Academic achievement after a CT examination toward the head in childhood: Follow up of a randomized controlled trial.

INTRODUCTION: Increasing use of CT examinations has led to concerns of possible negative cognitive effects for children. The objective of this study is to examine if the ionizing radiation dose from a CT head scan at the age of 6-16 years affects academic performance and high school eligibility at the end of compulsory school. MATERIALS AND METHODS: A total of 832 children, 535 boys and 297 girls, from a previous trial where CT head scan was randomized on patients presenting with mild traumatic brain injury, were followed. Age at inclusion was 6-16 years (mean of 12.1), age at follow up 15-18 years (mean of 16.0), and time between injury and follow up one week up to 10 years (mean of 3.9). Participants' radiation exposure status was linked with the total grade score, grades in mathematics and the Swedish language, eligibility for high school at the end of compulsory school, previously measured GOSE-score, and their mothers' education level. The Chi-Square Test, Student's t-Test and factorial logistics were used to analyze data. RESULTS: Although estimates of school grades and high school eligibility were generally higher for the unexposed, the results showed no statistically significant differences between the exposed and unexposed participants in any of the aforementioned variables. CONCLUSIONS: Any effect on high school eligibility and school grades from a CT head scan at the age of 6-16 years is too small to be detected in a study of more than 800 patients, half of whom were randomly assigned to CT head scan exposure.

MRI Markers of Small Vessel Disease and the APOE Allele in Cognitive Impairment.

Objective: The apolipoprotein E (APOE) ε4 allele is the main genetic risk factor for dementia and Alzheimer's disease (AD), but the underlying mechanism for the increased risk is not well understood. Cerebral small vessel disease (SVD) is prevalent among patients with cognitive impairment and is thought to play an important role in the pathophysiology of dementia. We aimed to investigate the association between the APOE ε genotype and magnetic resonance imaging (MRI) markers of SVD in a memory clinic population. Material and Methods: This is a cross-sectional study with a total of 520 patients undergoing dementia investigation, including an MRI brain scan and APOE genotyping in all patients enrolled, and cerebrospinal fluid (CSF) analysis for routine AD biomarkers in 399 patients. MR images were assessed for markers of SVD: cerebral microbleeds (CMBs), cortical superficial siderosis, intracerebral hemorrhage, white matter hyperintensities, lacunar infarcts, and enlarged perivascular spaces. Results: Apolipoprotein E carriers with AD had a higher number of CMBs when looking at all brain regions and lobar brain regions (p < 0.001). A lower number of CMBs were seen in APOE ε2 (p < 0.05), ε3 and ε3/3 carriers (p < 0.001) when looking at all brain regions. A higher number of CMBs in deep and infratentorial regions were seen in APOE ε2 and ε3 (p < 0.05). In APOE ε4/4 carriers, CMBs, cortical superficial siderosis, white matter hyperintensities, and enlarged perivascular spaces were associated with lower levels of CSF amyloid ß (Aß) 42 in the whole cohort, and in individuals with AD and mild cognitive impairment (p < 0.05). Conclusion: Apolipoprotein E ε4 is associated with MRI markers of SVD related to amyloid pathology, specifically CMBs and Aß42 plaque formation in the brain, as reflected by decreased CSF Aß42 levels, whereas APOE ε3 and ε2 are associated with the markers of hypertensive arteriopathy, as reflected by the association with CMBs in deep and infratentorial brain regions.

Regarding Iodixanol for Pediatric CTA. Comment on Pop, M. Cardiothoracic CTA in Infants Referred for Aortic Arch Evaluation-Retrospective Comparison of Iomeprol 350, Ioversol 350, Iopromide 370 and Iodixanol 320. Children 2021, 8, 949.

With interest, we read the publication 'Cardiothoracic CTA in Infants Referred for Aortic Arch Evaluation-Retrospective Comparison of Iomeprol 350, Ioversol 350, Iopromide 370 and Iodixanol 320' by Pop [...].

Radiology reporting in rectal cancer using MRI: adherence to national template for structured reporting.

