Admission Computed Tomography Research Articles

Predicting full-thickness necrosis in adult acute corrosive ingestion injuries in a sub-Saharan African setting.

Corrosive ingestion remains an important global pathology with high morbidity and mortality. Data on the acute management of adult corrosive injuries from sub-Saharan Africa is scarce, with international investigative algorithms, relying heavily on computed tomography (CT), having limited availability in this setting. To investigate the corrosive injury spectrum in a low-resource setting and the applicability of parameters for predicting full-thickness (FT) necrosis and mortality. A retrospective analysis of a prospective corrosive injury registry (March 1, 2017-October 31, 2023) was performed to include all adult patients with acute corrosive ingestion managed at a single, academic referral centre in Cape Town, South Africa. Patient demographics, corrosive ingestion details, initial investigations, management, and short-term outcomes were described using descriptive statistics while multivariate analysis with receiver operator characteristic area under the curve graphs (ROC AUC) were used to identify factors predictive of FT necrosis and 30-day mortality. One-hundred patients were included, with a mean age of 32 years (SD: 11.2 years) and a male predominance (65.0%). The majority (73.0%) were intentional suicide attempts. Endoscopy on admission was the most frequent initial investigation performed (95 patients), while only 17 were assessed with CT. Seventeen patients had full thickness necrosis at surgery, of which eleven underwent emergency resection and six were palliated. Thirty-day morbidity and mortality were 27.0% and 14.0%, respectively. Patients with full thickness necrosis and those with an established perforation had a 30-day mortality of 58.8% and 91.0%, respectively. Full thickness necrosis was associated with a cumulative 2-year survival of only 17.6%. Multivariate analyses with ROC AUC showed admission endoscopy findings, CT findings, and blood gas findings (pH, base excess, lactate), to all have significant predictive value for full thickness necrosis, with endoscopy proving to have the best predictive value (AUC 0.850). CT and endoscopy findings were the only factors predictive of early mortality, with CT performing better than endoscopy (AUC 0.798 vs 0.759). Intentional corrosive injuries result in devastating morbidity and mortality. Locally, early endoscopy remains the mainstay of severity assessment, but referral for CT imaging should be considered especially when blood gas findings are abnormal.

Clinical Significance of the Control CT Rotterdam Score Compared With the Admission CT Rotterdam Score in Patients With Isolated Severe Traumatic Brain Injury in the Intensive Care Unit.

The Rotterdam scale is one of the most commonly used radiological scales for evaluating and predicting outcomes in traumatic brain injury (TBI) cases. Given the evolving nature of TBI, our study is designed to compare the Rotterdam score of computed tomography (CT) findings upon admission (Rotterdam score I) with the score after 72 hours (Rotterdam score II) of treatment in the trauma intensive care unit (ICU). A retrospective observational study was conducted on 54 patients who received intensive care treatment for isolated severe TBI over five years. We included severe TBI patients with no age restrictions who required admission to the ICU within 12 hours of the onset of trauma. An initial Rotterdam CT score was obtained via a CT head scan within four hours of the trauma, followed by a control CT head scan 72 hours after ICU admission. It was essential to have documentation on the clinical and laboratory treatment course and access to radiological CT diagnostics. Receiver operating characteristic (ROC) curves were employed in this study to evaluate the accuracy of diagnostic tests, such as the Rotterdam score. The ROC curves provided a graphical representation of the tests' diagnostic performance, which helped assess their effectiveness. There was a significant difference (p < 0.001) in the diagnostic scores of CT scans upon admission (Rotterdam score I) and control CT scans after 72 hours (Rotterdam score II) in the total sample. The Rotterdam score I was notably higher, 3.6 (±0.8), in patients requiring neurosurgical intervention compared to those who did not, 2.8 (±0.9), with significance (p = 0.003). The Rotterdam score I demonstrated a substantial predictive value for unfavorable outcomes (p = 0.048), as did the Rotterdam score II after the 72-hour mark (p = 0.006). The control Rotterdam score 72 hours after admission predicts mortality in isolated TBI patients more significantly than the Rotterdam score determined at the patient's admission to the intensive care unit.

