The diagnostic yield of three clinical prediction rules for pulmonary embolism / Rendimiento diagnóstico de tres reglas de predicción clínica para embolia pulmonar

Abstract Objective: pulmonary embolism (PE) is the third cause of cardiovascular death worldwide. The evaluation of pre-test probability using the Wells, Geneva and Pisa clinical prediction rules has been amply validated in prior studies. However, there are insufficient data for evaluating their diagnostic yield in a Colombian population. The goal of this article is to evaluate the yield of these scales in our population. Methods: this was a retrospective cohort study with diagnostic test analysis in a tertiary level hospital from 2009 to 2017, which included all subjects over the age of 18 who had undergone a chest computed tomography angiography (CTA) due to a clinical suspicion of PE. All the necessary variables for constructing the Wells, Geneva and Pisa rules were recorded. Each score was calculated numerically and then classified according to probability. Pulmonary embolism was diagnosed through a CTA read by a radiologist. The data were entered on an Excel spreadsheet and analyzed using a licensed SPSS statistical program. Results: a total of 507 subjects were included for Wells and Geneva scores and 339 for the Pisa score. The average age was 56 years (SD: 19.8) and 56.6% were males. A statistically significant relationship was found between the different calculated scores and the diagnosis of pulmonary embolism: low, intermediate and high Wells probability p<0.001; less probable and probable Wells p<0.001; low, intermediate and high Geneva p=0.006; and low, intermediate, moderate and high Pisa p=0.001. The ACOR for Wells was 0.715 (95% CI:0.663-0.767) (p<0.001), for Geneva was 0.611 (95% CI:0.553-0.668) (p<0.001), and for Pisa was 0.643 (95% CI:0.574-0.713) (p<0.001). Conclusions: the study showed a greater PE diagnostic yield using the Wells score in our setting. There are limitations to the application and development of the Pisa score asociated with a lower yield in our patients.(Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1384).

Resumen Objetivo: la embolia pulmonar (EP) es la tercera causa de muerte cardiovascular en el mundo. La evaluación de la probabilidad pre test a través de reglas de predicción clínica Wells, Ginebra y Pisa ha sido ampliamente validada en estudios previos. Sin embargo, hay datos insuficientes que evalúen el rendimiento diagnóstico de las mismas en población colombiana, este artículo tiene como fin evaluar el rendimiento de estas escalas en nuestra población. Métodos: estudio de cohorte retrospectivo con análisis de prueba diagnóstica en un hospital de III nivel de atención entre los años 2009 y 2017, donde se incluyeron todos los sujetos mayores de 18 años con realización de angiotomografía de tórax (ATC) solicitada por sospecha clínica de EP. Se registraron todas las variables necesarias para la construcción de las reglas de Wells, Ginebra y Pisa. Cada uno de los puntajes se calculó de manera numérica y posteriormente se clasificó según la probabilidad. El diagnóstico de EP se realizó mediante ATC leída por radiólogo. Los datos se ingresaron en una hoja de cálculo de Excel y se analizaron con el programa estadístico SPPS licenciado. Resultados: se ingresaron 507 sujetos para los puntajes de Wells y Ginebra y 339 para el puntaje de Pisa. El promedio de edad fue de 56 años (DS:19.8) y 56.6% de sexo masculino, se encontró una relación estadísticamente significativa entre los diferentes puntajes evaluados y el diagnóstico de embolia pulmonar, Wells probabilidad baja, intermedia y alta p<0.001, Wells menos probable y probable p<0.001, Ginebra bajo, intermedio y alto p=0.006, Pisa bajo, intermedio, moderada y alta p=0.001. El ACOR para Wells fue 0.715(IC95%:0.663-0.767) (p<0.001), Ginebra 0.611(IC95%:0.553-0.668) (P<0.001), Pisa 0.643(IC95%:0.574-0.713) (p<0.001). Conclusiones: se determinó un rendimiento superior para el diagnóstico de EP con el puntaje de Wells en nuestro medio, hay limitaciones con la aplicación y desarrollo del puntaje de Pisa asociado a un rendimiento inferior en nuestros pacientes.(Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1384).

