Typical symptoms for prediction of outcome and risk stratification in acute pulmonary embolism.

BACKGROUND: Clinical presentation of pulmonary embolism (PE) comprises a wide spectrum from asymptomatic incidental finding to typical symptoms with chest pain, dyspnea, hemoptysis and syncope/collapse. We aimed to investigate typical symptoms of PE and increasing number of these symptoms to predict outcome in acute PE. METHODS: Data of PE patients were analysed retrospectively. According to the typical symptoms patients were subdivided in groups with 0, 1, 2, or ≥3 symptoms, which were compared with Kruskal-Wallis-Test. Logistic regression models were computed to investigate the association between the symptoms as well as the groups with the outcome parameters in-hospital death, myocardial necrosis, Shock-Index ≥1.0 and (right ventricular dysfunction (RVD). ROC curves were calculated to test the effectiveness of increasing number of symptoms to predict the outcome parameters. RESULTS: One hundred eighty-two PE patients (61.5% female, mean age 68.5±15.3 years) were included in this study. 5 patients (2.7%) died in-hospital. Logistic regression models revealed associations between syncope/collapse and in-hospital death (OR 7.269, 95%CI 0.894-59.130, P=0.0636), myocardial necrosis (OR2.872, 0.904-9.130, P=0.0738), Shock-Index ≥1.0 (OR 4.906, 1.440-16.721, P=0.00110) and RVD (OR 5.265, 1.078-25.708, P=0.0401). Dyspnea and myocardial necrosis were also associated (OR 3.245, 1.127-9.348, P=0.0292). Increasing number of symptoms were not associated with in-hospital death, but absence of typical symptoms was associated with lower frequency of myocardial necrosis (OR 0.212, 0.046-0.976, P=0.0464). Effectiveness of increasing number of symptoms to predict myocardial necrosis was only moderate (AUC 0.608). CONCLUSIONS: The symptom syncope/collapse is connected with poorer outcome in acute PE. An increasing number of symptoms failed to be useful for outcome prediction and risk stratification in acute PE.

Comparative study between mobile computed radiography and mobile flat-panel radiography for bedside chest radiography: impact of an antiscatter grid on the visibility of selected diagnostically relevant structures.

OBJECTIVES: The objective of this study was to evaluate the diagnostic performance of 2 different imaging systems in adult bedside chest radiography and the impact on the visibility of selected diagnostically relevant structures in the images acquired with these systems, with and without an antiscatter grid. MATERIALS AND METHODS: We acquired bedside chest radiographs of 103 intensive-care patients (36 women, 67 men; age range, 17-90 years; mean age, 66.4 years) using 4 acquisition techniques (computed radiography [CR] and digital radiography [DR], with and without grid). Image quality was evaluated independently by 4 radiologists using a 9-point visibility scale. Evaluated were lung parenchyma, soft tissues, thoracic spine, foreign bodies, and the overall image quality. Interobserver agreement and differences between the systems were tested using an interclass correlation (ICC) test. Mean scores were compared using the analysis of variance, followed by the post hoc pairwise testing (the Tukey test) in case of multiple group comparisons and by the Student t test in case of single group comparisons (P < 0.05, significant). RESULTS: The image quality of the structures evaluated in the DR images with a grid was significantly higher than that obtained without a grid (P < 0.001) for all structures. The use of a grid in CR significantly improved the overall image quality, lung parenchyma, and soft tissue delineation (P < 0.001). Foreign body delineation, however, was significantly better in the CR images obtained without a grid (P < 0.001), whereas the 2 systems showed no significant difference regarding thoracic spine delineation (P = 0.554). The scores of the DR images were significantly higher than those of the CR images for all structures. The interobserver agreement was substantial for lung parenchyma (ICC, 0.77), soft tissue (ICC, 0.78), thoracic spine (ICC, 0.80), and the overall image quality (ICC, 0.78) and was almost perfect for foreign bodies (ICC, 0.81). CONCLUSIONS: The use of an antiscatter grid significantly improved the image quality of bedside DR radiographs. A similar effect was seen with CR radiographs but only for lung parenchyma, soft tissue, and the overall image quality. Mobile DR outperformed CR in all structures.

Analysis of disk volume before and after CT-guided intradiscal and periganglionic ozone-oxygen injection for the treatment of lumbar disk herniation.