BACKGROUND: In 2014, a national workshop program was initiated and a reporting template and manual for rectal cancer primary staging using magnetic resonance imaging (MRI) was introduced and made available by the national Swedish Colorectal Cancer Registry. PURPOSE: To evaluate the effect of the national template program by identify if there was a gap between the content in Swedish MRI reports from 2016 and the national reporting template from 2014. The aim was to explore and compare differences in content in reporting practice in different hospitals in relation to the national reporting template, with focus on: (i) identifying any implementational differences in reporting styles; and (ii) evaluating if reporting completeness vary based on such implementational differences. MATERIAL AND METHODS: A total of 250 MRI reports from 10 hospitals in four healthcare regions in Sweden were collected. Reports were analyzed using qualitative content analysis with a deductive thematic coding scheme based on the national reporting template. RESULTS: Three different implemented reporting styles were identified with variations of content coverage in relation to the template: (i) standardized and structured protocol (reporting style A); (ii) standardized semi-structured free-text (reporting style B); and (iii) regular free-text (reporting style C). The relative completeness of reporting practice of rectal cancer staging in relation to the national reporting template were 92.9% for reporting style A, 77.5% for reporting style B, and 63.9% for reporting style C. CONCLUSION: The implementation of template-based reporting according to reporting style A is a key factor to conform to evidence-based practice for rectal cancer reporting using MRI.

Rectal cancer staging using MRI: adherence in reporting to evidence-based practice.

BACKGROUND: Magnetic resonance imaging (MRI) is the first-line imaging modality for local staging of rectal cancer. The radiology report should deliver all relevant available imaging information to guide treatment. PURPOSE: To explore and describe if there was a gap between the contents in MRI reports for primary staging of rectal cancer in Sweden in 2010 compared to evidence-based practice. MATERIAL AND METHODS: A total of 243 primary MRI staging reports from 2010, collected from 10 hospitals in four healthcare regions in Sweden, were analyzed using content analysis with a deductive thematic coding scheme based on evidence-based practice. Focus was on: (i) most frequently reported findings; (ii) correlation to key prognostic findings; and (iii) identifying if any findings being reported were beyond the information defined in evidence-based practice. RESULTS: Most frequently reported findings were spread through the bowel wall or not, local lymph node description, tumor length, and distance of tumor from anal verge. These items accounted for 35% of the reporting content. Of all reported content, 86% correlated with the evidence-based practice. However, these included more information than was generally found in the reports. When adjusting for omitted information, 48% of the reported content were accounted for. Of the reported content, 20% correlated to key pathological prognostic findings. Six types of findings were reported beyond the evidence-based practice, representing 14% of the total reporting content. CONCLUSION: There was a gap between everyday practice and evidence-based practice in 2010. This indicates a need for national harmonization and implementation of standardized structured reporting templates.

Preventing contrast medium-induced acute kidney injury : Side-by-side comparison of Swedish-ESUR guidelines.

A side-by-side comparison of updated guidelines regarding contrast medium-induced acute kidney injury (CI-AKI) from the Swedish Society of Uroradiology (SSUR) and the European Society of Urogenital Radiology (ESUR) is presented. The major discrepancies include a higher glomerular filtration rate (GFR) threshold as a risk factor for CI-AKI and for discontinuation of metformin by SSUR, i.e., < 45 ml/min versus < 30 ml/min/1.73 m2 by ESUR, when intravenous or intra-arterial contrast media (CM) with second-pass renal exposure is administered. SSUR also continues to recommend consideration of traditional non-renal risk factors such as diabetes and congestive heart failure, while ESUR considers these factors as non-specific for CI-AKI and does not recommend any consideration. Contrary to ESUR, SSUR also recommends discontinuation of NSAID and nephrotoxic medication if possible. Insufficient evidence at the present time motivates the more cautionary attitude taken by SSUR. Furthermore, SSUR expresses GFR thresholds in absolute values in ml/min as recommended by the National Kidney Foundation for drugs excreted by glomerular filtration, while ESUR uses the relative GFR normalised to body surface area in ml/min/1.73 m2. CM dose/GFR ratio thresholds established for coronary angiography/interventions are also applied as recommendations for CM-enhanced CT by SSUR, since SSUR regards coronary procedures as a second-pass renal exposure of CM with no obvious difference in the incidence of AKI compared with IV CM administration. Finally, SSUR recommends reducing the gram-iodine dose/GFR ratio from < 1.0 in patients not at risk to < 0.5 in patients at risk of CI-AKI, while ESUR has no such recommendation. KEY POINTS: • The more cautionary attitude taken by SSUR compared with that of ESUR is motivated by insufficient evidence regarding risk for contrast medium-induced acute kidney injuries (CI-AKI). • SSUR recommends that absolute and not relative GFR should be used when dosing drugs eliminated by the kidneys such as contrast media. • According to SSUR the gram-iodine dose/GFR ratio should be < 0.5 in patients at risk of CI-AKI, while ESUR has no such recommendation.