Radiomics of intrathrombus and perithrombus regions for Post-EVT intracranial hemorrhage risk Prediction: A multicenter CT study

ObjectivesThis study aimed to assess the predictive performance of radiomics derived from computed tomography (CT) images of thrombus regions in predicting the risk of intracranial hemorrhage (ICH) following endovascular thrombectomy (EVT). Materials and MethodsThis retrospective multicenter study included 336 patients who underwent admission CT and EVT for acute anterior-circulation large vessel occlusion between December 2018 and December 2023. Follow-up imaging was performed 24 h post-procedure to evaluate the occurrence of ICH. 230 patients from centers A and B were randomly allocated into training and test groups in a 7:3 ratio, while the remaining 106 patients from center C comprised the validation cohort. Radiologists manually segmenting the thrombus on CT images, and the perithrombus region was defined by expanding the initial region of interest (ROI). A total of 428 radiomics features were extracted from both intrathrombus and perithrombus regions on CT images. The Mann–Whitney U test was used for feature selection, and least absolute shrinkage and selection operator (LASSO) regression was employed for model development, followed by validation using a 5-fold cross-validation approach. Model performance was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC). ResultsAmong the eligible patients, 128 (38.1 %) experienced ICH after EVT. The combined model exhibited superior performance in the training cohort (AUC: 0.913, 95 % CI: 0.861–0.965), test cohort (AUC: 0.868, 95 % CI: 0.775–0.962), and validation cohort (AUC: 0.850, 95 % CI: 0.768–0.912). Notably, in the validation group, both the perithrombus and combined models demonstrated higher predictive accuracy compared to the intrathrombus model (0.837 vs. 0.684, p = 0.02; AUC: 0.850 vs. 0.684, p = 0.01). ConclusionsRadiomics features derived from the perithrombus region significantly enhance the prediction of ICH after EVT, providing valuable insights for optimizing post-procedural clinical decisions. Clinical relevance statementThis study highlights the importance of radiomics extracted from intrathrombus and perithrombus region in predicting intracranial hemorrhagefollowing endovascular thrombectomy, which can aid in improving patient outcomes.

Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury

PurposeBlunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI.MethodsWe conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI.ResultsOne hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67–0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64–0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75–0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55).ConclusionRadiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist’s impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.

Clinical findings of acute necrotizing esophagitis complicated by diabetic ketoacidosis.

Acute necrotizing esophagitis (ANE) is a rare and potentially life-threatening complication of diabetic ketoacidosis (DKA). While its association with DKA is established, specific clinical characteristics that predict ANE in DKA patients remain less understood. This study aimed to identify these characteristics by analyzing data from 30 DKA patients admitted from January 2018 to September 2022. Seven patients in this study presented with ANE, forming the ANE group. The remaining 23 constituted the non-ANE group. We compared the clinical parameters and computed tomography (CT) between the groups. The mean age of participants was 57.7 ± 20.4 years, and their mean HbA1c was 11.1 ± 3.3%. Notably, ethanol intake was significantly higher in the ANE group (44.4 ± 25.4 g/day) compared to the non-ANE group (6.8 ± 14.0 g/day; p = 0.013). Additionally, sodium-glucose transport protein 2 inhibitor use was significantly more prevalent in the ANE group (p = 0.013). Gastrointestinal symptoms were also significantly more pronounced in the ANE group, with vomiting occurring in 85.7% of patients compared to only 13.0% in the non-ANE group. Admission CT scans revealed further distinguishing features, with the ANE group showing significantly higher rates of esophageal wall thickening, intra-esophageal effusion, and calcification of the celiac artery origin (p < 0.0001, 0.0038, 0.0038, respectively). In conclusion, our study suggests that heavy alcohol consumption and strong gastrointestinal symptoms in DKA patients warrant a heightened suspicion of ANE. Early consideration of CT or upper gastrointestinal endoscopy is recommended in such cases.

The relationship between thorax computed tomography findings and prognosis in patients diagnosed with COVID-19.

