Right-sided aortic arch with isolation of the left innominate artery and hypoplasia of the left internal carotid artery.

PURPOSE: Here, we report a case of the right-sided aortic arch with isolation of the left innominate artery and hypoplasia of the left internal carotid artery. METHODS: A 42-year-old male patient underwent a whole-body computed tomography angiography (CTA) examination upon the clinical suspicion of vasculitis. RESULTS: CTA revealed a right-sided aortic arch with the isolation of the left innominate artery and hypoplasia of the left internal carotid artery. CONCLUSION: The right-sided aortic arch, with the isolation of the left innominate artery, is a scarce vascular variation that may occur with other cardiovascular anomalies such as ventricular septal defect. It can be asymptomatic or can present with symptoms of subclavian steal syndrome. Although its association with the agenesis of the left internal carotid artery has been reported, its association with the hypoplasia of the left internal carotid artery has not been reported previously to the best of our knowledge.

A blind-ending branch of celiac artery: a persistent embryologic vascular remnant?

The celiac artery classically divides into three major branches, but it may have variations in branching pattern. Here we report a case of celiac artery having a blind-ending branch in a 54-year-old man who underwent computed tomography of the abdomen before the kidney transplantation surgery. Preprocedural assessment of celiac artery variations is critical for surgical and angiographic procedures involving the upper abdomen.

Type 4 retro-aortic left renal vein with an aneurysm.

Type 4 retro-aortic left renal vein (RLRV) and renal vein aneurysms are rare entities which may have clinical and surgical implications. Here we present computed tomography (CT) angiography images of a case of retro-aortic left renal vein draining into the left common iliac vein with a venous aneurysm.

The combined intrathyroidal course of the brachiocephalic artery, right common carotid artery and right subclavian artery.

PURPOSE: We present an extremely rare vascular variant in which the brachiocephalic artery, right common carotid artery, and right subclavian artery course through the right lobe of the thyroid gland. METHODS: A 54-year-old woman underwent a coronary computed tomography (CT) angiography examination with the suspicion of infective endocarditis. RESULTS: Unexpectedly, the distal brachiocephalic artery, the proximal right common carotid artery, and right subclavian artery had a course through the right lobe of the thyroid gland. Otherwise, the arcus aorta branching pattern was normal. CONCLUSION: The supraaortic major branches seldom have intrathyroidal course. The intrathyroidal course of the right common carotid artery was described previously only in one case. But, to our best knowledge, the combined intrathyroidal course of these three major vessels has not been previously reported. Although asymptomatic, such variations may complicate lower neck procedures involving thyroidectomies and thyroid biopsies if undetected and unreported. So, the awareness of this atypical course while reporting CT examinations is crucial prior to neck interventions.

Role of interventional radiology in the management of iatrogenic urinary tract injury: the factors affecting the outcome.

PURPOSE: To evaluate the efficacy of interventional radiological (IR) procedures in iatrogenic urinary tract injury and investigate the factors affecting the outcome. METHODS: Fifty-eight patients (21 male) with a mean age of 50.3 ± 15.8 years referred for iatrogenic urinary tract injury were enrolled in this study. Technical success was defined as (i) successful placement of a nephrostomy catheter within the renal pelvis and/or (ii) successful antegrade ureteral stent placement (double J stent) between the renal pelvis and bladder lumen. Complete resolution was defined as maintained ureteral patency without an external drain and ureteral stent. The factors that may affect complete resolution [ureteral avulsion, ureterovaginal fistula (UVF), history of malignancy/radiotherapy, and time to IR management] were also investigated. The receiver operating characteristic analysis was performed to estimate the cut-off time point for the IR management timing affecting complete resolution. RESULTS: The technical success rate for nephrostomy and ureteral stent placement was 100% (n = 58/58) and 78% (n = 28/36), respectively. In 14 patients, non-dilated pelvicalyceal systems were evident. In 18 patients, no further intervention after percutaneous nephrostomy was performed due to (i) poor performance status (n = 6) and (ii) reconstruction surgery upon clinicians' and/or patients' request (n = 12). Reconstruction surgery was required in 11 of the remaining 40 patients due to failure of percutaneous treatment (n = 11/40, 27.5%). In six of the patients, ureteral stents could not be removed due to the development of benign ureteral strictures (n = 6/40, 15%). Our complete resolution rate was 57.5% (n = 23/40). Age, gender, type of surgery (endoscopic or open), side and location of the injury did not statistically affect the complete resolution rate. The presence of ureteral avulsion, history of malignancy and radiotherapy individually or in combination significantly affected the complete resolution rate negatively. The presence of UVF also had a negative effect on the complete resolution rate; however, it did not reach statistical significance. Delayed intervention was also a significant factor related to lower complete resolution. The optimal cut-off point of the time interval for favorable clinical outcome was found to be 0-19th day following the surgery. CONCLUSION: IR procedures are safe and effective in the management of iatrogenic urinary tract injuries. Antegrade ureteral stenting should be performed as soon as possible to establish ureteral integrity without the development of stricture.