The contribution of small vessel disease to subtypes of Alzheimer's disease: a study on cerebrospinal fluid and imaging biomarkers.

We investigated whether subtypes of Alzheimer's disease (AD), that is, typical, limbic-predominant, hippocampal-sparing, and minimal atrophy AD, had a specific signature of small vessel disease and neurodegeneration. Four hundred twenty-three clinically diagnosed AD patients were included (161 typical, 121 limbic-predominant, 70 hippocampal-sparing, 71 minimal atrophy). One hundred fifty-six fulfilled a biomarkers-based AD diagnosis. White matter hyperintensities and cerebral microbleeds (CMB) had the highest prevalence in limbic-predominant AD, and the lowest prevalence in minimal atrophy AD. CMB existed evenly in lobar and deep brain areas in limbic-predominant, typical, and hippocampal-sparing AD. In minimal atrophy AD, CMB were mainly located in brain lobar areas. Perivascular spaces in the centrum semiovale were more prevalent in typical AD. Small vessel disease contributed to the prediction of Mini-Mental State Examination. Minimal atrophy AD showed highly pathological levels of cerebrospinal fluid Aß1-42, total tau, and phosphorylated tau, in the absence of overt brain atrophy. Cerebral amyloid angiopathy seems to have a stronger contribution to hippocampal-sparing and minimal atrophy AD, whereas hypertensive arteriopathy may have a stronger contribution to typical and limbic-predominant AD.

Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis?

Background: The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria. Methods: This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis. Results: Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities. Conclusions: Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.

Cognitive function following head CT in childhood: a randomized controlled follow-up trial.

Background The question has been raised whether low dose radiation toward the brain in childhood can affect cognitive functions. Purpose To examine if a head computed tomography (CT) examination in childhood affect later cognitive functions. Material and Methods A total of 147 participants (67 girls/women, 80 boys/men) from a previous randomized controlled trial on management strategies after mild head injury (head CT examination or in-hospital observation) were followed up. Participants were aged 6-16 years (mean age = 11.2 ± 2.8) at first inclusion and 11-24 years (mean age = 17.8 ± 2.9) at follow-up. Computerized neuropsychological measures used for the assessment were motor speed and coordination, reaction time, selective attention, visuospatial ability, verbal and non-verbal short-term and long-term memory, and executive function tests from the neurocognitive test battery EuroCog and the Wechsler Memory Scale III. Results were analyzed with Student's t-tests and multivariate analyses adjusting for sex, age at time of injury/exposure, and age at assessment were performed with Factorial ANOVAs. Results The exposed and unexposed groups did not differ in any of the neuropsychological measures and results did not change when sex, age at time of injury/exposure, and age at assessment were included in the analyses. Conclusion A head CT examination at the age of 6-16 years does not seem to affect later cognitive functions.

Diabetic osteoarthropathy care in Sweden - Need for improvement: A national inventory.

AIMS: Osteoarthropathy, a rare foot complication in patients with diabetes mellitus, calls for immediate and optimal management to prevent irreversible bone/joint destruction and risk of amputation. Awareness of the condition and adequate guidelines would minimize the consequences and the costs, both for the patient and for the society. We investigated the diabetic osteoarthropathy care in Swedish orthopedic clinics. METHODS: A questionnaire was distributed to 63 Swedish hospitals with emergency department for orthopedic patients. There was a 95% response rate. RESULTS: Most of the respondents (79%) specified absence of established procedures including guidelines for managing patients with osteoarthropathy. The most common diagnostic method was clinical diagnosis and plain X-ray (95%). MRI or scintigraphy was used by 19% and 10.5% respectively. As treatment method, 84% used a total contact cast, while 38% used orthoses. Treatment duration <3 months was reported in 4%, 3-6 months in 53% and 6-12 months in 28% of the clinics. Four clinics reported treatment duration >12 months and two clinics provided no treatment. CONCLUSION: Our national inventory indicates a need for improvement in knowledge as well as guidance and organization at orthopedic clinics regarding optimal care of patients with diabetic osteoarthropathy.

