Initial Computed Tomography Scan Research Articles

Accuracy of Initial Chest Computed Tomography Scan for Diagnosis of COVID-19: A Systematic Review

Abstract Background Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus (SARS- COVID-19) with recent outbreak occurred on 11 March 2020. A computerized tomography (CT) scan for chest was proved to be a helpful tool for diagnosis of COVID-19 pneumonia. But little is known about its diagnostic accuracy. Aim of the Work This systematic review aims at determining current evidence regarding accuracy of initial chest CT scan for detection of COVID-19 infection. Patients and Methods We conducted an electronic search through different databases; PubMed, SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL). We included clinical trials whether randomized or nonrandomized prospective or retrospective cohorts, case control, cross sectional studies and case series larger than 10 cases). All studies that reported data about the diagnostic accuracy of initial chest CT for diagnosis of COVID-19 infection were enrolled. We evaluated the methodological quality for included studies using QUADAS-2 Risk of Bias tool. Results From a total 4617 screened citations, 40 studies met our inclusion criteria. We divided the identified studies into two groups: studies that reported both sensitivity and specificity (6 studies, n = 1431) and studies that included only positive COVID-19 cases from which we could estimate only sensitivity (34 studies, n = 3515). Among six studies that evaluated accuracy of CT chest, there was high sensitivity ranged from to 93% to 100% but CT chest specificity was low ranged from to 10% to 56%. Rest of 34 studies had a wide range of sensitivity between 61% and 100% with few studies reported sensitivity below 80%. Conclusion Our results suggest that CT chest is a great screening tool for COVID-19 with high sensitivity but it had low specificity. However, interpretation of CT chest along with other laboratory could enhance its diagnostic accuracy.

Imaging Findings in Pediatric Accessory Cranial Sutures using 3D CT Reconstruction: Fracture or Rudimentary Suture.

Objective:Although accessory sutures are considered to be relatively rare, the consequences of a missed diagnosis are profound. Distinguishing between accessory sutures and cranial fractures can be difficult, especially in cases of suspected non-accidental trauma. High-resolution imaging is the best way to discern between two- and three-dimensional computerized tomography (3D CT) is considered the preferred method for evaluation. The goal of this study was to determine the impact of 3D CT scans in distinguishing between accessory sutures and cranial fractures in suspected child abuse cases in a rural community and the importance of early detection in such cases, as well as call attention to the consequences of initial misinterpretation. Materials and methods:The researchers conducted a retrospective chart review of all pediatric patients diagnosed with cranial fractures (265 in total) at University Medical Center between May 30, 2016, and May 30, 2021. Initial computed tomography (CT) scans and subsequent 3D CT scans were evaluated for each patient that fit the inclusion criteria, 13 in total. Patients were then categorized into two groups based on the final diagnosis on the radiology report: accessory cranial suture or cranial fracture. Once these patients were identified, the etiology and structural components of each were evaluated, and the key differences were highlighted. Results:Our results showed that, of the 11 cases of suspected non-accidental trauma, six were finally diagnosed with accessory sutures with the use of 3D CT scans, and of those six, four were diagnosed with cranial fractures from the initial CT scan report due to a similar presentation and asymmetric nature. Conclusion:Discerning between fracture and accessory suture is essential in evaluating pediatric patients presenting with signs ofcranial fracture due to the increased risk of misinterpretation that can lead to severe legal consequences considering that cranial suture variants may mimic intentional injury and be mistaken for child abuse, causing significant distress for patients and their families.

Management of Isolated Thoracic Lymphadenopathy of Unclear Etiology: A Survey of Physicians and Literature Review.

