Accuracy Of Computed Tomography Angiography Research Articles

The Accuracy of Computed Tomography Angiography Compared With Technetium-99m Labelled Red Blood Cell Scintigraphy for the Diagnosis and Localization of Acute Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

Imaging tests are commonly used as an initial or early investigation for patients presenting with suspected acute gastrointestinal bleeding (AGIB). However, controversy remains regarding which of two frequently used modalities, computed tomography angiography (CTA) or technetium-99m labelled red blood cell scintigraphy (RBCS), is most accurate. This systematic review and meta-analysis was performed to compare the accuracy of CTA and RBCS for the detection and localization of AGIB. Five electronic databases were searched with additional manual searching of reference lists of relevant publications identified during the search. Two reviewers independently performed screening, data extraction and methodological assessments. Where appropriate, the bivariate model was used for meta-analysis of sensitivities and specificities for the detection of bleeding and Freeman-Tukey double-arcsine transformation used for meta-analysis of proportions of correctly localized bleeding sites. Forty-four unique primary studies were included: twenty-two investigating CTA, seventeen investigating RBCS and five investigating both modalities. Meta-analysis produced similar pooled sensitivities; 0.83 (95% CI 0.74-0.90) and 0.84 (0.68-0.92) for CTA and RBCS respectively. Pooled specificity for CTA was higher than RBCS; 0.90 (0.72-0.97) and 0.84 (0.71-0.91) respectively. However, differences were not statistically significant. CTA was superior to RBCS in correctly localizing bleeding; pooled proportions of 1.00 (0.98-1.00) and 0.90 (0.83-0.96) respectively (statistically significant difference, P < 0.001). There is no evidence that CTA and RBCS have different diagnostic performance with respect to the detection of AGIB. However, CTA is superior to RBCS in terms of correctly localising the bleeding site, supporting usage of CTA over RBCS as the first line imaging investigation.

Diagnostic accuracy of CT angiography and CT perfusion imaging for detecting distal medium vessel occlusions: Protocol for a systematic review and meta-analysis.

Distal medium vessel occlusions (DMVOs) represent 25-40% of all acute ischemic strokes (AIS). DMVO clinical syndromes are heterogenous, but as eloquent brain regions are frequently involved, they are often disabling. Since current intravenous fibrinolytic therapies may fail to recanalize up to two-thirds of DMVOs, endovascular treatment is progressively being considered in this setting. Nevertheless, the optimal imaging method for diagnosis remains to be defined. Stroke centers that use computed tomography as a routine stroke imaging approach rely on either isolated computed tomography angiography (CTA) or combined perfusion (CTP) studies. Despite a simplified non-CTP-dependent approach seeming reasonable for large vessel occlusion AIS diagnosis, CTP may still hold advantages for DMVOs workup. Therefore, this systematic review aims to compare the diagnostic performance of CTA and CTP in detecting DMVOs. We will perform a systematic search in PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. In addition, grey literature and ClinicalTrials.gov will be scanned. We will include any type of study that presents data on the diagnostic accuracy of CTA and/or CTP for detecting DMVOs. Two authors will independently review retrieved studies, and any discrepancies will be resolved by consensus or with a third reviewer. Reviewers will extract the data and assess the risk of bias in the selected studies. Data will be combined in a quantitative meta-analysis following the guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions. We will assess cumulative evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This will be the first systematic review and meta-analysis that compares two different imaging approaches for detecting DMVOs. This study may help to define optimal acute ischemic stroke imaging work-up. PROSPERO registration: CRD42022344006.

Transcranial Doppler versus CT angiography: a comparative analysis for the diagnosis of ischaemic cerebrovascular disease

To compare the sensitivity, specificity, accuracy, and clinical usefulness of transcranial Doppler (TCD) ultrasound against computed tomography angiography (CTA) for the diagnosis of ischaemic cerebrovascular disease. A total of 1,183 sites (vascular segments) of 169 patients who had been diagnosed with cerebrovascular disease using digital subtraction angiography (DSA) were evaluated by CTA and TCD for the diagnosis of the arterial lesions. Lesions were identified in 509 sites and 674 sites did not have lesions according to the DSA examination. Each individual site had higher sensitivity, specificity, and accuracy for TCD than those for CTA, respectively. For all sites, TCD had higher true-positive (p=0.0029) and -negative (p=0.0151) values and fewer false-positive and -negative (p<0.0001 for both) values than those of CTA. The sensitivity, specificity, and accuracy of CTA for all sites to detect lesions were 77%, 88%, and 84%, respectively. The same parameters for TCD were 94%, 97%, and 95%, respectively. The beneficial scores for CTA and TCD to detect lesions were 0-0.795 diagnostic confidence and 0-0.91 diagnostic confidence, respectively. Beneficial scores >0.795 and>0.91 indicated a risk of underdiagnosis of lesions at CTA and TCD, respectively. Compared with DSA (reference standard) and CTA, the study underscores the use of TCD in cerebrovascular pathology.

Accuracy and image quality of wide-detector revolution CT angiography combined with prospective ECG-triggered CT angiography in the diagnosis of congenital aortic arch anomalies in Chinese children.