Risk of Meningioma after CT of the Head.

Purpose To investigate the association between exposure to head computed tomography (CT) and subsequent risk of meningioma. Materials and Methods The study was approved by the local ethics committee. A cohort of 26 370 subjects was retrospectively collected from a radiology archive of CT examinations of the head performed from 1973 through 1992. For comparison, an age- and sex-matched cohort of 96 940 subjects who were not exposed to CT (unexposed cohort) was gathered. The risk of meningioma was assessed by using data from the Swedish Cancer Registry; however, one-third of patients with meningioma had to be excluded because they either had a prevalent meningioma or other brain tumor at the first CT examination or had undergone radiation treatment to the head. Hazard ratios (HRs) were calculated from time of exposure to the occurrence of meningioma or death or until December 31, 2010, with logistic regression. Results Comparison of exposed and unexposed cohorts showed that there was no statistically significant increase in the risk of meningioma after exposure to CT of the head (HR: 1.49; 95% confidence interval: 0.97, 2.30; P = .07). If incident cases at the time of the first CT examination were not excluded, the risk of meningioma would have been falsely increased (HR: 2.28; 95% confidence interval: 1.56, 3.33; P = .0001). Conclusion When prevalent cases of meningioma at first exposure to CT of the head are excluded, no statistically significant increase in risk of meningioma was found among exposed subjects compared with unexposed control subjects. © RSNA, 2017.

[Lumbar spine radiography ­ unreliable diagnostic accuracy and negligible value for the patients]. / Ländryggsröntgen ger falsk säkerhet och ringa nytta för patienten - MRT och DT ger bättre och billigare resultat.

Lumbar spine radiography - unreliable diagnostic accuracy and negligible value for the patients In 2016 140 000 lumbar spine radiographies were performed in Sweden (14 000 per million inhabitants) to a cost of about 85 million SEK (≈8.5 million Euro) and a negligible value for the patients with low back pain. In the work-up of low back pain, when imaging is indicated, lumbar spine radiography should be replaced by limited magnetic resonance imaging including a whole lower body coronal STIR sequence or computed tomography with radiation dose adapted to indication and patient age. Indication for imaging should be restricted to 1) low back pain with more than 3-4 weeks duration in combination with at least one ¼red flag«, 2) radicular pain without improvement on conservative treatment, or 3) low back pain with more than 8 weeks duration in combination with ¼yellow flags«.

Arterio-portal shunts in the cirrhotic liver: perfusion computed tomography for distinction of arterialized pseudolesions from hepatocellular carcinoma.

OBJECTIVES: To determine perfusion computed tomography (P-CT) findings for distinction of arterial pseudolesions (APL) from hepatocellular carcinoma (HCC) in the cirrhotic liver. METHODS: 32 APL and 21 HCC in 20 cirrhotic patients (15 men; 65 ± 10 years), who underwent P-CT for evaluation of HCC pre- (N = 9) or post- (N = 11) transarterial chemoembolization, were retrospectively included using CT follow-up as the standard of reference. All 53 lesions were qualitatively (visual) and quantitatively (perfusion parameters) analysed according to their shape (wedge, irregular, nodular), location (not-/adjunct to a fistula), arterial liver perfusion (ALP), portal venous liver perfusion (PLP), hepatic perfusion index (HPI). Accuracy for diagnosis of HCC was determined using receiver operating characteristics. RESULTS: 18/32 (56 %) APL were wedge shaped, 10/32 (31 %) irregular and 4/32 (12 %) nodular, while 11/21 (52 %) HCC were nodular or 10/21 (48 %) irregular, but never wedge shaped. Significant difference between APL and HCC was seen for lesion shape in pretreated lesions (P < 0.001), and for PLP and HPI in both pre- and post-treated lesions (all, P < 0.001). Diagnostic accuracy for HCC was best for combined assessment of lesion configuration and PLP showing an area under the curve of 0.901. CONCLUSION: Combined assessment of lesion configuration and portal venous perfusion derived from P-CT allows best to discriminate APL from HCC with high diagnostic accuracy. KEY POINTS: • Arterio-portal shunting is common in the cirrhotic liver, especially after local treatment. • Arterial pseudolesions (APL) due to shunting might mimic hepatocellular carcinoma (HCC). • Perfusion-CT allows for qualitative and quantitative assessment of liver lesions. • Lesion configuration fails to discriminate APL from HCC in locally treated patients. • Integration of quantitative perfusion analysis improves accuracy for diagnosis of HCC.

