Effective radiation doses associated with non-invasive versus invasive assessment of coronary anatomy and physiology.

OBJECTIVES: To compare the effective radiation dose (ERD) needed to obtain information on coronary anatomy and physiology by a non-invasive versus an invasive diagnostic strategy. BACKGROUND: Knowledge of anatomy and physiology is needed for management of patients with coronary artery disease (CAD). There is, however, a growing concern about detrimental long-term effects of radiation associated with diagnostic procedures. METHODS: In a total of 671 patients with suspected CAD, we compared the ERD needed to obtain anatomical and physiological information through a non-invasive strategy or an invasive strategy. The non-invasive strategy consisted of coronary computed tomography angiography (CCTA) and single photon emission computed tomography (SPECT). The invasive strategy included coronary angiography (CA) and fractional flow reserve (FFR) measurement. In 464 patients, the data were acquired in Period 2009 and in 207 the data were acquired in Period 2011 (after each period, the CCTA- and the CA-equipment had been upgraded). RESULTS: For the Period 2009 total ERD of the non-invasive approach was significantly larger compared to the invasive approach (28.45 ± 5.37 mSv versus 15.79 ± 7.95 mSv, respectively; P < 0.0001). For Period 2011, despite the significant decrease in ERD for both groups (P<0.0001 for both), the ERD remained higher for the non-invasive approach compared to the invasive approach (16.67 ± 10.45 mSv vs. 10.36 ± 5.87 mSv, respectively; P < 0.0001). Simulation of various diagnostic scenarios showed cumulative radiation dose is the lowest when a first positive test is followed by an invasive strategy. CONCLUSION: To obtain anatomic and physiologic information in patients with suspected CAD, the combination of CA and FFR is associated with lower ERD than the combination of CCTA and SPECT.

Avoidable surgical consultations in women with a positive screening mammogram: experience from a southern region of the Dutch breast screening programme.

INTRODUCTION: According to current Dutch guidelines, all women with a positive screening mammogram are referred for a full hospital assessment, which includes surgical consultation and radiological assessment. Surgical consultation may be unnecessary for many patients. Our objective was to determine how often surgical consultations can be avoided by radiological pre-assessment. MATERIALS AND METHODS: All women with a positive screening mammogram, referred to our radiology department between 2002 and 2007, were included (n=1014). Percentage of women that was downstaged to BI-RADS category 1 or 2 by radiological pre-assessment was calculated. Negative predictive value (NPV) for malignancy was estimated from the in-hospital follow-up, which was available up to September 2012. RESULTS: 423 of 1014 women (42%) were downstaged to BI-RADS category 1 or 2 by radiological pre-assessment. During follow-up, 8 of these 423 women (2%) developed a malignancy in the same breast. At least 6 of these malignancies were located at a different location as the original screening findings which led to the initial referral. The estimated NPV for malignancy was 99.5% (95%CI, 98.3-99.9). CONCLUSION: By referring women with a positive screening mammogram to the radiology department for pre-assessment, a surgical consultation was avoided in 42%, with an estimated NPV of 99.5% for malignancy.

Locally advanced rectal cancer: is diffusion weighted MRI helpful for the identification of complete responders (ypT0N0) after neoadjuvant chemoradiation therapy?

OBJECTIVES: To determine retrospectively the additional value of DWI-MRI toT2-MRI for predicting complete response (ypT0N0 = CR) after chemoradiation-therapy (CRT) in locally advanced rectal cancer. METHODS: Seventy locally advanced rectal cancer patients underwent CRT followed by restaging MRI and resection. Two readers with different experience levels independently scored T2 images for CR and, in a second reading, combined T2 and DWI. A 5-point confidence-level score was used to generate ROC curves. Areas under the ROC curves (AUC) and interobserver agreement were compared for both readings. Histology served as reference standard. RESULTS: The interobserver agreement increased after addition of DWI from 0.35 to 0.58 but the AUC improved only for the experienced reader (0.77 to 0.89, p = 0.005 vs. 0.74 to 0.70, p > 0.05). Sensitivity and NPV improved from 20-30 % to 40-70 %, respectively 88 % to 91-95 %. Specificity and PPV improved only for the experienced reader (87 to 93 % respectively 27 to 63 %). CONCLUSION: Adding DWI to T2-MRI improves consistency between readers and has potential to improve readers' accuracy dependent on his/her experience. DWI could be of additional value, particularly in ruling out CR (high NPV), but considering the sub-optimal PPV one should be cautious about relying solely on MRI for the clinical decision to offer a wait-and-see strategy.

Takotsubo cardiomyopathy or apical ballooning: a case report and a short literature study.

Takotsubo cardiomyopathy is an important differential diagnosis in patients with an acute coronary syndrome. This syndrome is typically characterized by a reversible contractile dysfunction of the left ventricular myocardium without any obstructive etiological coronary disease. This is not a rare entity in acute settings and a better knowledge of the syndrome could result in a heightened alertness and a higher detection. We present a case of takotsubo showing the importance of cardiac MRI in the differential diagnosis and reviewed the present literature concerning this syndrome and the usefulness of MRI in the detection.

MDCT imaging before transcutanous aortic valve implantation: rationale and measurements.

Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has assumed growing importance in the treatment of patients with severe aortic stenosis (AS), because it offers a much less invasive alternative for those in high risk for surgery. Good early results and advances in percutaneous valve technology have led to a substantial increase in procedural success rate and number of patients undergoing this less invasive treatment. Pre-procedural screening of several anatomic factors to assess the feasibility of this technique is important. Multidetector row computed tomography (MDCT) is the technique of choice in assessing these factors.This technical note aims to describe and illustrate the key elements that need to be evaluated before the procedure.

Cost effectiveness of multi detector CT angiography of the coronary arteries for the diagnosis of suspected non-ST elevation acute coronary syndrome (NSTE-ACS) in the emergency department. Mathematical analysis with a decision model.

The purpose of our study is to model cost-effectiveness of MDCTA for the diagnosis of NSTE-ACS with initially negative enzymes, in the emergency department. In Belgium, the use of multi-detector computed tomography (MDCTA) is probably cost-effective in the diagnosis of NSTE-ACS in the acute setting A decision tree model was developed and a mathematical study was performed that included two hypothetical strategies: MDCTA and admission with classic clinical follow-up and treatment. Cost-effectiveness for the Belgian situation was simulated with sensitivity analysis using known values for diagnostic performance and known costs for the different strategies or components of strategies.

Acute thrombosis of an abdominal aortic aneurysm: a short report.

INTRODUCTION: Sudden thrombosis of an abdominal aortic aneurysm is a rare condition with a high mortality rate. REPORT: We present a patient with acute neurological deficits in both legs based on a thrombosis of a nine centimetre infrarenal abdominal aortic aneurysm. Successful iliac thrombectomy with aortic tube graft reconstruction was performed. DISCUSSION: Sudden thrombosis of an abdominal aortic aneurysm is a rare condition, but should be taken into consideration in patients with acute neurological deficits of the lower extremities. Prompt diagnosis and surgical management can lead to a successful outcome. A review of the literature is presented.