Evaluation of the Aortic Arch from the Suprasternal Notch View Using Focused Cardiac Ultrasound.

BACKGROUND: The suprasternal notch view (SSNV) is an additional echocardiographic view not routinely used by emergency physicians (EPs) performing focused cardiac ultrasound (FOCUS). OBJECTIVE: This pilot study determined the ease and self-perceived accuracy of the SSNV as performed by EPs. Additionally, we assessed the accuracy of FOCUS including the SSNV in thoracic aortic measurements compared to chest CT angiography (CTA). METHODS: This was a prospective, observational, pilot study of adult patients undergoing chest CTA. Thoracic aortic measurements were recorded at the sinus of Valsalva, sinotubular junction, and ascending aorta at its widest diameter in the parasternal long axis (PSL) view and SSNV. EPs rated ease of acquisition and self-perceived accuracy of thoracic aorta measurements. Two blinded radiologists performed thoracic aortic CTA measurements at predefined locations corresponding to the ultrasound measurements. RESULTS: Of the 79 patients (median age 57 years) enrolled, the SSNV was obtained in 97% of cases. EPs rated the ease of obtaining the SSNV as "easy" in 64.5% of cases and "very difficult" in 7.6% of cases. The mean difference between ultrasound (FOCUS plus SSNV) and CTA measurements were 1.2 mm (95% limits of agreement -2.9 to 5.3) at the sinus of Valsalva, 1.0 mm (95% limits of agreement -5.5 to 3.6 mm) at the sinotubular junction, 0.8 mm (95% limits of agreement -6.2 to 4.6 mm) at the proximal ascending aorta, and 0.6 mm (95% limits of agreement -2.8 to 4.0) at the aortic arch. CONCLUSIONS: Our findings suggest that the SSNV is an easily attainable and accurate view of the thoracic aorta that can be obtained by EPs in the majority of ED patients.

Synergistic Radiation Dose Reduction by Combining Automatic Tube Voltage Selection and Iterative Reconstruction.

PURPOSE: The aim of the study was to evaluate radiation dose and image quality in computed tomographic pulmonary angiography (CTPA) scans performed with automatic tube voltage selection (ATVS, CarekV) before and after implementation of iterative reconstruction (IR, Safire). MATERIALS AND METHODS: This IRB-approved study was conducted with waiver of informed consent. The cohort included 100 consecutive "standard protocol" CTPAs performed using ATVS and 100 consecutive "combined protocol" CTPAs performed using ATVS with a 33% reduction in reference mAs and IR. CTDIvol and main pulmonary artery enhancement, noise, and signal-to-noise ratio were recorded, along with blinded grading of subjective image quality. Dose and image quality were compared between cohorts with univariate analyses and linear regression models. RESULTS: The 33% reduction in reference mAs with the combined protocol allowed ATVS to select reduced kVp more often than with the standard protocol, with a reduction in 120 and 100 kVp scans (26% to 0% and 61% to 51%, respectively) and an increase in 80 kVp scans (13% to 49%). The combined protocol yielded a CTDIvol reduction of 43% (P<0.0001) and increases in main pulmonary artery enhancement (57 HU, P=0.005) and noise (P=0.019) with unchanged signal-to-noise ratio (P=0.17). With the combined protocol, subjective image quality was unchanged for evaluation of vascular structures but was decreased for evaluation of soft tissues and lung parenchyma. CONCLUSIONS: The combination of ATVS and IR resulted in a 43% dose reduction, greater than the 33% reduction that would be achieved by reducing the reference mAs alone. This was accomplished with preserved vascular image quality.

Prospective diagnosis of marginal ulceration following Roux-en-Y gastric bypass with computed tomography.

Marginal ulcers are reported to be the most common complication following Roux-en-Y gastric bypass surgery. Despite their frequency, they are rarely diagnosed prospectively with cross-sectional imaging. We present four cases in which the diagnosis of marginal ulceration was made prospectively with CT and confirmed with endoscopy.

Cholecystocolonic fistula mimicking acute cholecystitis diagnosed unequivocally by computed tomography.

Cholecystocolonic fistula is an uncommon potential complication of cholecystitis found intraoperatively in 0.06-0.14 % of patients undergoing cholecystectomy and 0.1-0.5 % of autopsy series. Although cholecystocolonic fistula is the second most common cholecystoenteric fistula, second only to cholecystoduodenal fistula, it is diagnosed preoperatively in only 7.9 % of patients. Failure to preoperatively diagnose cholecystocolonic fistula places surgeons in precarious positions, as they may be forced to convert a seemingly routine cholecystectomy to a more sophisticated procedure coupled with adhesiolysis, colonic suturing, or colonic resection. We report a young patient who presented to the emergency department with complaints indicative of acute cholecystitis; however, preoperative ultrasound was suggestive of a cholecystoenteric fistula. Computed tomography and pathology were pathognomonic with clear visualization of the cholecystocolonic fistulous tract.