Two in one: Overlapping CT findings of COVID-19 and underlying lung diseases.

Coronavirus disease 2019 (COVID-19) is associated with pneumonia and has various pulmonary manifestations on computed tomography (CT). Although COVID-19 pneumonia is usually seen as bilateral predominantly peripheral ground-glass opacities with or without consolidation, it can present with atypical radiological findings and resemble the imaging findings of other lung diseases. Diagnosis of COVID-19 pneumonia is much more challenging for both clinicians and radiologists in the presence of pre-existing lung disease. The imaging features of COVID-19 and underlying lung disease can overlap and obscure the findings of each other. Knowledge of the radiological findings of both diseases and possible complications, correct diagnosis, and multidisciplinary consensus play key roles in the appropriate management of diseases. In this pictorial review, the chest CT findings are presented of patients with underlying lung diseases and overlapping COVID-19 pneumonia and the various reasons for radiological lung abnormalities in these patients are discussed.

Admission chest CT findings and risk assessment for stroke-associated pneumonia.

INTRODUCTION: Stroke-associated pneumonia (SAP) is a significant cause of morbidity and mortality after stroke. Various factors, including dysphagia and stroke severity, are closely related to SAP risk; however, the contribution of the baseline pulmonary parenchymal status to this interplay is an understudied field. Herein, we evaluated the prognostic performance of admission chest computed tomography (CT) findings in predicting SAP. METHODS: We evaluated admission chest CT images, acquired as part of a COVID-19-related institutional policy, in a consecutive series of acute ischemic stroke patients. The pulmonary opacity load at baseline was quantified using automated volumetry and visual scoring algorithms. The relationship between pulmonary opacities with risk of pneumonia within 7 days of symptom onset (i.e., SAP) was evaluated by bivariate and multivariate analyses. RESULTS: Twenty-three percent of patients in our cohort (n = 100) were diagnosed with SAP. Patients with SAP were more likely to have atrial fibrillation, COPD, severe neurological deficits, and dysphagia. The visual opacity score on chest CT was significantly higher among patients who developed SAP (p = 0.014), while no such relationship was observed in terms of absolute or relative opacity volume. In multivariate analyses, admission stroke severity, presence of dysphagia and a visual opacity score of ≥ 3 (OR 6.37, 95% CI 1.61-25.16; p = 0.008) remained significantly associated with SAP risk. CONCLUSIONS: Pulmonary opacity burden, as evaluated on admission chest CT, is significantly associated with development of pneumonia within initial days of stroke. This association is independent of other well-known predisposing factors for SAP, including age, stroke severity, and presence of dysphagia.

Comprehensive assessment and outcomes of patients with chronic periaortitis.