Cerebral microbleeds topography and cerebrospinal fluid biomarkers in cognitive impairment.

Cerebral microbleeds, a marker of small vessel disease, are thought to be of importance in cognitive impairment. We aimed to study topographical distribution of cerebral microbleeds, and their involvement in disease pathophysiology, reflected by cerebrospinal fluid biomarkers; 1039 patients undergoing memory investigation underwent lumbar puncture and a brain magnetic resonance imaging scan. Cerebrospinal fluid samples were analyzed for amyloid ß(Aß)42, total tau(T-tau), tau phosphorylated at threonine 18(P-tau) and cerebrospinal fluid/serum albumin ratios. Magnetic resonance imaging sequences were evaluated for small vessel disease markers, including cerebral microbleeds, white matter hyperintensities and lacunes. Low Aß42 levels were associated with lobar cerebral microbleeds in the whole cohort and Alzheimer's disease ( P < 0.001). High cerebrospinal fluid/serum albumin ratios were seen with increased number of cerebral microbleeds in the brainstem ( P < 0.001). There were tendencies for increased Aß42 levels and decreased Tau levels with deep and infratentorial cerebral microbleeds ( P < 0.05). Lobar cerebral microbleeds were associated with white matter hyperintensities and lacunes ( P < 0.001). Probable cerebral amyloid angiopathy-related cerebral microbleeds were associated with low Aß42 levels and lacunes, whereas probable cerebral amyloid angiopathy-unrelated cerebral microbleeds were associated with white matter hyperintensities ( P < 0.001). Our findings show that cerebral microbleed distribution is associated with different patterns of cerebrospinal fluid biomarkers, supporting different pathogenesis of deep/infratentorial and lobar cerebral microbleeds.

Cortical superficial siderosis: Prevalence and biomarker profile in a memory clinic population.

OBJECTIVE: To gain further insight into cortical superficial siderosis (cSS), a new hemorrhagic neuroimaging marker of cerebral amyloid angiopathy (CAA), and to investigate the clinical, neuroimaging, genetic, and CSF biomarker profile of cSS in a large, consecutive memory clinic series. METHODS: We included 1,504 memory clinic patients undergoing dementia investigation including a brain MRI in our center. Routine CSF biomarker analysis was performed in 1,039 patients and APOE genotyping in 520 patients. MRIs were systematically evaluated for presumed marker of small vessel disease: cSS, cerebral microbleeds, enlarged perivascular spaces, white matter hyperintensities, and lacunes. RESULTS: cSS was detected in 40 patients (2.7%; 95% confidence interval [CI] 1.9-3.6); cSS was focal in 33 cases (2.2%; 95% CI 1.5-3.1) and disseminated in 7 (0.5%; 95% CI 0.2-1). Vascular dementia had the highest cSS prevalence (13%; 95% CI 5.4-24.9), followed by Alzheimer disease (5%; 95% CI 3.1-7.5). The most commonly affected area was the occipital lobe (70%; 95% CI 53.5-83.4). cSS was associated with lobar cerebral microbleeds (odds ratio [OR] 7.9; 95% CI 3.4-18.1; p < 0.001), high-degree centrum semiovale perivascular spaces (OR 1.7; 95% CI 1.2-2.6; p = 0.008), and white matter hyperintensities (OR 1.5; 95% CI 1.0-2.2; p = 0.062). APOE ε4/4 genotype was more common in cSS cases compared to those without. CSF ß-amyloid 42 was lower in patients with cSS (coefficient -0.09; 95% CI -0.15 to -0.03; p = 0.004). CONCLUSIONS: Our large series of memory clinic patients provides evidence that cSS is related to cerebrovascular disease and may be a manifestation of severe CAA, even in patients without intracerebral hemorrhage.