Native CT Research Articles

MR Imaging for Acute Stroke

Cerebral imaging is essential to differentiate the pathologies behind acute stroke. Excluding hemorrhage with a native CT is a prerequisite before thrombolytic drugs can be administered. With stroke MRI, vessel occlusion, ischemia and infarction can be visualized. This detailed diagnostic information can facilitate the decision for or against thrombolysis. Analysis of FLAIR and diffusion-weighted images enables the identification of patients in an early time window after ictus and is currently used in randomized trials of wake-up stroke.

A Rare Case of Subtentorial Arterio-Venous Malformation Case Report

Summary The majority - over 80%, of arteriovenous malformations (AVMs) are supratentorial. The infratentorial AVM are uncommon and different from other intracranial AVMs in terms of history, diagnosis, treatment, prognosis, and follow up. The authors present a case of an intracranial hemorrhage, caused by rupture of an AVM in the posterior cranial fossa. Native (unenhanced) CT and computed tomography angiography (CTA) images of this rare location of AVM are presented.

Value of Transcranial Doppler, Perfusion-CT and Neurological Evaluation to Forecast Secondary Ischemia after Aneurysmal SAH

This study was conducted to prospectively evaluate the diagnostic value of detailed neurological evaluation, transcranial Doppler sonography (TCD) and Perfusion-CT (PCT) to predict delayed vasospasm (DV) and delayed cerebral infarction (DCI) within the following 3 days in patients with aneurysmal subarachnoid hemorrhage (SAH). A total of 61 patients with aneurysmal SAH were included in the study. All patients were amenable for neurological evaluation throughout the critical phase to develop secondary ischemia after SAH. The neurological status was assessed three times a day according to a detailed examination protocol. Mean flow velocities (MFV) in intracranial vessel trunks were measured daily by TCD. Native CT and PCT were routinely acquired at 3-day intervals and, in addition, whenever it was thought to be of diagnostic relevance. The predictive values of abnormal PCT and accelerations in TCD (MFV > 140 cm/s) to detect angiographic DV and DCI within the following 2 days were calculated and compared to the predictive value of delayed ischemic neurological deficits (DIND). The accuracy of TCD and PCT to predict DV or DCI was 0.65 and 0.63, respectively. In comparison, DIND predicted DV or DCI with an accuracy of 0.96. Pathological PCT findings had a higher sensitivity (0.93) and negative predictive value (0.98) than TCD (0.81 and 0.96). Neurological assessment at close intervals is the most accurate parameter to detect DV and DCI in the following 3 days. However, DIND may not be reversible. The routine acquisition of PCT in addition to daily TCD examinations seems reasonable, particularly in patients who are not amenable to a detailed neurological examination since it has a higher sensitivity and negative predictive value than TCD and leaves a lower number of undetected cases of vasospasm and infarction.

Cardiac conduction and rhythm disturbances in a patient with postinfectious polyradiculoneuritis and unilateral diaphragmatic paralysis

Introduction: Autonomic dysfunction, ranging from labile blood pressure to life-threatening cardiac conduction and rhythm disturbances, can result as a consequence of postinfectious polyradiculoneuritis. Case report description: We report the case of a 57-year-old male admitted to our hospital for intense dyspnoea and chest pain when changing to supine position. The symptoms installed four months previously, following an episode of acute pneumopathy. At that moment he was diagnosed with left diaphragmatic paralysis, the native cranian and cervico-thoracic CT scan was normal and any chronic autoimmune disease was ruled out. In the supine position, we found an intensely dyspnoeic patient, the ECG showing progressive bradycardia, sinus arrest and episodes of accelerated idioventricular rhythm. With any change in body position the symptoms and the conduction abnormalities disappeared and the heart rate stabilized at 120 beats/min. The neurologic examination showed signs of C7-T11 left and T6-T8 right polyradiculitis, associated with left brachial plexitis and a secondary myasthenic syndrome. Although the patient presented months after the onset of symptoms, treatment with dexamethasone was initiated and continued for a month with significant symptomatic and electromyographic improvement. Following therapy, the Holter ECG control monitoring showed no further cardiac conduction or rhythm disturbances, as a result the electrophysiology team deciding there was no need for the insertion of a permanent cardiac pacemaker. The patient had several episodes of symptomatic exacerbations over the following year that responded each time to cortisonic treatment. Discussion: Autonomic dysfunction represents a severe, but usually transient complication of postinfectious polyradiculoneuritis. Serious bradyarrhythmias result from either an under activity of the sympathetic pathways or an excessive activity of the parasympathetic ones. The peculiarity of the case reported consists in the presence of the cardiac conduction and rhythm disturbances only in relation to the supine position. The anomaly can be explained as a consequence of the left diaphragmatic paralysis and may be caused by two mechanisms: the compression of the vegetative cardiac plexuses at the base of the heart and the upward traction of the celiac plexus by the elevated diaphragm, leading to parasympathetic stimulation. Conclusion: Cardiac autonomic impairment can be a complicating factor in postinfectious polyradiculoneuritis. Careful monitoring of these patients by a team formed by cardiology, electrophysiology and neurology specialists is mandatory.