To explore the accuracy and image quality of wide-detector revolution CT angiography combined with prospective ECG-triggered CT angiography in the diagnosis of congenital aortic arch anomalies in Chinese children. From January 2020 to July 2022, the clinical data of 57 children with congenital aortic arch anomalies confirmed by surgery were collected. All patients underwent CT angiography (CTA) with Revolution CT and transthoracic echocardiography (TTE) before the operation. The accuracy of CTA and TTE in the diagnosis of aortic arch anomalies was compared with the surgical results. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CTA and TTE for congenital aortic arch anomalies (including intracardiac and extracardiac structural abnormalities) were 92.2% and 85.5%, 99.4%, and 99.1%, 97.4% and 95.6%, 98.1% and 96.9%, and 97.2% and 95.2%, respectively. Regarding extracardiac structural malformations, the sensitivity of CTA was 100%, whereas that of TTE was 78.6% (P < 0.001). Regarding intracardiac structural malformations, the sensitivity of CTA was 84.5%, whereas that of TTE was 92.5% (P < 0.001). Regarding satisfaction with the images in aortic arch anomalies, surgeons noted that the CTA images were more useful for diagnosis and operation planning compared with TTE. Wide-detector revolution CT angiography combined with prospective ECG triggering can be routinely used to assess congenital aortic arch anomalies, providing adequate image quality and high diagnostic accuracy. However, limitations in the identification of intracardiac structural abnormalities are noted.

The value of coronary computed tomography and very early invasive coronary angiography compared to standard intervention in older patients after non-ST segment elevation acute coronary syndromes

Abstract Background The optimal management of patients with non-ST elevation acute coronary syndromes (NSTEACS) remains a challenge. The merits of both computed tomography angiography (CTA) as a rule-out test for significant coronary artery disease and early invasive coronary angiography (ICA) are debated. Furthermore, there are limited data in older NSTEACS patients, who likely have more coronary artery calcification and are at higher risk of ACS-related complications. Methods This is a post hoc analysis of patients ≥75 years included in the Very Early Versus Standard Care Invasive Examination and Treatment of Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Trial (VERDICT). The diagnostic accuracy of CTA was investigated in patients without previous coronary artery bypass grafting, renal dysfunction, or atrial fibrillation; the presence of a coronary artery stenosis ≥50% determined by ICA was used as reference. Patients were randomised to very early ICA within 12 hours of diagnosis or standard care (ICA within 48–72 hours of diagnosis) and followed for up to five years. The primary endpoint was the composite of all-cause mortality, nonfatal recurrent MI, hospital admission for refractory myocardial ischaemia or hospital admission for heart failure. Results From November 2010 to June 2016, 2147 patients were included in the VERDICT trial. Of these, 452 (21%) patients were ≥75 years of age. Most older patients had a GRACE score &amp;gt;140 (n=388, 88.8%). At the time of admission, older patients had lower levels of haemoglobin, estimated glomerular filtration rate, and left ventricular ejection fraction, and more often displayed elevated troponins and electrocardiogram changes indicating new ischaemia, than those &amp;lt;75 years. Of patients ≥75 years of age, 161 (35.6%) underwent CTA before ICA. Older patients had significantly higher calcium scores than younger patients (1187±1445 vs. 499±858 Agatston units, p&amp;lt;0.001). 19% of CTAs excluded significant coronary artery disease. The negative predictive value of the CTAs was 94 (95% CI 79–99)% and the sensitivity was 98 (95% CI 94–100)%, figure 1. The primary endpoint was observed more frequently in patients ≥75 years as compared to younger patients (n=222, 49% vs. n=390, 23%, p&amp;lt;0.001), even after adjustment for allocated treatment (adjusted HR 2.65, 95% CI 2.25–3.13, p&amp;lt;0.001). Among older patients randomised to very early ICA, there were no differences in the cumulated number of primary endpoints compared to older patients randomised to standard ICA (log-rank p=0.36), figure 2. Conclusion Among patients ≥75 years old with NSTEACS, CTA showed a high diagnostic accuracy. A very early ICA within 12 hours of diagnosis did not improve long-term composite outcome in these older patients with NSTEACS. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Rigshospitalets Research Foundation

CT and DSA for evaluation of spontaneous intracerebral lobar bleedings.

PurposeThis study retrospectively examined the extent to which computed tomography angiography (CTA) and digital subtraction angiography (DSA) can help identify the cause of lobar intracerebral bleeding.Materials and methodsIn the period from 2002 to 2020, data from patients who were >18 years at a university and an academic teaching hospital with lobar intracerebral bleeding were evaluated retrospectively. The CTA DSA data were reviewed separately by two neuroradiologists, and differences in opinion were resolved by consensus after discussion. A positive finding was defined as an underlying vascular etiology of lobar bleeding.ResultsThe data of 412 patients were retrospectively investigated. DSA detected a macrovascular cause of bleeding in 125/412 patients (33%). In total, sixty patients had AVMs (15%), 30 patients with aneurysms (7%), 12 patients with vasculitis (3%), and 23 patients with dural fistulas (6%). The sensitivity, specificity, positive and negative predictive values, and accuracy of CTA compared with DSA were 93, 97, 100, and 97%. There were false-negative CTA readings for two AVMs and one dural fistula.ConclusionThe DSA is still the gold standard diagnostic modality for detecting macrovascular causes of ICH; however, most patients with lobar ICH can be investigated first with CTA, and the cause of bleeding can be found. Our results showed higher sensitivity and specificity than those of other CTA studies.