This study aimed to demonstrate the relationship between thorax computed tomography (CT) findings at the time of admission and prognosis using a semiquantitative CT severity scoring system in patients diagnosed with coronavirus disease 2019 (COVID-19) who tested positive for reverse transcriptase polymerase chain reaction (RT-PCR). A total of 305 patients aged 18 years and older who were diagnosed with COVID-19 confirmed by RT-PCR and underwent thorax CT at the time of admission, were included in the study between March and July 2020. The demographic data of the patients, their presenting complaints at the time of admission, RT-PCR results, and thorax CT images were scanned retrospectively from electronic medical records. Lesions on thorax CT were evaluated for the presence of ground glass opacity, consolidation, and septal thickening and scoring. No significant relationship was found between mortality and CT score or other parameters. A significant relationship was found between admission to the intensive care unit and CT scoring (p=0.014), aortic diameter (p=0.032), chronic pulmonary disease (p=0.004), halo sign (p=0.031), mortality (p<0.001), fever (p=0.038), and dyspnea (p=0.031). A statistically significant difference was detected in the score parameter between discharged patients and intensive care unit patients who survived and those who died (p<0.001). In the parameter of the number of lobes, a statistically significant difference was found only between discharged patients and intensive care unit patients who survived (p=0.016). Thorax CT is an advisor for early diagnosis, treatment, and prognosis assessment of the disease. Semiquantitative CT severity scoring can provide valuable information about the prognosis of the patient.

Abstract 110: Autoangiogenesis Secondary to Chronic Cocaine Use Mimicking Moya‐Moya

Introduction We present the case of a young male presenting with syncope who was found to have incidental hypodensities on computed tomography (CT) of his head, with magnetic resonance imaging (MRI) concerning for Moya‐Moya related occlusion of the right internal carotid artery, but with digital subtraction angiography (DSA) showing extensive autoangiogenesis and collateralization from all other intracranial vascular territories, without Moya‐Moya related changes. This presumably developed as reactive changes to severe chronic cocaine use. Methods We present a case from a tertiary care center in the borough of Manhattan, New York City, USA. All information is deidentified and exempt from IRB approval. Results A 36‐year‐old man with history significant for asthma, active smoker status, and active cocaine use, presented for loss of consciousness. The patient reported 3 days of upper respiratory symptoms and decreased oral intake with subsequent loss of consciousness immediately preceded by lightheadedness and nausea, and without any post‐event confusion, lacerations, or incontinence. Neurologic history is significant for right upper extremity weakness from 9/2022‐12/2022 that self‐resolved and was believed to be a peripheral nerve pathology. Admission exam without focal deficits. Admission CT of his head showed multifocal confluent hypodensities in the subcortical right frontal lobe. CT Angiogram of head and neck showed severe narrowing at right Internal Carotid Artery (ICA) terminus and right M1 segment with lenticulostriate arterial collateralization, severe bilateral A1 stenosis with distal Anterior Cerebral Artery (ACA) flow suggestive of chronic collateralization, and significant right Posterior Cerebral Artery (PCA) collateralization. Given concern for Moya‐Moya disease, MRI of the brain was obtained and despite no acute infarct, MRI was significant for multifocal white matter T2/FLAIR hyperintensities with the largest in the right frontal lobe. The patient subsequently underwent digital subtraction angiography (DSA) to assess collaterals and stratify for possible need for future encephaloduroarteriosynangiosis (EDAS). DSA showed significant auto‐angiogenesis between numerous vascular territories, including recruitment of right Posterior Cerebral Artery and External Carotid Artery branches to perfuse the territory of the severe right ICA terminus steno‐occlusive disease. With minimal anterograde flow into the right Anterior Choroidal Artery and none to the right Middle Cerebral Artery (MCA), the characteristic Moya‐Moya appearance was not appreciated on DSA given minimal anigogenesis around the right ICA occlusion site. Rather, distal perfusion of the R ICA territory was dependent on collaterals from the right PCA, right ACA via the Anterior Communicating Artery, angiogenesis between the right Anterior Falcine Artery and R ACA, and angiogenesis between the right MCA and ACA/MCA cortical branches. These proliferative changes involved all cranial vascular territories, including those without steno‐occlusive disease. Conclusion Acute cocaine use is associated with increased risk of acute ischemic stroke[1], due in part to its sympathomimetic effects causing vasospasm and to its arrhythmic properties[2]. Neuroadaptation after chronic cocaine use is less well understood though rat models suggest that as cerebral ischemia develops from chronic cocaine use, the HIF‐VEGF pathway is activated to promote angiogenesis to restore local blood flow[3]. We present this case as evidence of a similar angiogenic physiologic response in humans to minimize the microvascular ischemic injury from chronic cocaine use.