Background After identifying incidental mediastinal lymph nodes, decisions need to be made regarding the required follow-up imaging, the intervals at which this imaging should be performed, the types of imaging and procedures needed, and when to discontinue the follow-up. The purpose of this study is to determine the majority opinion on the management of these findings and provide recommendations for future management of incidental mediastinal lymphadenopathy. Methodology Sixty-two healthcare providers from a variety of specializations were surveyed on their preference for diagnostic workup and subsequent follow-up following the finding of incidental mediastinal lymphadenopathy on computed tomography (CT) of the chest. Results For thoracic lymphadenopathy of unclear etiology and patients who are not offered endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), most providers (47/62, 75.8%) initiate the CTscan follow-up at size 10 to 14 mm. Of those patients, 51.6% (32/62) of providers repeat the initial CT scan in three monthsand 41.9% (26/62) repeat the initial CT scan in six months. If the follow-up CT chest shows stable lymphadenopathy, 47.5% (29/62) repeat a CT chest every sixmonths and 37% (23/62) repeat a CT chest every 12 months. The majority of providers (42/62, 67.7%) do not use positron emission tomography (PET)-CT for the initial evaluation of isolated thoracic lymphadenopathy and follow-up of lymphadenopathy with increasing size. For thoracic lymph nodes with a maximum diameter of 10 mm, only 4.8% (3/62) of providers continue CT screening after 24 months, while 24.6% (15/62) of providers continue CT screening after 24 months for sizes greater than 20 mm. Regarding the timing of EBUS-TBNA, 40.3% (25/62) of providers consider referring/performing this procedure at lymph nodes of size 11-15 mm, followed by 21% (13/62) of providers referring/performing the procedure at size 10 mm. Conclusions The majority of providers initiate CT scan follow-ups at 10 to 14 mm size for patients with isolated thoracic lymphadenopathy. The majority of providers do not use PET-CT for the initial evaluation of isolated thoracic lymphadenopathy. We found variable responses from providers regarding the timing of follow-up intervals and total duration. There is a need for consensus guidelines regarding the management of thoracic lymphadenopathy of unclear etiology.

Low-Dose Computed Tomography Screening in Relatives With a Family History of Lung Cancer

IntroductionThe role of a family history of lung cancer (LCFH) in screening using low-dose computed tomography (LDCT) has not been prospectively investigated with long-term follow-up. MethodsA multicenter prospective study with up to three rounds of annual LDCT screening was conducted to determine the detection rate of lung cancer (LC) in asymptomatic first- or second-degree relatives of LCFH. ResultsFrom 2007 to 2011, there were 1102 participants enrolled, including 805 and 297 from simplex and multiplex families (MFs), respectively (54.2% women and 70.0% never-smokers). The last follow-up date was May 5, 2021. The overall LC detection rate was 4.5% (50 of 1102). The detection rate in MF was 9.4% (19 of 202) and 4.4% (4 of 91) in never-smokers and in those who smoked, respectively. The corresponding rates for simplex families were 3.7% (21 of 569) and 2.7% (6 of 223), respectively. Of these, 68.0% and 22.0% of cases with stage I and IV diseases, respectively. LC diagnoses within a 3-year interval from the initial screening tend to be younger, have a higher detection rate, and have stage I disease; thereafter, more stage III–IV disease and 66.7% (16 of 24) with negative or semipositive nodules in initial computed tomography scans. Within the 6-year interval, only maternal (modified rate ratio = 4.46, 95% confidence interval: 2.32–8.56) or maternal relative history of LC (modified rate ratio = 5.41, 95% confidence interval: 2.84–10.30) increased the risk of LC. ConclusionsLCFH is a risk factor for LC and is increased with MF history, among never-smokers, younger adults, and those with maternal relatives with LC. Randomized controlled trials are needed to confirm the mortality benefit of LDCT screening in those with LCFH.

Analysis of traumatic intracranial hemorrhage and delayed traumatic intracranial hemorrhage in patients with isolated head injury on anticoagulation and antiplatelet therapy.