OBJECTIVES: Chronic periaortitis (CP) is a less known but more frequently diagnosed fibro-inflammatory disorder, but we know little about it and data regarding follow-up and outcome are still very limited. This study aims to identify the clinicopathologic, laboratory, and radiologic features, as well as outcomes of CP patients. METHODS: Patients with CP from HUVAC database were included in the study. CP was diagnosed based on compatible imaging findings and histopathological evaluation (if available), in addition to clinical findings. Demographics, laboratory, clinical, and imaging data were retrospectively reviewed from medical records. RESULTS: A total of 51 (male/female:37/14) patients were included in the study. Median (IQR) age was 63 (53-69) years and follow-up duration was 40 (4-60) months. 32 of the patients were IgG4-related CP. The most common form of CP in our cohort was idiopathic retroperitoneal fibrosis (82%), followed by inflammatory abdominal aortic aneurysms (12%) and peri-aneurysmal retroperitoneal fibrosis (8%). 8 (15.6%) patients had thoracic periaortitis and 16 (31.6%) venous involvement. Cyclophosphamide (CYC) combined with steroids was the most preferred treatment modality (43%), followed by rituximab (RTX) (31.3%). Follow-up imaging was done after a median (IQR) of 7(3-11) months, 30% of the patients were stable and 64.1% showed regression. A total of 18 (35.2%) had been taken off therapy at the last visit. CONCLUSIONS: Idiopathic retroperitoneal fibrosis was the most frequent presentation, whereas 15.6% of patients had thoracic involvement. Venous involvement was also not uncommon. Optimal time for follow-up imaging was determined as 6-9 months. Steroids along with CYC/RTX had a favourable outcome in the treatment of these patients.

Imaging of congenital lung diseases presenting in the adulthood: a pictorial review.

Congenital lung diseases in adults are rare diseases that can present with symptoms or be detected incidentally. Familiarity with the imaging features of different types of congenital lung diseases helps both in correct diagnosis and management of these diseases. Congenital lung diseases in adults are classified into three main categories as bronchopulmonary anomalies, vascular anomalies, and combined bronchopulmonary and vascular anomalies. Contrast-enhanced computed tomography, especially 3D reconstructions, CT, or MR angiography, can show vascular anomalies in detail. The tracheobronchial tree, parenchymal changes, and possible complications can also be defined on chest CT, and new applications such as quantitative 3D reconstruction CT images, dual-energy CT (DECT) can be helpful in imaging parenchymal changes. In addition to the morphological assessment of the lungs, novel MRI techniques such as ultra-short echo time (UTE), arterial spin labeling (ASL), and phase-resolved functional lung (PREFUL) can provide functional information. This pictorial review aims to comprehensively define the radiological characteristics of each congenital lung disease in adults and to highlight differential diagnoses and possible complications of these diseases.

AI-Based Quantitative CT Analysis of Temporal Changes According to Disease Severity in COVID-19 Pneumonia.

OBJECTIVE: To quantitatively evaluate computed tomography (CT) parameters of coronavirus disease 2019 (COVID-19) pneumonia an artificial intelligence (AI)-based software in different clinical severity groups during the disease course. METHODS: From March 11 to April 15, 2020, 51 patients (age, 18-84 years; 28 men) diagnosed and hospitalized with COVID-19 pneumonia with a total of 116 CT scans were enrolled in the study. Patients were divided into mild (n = 12), moderate (n = 31), and severe (n = 8) groups based on clinical severity. An AI-based quantitative CT analysis, including lung volume, opacity score, opacity volume, percentage of opacity, and mean lung density, was performed in initial and follow-up CTs obtained at different time points. Receiver operating characteristic analysis was performed to find the diagnostic ability of quantitative CT parameters for discriminating severe from nonsevere pneumonia. RESULTS: In baseline assessment, the severe group had significantly higher opacity score, opacity volume, higher percentage of opacity, and higher mean lung density than the moderate group (all P ≤ 0.001). Through consecutive time points, the severe group had a significant decrease in lung volume (P = 0.006), a significant increase in total opacity score (P = 0.003), and percentage of opacity (P = 0.007). A significant increase in total opacity score was also observed for the mild group (P = 0.011). Residual opacities were observed in all groups. The involvement of more than 4 lobes (sensitivity, 100%; specificity, 65.26%), total opacity score greater than 4 (sensitivity, 100%; specificity, 64.21), total opacity volume greater than 337.4 mL (sensitivity, 80.95%; specificity, 84.21%), percentage of opacity greater than 11% (sensitivity, 80.95%; specificity, 88.42%), total high opacity volume greater than 10.5 mL (sensitivity, 95.24%; specificity, 66.32%), percentage of high opacity greater than 0.8% (sensitivity, 85.71%; specificity, 80.00%) and mean lung density HU greater than -705 HU (sensitivity, 57.14%; specificity, 90.53%) were related to severe pneumonia. CONCLUSIONS: An AI-based quantitative CT analysis is an objective tool in demonstrating disease severity and can also assist the clinician in follow-up by providing information about the disease course and prognosis according to different clinical severity groups.