PURPOSE: To quantify the change in volume in herniated lumbar disk after computed tomography (CT)-guided intradiscal and periganglionic ozone-oxygen injection and to assess the effects of patient age, sex, and initial disk volume on disk volume changes. MATERIALS AND METHODS: A total of 283 patients with lumbar radiculopathy received a single intradiscal (3 mL) and periganglionic (7 mL) injection of an ozone-oxygen mixture (ratio, 3:97; ozone concentration, 30 µg/mL). Under CT guidance, intradiscal and periganglionic injection was performed through an extraspinal lateral approach with a 22-gauge spinal needle. All disk volume changes were evaluated on CT 6 months after the procedure in all patients. RESULTS: Initial mean disk volume was 17.37 cm(3) ± 4.70 (standard deviation; range, 8.12-29.15 cm(3)). Disk volume reduction (mean, 7.70% ± 5.45; range, 0.29%-22.31%) was seen in 96.1% of treated disks (n = 272) at 6 months after treatment and was found to be statistically significant (P < .0001). In 3.9% of patients (n = 11), disk volume increased (mean, 0.59% ± 0.24; range, 0.11%-0.81%). Patient age correlated negatively with disk volume reduction (r = -0.505; P < .0001) at 6 months after treatment, whereas initial disk volume correlated positively with volume reduction (r = 0.225; P = .00014) after therapy. No correlation was noted between patient sex and disk volume reduction after treatment (P = .09). CONCLUSIONS: Intradiscal administration of medical ozone is associated with a statistically significant volume reduction of the herniated lumbar disk. The volume-reduction effect of ozone correlates negatively with the patient's age and positively with initial disk volume.

Novel, portable, cassette-sized, and wireless flat-panel digital radiography system: initial workflow results versus computed radiography.

OBJECTIVE: The purpose of this article is to compare workflow efficiency between a conventional computed radiography (CR) system and a novel, portable, cassette-sized, and wireless flat-panel digital radiography (DR) system. MATERIALS AND METHODS: Observational time-motion analyses were performed at one site at which CR and the new portable DR system are used concurrently. The workflow steps of both systems were identified and categorized to facilitate comparison. The times required for examination preparation, patient positioning, exposure, postacquisition processing, and the examination as a whole were recorded by a neutral observer. Timing differences between the CR and portable DR systems were compared, and all data were analyzed using commercially available statistical software. Nine general radiographic examination types were selected, with approximately 50 patients per examination type. RESULTS: A total of 941 examinations (CR, n = 474; portable DR, n = 467) were timed in this study. Total examination time differences between CR and portable DR system (mean, 26.44 seconds; median 26.99 seconds) were found to be statistically significant (p < 0.001), with DR proving faster than CR. The single largest contributor to the time difference between CR and portable DR was postacquisition processing (mean, 26.58 seconds; median, 25.91 seconds), which was a composite of multiple individual steps, including cassette transport (CR only, mean, 13.22 seconds; median, 12.74 seconds), cassette readout (mean, 10.15 seconds; median, 10.4 seconds), and postprocessing (mean, 3.21 seconds; median, 3.11 seconds). CONCLUSION: Overall radiographer time was significantly shorter when performing examination-related tasks with the novel, portable DR system than when performing comparable tasks with the CR system, a difference that appears to result largely from technology configuration.

[Endovascular interventions of the descending thoracic aorta]. / Endovaskuläre Interventionen der thorakalen Aorta descendens.

Endovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well. In the elective setting, endovascular interventions significantly lowered short-term morbidity and mortality. These excellent perioperative results were reproducible in the emergency setting, thereby leading to superior outcomes for patients treated by endovascular stent grafts when compared to the conventional open surgical approach. However, some questions regarding long-term durability of these devices remain unanswered. Stent-graft failures at mid and long-term follow-up have been reported in the literature. The progressive nature of stent graft-related mid- and long-term complications stresses the need for continued surveillance of these patients.

Peripheral artery stent visualization and in-stent stenosis analysis in 16-row computed tomography: an in-vitro evaluation.

