Illuminating the nidus: The role of FDG PET/CT in high flow arteriovenous vascular malformations.

The appropriate identification and localization of a nidus of a high flow arteriovenous malformation is crucial to guide targeted interventional therapy. However, the nidus of a complex or previously treated HFAVM can be difficult to non-invasively demonstrate on magnetic resonance imaging alone. We describe a unique case of a 56-year-old female with a complex high flow arteriovenous malformation in which we demonstrated the feasibility of fluorodeoxyglucose positron emission tomography/computed tomography to non-invasively delineate the nidus which subsequently guided successful targeted interventional therapy.

Appearance of Florid Cemento-Osseous Dysplasia on SPECT/CT.

Florid cemento-osseous dysplasia, a benign fibro-osseous condition, is diagnosed based on characteristic radiographic appearances of multifocal round or lobulated sclerotic lesions associated with the teeth in multiple quadrants of the jaws. We report a case of a 73-year-old woman who presented with a painless sharp bony area on the right side of her maxilla. SPECT/CT of facial bones demonstrated multifocal intense increased uptake in both the maxilla and mandible, corresponding to ill-defined florid sclerotic periapical lesions seen on CT, in keeping with a classical appearance of florid cemento-osseous dysplasia.

SPECT/CT-Guided Ultrasound for Parathyroid Adenoma Localization: A 1-Stop Approach.

Our rationale was to evaluate the accuracy of 1-stop (single patient-attendance) SPECT/CT-guided ultrasound in the localization of parathyroid adenomata. Secondary aims included analyzing the effect of multiple parathyroid adenomata and concurrent thyroid disease on sensitivity. Methods: Patients with hyperparathyroidism who had undergone parathyroidectomy were identified over a 5-y period. Pathologic correlation with results from preoperative 99mTc-sestamibi SPECT/CT followed by targeted ultrasound of the neck was performed. The number of glands, the location, and the presence of concurrent thyroid disease were reviewed. Results: The study included 146 patients (88% single gland, 7% multigland, and 5% negative explorations). The sensitivity and specificity of SPECT/CT-guided ultrasound were 83% and 96%, respectively. The sensitivity was higher for single gland (87%) than multigland disease (70%). The addition of ultrasound significantly increased the sensitivity of the technique (P < 0.001). The presence of concurrent thyroid disease (nodules/thyroiditis) did not adversely affect sensitivity (85% confidence interval, 74.2%-93.1%) compared with normal or atrophic glands (82% confidence interval, 72.3%-89.7%). Conclusion: SPECT/CT-guided ultrasound represents a useful means of localizing parathyroid adenomata, thereby aiding the decision to undertake minimally invasive or exploratory surgery. The 1-stop approach offers patient convenience and enables the radiologist to use the additive benefits of both modalities to optimize localization. The technique is less sensitive in multigland disease, but concurrent thyroid disease does not adversely affect sensitivity.

99mTc-HDP SPECT-CT Aids Localization of Joint Injections in Degenerative Joint Disease of the Foot and Ankle.

BACKGROUND: Pain relating to degenerative joint disease within the foot and ankle can be difficult to localize with clinical examination alone due to the complex anatomy of the joints. The aim of this study was to determine whether single-photon emission computed tomography combined with conventional computed tomography (SPECT-CT) could be used to localize the site of degenerative joint disease for intra-articular injection and thereby improve the clinical success of the procedure. METHODS: A prospective study was performed involving 203 patients who had undergone triple-phase (99m)Tc-hydroxymethylene diphosphonate bone scans with SPECT-CT of the foot and ankle for degenerative joint disease. Fifty-two patients went on to have joint injections for degenerative joint disease, with clinical follow-up. Correlation with the clinical diagnosis and the outcome of intra-articular injections with 0.5% bupivacaine and 80 mg of Depo-Medrone was performed. A successful outcome was determined by an improvement in the visual analog pain score of at least 50%. RESULTS: In 19 (37%) patients, the site of degenerative joint disease determined by SPECT-CT differed from the initial clinical assessment and resulted in a change in management. Overall, 46 (88%) patients showed an improvement in symptoms. CONCLUSION: The study demonstrated a high clinical success rate for SPECT-CT-guided joint injections. The technique was useful in localizing degenerative joint disease of the ankle, hindfoot, and midfoot as an adjunct to clinical examination. LEVEL OF EVIDENCE: Level IV, case series.

Delays and errors in abnormal chest radiograph follow-up: a systems approach to promoting patient safety in radiology.

RATIONALE, AIMS AND OBJECTIVES: This study aimed to apply the 'systems approach' to patient safety in order to identify causes for delays and errors in lung cancer diagnoses following an abnormal chest radiograph. METHODS: In the first part of this study, the systems approach to patient safety was comprehensively reviewed by three radiologists and seven patient safety experts. In the second part of this study, a retrospective review was performed of all patients referred to the lung cancer multidisciplinary team (MDT) meeting over a 1-year period. All abnormal chest radiograph reports were examined and a root-cause analysis performed of cases where errors and delays in diagnoses were deemed to have occurred. RESULTS: A total of 124 cases were reviewed, of which 36 (29%) patients had an abnormal preceding chest radiograph prior to MDT referral. In six cases, serious errors from delay and lack of follow-up were identified. These are analysed and discussed in detail in this article. Application of the systems approach to each case identified poor communication and lack of clinical action as prime causes. CONCLUSIONS: Both reporting radiologists and referring clinicians have a responsibility to ensure appropriate action following an abnormal chest radiograph. The main error lies in communication between the referring clinicians and the radiologists. Direct electronic communication is potentially a more robust method to overcome this.

The diagnostic value of single photon-emission computed tomography bone scans combined with CT (SPECT-CT) in diseases of the foot and ankle.

BACKGROUND: A radionuclide bone scan with single photon-emission computed tomography and CT (SPECT-CT) is a new imaging modality which combines highly detailed CT with the functional information from a triple phase radionuclide bone scan. Little has been published about its diagnostic accuracy and usefulness in foot and ankle pathology. The aim of this study is to evaluate whether bone scans with SPECT-CT provide a useful contribution to the management of patients with foot and ankle pain, and whether it results in changes to clinical management. METHODS: A retrospective study involving 50 patients was conducted between March 2010 and April 2011. SPECT-CT was requested in cases where definitive clinical diagnosis could not be achieved after clinical examination and plain radiography. Pathology as highlighted on SPECT-CT was taken as the definitive diagnosis in these patients and was treated accordingly. Patients were subsequently seen in the follow up clinic to evaluate the outcome of their treatment. RESULTS: In 11 patients (22%), the provisional clinical diagnosis matched with the findings of the SPECT-CT and no change in treatment was necessary. In 39 patients (78%) the findings of the SPECT-CT did not correlate exactly with the initial clinical diagnosis and led to a modified treatment plan. The accuracy, sensitivity, specificity, positive predictive and negative predictive value of SPECT-CT in this series was 94%, 95.45%, 83.3%, 97.6% and 71.43% respectively. CONCLUSIONS: SPECT-CT is a useful investigation tool in foot and ankle pathologies. The present study shows a high diagnostic accuracy and we recommend its use in cases with diagnostic uncertainty.