Clinical impact of screening computed tomography in extracorporeal membrane oxygenation: a retrospective cohort study

BackgroundData on the prevalence and clinical impact of extrapulmonary findings at screening computed tomography (CT) on initiation of veno-venous extracorporeal membrane oxygenation (V-V ECMO) are limited. We aimed to identify the prevalence of extrapulmonary findings on screening CT following V-V ECMO initiation. We hypothesized that extrapulmonary findings would influence clinical management and outcome.MethodsRetrospective analysis (2011–2021) of admission screening CT including head, abdomen and pelvis with contrast of consecutive patients on initiation of V-V ECMO. CT findings identified by the attending consultant radiologist were extracted. Demographics, admission physiological and laboratory data, clinical decision-making following CT and ECMO ICU mortality were recorded from the electronic medical record. We used multivariable logistic regression and Kaplan–Meier curves to evaluate associations between extrapulmonary findings and ECMO ICU mortality.ResultsOf the 833 patients receiving V-V ECMO, 761 underwent routine admission CT (91.4%). ECMO ICU length of stay was 19 days (IQR 12–23); ICU mortality at the ECMO centre was 18.9%. An incidental extrapulmonary finding was reported in 227 patients (29.8%), leading to an invasive procedure in 12/227 cases (5.3%) and a change in medical management (mainly in anticoagulation strategy) in 119/227 (52.4%). Extrapulmonary findings associated with mortality were intracranial haemorrhage (OR 2.34 (95% CI 1.31–4.12), cerebral infarction (OR 3.59 (95% CI 1.26–9.86) and colitis (OR 2.80 (95% CI 1.35–5.67).ConclusionsScreening CT frequently identifies extrapulmonary findings of clinical significance. Newly detected intracranial haemorrhage, cerebral infarction and colitis were associated with increased ICU mortality.

Blunt Pulmonary Contusion: Admission Computed Tomography Scan Predicts Mechanical Ventilation

INTRODUCTION Road traffic injury is one of the fastest growing health problems in Nepal with increasing number every year leading to morbidi- ty and mortality. Blunt pulmonary contusion may not be seen in the initial plain radiographs as they evolve over 12-24 hours. Thus CT (Computed Tomography) scan can provide detailed information about the contusion and predict the need for mechanical ventilation. MATERIAL AND METHODS This is a prospective, observational longitudinal study conducted at Universal College of Medical Sciences, Bhairahawa from 1st January 2020 to 31st December 2020. The predictors for requirement of mechanical ventilation like Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), GCS score and number of fractured ribs at the time of admission were recorded. RESULTS In this study, 100 cases with blunt pulmonary contusion were evaluated. Average age of patients with blunt pulmonary contusion was around 39.10±17.56 years with male predominance (82%). Total of 7 patients required mechanical ventilation among whom the AIS chest was 3.0±0.82, ISS score was 29.14±6.89, and GCS 9.14±3.13. The ROC curve showed that ISS score predicted significantly about the requirement of mechanical ventilation with sensitivity of 85.5% and specificity of 99.8 %. CONCLUSION Initial CT done in patients can show the presence or absence of pulmonary contusion and associated thoracic injuries and along with AIS, ISS and GCS scores we can predict early the requirement of mechanical ventilation.

Incidence and predictors of development of new onset hypertension post COVID-19 disease

AimsThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) affects vital organs and causes vascular injury. There are concerns that this injury may have long-term consequences on the cardiovascular system after recovery from COVID-19. We investigated the incidence and predictors of new-onset hypertension at 1-year follow-up post-COVID-19 disease. MethodsIn this prospective observational study, 393 patients hospitalised and diagnosed with COVID-19 disease at a tertiary cardiac care hospital during 27th March 2021 to 27th May 2021. Eligible 248 patients whose baseline characteristics, laboratory findings, treatment and outcome data were received systematically. Patients were followed up at 1 year of COVID-19 disease recovery. ResultsWe found that 32.3% of the population had new onset of hypertension at 1 year follow-up post-COVID-19 disease recovery. More hypertensive patients had severe computed tomography (CT) score severity (28.7 vs 14.9%; P 0.02). More number of patients in the hypertensive group were treated with steroids (73.8% vs 39%; p < 0.0001) during hospital stay. In-hospital complications were higher (12.5 vs 4.2%; P 0.03) in the hypertensive group. Patients who developed new-onset hypertension had statistically significantly higher baseline values of serum ferritin and C-reactive protein (CRP) (P 0.02 and 0.03 respectively). Vascular age was found 12.5 ± 3.96 years more than chronological age in hypertensive patients. ConclusionNew onset of hypertension was detected in 32.3% of patients at one-year follow-up post-COVID-19 disease recovery. Severe inflammation at the time of admission and severe CT severity score were associated with the development of new onset of hypertension on follow-up.

Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma.

Acute subdural hematoma (aSDH) is one of the most devastating entities secondary to traumatic brain injury (TBI). Even though radiological computed tomography (CT) findings, such as hematoma thickness (HT), midline shift (MLS), and MLS/HT ratio, have an important prognostic role, they suffer from important drawbacks. We hypothesized that relative cross-sectional area (rCSA) of specific brain regions would provide valuable information about brain compression and swelling, thus being a key determining factor governing the clinical course. We performed an 8-year retrospective analysis of patients with moderate to severe TBI with surgically evacuated, isolated, unilateral aSDH. We investigated the influence of aSDH rCSA and ipsilateral hemisphere rCSA along the supratentorial region on the subsequent operative technique employed for aSDH evacuation and patient's clinical outcomes (early death and Glasgow Outcome Scale [GOS] at discharge and after 1-year follow-up). Different conventional radiological variables were also assessed. The study included 39 patients. Lower HT, MLS, hematoma volume, and aSDH rCSA showed a significant association with decompressive craniectomy (DC) procedure. Conversely, higher ipsilateral hemisphere rCSA along the dorso-ventral axis and, specifically, ipsilateral hemisphere rCSA at the high convexity level were predictors for DC. CT segmentation analysis exhibited a modest relationship with early death, which was limited to the basal supratentorial subregion, but could not predict long-term outcome. rCSA is an objectifiable and reliable radiologic parameter available on admission CT that might provide valuable information to optimize surgical treatment.

Venous Outflow Profiles Are Linked to Clinical Outcomes in Ischemic Stroke Patients with Extensive Baseline Infarct.

Background and Purpose The benefit of endovascular thrombectomy (EVT) treatment is still unclear in stroke patients presenting with extensive baseline infarct. The use of additional imaging biomarkers could improve clinical outcome prediction and individualized EVT selection in this vulnerable cohort. We hypothesized that cerebral venous outflow (VO) may be associated with functional outcomes in patients with low Alberta Stroke Program Early CT Score (ASPECTS). Methods We conducted a retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Extensive baseline infarct was defined by an ASPECTS of ≤5 on admission computed tomography (CT). VO profiles were assessed on admission CT angiography using the Cortical Vein Opacification Score (COVES). Favorable VO was defined as COVES ≥3. Multivariable logistic regression was used to determine the association between cerebral VO and good clinical outcomes (90-day modified Rankin Scale score of ≤3). Results A total of 98 patients met the inclusion criteria. Patients with extensive baseline infarct and favorable VO achieved significantly more often good clinical outcomes compared to patients with unfavorable VO (45.5% vs. 10.5%, P<0.001). Higher COVES were strongly associated with good clinical outcomes (odds ratio, 2.17; 95% confidence interval, 1.15 to 4.57; P=0.024), independent of ASPECTS, National Institutes of Health Stroke Scale, and success of EVT. Conclusions Cerebral VO profiles are associated with good clinical outcomes in AIS-LVO patients with extensive baseline infarct. VO profiles could serve as a useful additional imaging biomarker for treatment selection and outcome prediction in low ASPECTS patients.

3D island sign on computed tomography predicts early perihematomal edema expansion and poor outcome in patients with intracerebral hemorrhage

Background and purposeTo determine the prognostics significance of the computed tomography (CT) 3D island sign for predicting early perihematomal edema (PHE) expansion and poor functional outcome in patients presenting with intracerebral hemorrhage (ICH). MethodsBetween July 2011 and March 2017, patients with intracerebral hemorrhage who had undergone baseline CT within 6 h after ICH symptom onsets and follow-up CT in our hospital were included. Two different readers independently assessed the presence of 3D island sign on admission CT scan of each patient. Multivariable logistic regression analysis was used to analyze association between 3D island sign and early perihematomal edema expansion and poor functional outcome, separately. ResultsA total of 214 patients who met the inclusion criteria were included in our study, 3D island sign was observed in 60 patients (28.0 %) on admission CT scan. The multivariate logistic regression analysis demonstrated that baseline hematoma volume, time to baseline and follow-up CT scans and the presence of 3D island sign were predictors of early PHE expansion. After adjusting for age, baseline hematoma and edema volume, time to baseline and follow-up CT scans, GCS on admission, presence of intraventricular hemorrhage (IVH) and systolic blood pressure, the 3D island sign was an independently imaging marker for poor outcome (OR, 2.803; 95 % confidence interval, 1.189–6.609; P = 0.018). ConclusionThe 3D island sign in patients with intracerebral hemorrhage was a reliable predictor for early perihematomal edema expansion and poor functional outcome. It may serve as a potential therapeutic target for intervention.