Anatomy of testicular artery: A proposal for a classification with MDCT angiography.

PURPOSE: Knowledge of normal anatomy and variations of testicular arteries are critical for planning before minimally invasive surgery. In this article, we aimed to evaluate the morphological characteristics of testicular arteries by MDCT and propose a new classification system. METHOD: A total of 400 adult patients (total of 819 testicular arteries) who underwent abdominal CT angiography examination for several unrelated reasons were enrolled in this study. Testicular arteries (TAs) were evaluated in terms of number, origin, course, and caliber. Based on our findings, we also proposed a novel anatomical classification for the TAs according to their origin (divided into 5 types-type 1-5-) and course (divided into three types-type a-c-). Type 4 origin and type a course are the expected normal origin and course of bilateral TAs. RESULTS: The most common type based on the origin was type 4, with the testicular artery originating from the abdominal aorta, inferior to the level of the renal artery within 5 cm distal to the renal arteries. 70.7% of the right and 75.6% of the left testicular arteries were type 4. The most common type of the vessel course was the normal expected trajectory (type a) with an incidence of 76.3% for the right and 82.6% for the left testicular arteries. CONCLUSION: Normal anatomy and variations of testicular arteries may be effectively evaluated by CT angiography in a non-invasive manner.

Coronary (peri)-arteritis in patients with IgG4-related disease: A case series from the Central Anatolia Region of Turkey.

OBJECTIVE: Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized fibro-inflammatory disease which affects many systems, as well as the cardiovascular system. Identifying the coronary involvement like periaortitis, coronary periarteritis and pericarditis is important, as they often cause unfavorable outcomes. METHODS: Eighty-one patients with IgG4-RD were retrospectively evaluated for symptomatic coronary artery involvement from Hacettepe University Vasculitis Research Center (HUVAC) database. The demographic, laboratory, radiologic and clinical characteristics of the patients were assessed. RESULTS: Among 81 patients with IgG4-RD, 6 patients (M/F:5/1) had coronary artery involvement. The patients' median age was 57 and serum IgG4 levels were above normal except for one case. All patients with coronary arteritis revealed an increased coronary vessel wall thickening and stenotic lesions. The coronary aneurysm and pericarditis were observed in half of the patients. Immunosuppressive treatments were given to all the patients and most of them followed in stable condition. CONCLUSION: Coronary arteritis is a rare but notable manifestation of IgG4-RD. Although coronary periarteritis can cause significant morbidity and mortality, it seems better results can be achieved with early diagnosis and treatment.

A sling of a normal right inferior vena cava around the abdominal aorta.

Variations in the anatomy of inferior vena cava (IVC) may have important clinical implications. In-depth knowledge of its embryology and variations are of fundamental importance to prevent any potential medical complications related to anatomic variations of the IVC. In this article, we described a previously unreported, to the best of our knowledge, a variation of IVC. In the case we presented, the IVC was seen almost completely encircling the abdominal aorta. We decided to call this anatomic variation as "a sling of a normal right IVC around the abdominal aorta". Cross-sectional imaging is a prompt and highly reliable method to evaluate IVC anatomy and may have significant clinical importance to prevent any potential complications related to IVC during surgery or interventional radiology procedures.

Lung and kidney perfusion deficits diagnosed by dual-energy computed tomography in patients with COVID-19-related systemic microangiopathy.