Computed Tomography Angiography and B-Mode Ultrasonography under Artificial Intelligence Plaque Segmentation Algorithm in the Perforator Localization for Preparation of Free Anterolateral Femoral Flap.

This research was aimed to investigate the accuracy of U-shaped network (UNet)-based computed tomography angiography (CTA) and B-mode ultrasonography (US) in the perforator localization of free anterolateral thigh flap (ALTF). Based on UNet, a fusion of deep supervision mechanism, squeeze-and-excitation module, and attention mechanism was introduced to optimize the algorithm. Then, a CTA segmentation model, DA-UNet, was established. The segmentation performance of DA-UNet and other algorithms was compared under the same conditions. 30 patients who were planned to receive ALTF surgery were selected as the research objects. According to different preoperative localization methods, they were divided into group A (CTA) and group B (B-mode US), 15 cases in each group. Combined with the actual situation during surgery, the diagnostic accordance rate, sensitivity (Sen), specificity, and the distance between the perforator location and the actual location were compared between the two groups. The Dice coefficient, Jaccard index, Sen, the area under curve (AUC), and average Hausdorff distance (AVD) of the DA-UNet segmentation algorithm were 80.70%, 69.97%, 77.56%, 0.887, and 2.48, respectively. These results were significantly better than those of other algorithms (P < 0.05). In group A, the diagnostic accordance rate, Sen, and specificity of patients were 96.55%, 90.52%, and 73.58%, respectively, which were higher than 91.53%, 81.36%, and 15.60% of patients in group B significantly (P < 0.05). There was no statistical difference in the distance between the perforator location and the actual location (P > 0.05). It showed that the accuracy of CTA under the UNet-based DA-UNet segmentation model in the perforator localization of ALTF was better than that of B-mode US. Thus, a reference could be provided for the preparation of free ALTF and its clinical application.

Computed tomography angiography versus Agatston score for diagnosis of coronary artery disease in patients with stable chest pain: individual patient data meta-analysis of the international COME-CCT Consortium

ObjectivesThere is conflicting evidence about the comparative diagnostic accuracy of the Agatston score versus computed tomography angiography (CTA) in patients with suspected obstructive coronary artery disease (CAD).PurposeTo determine whether CTA is superior to the Agatston score in the diagnosis of CAD.MethodsIn total 2452 patients with stable chest pain and a clinical indication for invasive coronary angiography (ICA) for suspected CAD were included by the Collaborative Meta-analysis of Cardiac CT (COME-CCT) Consortium. An Agatston score of > 400 was considered positive, and obstructive CAD defined as at least 50% coronary diameter stenosis on ICA was used as the reference standard.ResultsObstructive CAD was diagnosed in 44.9% of patients (1100/2452). The median Agatston score was 74. Diagnostic accuracy of CTA for the detection of obstructive CAD (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) was significantly higher than that of the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001). Among patients with an Agatston score of zero, 17% (101/600) had obstructive CAD. Diagnostic accuracy of CTA was not significantly different in patients with low to intermediate (1 to < 100, 100–400) versus moderate to high Agatston scores (401–1000, > 1000).ConclusionsResults in our international cohort show CTA to have significantly higher diagnostic accuracy than the Agatston score in patients with stable chest pain, suspected CAD, and a clinical indication for ICA. Diagnostic performance of CTA is not affected by a higher Agatston score while an Agatston score of zero does not reliably exclude obstructive CAD.Key Points• CTA showed significantly higher diagnostic accuracy (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) for diagnosis of coronary artery disease when compared to the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001).• Diagnostic performance of CTA was not affected by increased amount of calcium and was not significantly different in patients with low to intermediate (1 to <100, 100–400) versus moderate to high Agatston scores (401–1000, > 1000).• Seventeen percent of patients with an Agatston score of zero showed obstructive coronary artery disease by invasive angiography showing absence of coronary artery calcium cannot reliably exclude coronary artery disease.

Computed tomography angiography for quantification of cerebral vasospasm following aneurysmal subarachnoid hemorrhage