Value of Thrombus Imaging Characteristics as a Guide for First‐Line Endovascular Thrombectomy Device in Patients With Acute Ischemic Stroke

Background It has been suggested that selection of a first‐line endovascular thrombectomy device, that is, contact aspiration (CA) or stent retriever (SR) thrombectomy, could be based on thrombus type. Thrombus composition and mechanical behavior can partially be predicted with thrombus computed tomography (CT) characteristics. We aimed to assess the influence of thrombus CT characteristics on the association between first‐line device and outcomes of endovascular thrombectomy. Methods For patients enrolled in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry between March 2014 and November 2017, we assessed thrombus density, thrombus length, and presence of hyperdense artery sign on thin‐slice (≤2.5 mm) admission CT. We used regression models to estimate the relationship between first‐line endovascular thrombectomy device (CA versus stent retriever) and first‐pass reperfusion (FPR, expanded Thrombolysis in Cerebral Infarction score 2C‐3 after first attempt), final reperfusion, procedure duration, 24‐hour National Institutes of Health Stroke Scale, and 90‐day modified Rankin scale score and tested for interaction of thrombus characteristics with first‐line device by adding interaction terms. Results Of 703 included patients, 520 (74%) received first‐line stent retriever and 183 (26%) first‐line CA. Overall, the first‐line device was not associated with FPR (adjusted odds ratio [aOR], 1.32 [95% CI, 0.88–1.98]). In patients with thrombus density below the median (&lt;50 Hounsfield units), FPR was more often achieved with CA than with a stent retriever (34% versus 24%, aOR, 1.95 [95% CI, 1.09–3.50]), whereas in patients with thrombus density above the median (≥50 Hounsfield units), first‐line device was not associated with FPR (aOR, 0.90 [95% CI, 0.50–1.62]). The interaction between thrombus density as a continuous variable and first‐line device on outcome was not significant ( P =0.38). There was also no interaction between first‐line device and the other thrombus characteristics for FPR or the other outcomes. Conclusion Our study does not provide evidence that the association between first‐line thrombectomy device and endovascular thrombectomy outcomes depends on thrombus CT characteristics. Based on our results, there are no arguments for thrombectomy device selection based on thrombus CT characteristics. A possible better performance of CA in low‐density, fibrin‐rich clots needs further study.

Net water uptake, a neuroimaging marker of early brain edema, as a predictor of symptomatic intracranial hemorrhage after acute ischemic stroke.

ObjectiveWe hypothesized that quantitative net water uptake (NWU), a novel neuroimaging marker of early brain edema, can predict symptomatic intracranial hemorrhage (sICH) after acute ischemic stroke (AIS).MethodsWe enrolled patients with AIS who completed admission multimodal computed tomography (CT) within 24 h after stroke onset. NWU within the ischemic core and penumbra was calculated based on admission CT, namely NWU-core and NWU-penumbra. sICH was defined as the presence of ICH in the infarct area within 7 days after stroke onset, accompanied by clinical deterioration. The predictive value of NWU-core and NWU-penumbra on sICH was evaluated by logistic regression analyses and the receiver operating characteristic (ROC) curve. A pure neuroimaging prediction model was built considering imaging markers, which has the potential to be automatically quantified with an artificial algorithm on image workstation.Results154 patients were included, of which 93 underwent mechanical thrombectomy (MT). The median time from symptom onset to admission CT was 262 min (interquartile range, 198–368). In patients with MT, NWU-penumbra (OR =1.442; 95% CI = 1.177–1.766; P < 0.001) and NWU-core (OR = 1.155; 95% CI = 1.027–1.299; P = 0.016) were independently associated with sICH with adjustments for age, sex, time from symptom onset to CT, hypertension, lesion volume, and admission National Institutes of Health Stroke Scale (NIHSS) score. ROC curve showed that NWU-penumbra had better predictive performance than NWU-core on sICH [area under the curve (AUC): 0.773 vs. 0.673]. The diagnostic efficiency of the predictive model was improved with the containing of NWU-penumbra (AUC: 0.853 vs. 0.760). A pure imaging model also presented stable predictive power (AUC = 0.812). In patients without MT, however, only admission NIHSS score (OR = 1.440; 95% CI = 1.055–1.965; P = 0.022) showed significance in predicting sICH in multivariate analyses.ConclusionsNWU-penumbra may have better predictive performance than NWU-core on sICH after MT. A pure imaging model showed potential value to automatically screen patients with sICH risk by image recognition, which may optimize treatment strategy.