The accuracy of 16-row multidetector CT in the visualization of different peripheral artery stents and in the appraisal of in-stent stenosis was assessed. Nine different stent types (nitinol and stainless steel) with three diameters (6, 8 and 10 mm) were used; altogether 27 stents were analyzed in a barrel-shaped vascular model. Low-grade (<40%) and high-grade (>60%) in-stent stenoses were simulated by polyurethane sticks (70 HU) of differing diameters (2-6 mm). Imaging was performed with 16x0.75-mm detector collimation, 130 mAs, 120 kV, 12-mm table feed/rotation, 1.0-mm slice thickness and 0.5-mm increment. The stent diameter, strut thickness, in-stent attenuation values, degree and degree of in-stent stenosis were evaluated. Nitinol stents showed significantly (P<10-6) less stent lumen narrowing, artificial strut thickening and overestimation of the degree of in-stent stenoses than stainless steel stents. In-stent attenuation values and artificial strut thickening were significantly (P<10-6) lower in 10- and 8-mm stents than in 6-mm stents. Stent lumen narrowing was significantly less in 10-mm stents than in 8-mm (P<10-4) or 6-mm (P<10-6) stents. In-stent stenoses were significantly overestimated, irrespective of the stent diameter. In 6-mm stents overestimation was significantly higher than in 8-mm (P<0.01) or 10-mm stents (P<10-6). Under in-vitro conditions 16-row MDCT allowed an accurate identification of in-stent stenosis, but significantly overestimated the effective degree of the stenosis.

Evaluation of the stereotactic 8G vacuum-assisted breast biopsy in the histologic evaluation of suspicious mammography findings (BI-RADS IV).

PURPOSE: The purpose of this study was to evaluate the potential of the new 8G stereotactic vacuum-assisted breast biopsy (ST-driver, Mammotome; Ethicon Endosurgery) in the histologic evaluation of BI-RADS IV microcalcifications. MATERIALS AND METHODS: Fifty-eight patients with 61 mammographic BI-RADS IV microcalcifications underwent stereotactic vacuum-assisted breast biopsy (SVAB). The new 8G system was mounted on the ST driver, which was formerly used only with the hand-held version under sonographic guidance. The evaluation criteria for each biopsy were minimally invasive and operative histologies, the time needed for biopsy, the amount of bleeding, number of rotations and specimen, the degree of resection, and the complications. RESULTS: Fifty-eight of 61 biopsies were technically successful because > or = 50% were resected (29 x 100%, 8 x 90%, 5 x 80%, 6 x 70%, 3 x 50%, 3 x 0%). In 7 cases with representative biopsies of segmental suspicious microcalcifications, the degree of resection could not be exactly measured. All but 2 biopsies were performed without clinically relevant complications and after gaining enough specimens (Ø 12.6 specimen, 1.85 rotations). Those 2 patients showed evidence of severe bleeding into the breast tissue and operative revision had to be performed (3.5%). The size of intramammary hematoma was measurable in 27 biopsies and showed a range from 0.5 to 5 cm (Ø 2.7 cm). The average external bleeding was still low with 16 mL (5-80 mL). In 3 of 61 lesions, it was not possible to gain representative tissue as a result of displacement of the lesion after introducing or shooting the needle. The average time needed for all biopsies was 28.2 minutes for all but 5 very complicated biopsies, which took 16.1 minutes. The histologic findings with further operative workup were: 10 ductal carcinomas in situ (DCIS), 4 atypical ductal hyperplasias, 1 atypical lobular hyperplasias (ALH), 3 lobular carcinomas in situ (LCIS), and 6 invasive ductal carcinomas. In 7 of 12 of the initial DCIS histologies, the operative histology was also DCIS, whereas in 4 of 12, no residual malignant tumor was found. In 1 of 12 patients with an initial DCIS histology, operative histology revealed invasive ductal cancer (8.3%). The cases with lobular lesions (ALH, LCIS) did not show any evidence for residual tissue in the operative workup. Most frequent benign histologies were mastopathy (13), ductal hyperplasia (9), fibroadenoma (8), and sclerosing adenosis (5). The control examinations (maximum 1 year) did not show any signs for a false-negative biopsy. CONCLUSION: The 11-G SVAB has proven to be a perfect adjunct to the existing breast biopsy methods. The new 8G SVAB speeds up the method when used for the same size of lesions and enables the user to representatively biopsy lesions up to 3 cm in diameter. The method is still minimally invasive; however, the amount of hematomas as well as clinically relevant complications is increased.

Emergency endovascular interventions for acute thoracic aortic rupture: four-year follow-up.