Risk Factors and Intracranial Vascular Characteristics in Elderly Patients with Cerebral Watershed Infarction / 中国医科大学学报

Objective To explore the risk factors and investigate the intracranial vascular characteristics in elderly patients with WSI. Methods According to imaging features of DWI,56 cases of WSI were divided into CWSI,IWSI and MWSI group. Distribution of intracranial vascular le?sions in different groups was compared. The degree of middle cerebral artery(MCA)and internal carotid artery(ICA)stenosis in different types of WSI was investigated. Results Among 56 cases,85.7%of them had a history of hypertension,53.6%had diabetes,62.5%had hyperlipoidemia, 51.8%had coronary heart disease(CHD),51.8%had smoking,and 73.2%of them had two or more risk factors. Totally 11 cases(19.6%)of them were cortical watershed infarction(CWSI),13(23.2%)of them were interior watershed infarction(IWSI),and 32(57.1%)of them were mixed cerebral watershed infarction(MWSI). Among all the patients,the incidence of MCA stenosis(37.5%)and ICA stenosis(53.6%)were signifi?cantly higher than the other intracranial vessels(χ2=37.188,P<0.001). The incidence of MCA stenosis in IWSI group was significant higher than CWSI and MWSI group(χ2=12.00,P<0.01). The incidence of ICA stenosis in MWSI group was significantly higher than CWSI group and IWSI group(χ2=11.10,P<0.01). Among all the patients,17 of them had severe stenosis or occlusion in MCA(30.4%),and 22 of them had severe ste?nosis or occlusion in ICA(39.3%). The incidence of severe stenosis or occlusion in MCA(58.8%)was significant higher in IWSI group(χ2=7.588,P<0.05)and those in ICA was significantly higher in MWSI group(χ2=7.091,P<0.05). Conclusion MWSI is more common in elderly patients with WSI. Most of the patients have more than one risk factors such as hypertension,diabetes,hyperlipoidemia,CHD and smoking. MCA and ICA lesions are more common than other intracranial vessels in elderly patients. IWSI is closely related with severe stenosis and occlusion of MCA,while MWSI is closely related with severe stenosis and occlusion of ICA.

Association between Red Blood Cell Distribution Width and Coronary Artery Calcification in Patients Undergoing 64-Multidetector Computed Tomography

BACKGROUND AND OBJECTIVES: The red blood cell distribution width (RDW) has been found to be associated with cardiovascular morbidity and mortality. The objective of this study was to determine whether the RDW measures are associated with the coronary artery calcification score (CACS) in patients who did not present with obvious coronary heart disease (CHD). SUBJECTS AND METHODS: A total of 527 consecutive patients with a low to intermediate risk for CHD but without obvious disease were enrolled in this study. The study subjects underwent coronary computerized tomography angiography and CACS was calculated. The patients were divided into two groups based on CACS: Group I (CACS100). The two groups were compared in terms of classic CHD risk factors and haematological parameters, particularly the RDW. RESULTS: Group I patients were younger than Group II patients. The Framingham risk score (FRS) in patients of Group II was significantly higher than that in patients of Group I. Group II patients had significantly elevated levels of haemoglobin, RDW, neutrophil count, and neutrophil/lymphocyte ratio compared with Group I patients. CACS was correlated with age, RDW, and ejection fraction. In the multivariate analysis, age, RDW, and FRS were independent predictors of CACS. Using the receiver-operating characteristic curve analysis, a RDW value of 13.05% was identified as the best cut-off for predicting the severity of CACS (>100) (area under the curve=0.706). CONCLUSION: We found that the RDW is an independent predictor of the CACS, suggesting that it might be a useful marker for predicting CAD.

CT perfusion imaging and CT angiography in diagnosis of transient ischemic attack of internal carotid artery system / 中华神经医学杂志

Objective To observe the changes of regional cerebral blood flow and blood-supply artery and study the value of computerized tomography perfusion imaging (CTPI) and computerized tomography angiography (CTA) in the clinical diagnosis of transient ischemic attack (TIA) of internal carotid artery system to further explore the etiological factors and pathophysiological mechanism of TIA of internal carotid artery system.Methods Thirty-five patients with TIA of internal carotid artery system,admitted to our hospital from April 2008 to January 2009,were enrolled into patient group,and 22 healthy subjects without TIA of internal carotid artery system symptoms and negative CTA features were enrolled as control group.These patients were examined with 16 slice CTPI and CTA in head and neck within 48 h of onset; the mean transmit time (MTT),cerebral blood flow (CBF) and cerebral blood volume (CBV) in the region of interests (ROIs) between the two sides of the patient group and between patient group and control group were analyzed,and the relationship with CTA features and clinical manifestations were discussed.Results Twenty-eight of 35 patients (80％) with TIA of internal carotid artery system revealed abnormal perfusion regions corresponding to clinical symptoms in CTPI,of which there were 28 revealing abnormal perfusion regions on MTT maps,23 on CBF maps,and only 15 on CBV maps.Other 7 patients showed normal results in CTPI.The correspondence relationship between CTPI and CTA abnormality had the following 4 types:(1) there were 25 patients (71％) with perfusion abnormalities accompanied by abnormal vascular supplying the abnormal perfusion region (convict vascular); among them,16 had carotid artery stenosis,13 had many weak vascular plaques,and 6 had carotid artery dysplasia; the coexistence of a number of factors and situation existed.(2) There were 3 patients (9％) with perfusion abnormalities in CTPI but without abnormal vascular in CTA.(3) There were 3 patients (9％) with abnormal vascular in CTA but without perfusion abnormalities in CTPI.(4) There were 4 patients (11％) had neither abnormal vascular nor perfusion abnormalities.Conclusions MTT is the most sensitive and primary indicator in CTPI of TIA of internal carotid artery system; the changes of CBF and CBV can reveal the various pathophysiological state of TIA of internal carotid artery system.The hypoperfusion is one of the pathophysiological bases of TIA of internal carotid artery system,and carotid artery stenosis and many weak vascular plaques may be the etiological factors of TIA of internal carotid artery system.CTPI combined with CTA is important to study the etiology of TIA.