PurposeThe purpose of this study was to assess the accuracy of computed tomography angiography (CTA) for quantification of cerebral vasospasm following aneurysmal subarachnoid hemorrhage in proximal and middle segments of intracranial arteries. Materials and methodsTwenty consecutive patients (7 men, 13 women; mean age, 47 ± 7 [SD] years; age range: 27–78 years) with aneurysmal subarachnoid hemorrhage who underwent CTA and digital subtracted angiography (DSA) with a 6-hour window at baseline and during vasospasm period were included. Twelve artery segments were analyzed in each patient. Vasospasm was blindly quantified on CTA and digital subtracted angiography (DSA) by two independent readers with discordance > 10% resolved by open data consensus. Inter-reader and inter-test correlations with DSA as reference, and causes of discordant readings were analyzed. The best sensitivity and specificity of CTA for determination of vasospasm ≥ 50% on DSA was determined using receiver operating curve analysis. ResultsTwo-hundred-and-ten arterial segments were analyzed after exclusion of 30 segments with missing data or metallic artifacts. An inter-reader discordance >10% was observed in 82 segments (82/210; 39% [95% CI: 32–46]). Inter-test discordances >10% were observed respectively in 115 segments (115/210; 55% [95% CI: 49–62]) with the junior reader and in 73 segments (73/210; 35% [95% CI: 29–42]) with the senior reader. They were related to reader error in 55 (55/210; 26% [95% CI: 20–32]) with the junior reader and 13 (13/210; 6% [95% CI: 3–9]) with the senior reader, as well systematic biases in 8 (8/210; 4% [95% CI: 1–6]), and intrinsic limitation in 52 (52/210; 25% [95% CI: 19–31]). Best sensitivity and specificity of CTA were observed for a threshold value of 30% (sensitivity = 88% [95% CI: 78–97%]; specificity = 84% [95% CI: 77–90%]; area under curve = 0.92 [95% CI: 0.86–0.97]). On a patient basis, sensitivity was 100% (specificity = 60% [95% CI: 38–81%]; area under curve = 0.97 [95% CI: 89–100%] for this same threshold. ConclusionOur study shows a moderate accuracy of CTA for the quantification of cerebral vasospasm, mostly related to challenging interpretation and intrinsic limitations. CTA may rule-out angiographic vasospasm ≥ 50% when no segment has vasospasm over than 30%.

Application value of CTA combined with digital technology in the design of anterolateral thigh flap in repairing operative defect of head, neck and maxillofacial tumor resection

Objective:To explore the value of computed tomography angiography （CTA） combined with digital technology in the vascular anatomy of the anterior thigh flap in patients with operative defects after head, neck and maxillofacial tumor operation, and in the design of preoperative and intraoperative flaps. Methods:Twenty-five cases of patients with postoperative defect after head, neck and maxillofacial tumor surgery admitted to our hospital from April 2018 to April 2019 were selected. Preoperative CTA and digital technology were used to clarify vascular anatomy and other related conditions, and the operation was carried out. Consistency analysis was applied to evaluate the value of CTA, digital technology and CTA combined digital technology in the localization of anterolateral thigh perforator flap with operative defects after head, neck and maxillofacial tumor resection, and the diagnostic efficacy of the three methods was compared. Results:The preoperative CTA examination revealed that there were 26 intermuscular perforators with a diameter greater than 0.8 mm in the flap donor site, and 17 musculocutaneous perforators with a diameter greater than 1.0 mm. During the operation, it was actually found that there were 27 intermuscular perforators with a diameter greater than 0.8 mm and 17 musculocutaneous perforators with a diameter greater than 1.0 mm. The accuracy rates of Pre-operative examination were 96.29% and 100.00%, respectively.In addition, the lateral femoral circumflex artery determined by digital technology. The starting position of the descending branch, the diameter of the vessel, the direction of the perforating vessel, and the maximum length of the pedicle that can be cut were consistent with the actual observation during the operation. All the patients in the group successfully underwent flap removal and repair. After the operation, 2 skin flaps suffered from vascular crisis, and survived under the managements of anticoagulation, lifting of restraint, and massage. The rest of the flaps survived smoothly. The patients were followed up for 3-12 months postoperatively. Twenty-four cases of skin flaps had good appearance. One case had swollen wound And the appearance of the skin flap was satisfactory after elective secondary thinning. Among the 25 patients with head and neck defects, in the perforator location examination, 18 cases were detected by CTA, with a sensitivity of 90.0%, a specificity of 60.0%, an accuracy of 84.0%, and Kappa=0.500. 19 cases was detected by digital technology, with a sensitivity of 86.36%, a specificity of 66.67%, a accuracy rate of 84.00%, and Kappa=0.412. 21 cases was detected by CTA combined with digital technology,with a sensitivity of 95.45%, a specificity of 66.67%, a accuracy of 92.00%, and Kappa=0.621. The accuracy of CTA combined with digital technology in the perforator positioning of patients with head and neck tumor defects was significantly higher than that of the single method（P<0.05）. Conclusion:CTA has good application value in the positioning of perforator in patients with head, neck and maxillofacial tumor defects. In addition, the combination of CTA and digital technology can improve the accuracy of the vascular anatomy of the anterior thighflap and the design of the preoperative and intraoperative flaps, which is beneficial to surgery clinical implementation.