Anticoagulants and antiplatelet (ACAP) agents are increasingly and frequently used, especially in the elderly. The present study was carried out to assess the prevalence of delayed traumatic intracranial hemorrhage (dtICH) after a normal result on an initial head computed tomography (CT) in adults who were taking ACAP medication. The present retrospective included all adult patients who arrived in the emergency department between January 2017 and January 2021 with a history of fall from the patient's own height, while being on ACAP medication with an isolated head injury. The Institutional Review Board approved the study with a waiver of consent. The primary outcome measures were prevalence of dtICH in patients who had initial normal CT scan brain and were on ACAP medication. There were 2137 patients on ACAP medication, of which 1062 were male, and 1075 were of the female gender. The mean age of the patients was 82.1 years. About 8.2% had positive first CT scans (176/2137), while 0.023 (27/1149) had dtICH. The most common positive finding on the CT scan was subarachnoid hemorrhage followed by subdural hemorrhage. Male gender positively correlated with increased risk for first CT being positive (P = 0.033). Patient's with comorbidity of cirrhosis and chemotherapy had higher risk of dtICH (P = 0.47, 0.011). There was a very low (0.023%) prevalence of dtICH. Dual therapy or Coumadin therapy made up the majority of tICH. Cirrhosis and chemotherapy were associated with the risk of a repeat CT scan being positive with an initial CT scan negative.

The value of ventricular measurements in the prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

ObjectiveChronic hydrocephalus requiring shunt placement is a common complication of aneurysmal subarachnoid hemorrhage (SAH). Different risk factors and prediction scores for post-SAH shunt dependency have been evaluated so far. We analyzed the value of ventricle measurements for prediction of the need for shunt placement in SAH patients.MethodsEligible SAH cases treated between 01/2003 and 06/2016 were included. Initial computed tomography scans were reviewed to measure ventricle indices (bifrontal, bicaudate, Evans’, ventricular, Huckman’s, and third ventricle ratio). Previously introduced CHESS and SDASH scores for shunt dependency were calculated. Receiver operating characteristic analyses were performed for diagnostic accuracy of the ventricle indices and to identify the clinically relevant cut-offs.ResultsShunt placement followed in 221 (36.5%) of 606 patients. In univariate analyses, all ventricular indices were associated with shunting (all: p<0.0001). The area under the curve (AUC) ranged between 0.622 and 0.662. In multivariate analyses, only Huckman’s index was associated with shunt dependency (cut-off at ≥6.0cm, p<0.0001) independent of the CHESS score as baseline prediction model. A combined score (0–10 points) containing the CHESS score components (0–8 points) and Huckman’s index (+2 points) showed better diagnostic accuracy (AUC=0.751) than the CHESS (AUC=0.713) and SDASH (AUC=0.693) scores and the highest overall model quality (0.71 vs. 0.65 and 0.67), respectively.ConclusionsVentricle measurements are feasible for early prediction of shunt placement after SAH. The combined prediction model containing the CHESS score and Huckman’s index showed remarkable diagnostic accuracy regarding identification of SAH individuals requiring shunt placement. External validation of the presented combined CHESS-Huckman score is mandatory.

Inter-observer variability with five computed tomography severity scales for COVID-19 pneumonia assessment.

By the end 2019 there was an outbreak of pneumonia caused by a new coronavirus, a disease that was called coronavirus disease 2019 (COVID-19). Computed tomography (CT) has played an important role in the diagnosis of COVID-19 patients. To demonstrate inter-observer variability with five scales proposed for measuring the extent of COVID-19 pneumonia on tomography. Thirty five initial chest CT scans of patients who attended respiratory triage for suspected COVID-19 pneumonia were analyzed. Three radiologists classified the tomographic images according to the severity scales proposed by Yang (1), Yuan (2), Chun (3), Wang (4) and Instituto Nacional de Enfermedades Respiratorias-Chung-Pan (5). The percentage of agreement between the evaluators for each scale was calculated using the intra-class correlation index. In most patients were five pulmonary lobes compromised (77.1% of the patients). Scales 1, 2, 4 and 5 showed an intra-class correlation > 0.91 (p < 0.0001), with agreement thus being almost perfect. Scale 4 (proposed by Wang) showed the best inter-observer agreement, with a coefficient of 0.964 (p = 0.001).