OBJECTIVES: There is increasing evidence that thrombotic events occur in patients with coronavirus disease (COVID-19). We evaluated lung and kidney perfusion abnormalities in patients with COVID-19 by dual-energy computed tomography (DECT) and investigated the role of perfusion abnormalities on disease severity as a sign of microvascular obstruction. METHODS: Thirty-one patients with COVID-19 who underwent pulmonary DECT angiography and were suspected of having pulmonary thromboembolism were included. Pulmonary and kidney images were reviewed. Patient characteristics and laboratory findings were compared between those with and without lung perfusion deficits (PDs). RESULTS: DECT images showed PDs in eight patients (25.8%), which were not overlapping with areas of ground-glass opacity or consolidation. Among these patients, two had pulmonary thromboembolism confirmed by CT angiography. Patients with PDs had a longer hospital stay (p = 0.14), higher intensive care unit admission rates (p = 0.02), and more severe disease (p = 0.01). In the PD group, serum ferritin, aspartate aminotransferase, fibrinogen, D-dimer, C-reactive protein, and troponin levels were significantly higher, whereas albumin level was lower (p < 0.05). D-dimer levels ≥ 0.485 µg/L predicted PD with 100% specificity and 87% sensitivity. Renal iodine maps showed heterogeneous enhancement consistent with perfusion abnormalities in 13 patients (50%) with lower sodium levels (p = 0.03). CONCLUSIONS: We found that a large proportion of patients with mild-to-moderate COVID-19 had PDs in their lungs and kidneys, which may be suggestive of the presence of systemic microangiopathy with micro-thrombosis. These findings help in understanding the physiology of hypoxemia and may have implications in the management of patients with COVID-19, such as early indications of thromboprophylaxis or anticoagulants and optimizing oxygenation strategies. KEY POINTS: • Pulmonary perfusion abnormalities in COVID-19 patients, associated with disease severity, can be detected by pulmonary DECT. • A cutoff value of 0.485 µg/L for D-dimer plasma levels predicted lung perfusion deficits with 100% specificity and 87% sensitivity (AUROC, 0.957). • Perfusion abnormalities in the kidney are suggestive of a subclinical systemic microvascular obstruction in these patients.

Visual and software-based quantitative chest CT assessment of COVID-19: correlation with clinical findings.

PURPOSE: The aim of this study was to evaluate visual and software-based quantitative assessment of parenchymal changes and normal lung parenchyma in patients with coronavirus disease 2019 (COVID-19) pneumonia. The secondary aim of the study was to compare the radiologic findings with clinical and laboratory data. METHODS: Patients with COVID-19 who underwent chest computed tomography (CT) between March 11, 2020 and April 15, 2020 were retrospectively evaluated. Clinical and laboratory findings of patients with abnormal findings on chest CT and PCR-evidence of COVID-19 infection were recorded. Visual quantitative assessment score (VQAS) was performed according to the extent of lung opacities. Software-based quantitative assessment of the normal lung parenchyma percentage (SQNLP) was automatically quantified by a deep learning software. The presence of consolidation and crazy paving pattern (CPP) was also recorded. Statistical analyses were performed to evaluate the correlation between quantitative radiologic assessments, and clinical and laboratory findings, as well as to determine the predictive utility of radiologic findings for estimating severe pneumonia and admission to intensive care unit (ICU). RESULTS: A total of 90 patients were enrolled. Both VQAS and SQNLP were significantly correlated with multiple clinical parameters. While VQAS >8.5 (sensitivity, 84.2%; specificity, 80.3%) and SQNLP <82.45% (sensitivity, 83.1%; specificity, 84.2%) were related to severe pneumonia, VQAS >9.5 (sensitivity, 93.3%; specificity, 86.5%) and SQNLP <81.1% (sensitivity, 86.5%; specificity, 86.7%) were predictive of ICU admission. Both consolidation and CPP were more commonly seen in patients with severe pneumonia than patients with nonsevere pneumonia (P = 0.197 for consolidation; P < 0.001 for CPP). Moreover, the presence of CPP showed high specificity (97.2%) for severe pneumonia. CONCLUSION: Both SQNLP and VQAS were significantly related to the clinical findings, highlighting their clinical utility in predicting severe pneumonia, ICU admission, length of hospital stay, and management of the disease. On the other hand, presence of CPP has high specificity for severe COVID-19 pneumonia.