Quantitative thrombus characteristics on thin-slice computed tomography improve prediction of thrombus histopathology: results of the MR CLEAN Registry

ObjectivesThrombus computed tomography (CT) characteristics might be used to assess histopathologic thrombus composition in patients treated with endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). We aimed to assess the variability in thrombus composition that could be predicted with combined thrombus CT characteristics.MethodsThrombi of patients enrolled in the MR CLEAN Registry between March 2014 and June 2016 were histologically analyzed with hematoxylin-eosin staining and quantified for percentages of red blood cells (RBCs) and fibrin/platelets. We estimated the association between general qualitative characteristics (hyperdense artery sign [HAS], occlusion location, clot burden score [CBS]) and thrombus composition with linear regression, and quantified RBC variability that could be explained with individual and combined characteristics with R2. For patients with available thin-slice (≤ 2.5 mm) imaging, we performed similar analyses for general and quantitative characteristics (HAS, occlusion location, CBS, [relative] thrombus density, thrombus length, perviousness, distance from ICA-terminus).ResultsIn 332 included patients, the presence of HAS (aβ 7.8 [95% CI 3.9–11.7]) and shift towards a more proximal occlusion location (aβ 3.9 [95% CI 0.6–7.1]) were independently associated with increased RBC and decreased fibrin/platelet content. With general characteristics, 12% of RBC variability could be explained; HAS was the strongest predictor. In 94 patients with available thin-slice imaging, 30% of RBC variability could be explained; thrombus density and thrombus length were the strongest predictors.ConclusionsQuantitative thrombus CT characteristics on thin-slice admission CT improve prediction of thrombus composition and might be used to further guide clinical decision-making in patients treated with EVT for AIS in the future.Key Points• With hyperdense artery sign and occlusion location, 12% of variability in thrombus RBC content can be explained.• With hyperdense artery sign, occlusion location, and quantitative thrombus characteristics on thin-slice (≤ 2.5 mm) non-contrast CT and CTA, 30% of variability in thrombus RBC content can be explained.• Absolute thrombus density and thrombus length were the strongest predictors for thrombus composition.

Radiographic and Clinical Predictors of Therapeutic Pelvic Angiography

Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures. All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden's index was used to identify the optimal value of selected predictors identified on MLR. 177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, P = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, P < .0001) as independent predictors of therapeutic angiography. CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.

Features of trunk muscle wasting during acute care and physical function recovery with aortic disease.

BackgroundLow skeletal muscle area or density, such as myosteatosis, identified on computed tomography (CT) is associated with poor prognosis in patients with cardiovascular diseases. However, there is a lack of evidence regarding the clinical process of skeletal muscle decline as a short‐term change during acute care settings. This study focused on the use of routine CT imaging for aortic disease management and investigated the changes in skeletal muscle before and after acute care.MethodsThis prospective study included 123 patients who underwent abdominal CT before and after acute care. The all‐abdominal and each abdominal muscle areas were divided into eight parts (e.g. rectus abdominis, psoas, and erector spine), and their areas and densities were measured at the third lumbar vertebra level after the patients were discharged and de‐identified with blinding to avoid measurement bias. Short physical performance battery (SPPB) was measured at the start and end of in‐hospital cardiac rehabilitation. A generalized linear model with patients as random effects was made to investigate skeletal muscle loss during acute care. Multivariate linear regression analysis was also used to assess the relationship between the change in skeletal muscle during acute care and SPPB during in‐hospital cardiac rehabilitation.ResultsThe median age of the patients was 70 (interquartile: 58–77) years, and 69.9% (86/123) were men. The median day between acute care from the day of surgery or hospital admission and follow‐up CT was 7 (interquartile: 3–8) days. Overall muscle density declined after acute care (estimate value: −3.640, 95% confidence interval [CI]: −4.538 to −2.741), and each abdominal muscle density consistently declined (interaction: F value = 0.099, P = 0.998). In contrast, there was no significant change in the overall muscle area (estimate value: −0.863, 95% CI: −2.925 to 1.200). Changes in the muscle area were different for each skeletal muscle (interaction: F value = 2.142, P = 0.037), and only the erector spine muscle significantly declined (estimate value: −1.836, 95% CI: −2.507 to −1.165). After adjusting for confounding factors, a greater decline in muscle density was associated with lower recovery score on SPPB (β = 0.296, 95% CI: 0.066 to 0.400).ConclusionsMuscle density consistently declined after acute care, especially the erector spine muscles, which also significantly decreased in size. A higher decline in muscle density was associated with a slower recovery of physical function during in‐hospital cardiac rehabilitation in patients with aortic diseases.