Abstract Number ‐ 124: Spinal hemorrhage due to ruptured radicular artery aneurysm in patient with coarctation of the aorta

Introduction Spinal artery aneurysms associated with previously undiagnosed coarctation of the aorta in adults are exceptionally rare. Aortic coarctation often results in aberrant collateral circulation with hyperdynamic flow. Abundant and fragile collaterals provide favourable conditions for spinal artery aneurysm formation, growth and rupture. There are very few reports of spinal artery aneurysms associated with coarctation of the aorta in the literature, with even less describing current endovascular methods of their treatment. Management of such lesions is especially challenging due to aberrant anatomy and the presence of collaterals. We describe a case of a 67‐year old woman with a previously unrecognized coarctation of the aorta who presented a ruptured radicular artery aneurysm. The patient was treated with endovascular embolization using microcoils. Methods Case report. Results A 67‐year old female presented to the emergency room with severe bilateral lower extremity paresis. Patient’s history was significant of hypertension, ischemic heart disease, atrial fibrillation and a previous subarachnoid hemorrhage of an unknown cause. An initial computed tomography scan done at an outside hospital showed a spinal canal hemorrhage at the cervical level and was suspicious for vascular malformation of cervical spine. Diagnostic angiogram via radial approach revealed a previously undiagnosed coarctation of the aorta. The examination showed an extensive network of collaterals between both subclavian arteries and thoracic aorta. A spinal artery aneurysm was identified as the source of the hemorrhage. At the C7/Th1 level on the left side a dilated radicular artery providing collateral blood flow to the left subclavian artery was detected, with an irregularly shaped lobulated aneurysm (11×7 mm) on its course. The following day endovascular embolization of the aneurysm was performed. Both radial arteries were punctured. On the left side, a pigtail catheter was placed in the left subclavian artery, and on the right side, a 5F guiding catheter was placed in the left vertebral artery. A balloon catheter was introduced to the left vertebral artery and advanced to the branching point of the radicular artery with the aneurysm on its course. Functional test was performed and upon balloon inflation no neurological deterioration was observed. The radicular artery feeding the aneurysm was accessed with a microcatheter. Embolisation was performed and microcoils were deployed in the radicular artery proximal to the aneurysm site. A control angiogram via left subclavian showed retrograde inflow into radicular artery from which the anterior spinal artery branched off. Conclusions As our case demonstrates, spinal and radicular artery aneurysms induced by aortic coarctation are complex entities and pose a unique surgical and medical challenge. Treating the aneurysm should be prioritized in cases of subarachnoid hemorrhage. Transradial approach for interventional procedures can avoid anatomic restrictions posed by coarctation.

Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use.

Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.

Abstract Number ‐ 185: Variable Presentation of Basilar Occlusion: Lessons to be Learned

Introduction To present a case of basilar thrombosis with lessons for improving care. Methods Case presentation Results 89 year old Female with history of coronary artery disease with prior stenting brought in by ambulance for cardiac arrest. Patient last known normal 0900 per son. At 1100 patient called EMS for sudden onset nausea with projectile emesis. On arrival EMS staff noted patient to be walking and talking and administered zofran. After eight to ten minutes staff witnessed patient undergo cardiopulmonary arrest and initiated cardiac compressions. Return of spontaneous cardiac activity achieved after one dose of epinephrine and two minutes of compressions. In emergency department at 1132 patient moving extremities and following commands but intubated for encephalopathy and hypoxia. Computed Tomography (CT) head without contrast performed at 1222 showed hypodensity in left occipital lobe and left cerebellum suspicious for infarct. Neurology consulted routinely and National Institute of Health Stroke Scale (NIHSS) 21. Stat CT angiography of head and neck completed at 1657 and showed complete occlusion of basilar artery from origin to terminus. Patient evaluated by neurology fellow and found to be unresponsive with decerebrate posturing, NIHSS maximal; Neurosurgery service was paged at 1659 for stat evaluation. Patient arrived at cath lab at 1949 and thrombectomy performed with TICI 2b. Magnetic Resonance Imaging of brain performed next day at 432 showed diffuse diffusion restriction and T2 signal in bilateral occipital lobes, temporal lobes and thalami, throughout midbrain and pons consistent with acute/subacute infarct. Patient was transitioned to comfort care and extubated. Conclusions Acute basilar occlusion is recognized as a potentially treatable condition if diagnosed quickly. Outcomes of these infarcts remain poor but recent evidence from ATTENTION and BOAChE studies has shown that treatment by emergent thrombectomy provides for better outcomes than medical management alone despite higher risk of intracranial hemorrhage and that these benefits can be seen after 12 to 24 hours from symptom onset(1,2). This particular case is unique not only due to the rarity of stroke presenting as intractable emesis but also in its illustration of diagnostic pitfalls of posterior circulation (3,4). In order to provide appropriate treatment, recognition of abnormal presentation of basilar thrombosis becomes increasingly important. Paul et al identified isolated vertigo, vertigo with non‐focal symptoms, isolated double vision, transient generalized weakness, and binocular visual disturbance as significant transient symptoms preceding basilar occlusion (5). Savitz and Caplan report, “most common signs are limb weakness, gait and limb ataxia, oculomotor palsies, and oropharyngeal dysfunction” but also note that vomiting, vertigo, visual loss, numbness can also occur (6). Additionally this patient initial CT scan showed possible stroke but did not identify vessel occlusion. Developments in artificial intelligence are working towards identifying large vessel occlusion on plain noncontrast CT which would have benefitted this patient.