Intraindividual Evaluation of the Influence of Iterative Reconstruction and Filter Kernel on Subjective and Objective Image Quality in Computed Tomography of the Brain

To intraindividually evaluate the potential of 4th generation iterative reconstruction (IR) on brain CT with regard to subjective and objective image quality. 31 consecutive raw data sets of clinical routine native sequential brain CT scans were reconstructed with IR level 0 (= filtered back projection), 1, 3 and 4; 3 different brain filter kernels (smooth/standard/sharp) were applied respectively. Five independent radiologists with different levels of experience performed subjective image rating. Detailed ROI analysis of image contrast and noise was performed. Statistical analysis was carried out by applying a random intercept model. Subjective scores for the smooth and the standard kernels were best at low IR levels, but both, in particular the smooth kernel, scored inferior with an increasing IR level. The sharp kernel scored lowest at IR 0, while the scores substantially increased at high IR levels, reaching significantly best scores at IR 4. Objective measurements revealed an overall increase in contrast-to-noise ratio at higher IR levels, which was highest when applying the soft filter kernel. The absolute grey-white contrast decreased with an increasing IR level and was highest when applying the sharp filter kernel. All subjective effects were independent of the raters' experience and the patients' age and sex. Different combinations of IR level and filter kernel substantially influence subjective and objective image quality of brain CT.

Application of a Novel Metal Artifact Correction Algorithm in Flat-Panel CT After Coil Embolization of Brain Aneurysms: Intraindividual Comparison

To evaluate a novel algorithm for correcting beam hardening artifacts caused by metal implants in computed tomography performed on a C-arm angiography system equipped with a flat panel (FP-CT). 16 datasets of cerebral FP-CT acquisitions after coil embolization of brain aneurysms in the context of acute subarachnoid hemorrhage have been reconstructed by applying a soft tissue kernel with and without a novel reconstruction filter for metal artifact correction. Image reading was performed in multiplanar reformations (MPR) in average mode on a dedicated radiological workplace in comparison to the preinterventional native multisection CT (MS-CT) scan serving as the anatomic gold standard. Two independent radiologists performed image scoring following a defined scale in direct comparison of the image data with and without artifact correction. For statistical analysis, a random intercept model was calculated. The inter-rater agreement was very high (ICC = 86.3 %). The soft tissue image quality and visualization of the CSF spaces at the level of the implants was substantially improved. The additional metal artifact correction algorithm did not induce impairment of the subjective image quality in any other brain regions. Adding metal artifact correction to FP-CT in an acute postinterventional setting helps to visualize the close vicinity of the aneurysm at a generally consistent image quality.

Low dose dual-energy computed tomography in suspected body packers and body stuffers—Preliminary clinical experience

Background The detectability of drug packages with abdominal plain film radiography is limited by sophisticated packaging methods and overlying stool, organs and bones. The aim of this study was to investigate the accuracy and practicability of dual-energy CT in body packers and stuffers, and the discernibility of cocaine from heroine. Materials and methods From May to December 2012 two suspected body packers and six suspected body stuffers (mean age of 30 years, range 20–43 years) were referred to our institution. A low dose native dual-energy CT of the abdomen and pelvis was performed in each case with tube currents of 14 mA s at 140 kV and 72 mA s at 80 kV. The data sets were reviewed for drug packages in a soft tissue and bone window as well as on color-encoded reformations of the dual energy index (DEI). Three-dimensional renderings of the DEI (cocaine material in green, heroine material in red) were produced to demonstrate findings to the police. Results In two body packers and three body stuffers an average of five drug packages were detected (range 1–11) with a mean size of 19 mm (range 9–39 mm). The mean attenuation of the packages was 151 HU (range 93–215 HU) at 80 kVp with an average decrease in attenuation of −92 HU (range −27 to −139 HU) at 140 kVp, suspicious of cocaine content in all cases. These results have been confirmed by chemical analysis of the defecated drug packages. The mean effective dose was 2.1 mSv (range 1.9–2.2 mSv), comparable to abdominal plain film radiographs with a typical effective dose of 1.3 mSv. Conclusion Dual-energy CT is a promising novel technique in detecting and characterizing drug packages in suspected body packers and stuffers. As most of these traffickers are of young age, the application of a low dose protocol is essential to limit the harm of ionizing irradiation.

Calcifications of vertebrobasilar arteries on CT: detailed distribution and relation to risk factors in 245 ischemic stroke patients.