Diagnostic Accuracy of 64-Slice Computed Tomography Angiography in Patients with Chest Pain vs. SPECT in the Assessment of Significant Coronary Artery Disease: A Systematic Review and Meta-analysis

Context: This systematic review and meta-analysis intended to investigate the diagnostic accuracy of computed tomography angiography (CTA) in comparison with single-photon emission computed tomography (SPECT) for the diagnosis of coronary artery disease (CAD) in chest pain patients with no history of cardiovascular diseases (CVDs).&#x0D; Methods: Invasive angiography was considered as the reference test with a stenosis threshold of ≥ 50%. Cochrane, Scopus, Science Direct, PubMed, and Embase databases were comprehensively searched from the time of inception of these databases to May 15, 2018. A manual search in Google Scholar, a reference review of the obtained studies, and a review of gray literature (including those presented in conferences and congresses) regarding diagnostic performances of CTA and SPECT techniques were performed independently by two researchers. A meta-analysis was performed to determine pooling estimates of sensitivity, specificity, diagnostic odds ratio, and positive as well as negative likelihood ratios in CTA and SPECT tests. According to the 2 × 2 contingency table of each study, at 0.95 confidence interval, the diagnostic accuracy of CTA and SPECT was meta-analyzed by pooling estimates of sensitivity, specificity, diagnostic odds ratio (DOR), and positive and negative likelihood ratios based on DerSimonian-Laird’s random-effects model. Heterogeneity was assessed by calculating I2. Analyses were performed using MetaDiSc version 1.4 and Stata version 11. The qualities of the selected studies were assessed independently by two researchers according to the quality assessment of diagnostic accuracy studies (QUADAS) questionnaire. Sensitivity analyses were performed by the Jackknife method. Publication bias was evaluated by Deeks’ funnel plot.&#x0D; Results: Fourteen studies related to CTA (1206 individuals) and 15 related to SPECT (1638 individuals) were eligible for meta-analysis. The pooled sensitivity and the specificity of CTA for CAD diagnosis were 91% (95% CI, 88% - 94%) and 87% (95% CI, 84% - 98%), respectively. The pooled positive and negative likelihood ratios, the diagnostic odds ratio, and the area under the ROC curve for CTA were 7.93 (95% CI, 5.11 - 12.29), 0.1 (95% CI, 0.06 - 0.17), 95.71 (95% CI, 59.81 - 153.15), and 0.96, respectively. The pooled sensitivity and the specificity of SPECT for CAD diagnosis were 81% (95% CI, 79% - 83%) and 74% (95% CI, 71% - 78%), respectively. The pooled positive and negative likelihood ratios, the diagnostic odds ratio, and the area under the ROC curve for SPECT were 3.03 (95% CI, 2.34 - 3.91), 0.25 (95% CI, 0.21 - 0.30), 13.56 (95% CI, 10.60 - 12.34), and 0.86, respectively. According to the sensitivity analyses, the removal of any single study at a time did not change the effect size of the remaining studies. We observed symmetry in the Deeks’ funnel plot, indicating that there was ignorable publication bias for CTA and SPECT studies.&#x0D; Conclusions: This study demonstrated that the diagnostic accuracies of CTA and SPECT tests lie in the ‘excellent’ and the ‘very good’ ranges, respectively. CTA is stronger evidence, than SPECT, to rule out CVDs in patients with low and intermediate risks of CAD with no history of cardiovascular diseases.

Overestimation of carotid stenosis on CTA – Real world experience

BackgroundSymptomatic carotid stenosis is responsible for 10% of all strokes. Currently, CT angiography (CTA) is the main diagnostic tool for carotid stenosis. It is frequently the only diagnostic test preceding recommendations for carotid angioplasty and stenting (CAS) or carotid endarterectomy (CEA). However, the specificity of CTA, especially in patients with 50–70% stenosis, was previously reported to be relatively low. Most studies testing the diagnostic accuracy of CTA were published more than a decade ago. Therefore, we aimed to test the diagnostic accuracy of CTA, performed with current available technology, compared with digital subtraction angiography (DSA) in patients with carotid stenosis. This study aims to characterize patients who were candidates for CAS/CEA based on CTA, but may not require it based on DSA. MethodsConsecutive candidates for carotid interventions (CAS or CEA) following CTA were identified from prospectively maintained stroke center registries at two large academic centers. As part of our institutional practice all patients had a routine pre-procedural diagnostic DSA. In each patient, degree of carotid stenosis was compared between CTA and DSA. Patients with concordant degree of stenosis on DSA and CTA (true positive group) were compared to patients with a discordant degree of stenosis with less than 50% on DSA (false positive group). ResultsOut of 90 patients with significant stenosis on CTA, only 70 (78%) were found to have a significant stenosis on DSA. Severe plaque calcification was significantly more common in the false-positive group. In those patients whose CTA reported stenosis of ≥90%, we found a strong agreement between CTA and DSA (positive predictive value [PPV] – 0.9) for a significant stenosis (≥50%). Conversely, the correlation between CTA and DSA in patients with CTA reported 50–70% stenosis was poor (PPV – 0.29) (p < 0.001). ConclusionsOur results suggest that despite ongoing radiological progress, the specificity of CTA in accurately assessing carotid stenosis remains relatively low in patients with both moderate stenosis and heavily calcified plaques. Consequently, patients could possibly be referred for unnecessary CEA surgery and may become exposed to associated potential complications.