Neutrophil lymphocyte ratio (NLR) and systemic immune inflammatory index (SII) for the differential diagnosis of CT-negative mild acute ischemic stroke and transient ischemic attack

Background: A number of acute ischemic stroke (AIS) cases may be misdiagnosed as transient ischemic attack (TIA), due to no infarct on initial computed tomography scan and/or mild deficits upon presentation. Several studies have found that the neutrophil–lymphocyte ratio (NLR) is an accurate differential diagnostic biomarker for AIS versus TIA; however, no study has evaluated the use of the NLR in differentiating CT negative AIS from TIA. Furthermore, the systemic immune-inflammation index (SII) is a relatively novel immune biomarker that has been shown to be positively correlated with AIS severity, poor functional outcomes and mortality. The purpose of this study is to determine if NLR or SII can be used as a diagnostic biomarker for the differential diagnosis of mild AIS with a negative CT upon admission and TIA. Methods: We performed a retrospective medical record review of patients diagnosed with either AIS or TIA. We collected peripheral white blood cell counts within 24 h of symptom onset and calculated the NLR and SII. Logistic regression was utilized to determine if NLR or SII are significant predictors of CT negative mild AIS. Results: CT negative mild AIS patients were 2 times as likely to have an NLR ≥ 2.71 compared to TIA patients, and CT negative mild AIS patients were 2.1 times as likely to have an SII ≥ 595 compared to TIA patients. Conclusion: NLR and SII are easily obtained biomarkers that can be used in early clinical decision making in cases of mild AIS with negative CT scan upon admission.

Timing of operation for poor-grade aneurysmal subarachnoid hemorrhage: Relationship with delayed cerebral ischemia and poor prognosis.

To assess differences in the clinical prognosis between different treatment timings in poor-grade (Hunt and Hess grade 4-5) aneurysmal subarachnoid hemorrhage patients. The treated 127 poor-grade aneurysmal subarachnoid hemorrhage patients were divided into three groups: early treatment within 2 days, treatment on days 3 to 10, and treatment for more than 10 days after the hemorrhage. Odd ratios with a 95% confidence interval were calculated in logistic regression for different timing strategies regarding delayed cerebral ischemia and poor prognosis at 3 months. Subgroup analyses were conducted to determine whether the different timing strategies affect the prognosis. Patients who received the treatment on days 3 to 10 were prone to develop delayed cerebral ischemia and poor prognosis at 3 months. Postponing treatment in patients older than 55 years or diagnosed with an intraventricular hematoma on the initial computed tomography scan may lead to poor prognosis, with the early intervention group as a reference. Early intervention in poor-grade aneurysmal subarachnoid hemorrhage is suggested to be implemented. The treatment on 3 to 10 days harbored the highest risk of poor prognosis; patients might benefit more from early intervention, especially for ones older than 55 years or diagnosed with an intraventricular hematoma.

Applicability of the Edinburgh CT Criteria for Lobar Intracerebral Hemorrhage Associated with Cerebral Amyloid Angiopathy.