Short Observation Period and Aggressive Discharge of Patients With Head Injury and Serial CT Scans.

Background: Many patients undergo two head computed tomography (CT) scans after mild traumatic brain injury (TBI). Radiographic progression without clinical deterioration does not usually alter management. Evidence-based guidelines offer potential for limited repeat imaging and safe discharge. This study characterizes patients who had two head CTs in the Emergency Department (ED), determines the change between initial and repeat CTs, and describes timing of repeat scans.Methods: This retrospective series includes all patients with head CTs during the same ED visit at an urban trauma center between May 1st, 2016 and April 30th, 2018. Radiographic interpretation was coded as positive, negative, or equivocal.Results: Of 241 subjects, the number of positive, negative, and equivocal initial CT results were 154, 50, and 37, respectively. On repeat CT, 190 (78.8%) interpretations were congruent with the original scan. Out of the 21.2% of repeat scans that diverged from the original read, 14 (5.8%) showed positive to negative conversion, 1 (.4%) showed positive to equivocal conversion, 2 (.88%) showed negative to positive conversion, 20 (8.3%) showed equivocal to negative conversion, and 14 (5.8%) showed equivocal to positive conversion. Average time between scans was 4.4 hours, and median length of stay was 10.2 hours.Conclusions: In this retrospective review, most repeat CT scans had no new findings. A small percentage converted to positive, rarely altering clinical management. This study demonstrates the need for continued prospective research to update clinical guidelines that could reduce admission and serial CT scanning for mild TBI.

Quantitative Lesion Water Uptake as Stroke Imaging Biomarker: A Tool for Treatment Selection in the Extended Time Window?

Patients presenting in the extended time window may benefit from mechanical thrombectomy. However, selection for mechanical thrombectomy in this patient group has only been performed using specialized image processing platforms, which are not widely available. We hypothesized that quantitative lesion water uptake calculated in acute stroke computed tomography (CT) may serve as imaging biomarker to estimate ischemic lesion progression and predict clinical outcome in patients undergoing mechanical thrombectomy in the extended time window. All patients with ischemic anterior circulation stroke presenting within 4.5 to 24 hours after symptom onset who received initial multimodal CT between August 2014 and March 2020 and underwent mechanical thrombectomy were analyzed. Quantitative lesion net water uptake was calculated from the admission CT. Prediction of clinical outcome was assessed using univariable receiver operating characteristic curve analysis and logistic regression analyses. One hundred two patients met the inclusion criteria. In the multivariable logistic regression analysis, net water uptake (odds ratio, 0.78 [95% CI, 0.64-0.95], P=0.01), age (odds ratio, 0.94 [95% CI, 0.88-0.99]; P=0.02), and National Institutes of Health Stroke Scale (odds ratio, 0.88 [95% CI, 0.79-0.99], P=0.03) were significantly and independently associated with favorable outcome (modified Rankin Scale score ≤1), adjusted for degree of recanalization and Alberta Stroke Program Early CT Score. A multivariable predictive model including the above parameters yielded the highest diagnostic ability in the classification of functional outcome, with an area under the curve of 0.88 (sensitivity 92.3%, specificity 82.9%). The implementation of quantitative lesion water uptake as imaging biomarker in the diagnosis of patients with ischemic stroke presenting in the extended time window might improve clinical prognosis. Future studies could test this biomarker as complementary or even alternative tool to CT perfusion.