Computed tomography angiography in the “no-zone” approach era for penetrating neck trauma: A systematic review

Penetrating neck trauma (PNT) continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aerodigestive injuries in all neck zones. There is also an evolving evidence of "no-zone" approach where the decision to obtain a CTA is guided by physical examination findings and clinical presentation. The aim of this systematic review was to examine existing literature on the diagnostic accuracy of CTA as an integral component of the no-zone approach in stable patients with PNT. We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000 to 2017. A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83% to 100%; specificity, from 61% to 100%; positive predictive value, from 30% to 100%; and negative predictive value, from 90% to 100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries but low specificity for aerodigestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5% to 100% and specificity of 61% to 100% in stable patients presenting with soft signs (SSs). In a combined group of stable patients with either hard signs (HSs) or SSs, the sensitivity of CTA was 94.4% to 100% and the specificity was 96.7% to 100%. Among patients presenting with HSs, the sensitivity of CTA was 78.6% to 90% and the specificity was 100%. This is the first systematic review to examine the role of CTA in PNT. In combination with physical examination, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in PNT in stable patients with SSs of injury and select patients with HSs of injury. These results support the management of PNT using no-zone approach based on physical examination and the use of CTA in stable patients. Systematic review, level IV.

Role of digital subtraction angiography in detection of intracranial aneurysms compared with computed tomographic angiography

Objective To evaluate the role of digital subtraction angiography (DSA) in the detection of intracranial aneurysms among patients with spontaneous subarachnoid hemorrhage (SAH) compared with computed tomographic angiography (CTA) in a single center, Sri Lanka. Methods A total of 123 patients clinically and CT proven SAH were evaluated with CT angiography and DSA with a median interval of 3 days. The sensitivity, specificity and accuracy of CT angiography in detecting aneurysms were analyzed compared to DSA on a per-patient, per-size, per-site and per morphological basis. All data were analyzed using SPSS analytical package (version 18). Ethical approval for the study was from the institutional ethical review board. Results Among 123 patients with clinically and CT proven SAH, 51 (41.5%) patients showed aneurysms on CT angiography. 72 were negative for aneurysms in CTA. In 13 out of 72 (18%) CTA negative patients subsequent DSA demonstrated aneurysms. Number of CTA negative but DSA positive aneurysm were 15 as two of the patients had two aneurysms each. Four CTA detected aneurysms could not be appreciated in the subsequent DSAs. Aneurysms (47)detected by both CT angiography and DSA were more than 6mm in size (56.7%) , sacculartype (96.5%) and were located in the anterior circulation system (92.4%). Most CTA negative aneurysms detected by DSA were less than 6mm in size (80%), saccular type (60%) and were located in anterior (53.8%) and posterior (46.7%) circulation system. The sensitivity, specificity, positive predictive value and negative predictive value of CT angiography compared to DSA per patient basis were 78.3%, 93.7%, 92.2% and 81.9% respectively. CT angiography has a low sensitivity to detect aneurysms less than 6mm size (65.7%%), in posterior circulation (36.4%) and other morphological types (0%) compared to aneurysms more than 6mm size (90.9%), in anterior circulation (85.9%) and saccular type (85.5%). Conclusion Digital subtraction angiography (DSA) has a significant role in detecting intracranial aneurysms which are less than 6mm in size, are located in posterior circulation system and of non-saccular morphological type.

256-row multislice CT angiography in the postoperative evaluation of cerebral aneurysms treated with titanium clips: using three-dimensional rotational angiography as the standard of reference.

To assess the diagnostic accuracy of 256-row multislice computed tomographic angiography (CTA) compared with three-dimensional rotational angiography (3DRA) in the postoperative evaluation of cerebral aneurysms treated with titanium clips. A total of 128 patients (42 men, 86 women; mean age, 57.6 years) with 143 cerebral aneurysms treated using titanium clips underwent both CTA and 3DRA. Two reviewers retrospectively evaluated the following parameters on CTA and 3DRA: (1) residual/recurrent aneurysm (absent or present), (2) patency of parent artery (patent or occluded/severe stenotic (> 70%)), and (3) patency of adjacent branch (patent or occluded/absent). A total of 24 residual/recurrent aneurysms were detected by 3DRA. The sensitivity, specificity, and accuracy of CTA for the detection of residual/recurrent aneurysms were 83.3%, 100%, and 97.2% for reviewer 1 and 79.2%, 100%, and 96.5% for reviewer 2, respectively. The sensitivity, specificity, and accuracy of CTA for the evaluation of patency of parent artery were 100%, 100%, and 100%, respectively, for both reviewers. The sensitivity, specificity, and accuracy of CTA for evaluation of the patency of adjacent branch were 85.1%, 100%, and 92.3% for reviewer 1 and 82.4%, 100%, and 90.9% for reviewer 2, respectively. A 256-row multislice CTA is a valuable non-invasive tool for assessment of cerebral aneurysms treated with titanium clips. • A 256-row multislice CTA is an accurate imaging technique for the postoperative assessment of cerebral aneurysms treated with titanium clips. • Sensitivity of CTA for the detection of residual/recurrent aneurysms was 79-83% compared with 3DRA. • CTA is still limited in detecting residual/recurrent aneurysms of < 2 mm and small adjacent branches.

Computed tomography angiography accuracy in brain death diagnosis.