Based on histopathology, Edinburgh diagnostic criteria were proposed to consider anontraumatic intracerebral lobar hemorrhage (ICH) as related to cerebral amyloid angiopathy (CAA) using the initial computed tomography (CT) scan and the APOE genetic status. We aimed to externally validate the Edinburgh prediction model, excluding the APOE genotyping and based on the modified Boston criteria on the MRI for CAA diagnosis METHODS: We included patients admitted for spontaneous lobar ICH in the emergency department between 2016 and 2019 who underwent noncontrast CT scan and MRI. According to the MRI, patients were classified into the CAA group or into the non-CAA group in the case of other causes of ICH. Two neuroradiologists, blinded to the final retained diagnosis, rated each radiological feature on initial CT scan described in the Edinburgh study on initial CT scan RESULTS: A total of 102 patients were included, of whom 36were classified in the CAA group, 46in the non-CAA causes group and 20of undetermined cause (excluded from the primary analysis). The Edinburgh prediction model, including finger-like projections and subarachnoid extension showed an area under receiver operating characteristic curves (AUC) of 0.760 (95% confidence interval, CI: 0.660-0.859) for the diagnosis of CAA. The AUC reached 0.808 (95%CI: 0.714-0.901) in anew prediction model integrating athird radiologic variable: the ICH cortical involvement. Using the Boston MRI criteria as afinal assessment, we provided anew external confirmation of the radiological Edinburgh CT criteria, which are directly applicable in acute settings of spontaneous lobar ICH and further proposed an original 3‑set model considering finger-like projections, subarachnoid extension, and cortical involvement that may achieve ahigh discrimination performance.

The location of intraparenchymal bleeding determines functional outcome after spontaneous subarachnoid hemorrhage.

Non-traumatic subarachnoid hemorrhage (SAH) is a devastating disease associated with high morbidity and mortality. A higher blood burden and the presence of intraparenchymal extension of the bleeding (intracerebral hemorrhage [ICH]) are well known predictors of poor outcome. Only few studies have addressed the role of hematoma location on patient's functional outcome. The main aims were to compare clinical and radiographic characteristics between SAH patients with and without ICH and to compare different ICH localizations in relation to long-term functional outcome. We prospectively collected data on 280 consecutive SAH patients (aneurysmal and non-aneurysmal) admitted to a tertiary care hospital between 2010 and 2017 and assessed the initial computed tomography scans of the brain acquired after intensive care unit admission. Poor functional outcome was defined as a modified Rankin Scale score >2, 3 months after SAH. We used multivariable logistic linear regression to investigate associations between ICH location and clinical variables as well as functional outcome. Intraparenchymal extension of the hemorrhage was observed in 59/280 patients (21%). The median (interquartile range) ICH volume was 11.3 (4.9-16.2) ml and the location was supratentorial in 55/59 patients (93%). Most parenchymal hemorrhages were located in the frontal (n=24.41%) and temporal lobes (n=12.21%), followed by insular ICH (n=7.12%), corpus callosum (n=6.10%), parietal (n=2.3%) and occipital locations (n=2.3%). Among SAH patients with ICH, those with lesions located in the corpus callosum (n=6/59) had a significantly higher risk of 3-month poor functional outcome in comparison to all other ICH locations, even after adjusting for Hunt and Hess grade and age (adjusted odds ratio [adjOR] 50.5, 95% confidence interval [CI] 1.3-2004.2, p=0.034). These results remained robust when comparing the whole SAH cohort (adjOR 21.7, 95% CI 1.4-347.8, p=0.030). CONCLUSIONS: Intraparenchymal bleeding in patients with non-traumatic SAH, in particular that involving the corpus callosum, strongly predicts functional outcome.

Appendiceal Mucinous Tumor Presenting as Recurrent Bowel Obstruction.