Is Computerized Tomography Angiographic Surveillance Valuable for Prevention of Tracheoinnominate Artery Fistula, a Life-Threatening Complication after Tracheostomy?

OBJECTIVE: The aim of this study was to evaluate the utility of volume-rendered helical computerized tomography (CT) angiography focusing tracheostomy tube and innominate artery for prevention of tracheoinnominate artery fistula. METHODS: The authors retrospectively analyzed 22 patients with tracheostomy who had checked CT angiography. To evaluate the relationship between tracheostomy tube and innominate artery, we divided into three categories. First, proximal tube position based on cervical vertebra, named "tracheostomy tube departure level (TTDL)". Second, distal tube position and course of innominate artery, named "tracheostomy tube-innominate artery configuration (TTIC)". Third, the gap between the tube and innominate artery, named "tracheostomy tube to innominate artery gap (TTIG)". The TTDL/TTIC and TTIG are based on 3-dimensional (3D) reconstruction around tracheostomy and enhanced axial slices of upper chest, respectively. RESULTS: First, mean TTDL was 6.8+/-0.6. Five cases (23%) were lower than C7 vertebra. Second, TTIC were remote to innominate artery (2 cases; 9.1%), matched with it (14 cases; 63.6%) or crossed it (6 cases; 27.3%). Only 9% of cases were definitely free from innominate artery injury. Third, average TTIG was 4.3+/-4.6 mm. Surprisingly, in 6 cases (27.3%), innominate artery, trachea wall and tracheostomy tube were tightly attached all together, thus have much higher probability of erosion. CONCLUSION: If low TTDL, match or crossing type TTIC with reverse-L shaped innominate artery, small trachea and thin TTIG are accompanied all together, we may seriously consider early plugging and tube removal.

Practical role of TCD and 3D-CTA in planning the angioplasty for the treatment of DIND after aneurismal subarachnoid hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: We evaluated the relationship between transcranial Doppler sonography (TCD) and three-dimensional computerized tomography angiography (3D-CTA) under delayed ischemic neurologic deficit (DIND) with angioplasty following vasospasm. MATERIALS & METHODS: Twenty consecutive patients with DIND following vasospasm who received sequential TCD and CTA were analyzed. On TCD, vasospasm was defined as anterior circulation peak mean velocity>120 cm/s, daily increases of 50cm/s, and a Lindegaard ratio (LR)degrees root 3. On 3D-CTA data were subdivided into local and combined types according to the position where vasospasm occurred, and into mild, moderate, and severe by the blood vessel diameter. RESULTS: Among the 20 consecutive patients with DIND, 13 of them received angioplasty. On TCD, the angioplasty group had more frequent vasospasm and tended to have an LR higher than 3. The mean blood flow velocity of MCA in the angioplasty group was 40 cm/sec higher than the group without angioplasty. On CTA, the angioplasty group showed combined, moderate types more frequently. After 3D-CTA evaluation, TCD sensitivity, specificity, positive predictive value and negative predictive value, analyzed with the index of diminished vessel diameter that was more than moderate, were 92.6%, 83.3%, 72.2% and 50.0%, respectively. CONCLUSION: TCD and 3D-CTA could be useful tools for evaluation and management planning of critical patients suspected of having DIND by vasospasm.

Rebleeding of Cerebral Aneurysm during Three-Dimensional Computerized Tomographic Angiography

The authors report a 59-year-old woman who presented with diffuse subarachnoid hemorrhage and focal intracerebral hemorrhage in the right frontotemporal region with intraventricular hemorrhage after the right middle cerebral artery bifurcation aneurysmal rupture. The aneurysm was rebled during the 3-dimensional computerized tomographic angiography, which was performed 3 hours after initial attack. Although the aneurysm was successfully clipped, the patient died on the second hospital day. We discuss the risk factor of rebleeding of ruptured cerebral aneurysm and whether 3-dimensional computerized tomography angiography is a really safe method of detection of cerebral aneurysm in terms of rebleeding.