies in Prisoners Sheth, Pooja, MD; Finkelstein, Evan, MD; Campbell, Danea, MD ...
Seminars in ultrasound, CT, and MRI,
02/2015, Letnik:
36, Številka:
1
Journal Article
Recenzirano
Foreign body ingestion or insertion is occasionally encountered by radiologists and is associated with significant morbidity, financial burden, and potential mortality. Incarcerated individuals are a ...unique group where foreign body ingestion or insertion is more common than the general population. Motivations include reprieve from the confines of prison, sexual stimulation or victimization, or may be secondary to compulsions in patients with psychiatric disorders. These foreign bodies may lead to perforation, obstruction, or infection. Radiologists can help clinicians identify unexpected ingested or inserted objects as well as the sequelae of foreign body ingestion or insertion.
Abstract Background Patients with lung cancer present to the emergency department (ED) in a variety of ways. Symptoms are often nonspecific and can lead to a delay in diagnosis. Here, a lung cancer ...mimicked two illnesses, adding to the diagnostic complexity. This case highlights diagnostic pitfalls as well as advantages and limitations of imaging utilized in the emergency setting. Case Report We report a case of an occult lung cancer occluding a pulmonary vein, which at first mimicked pneumonia and later a pulmonary embolism (PE) and arterial lung infarction. The patient presented to the ED with cough and a lung opacity on chest radiograph that was treated with antibiotics. However, recurrent visits to the ED with similar complaints were further investigated with computed tomography angiogram (CTA). At first the scan was considered positive for PE. Further inspection revealed that the CTA findings were not typical for PE, but rather a slow flow state likely caused by an occult mass occluding a pulmonary vein with venous infarction. Biopsy revealed a lung adenocarcinoma. In addition to the case presentation, the typical signs of PE on CTA with correlating images and diagnostic pitfalls are discussed. Why Should an Emergency Physician Be Aware of This? This case report raises two themes that can be of interest to emergency physicians. The first is that lung cancer has many guises. Here it mimicked two distinctly different diseases, pneumonia and PE. The second is that, although CTA is highly sensitive and specific for diagnosing PE, it has limitations that may lead to false positive readings. When clinical signs and symptoms fail to correlate with the imaging diagnosis, alternative explanations should be sought.
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