The present study was designed to answer several concerns disclosed by systematic reviews indicating no evidence to support the use of computed tomography angiography (CTA) in the diagnosis of brain death (BD). Therefore, the aim of this study was to assess the effectiveness of CTA for the diagnosis of BD and to define the optimal tomographic criteria of intracranial circulatory arrest. A unicenter, prospective, observational case-control study was undertaken. Comatose patients (Glasgow Coma Scale score ≤ 5), even those presenting with the first signs of BD, were included. CTA scanning of arterial and venous vasculature and transcranial Doppler (TCD) were performed. A neurological determination of BD and consequently determination of case (BD group) or control (no-BD group) was conducted. All personnel involved with assessing patients were blinded to further tests results. Accuracy of BD diagnosis determined by using CTA was calculated based on the criteria of bilateral absence of visualization of the internal cerebral veins and the distal middle cerebral arteries, the 4-point score (4PS), and an exclusive criterion of absence of deep brain venous drainage as indicated by the absence of deep venous opacification on CTA, the venous score (VS), which considers only the internal cerebral veins bilaterally. A total of 106 patients were enrolled in this study; 52 patients did not have BD, and none of these patients had circulatory arrest observed by CTA or TCD (100% specificity). Of the 54 patients with a clinical diagnosis of BD, 33 met the 4PS (61.1% sensitivity), whereas 47 met the VS (87% sensitivity). The accuracy of CTA was time related, with greater accuracy when scanning was performed less than 12 hours prior to the neurological assessment, reaching 95.5% sensitivity with the VS. CTA can reliably support a diagnosis of BD. The criterion of the absence of deep venous opacification, which can be assessed by use of the VS criteria investigated in this study, can confirm the occurrence of cerebral circulatory arrest.Clinical trial registration no.: 12500913400000068 (clinicaltrials.gov).

Adjuvant hepatic arterial infusion pump chemotherapy and resection versus resection alone in patients with low-risk resectable colorectal liver metastases \u2013 the multicenter randomized controlled PUMP trial

BackgroundRecurrences are reported in 70% of all patients after resection of colorectal liver metastases (CRLM), in which half are confined to the liver. Adjuvant hepatic arterial infusion pump (HAIP) chemotherapy aims to reduce the risk of intrahepatic recurrence. A large retrospective propensity score analysis demonstrated that HAIP chemotherapy is particularly effective in patients with low-risk oncological features. The aim of this randomized controlled trial (RCT) --the PUMP trial-- is to investigate the efficacy of adjuvant HAIP chemotherapy in low-risk patients with resectable CRLM.MethodsThis is an open label multicenter RCT. A total of 230 patients with resectable CRLM without extrahepatic disease will be included. Only patients with a clinical risk score (CRS) of 0 to 2 are eligible, meaning: patients are allowed to have no more than two out of five poor prognostic factors (disease-free interval less than 12 months, node-positive colorectal cancer, more than 1 CRLM, largest CRLM more than 5 cm in diameter, serum Carcinoembryonic Antigen above 200 μg/L). Patients randomized to arm A undergo complete resection of CRLM without any adjuvant treatment, which is the standard of care in the Netherlands. Patients in arm B receive an implantable pump at the time of CRLM resection and start adjuvant HAIP chemotherapy 4–12 weeks after surgery, with 6 cycles of floxuridine scheduled. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival, hepatic PFS, safety, quality of life, and cost-effectiveness. Pharmacokinetics of intra-arterial administration of floxuridine will be investigated as well as predictive biomarkers for the efficacy of HAIP chemotherapy. In a side study, the accuracy of CT angiography will be compared to radionuclide scintigraphy to detect extrahepatic perfusion. We hypothesize that adjuvant HAIP chemotherapy leads to improved survival, improved quality of life, and a reduction of costs, compared to resection alone.DiscussionIf this PUMP trial demonstrates that adjuvant HAIP chemotherapy improves survival in low-risk patients, this treatment approach may be implemented in the standard of care of patients with resected CRLM since adjuvant systemic chemotherapy alone has not improved survival.Trial registrationThe PUMP trial is registered in the Netherlands Trial Register (NTR), number: 7493. Date of registration September 23, 2018.

Comparison of Morphology of Intracranial Aneurysms on Computed Tomography Angiography with Digital Subtraction Angiography and Intraoperative Findings– A Single Centre Experience

Introduction: Multi-Detector Computed Tomography (MDCT) angiography is a non-invasive technique in emergency screening of Subarachnoid Haemorrhage (SAH) for accurately detecting aneurysms. Digital Subtraction Angiography (DSA) remains the gold standard for diagnosis of intracranial aneurysm. Computed Tomography Angiography (CTA) is being increasingly used for this purpose and can presently replace DSA as the most reliable means to detect intracranial aneurysms in SAH. Aim: To characterise the morphology of intracranial aneurysms with CTA and to compare it with DSA and intraoperative findings. Materials and Methods: This analytical study includes patients suspected to have intracranial aneurysm and underwent CTA on 16 slice MDCT scanner. Post-processing Multiplanar Reconstructions (MPR), 3D Volume Rendering (VR) and Maximum Intensity Projection (MIP) were performed. The findings of CTA findings were compared with DSA and intraoperative/indocyanine angiography images obtained by Leica neurosurgical operating microscope, wherever possible. Morphological parameters: size (dome, neck, height, dome to neck ratio, aspect ratio in saccular and length, diameter in fusiform), shape, lobulation, tit, location, thrombosis/ calcification, blood vessels arising, ruptured or not, grade of SAH (modified CT Fischer score) and vasospasm (grade, number/location of vasospastic segments) were assessed and compared with DSA and intraoperative findings. Results: In 71 patients, 97 intracranial aneurysms were studied. Saccular aneurysm was the most common and anterior communicating artery (ACOM) was the most common location. Significant correlation of dome: neck and aspect ratios between CTA and DSA (p=0.0089) was noted. The sensitivity, Positive Predictive Value (PPV) and accuracy of CTA for aneurysm >3 mm was 100%. Two aneurysms <3 mm were missed on CTA, but detected by DSA. Therefore, for aneurysms <3 mm in size, sensitivity was 92.86%, with a PPV and accuracy of 96.3% and 89.66%, respectively. Overall sensitivity of CTA irrespective of size was 97.9%, with 97.9% PPV and 95.9% accuracy was observed. Conclusion: MDCTA with 3D reconstructions and volume rendering is the ideal first line imaging modality in non-traumatic SAH for detection of aneurysm with a high degree of accuracy. DSA can be used to diagnose tiny aneurysms <3 mm if missed on CTA, if there is a high degree of suspicion.