Appendiceal mucinous tumors are rare, with variable malignant potential, and they are usually found incidentally. Clinical symptoms are nonspecific. Rarely, appendiceal mucinous neoplasm causes bowel obstruction and makes diagnosis more difficult. We present a case of an 84-year-old female who came to our emergency department having had abdominal fullness and constipation for 5 days. Ileus, due to an affected adhesion band, was diagnosed initially, and symptoms improved gradually under conservative treatment. However, 3 months later she presented to the emergency department again with abdominal pain and distension; small bowel obstruction due to adhesion was again diagnosed. Recurrent bowel obstruction prompted emergent surgery. Operative findings showed a whitish appendiceal tumor adhering to and directly invading the adjacent ileum, with a segment of herniated small bowel wedged in between, causing the obstruction. Upon reviewing the initial computed tomography scan, the dilated tubular structure of appendiceal tumor was misrecognized as small bowel loop; there was no surrounding inflammatory sign, leading to diagnosis difficulty. Instead of a common cause of bowel obstruction, such as adhesion band, this case revealed bowel obstruction can be caused by the direct invasion of an appendiceal tumor. Awareness of this condition with careful image evaluation of small bowel obstruction is essential for diagnosis.

Diaphragmatic Injuries among Severely Injured Patients (ISS ≥ 16)-An Indicator of Injury Pattern and Severity of Abdominal Trauma.

Background and Objectives: Abdominal trauma among severely injured patients with an injury severity score (ISS) of 16 and above can lead to potentially life-threatening injuries that might need immediate surgical intervention. Traumatic injuries to the diaphragm (TID) are a challenging condition often accompanied by other injuries in the thoracoabdominal region. Materials and Methods: We retrospectively analyzed the occurrence and clinical course of TID among severely injured patients treated at our center between 2008 and 2019 and compared them to other groups of severely injured patients without TID. Results: Thirty-five patients with TID and a median ISS of 41 were treated in the period mentioned above. They were predominantly middle-aged men and mostly victims of blunt trauma as a consequence of motor vehicle accidents. A total of 70.6% had left-sided TID, and in 69.6%, the size of defect was larger than 10 cm. The diagnosis was made with computed tomography (CT) in 68.6% of the cases, while in 25.8%, it was made intraoperatively or delayed by a false-negative initial CT scan, and in 5.7%, an intraoperative diagnosis was made without preoperative CT imaging. Surgical repair was mostly conducted via laparotomy, performing a direct closure with continuous suture. A comparison to 191 patients that required laparotomy for abdominal injuries other than TID revealed significantly higher rates of concomitant injuries to several abdominal organs among patients suffering from TID. Compared to all other severely injured patients treated in the same period (n = 1377), patients suffering from TID had a significantly higher median ISS and a longer mean duration of hospital stay. Conclusions: Our findings show that TID can be seen as an indicator of particularly severe thoracoabdominal trauma that requires increased attention from the treatment team so as not to miss relevant concomitant injuries that require immediate intervention.

Spontaneous pneumorrachia: a rare cause of thunderclap headache

Objective To present a rare cause of thunderclap headache Case presentation Female patient, 39 years old, was admitted to the emergency department of a private hospital in the city of São Paulo, after a sudden and explosive headache followed by two episodes of syncope and motor deficit in the left upper limb. Neurological examination showed weakness of the left upper limb without sensitive impairment. She had previous history of bipolar affective disorder, chronic anemia, and overweight with previous bariatric surgery. The patient was submitted to computed tomography (CT), arterial angiotomography of the skull and cervical neck, which showed rare small gaseous foci in the perivertebral soft tissues and extradural site on the left side in the craniovertebral transition, near the foramen magnum. Small foci of pneumocephalus were found in the posterior fossa, near the left sphenopetrous fissure. Electroneuromyography (ENMG) of four limbs and brain and cervical magnetic resonance imaging (MRI) were performed 48 hours after initial CT scan. ENMG was normal and MRI showed no more expression of the changes described on CT. She was treated with analgesia and was discharged with full reversion of initial symptoms. Conclusion Spontaneous pneumorrhachia is rare disease and is characterized by the presence of air in the spinal canal, both in the intradural and extradural compartments. It is usually benign with spontaneous resolution. Our patient was included in a stroke investigation protocol, due to the thunderclap headache and focal motor deficit. CT revealed the diagnosis. The cervical CT that was performed in the context of cervical CT angiography of the stroke protocol allowed the correct diagnosis. Key-words: Thunderclap headache, Spontaneous Pneumorrhachia, Cervical Computed Tomography Angiography.

Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial

ObjectiveTo assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease.DesignProspective, multicentre, randomised...

ABCL-242 Definition of Bulky Disease in Early-Stage Diffuse Large B-Cell Lymphoma on Longitudinal and Axial Planes

In early-stage diffuse large B-cell lymphoma (DLBCL), tumor bulkiness and stage-adjusted International Prognostic Index (sa-IPI) are the main determinants of treatment and prognosis. Bulky disease is variably defined from 5 to 10 cm. The aim of our study is to investigate the prognostic significance of bulky disease measured on longitudinal and axial planes on computed tomography (CT) imaging. Medical records of patients diagnosed with early-stage DLBCL and treated in King Hussein Cancer Center were reviewed. Maximal longitudinal and axial planes on initial CT scans were reviewed by two radiologists; sa-IPI was calculated as previously described. Correlation between tumor dimensions and relapse-free survival (RFS) and overall survival (OS) was done using the Pearson correlation test. Survival analyses were performed using the Kaplan-Meier method. A total of 127 patients were included with a median age of 47 years. Fifty-one (40.2%) patients were having extranodal involvement, and sa-IPI was 0-1 in 73 (57.4%). Eighty-two (64.6%) patients were treated with combined modality treatment (RCHOP followed by radiotherapy), and the remaining were treated with RCHOP only. A cut-off of 5 cm correlated with RFS in both the longitudinal and axial dimensions and was used to define bulky disease. Seventy-eight (61.5%) patients with bulky disease in either dimension had 3-year RFS of 76.4% versus 95.4% for patients with non-bulky disease (P=0.0045) and 3-year OS of 71.8% versus 93.2% (P=0.0043), respectively. On multivariate analysis, bulky disease (P=0.028) and sa-IPI >1 (P=0.044) were significantly associated with RFS, whereas OS significantly correlated with sa-IPI >1 (P=0.014). In patients with bulky disease, the use of combined modality treatment resulted in better RFS (62.9% vs. 83.3%, P=0.0157) and OS (81.6% vs. 52.1%, P=0.0042). Tumor bulk of more than 5 cm in the longitudinal or axial dimensions on CT scan should be considered in treatment decisions of patients with early-stage DLBCL, including the use of consolidative radiotherapy. More studies are needed to define the best treatment approach in such patients.

Temporal Changes in Subcutaneous Fibrosis in Patients with Lower Extremity Lymphedema Following Surgery for Gynecologic Cancer: A Computed Tomography-Based Quantitative Analysis.

Lymphedema causes inflammation, which provokes fibrosis within the epifascial tissue. Temporal change in fibrosis according to severity of the lymphedema has not been widely investigated. We aimed to study the quantitative changes in epifascial fibrosis during lymphedema treatment using computed tomography (CT). Forty-five patients (mean age: 57.75 ± 11.12 years) who developed lymphedema following gynecologic surgery were included in this retrospective study. Two weeks of complete decongestive therapy and continued self-bandaging or compression garments were prescribed under regular follow-up monitoring. Lower-extremity epifascial fibrosis was quantitatively analyzed on the initial and follow-up CT scans. Circumference, skin fibrosis, subcutaneous tissue, and fibrosis ratio were calculated in the axial scan. Based on the change in lymphedema severity, we divided subjects into ‘improved’ and ‘aggravated’ groups. The affected lower extremities showed higher circumference, more skin fibrosis and subcutaneous tissue, and higher fibrosis ratio than the unaffected sides on initial CT scan. At follow-up, compared to the aggravated group, the improved group showed significant decreases in fibrosis of skin and subcutaneous tissue and fibrosis ratio. Subcutaneous fibrosis was reversible with volume resolution of lymphedema. Therapeutic approaches should be established on the basis of the reversible nature of fibrotic changes in patients with lower extremity lymphedema.