OBJECTIVE: High mortality and paraplegia rates associated with the surgical management of acute thoracic aortic ruptures limit its success. It was our objective to evaluate whether emergency endovascular interventions would improve the outcomes of these patients. METHODS: Sixty patients aged 28 to 83 years were admitted to our institution with an acute rupture of the thoracic aorta (27 ruptured aneurysms, 15 perforated type B dissections, 18 traumatic ruptures). Twenty-eight patients were treated surgically with cardiopulmonary bypass, and 32 patients were acutely treated with an endovascular stent graft. Medical records were reviewed for prehospital and emergency department data, operative findings, and outcomes. Patients were followed up at yearly intervals with high-resolution multidetector computed tomographic angiography. RESULTS: Perioperatively, there were 1 death (3.1%) among the 32 patients in the endovascular group and 5 deaths (17.8%) among the 28 patients in the surgical group. There were 4 late deaths in the endovascular group and 1 in the surgical group. There were 2 access failures in the endovascular group. There were 1 stroke in the endovascular group and 1 case of paraplegia in the surgical group. Three patients in the endovascular group had endovascular leaks develop that required reintervention. Two patients in the endovascular group had late thrombosis of the left subclavian artery. CONCLUSION: Despite encouraging early outcomes, midterm results suggest a trend toward increased reintervention and late complication rates in the endovascular group. Therefore continued surveillance of patients treated with stent grafts is necessary.

Value of electrical impedance scanning (EIS) in the evaluation of BI-RADS III/IV/V-lesions.

Two hundred and fifty-six (256) patients (72% preoperative, 28% pre-Mammotome) were prospectively examined with EIS using the TS 2000 (TransScan Research and Development Center, Israel; temporarily distributed by Siemens, Erlangen) with the "LOS"-software (level of suspicion). All exams were performed with the targeted scan probe, the observer knowing all clinical and imaging facts. The area of the lesions was examined with EIS at least with 5 single scans. The evaluation included a scaling of lesions from 1 (surely benign) up to 5 (highly suggestive for malignancy) as well as the additional notification of spots. Results of EIS were based upon the automatic scaling which is provided by the software and were compared with mammography and histology. Furthermore the influence of the histology, size of lesions, and presence/absence of spots on the EIS results were analyzed. Histology revealed benign results in 138 lesions and malignant results in 118 lesions (DCIS=61, ID-Ca=51, IL-Ca=5, mucinous Ca=1). Mammography as expected yielded high values with 91% sensitivity and 62% specificity. Overall sensitivity of EIS was 75.4%, specificity 42.03%, negative predictive value 66.7% and positive predictive value 52.7% (89 TP, 58 TN, 80 FP, 29 FN). EIS was false negative in 20 ID-Ca, 3 IL-Ca, 1 IDL-Ca, 4 DCIS, and 1 mucinous carcinoma. Sensitivity and specificity of EIS did not differ for the different histological differentiations neither for the degree of invasion. Also the additional notification of "spots" didn't show a correlation to malignancy. There were significant differences of the sensitivity of EIS regarding the tumor size. While EIS correctly diagnosed 85% of lesions <10 mm in size, only 64% of lesions >10 mm were detected. Most frequent lesion types for false positives were mastopathy (55/80 FP) and fibroadenoma (21/80 FP). Patient acceptance of EIS was perfect and there were no drop outs because of movement artifacts. In conclusion the "LOS"-software clearly improved the clinical performance of the TS 2000 as compared to the initial software. The high sensitivity of EIS in small cancers which was found in our study may indicate an advantage of this method. However, the overall sensitivity and specificity with this setup of EIS is still far too low. Further improvements especially including the measurement of higher frequencies should be realized.

Multidetector-row cardiac CT: diagnostic value of calcium scoring and CT coronary angiography in patients with symptomatic, but atypical, chest pain.

The aim of this study was to investigate the accuracy of multidetector-row cardiac CT (MDCT), calcium scoring (Ca-Sc), and MDCT coronary angiography (MD CTA) in the assessment of coronary atherosclerosis. Thirty-eight patients underwent invasive coronary angiography (CA) and MDCT (collimation 4x1 mm, pitch 1.5 mm, TI 500 ms, 120 kV, 300 mAs, and retrospective ECG-gating). Calcium scoring was calculated for the total coronary artery territory and for RCA, LCA, and LCX separately. The MD CTA served to assess the degree and the localization of stenoses. All findings were compared to invasive coronary angiography. Approximately 68.4% (390 of 570) of all coronary segments could be visualized by MDCT. Correlation coefficient for MD CTA and CA amounted to r=0.58, showing distinct differences for the individual segments. Proximal segments generally showed better correlation (range 0.81-0.77) than medial segments (range 0.91-0.20), distal segments (range 0.55-0.04), or side branches (range 0.76-0.00). Patients with hemodynamically relevant (>75%) stenoses were detected by MD CTA with 72.2% sensitivity (13 of 18) and 100% specificity (20 of 20). For Ca-Sc sensitivity ranged between 94.7% (17 of 18) and 66.7% (12 of 18), specificity between 20% (4 of 20) and 80% (16 of 20) respectively, depending on the prevailing cutoff value. Combination of both methods led to 83.3% sensitivity (15 of 18) and 100% specificity (20 of 20), reaching no level of significance as compared with Ca-Sc (p=0.73) or MD CTA (p=0.23) alone. Calcium scoring as a single method showed highest sensitivity in the detection of coronary atherosclerosis but at the expense of low specificity. In patients with no or moderate calcifications, combination with MD CTA helped to distinctly increase specificity and NPV.

Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience.

BACKGROUND: Surgical management of acute thoracic aortic ruptures is controversial, especially in patients with preexisting comorbidities; associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome. METHODS: From November 1999 to February 2002 a total of 54 patients, age 28 to 83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated type B dissections, 16 traumatic ruptures). Twenty-eight patients were managed surgically using cardiopulmonary bypass (group 1), and 26 patients were treated acutely with an endovascular stent graft (group 2). The resuscitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes. RESULTS: There were 5 of 28 deaths (17.8%) in the surgical group and 1 of 26 deaths (3.8%) in the endovascular group. In the surgical group 1 of 28 patients (3.6%) exhibited paraplegia; there were no cases of paraplegia in the endovascular group. There were 4 of 28 cases (14.3%) of renal failure in group 1 and 1 of 26 (3.8%) in group 2. In group 1, 8 patients (28.6%) required mechanical ventilation for more than 48 hours; there were 2 of 26 patients (7.7%) in group 2 with this ventilatory requirement. Three patients required a repeat thoracotomy for hemorrhage in the surgical group. There were two access failures in the endovascular group. CONCLUSIONS: In the treatment of acute ruptures of the thoracic aorta, the immediate outcome of patients treated with endovascular stent grafts appears to be better than with management by conventional surgical repair.

Emergent endovascular stent grafting for perforated acute type B dissections and ruptured thoracic aortic aneurysms.

BACKGROUND: The purpose of our study was to demonstrate the effectiveness of endovascular stent grafts in the treatment of acutely ruptured thoracic aortic aneurysms and type B dissections as an alternative to the conventional surgical approach in an emergency setting. METHODS: From January 2001 to October 2001, we deployed 11 emergent endovascular stent grafts into the thoracic aorta. We treated seven ruptured aortic aneurysms and four acutely perforated type B dissections. Aortic rupture was confirmed preoperatively by spiral computed tomography. In all cases, hemothorax was present. The average interval from onset of symptoms to treatment was 28.5 hours. We used nine Talent and two Excluder stent grafts. RESULTS: Deployment of the stent grafts was successful in nine cases. There were two cases of access failure due to small caliber of iliac arteries, and 1 of these patients died shortly after the procedure was abandoned, At 12 months of follow-up, there were no cases of paraplegia, stent migration, or endoleaks. There was, however, one temporary renal failure, and 2 patients required mechanical ventilation for more than 48 hours. CONCLUSIONS: Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in high-risk patients.

Multidetector-row CT: cardiosurgery indications.

This article critically evaluates the role of multidetector-row CT before and after cardiosurgical procedures. In addition, technical aspects, such as scan protocols, optimal image reconstruction intervals, image reformation techniques, and data evaluation, are presented and briefly discussed.

Heart-rate-adapted image reconstruction in multidetector-row cardiac CT: influence of physiological and technical prerequisite on image quality.

The purpose of this study was to develop strategies for optimal image reconstruction in multidetector-row cardiac CT and to discuss the results in the context of individual heart rate, cardiac physiology, and technical prerequisite. Sixty-four patients underwent multidetector-row cardiac CT. Depending on the heart rate either a single-segmental reconstruction (SSR) or an adaptive two-segmental reconstruction (ASR) was applied. Image reconstruction was done either antegrade (a) or retrograde (r) in relation to the R-peak. Reconstruction of all data sets was performed at multiple time points within the t-wave/p-wave interval, differing from each other by 50 ms. In addition, each reconstruction was assigned to one of six reconstruction intervals (A-F), each corresponding to a specific event in the cardiac cycle. While no significant time points were found for absolute values, the following interval/reconstruction technique combinations provided significant better image quality: F/r at HR <60 bpm for all coronary segments ( p65 bpm for all segments ( p