Clinical value of multi-slice spiral CT angiography in the diagnosis of intracranial aneurysms

Objective To investigate the clinical value of multi-slice spiral CT angiography(CTA) in the diagnosis of intracranial cerebral aneurysms. Methods From January 2014 to December 2016, the clinical data of 60 patients with suspected intracranial aneurysms in Yiwu Central Hospital were retrospectively analyzed.The patients received CTA, digital subtraction angiography(DSA) examination.Based on the postoperative pathological results, the specificity, accuracy, consistency of CTA and DSA in the diagnosis of intracranial aneurysm were calculated.CTA, DSA diagnosis results and cerebral aneurysm surgery results were analyzed.The intracranial aneurysm diameter, the maximum diameter of the aneurysm neck of CTA, DSA inspection were compared. Results Based on the postoperative pathological results, the diagnostic sensitivity, specificity and accuracy of CTA for intracranial aneurysms were 97.06%, 92.31%, 95.00%, respectively, which of DSA were 94.12%, 96.15%, 95.00%, respectively, there were no statistically significant differences between the two groups(all P>0.05). The consistency coefficient of CTA was 0.719, and DSA coefficient of agreement with the findings in operation was 0.736, the consistency was good.The intracranial artery tumor maximum diameter, maximum diameter of aneurysm neck by CTA, DSA examination had no statistically significant differences(all P>0.05). Conclusion CTA in the diagnosis of intracranial aneurysm has high sensitivity and accuracy, the diagnostic value is close to DSA and can be used as auxiliary means of DSA. Key words: Intracranial aneurysm; Cerebral angiography; Tomography, spiral computed; Angiography, digital subtraction; Diagnosis

A37 EFFICACY OF CTA IN DIAGNOSING NON-TRAUMATIC NON-VARICEAL GASTROINTESTINAL BLEEDING PRIOR TO TRANSARTERIAL EMBOLIZATION AFTER ENDOSCOPIC FAILURE IN MANAGING ACUTE GASTROINTESTINAL BLEEDING

AbstractBackgroundNon-variceal gastrointestinal bleeding (NVGIB) is associated with a high mortality and morbidity. 10–30% of these patients tend to fail endoscopy and receive transarterial embolization (TAE) as an alternative. Studies suggest that performing pre-angiography computed tomography angiography (CTA) increases the positive yield of visceral angiography.AimsOur objective was to determine (1) the accuracy of CTA in diagnosing NVGIB following failed endoscopy and (2) the impact of CTA pre-TAE on the angiographic technique.MethodsData was collected from 83 consecutive patients who presented to the emergency department with acute NVGIB and received TAE after endoscopy failed to manage their NVGIB. Of these 83 patients, 40 underwent pre-angiography CTA. These CTA examinations were retrospectively reviewed by 2 radiology residents and 2 staff radiologists. These findings were compared to angiography, or/and surgery. Inter-reader reliability was evaluated with kappa coefficient (κ).ResultsSensitivity, specificity, PPV, NPV, and accuracy of CTA in diagnosing NVGIB was 89%, 100%, 100%, 86%, and 93%, respectively. CTA was able to accurately diagnose the cause and source of NVGIB in 85% of the patients respectively. The inter-reader reliability coefficient for identifying the cause and source of NVGIB was κ=0.72 and κ=0.66 respectively. In 20 cases, in whom CTA localized NVGIB, no diagnostic catheter angiogram was required. In 6/20 cases, pre-TAE CTA enabled the identification of the bleeding site, which would not have been visualized on a routine diagnostic angiogram. When comparing patients that received CTA prior to their therapeutic embolization for NVGIB to the patients that did not receive a pre-embolization CTA, there was an overall reduction of 20 minutes of procedural time.ConclusionsCTA is an accurate diagnostic modality in detecting NVGIB. Performing abdomen and pelvis CTA before TAE improves the localization of gastrointestinal bleeding and facilitates embolization by reducing the overall procedural time. Impact of pre-angiography CTA on reducing the overall number of imaging studies, amount of contrast administered, and overall mortality and morbidity needs to be further investigated.Funding AgenciesNone