Introduction. Intracranial atherosclerosis is responsible for a substantial proportion of strokes worldwide but its detailed morphology in the vertebrobasilar arteries (VBA) is unknown. Subject and Methods. Cases with ischemic strokes were retrospectively sought from the hospital database. Native CT scans were assessed for vessel area and intracranial artery calcifications (ICACs) in VBA. The calcifications were classified as focal (FCs), crescent, and circular. Results. 245 patients (mean age: 77.1 ± 10.2 years, 57.6% females) had visible ICACs. Calcifications were found in 75.9%, 63.3%, and 17.1% in the left vertebral artery (LVA), the right vertebral artery (RVA), and the basilar artery (BA), respectively. FCs were present in 91.0%, 90.3%, and 100.0%; crescents in 30.3%, 29.0%, and 7.1%, and circulars in 6.4%, 4.8%, and 0.0% of the RVA, LVA, and BA, respectively. FCs in dorsolateral quadrant were least prevalent in both vertebral arteries (VAs): 46 (29.8%) and 46 (27.4%) for RVA and LVA, respectively. Risk factors associated with vertical dispersion of ICACs were male gender (OR : 2.69, 1.38–5.28) and diabetes (OR : 2.28, 1.04–4.99). Conclusions. FCs in VAs are least prevalent in dorsolateral quadrants. The vertical dispersion of ICACs seems to be associated with the male gender and diabetes.

Diagnostic value of lipopolysaccharide-binding protein and procalcitonin for sepsis diagnosis in forensic pathology

The aims of this study were twofold. The first was to investigate the diagnostic performance of two biochemical markers, procalcitonin (PCT) and lipopolysaccharide-binding protein (LBP), considering each individually and then combined, for the postmortem diagnosis of sepsis. We also tested the usefulness of pericardial fluid for postmortem LBP determination. Two study groups were formed, a sepsis-related fatalities group of 12 cases and a control group of 30 cases. Postmortem native CT scans, autopsy, histology, neuropathology, and toxicology as well as other postmortem biochemical investigations were performed in all cases. Microbiological investigations were also carried out in the septic group. Postmortem serum PCT and LBP levels differed between the two groups. Both biomarkers, individually considered, allowed septic states to be diagnosed, whereas increases in both postmortem serum PCT and LBP levels were only observed in cases of sepsis. Similarly, normal PCT and LBP values in postmortem serum were identified only in non-septic cases. Pericardial fluid LBP levels do not correlate with the presence of underlying septic states. No relationship was observed between postmortem serum and pericardial fluid LBP levels in either septic or non-septic groups, or between pericardial fluid PCT and LBP levels.

Surgical interventions with fatal outcome: Utility of multi-phase postmortem CT angiography

Cases of fatal outcome after surgical intervention are autopsied to determine the cause of death and to investigate whether medical error caused or contributed to the death. For medico-legal purposes, it is imperative that autopsy findings are documented clearly. Modern imaging techniques such as multi-detector computed tomography (MDCT) and postmortem CT angiography, which is used for vascular system imaging, are useful tools for determining cause of death. The aim of this study was to determine the utility of postmortem CT angiography for the medico-legal death investigation.This study investigated 10 medico-legal cases with a fatal outcome after surgical intervention using multi-phase postmortem whole body CT angiography. A native CT scan was performed as well as three angiographic phases (arterial, venous, and dynamic) using a Virtangio® perfusion device and the oily contrast agent, Angiofil®. The results of conventional autopsy were compared to those from the radiological investigations. We also investigated whether the radiological findings affected the final interpretation of cause-of-death.Causes of death were hemorrhagic shock, intracerebral hemorrhage, septic shock, and a combination of hemorrhage and blood aspiration. The diagnoses were made by conventional autopsy as well as by postmortem CT angiography. Hemorrhage played an important role in eight of ten cases. The radiological exam revealed the exact source of bleeding in seven of the eight cases, whereas conventional autopsy localized the source of bleeding only generally in five of the seven cases. In one case, neither conventional autopsy nor CT angiography identified the source of hemorrhage.We conclude that postmortem CT angiography is extremely useful for investigating deaths following surgical interventions. This technique helps document autopsy findings and allows a second examination if it is needed; specifically, it detects and visualizes the sources of hemorrhages in detail, which is often of particular interest in such cases.

Procalcitonin and C-reactive protein in pericardial fluid for postmortem diagnosis of sepsis

The aim of this study was to investigate the presence and concentrations of procalcitonin and C-reactive protein in pericardial fluid and compare these levels to those found in the postmortem serum obtained from the femoral blood. Two groups were formed, a sepsis-related fatalities group and a control group. Postmortem native CT scans, autopsies, histology, neuropathology and toxicology as well as other postmortem biochemistry investigations were performed in all cases. Pericardial fluid procalcitonin levels were significantly different between the cases of sepsis-related fatalities and those of the control group. Postmortem serum procalcitonin levels below the detection limit were also reflected in undetectable pericardial fluid levels. Similarly, a large increase in postmortem serum procalcitonin levels was reflected in a large increase of procalcitonin pericardial fluid levels. Based on these findings, pericardial fluid could be an alternative to postmortem serum for the determination of procalcitonin levels in cases where postmortem serum is not available and measurements of procalcitonin are required to circumstantiate the pathogenesis of death.

Is the formula of Traub still up to date in antemortem blood glucose level estimation?

According to the hypothesis of Traub, also known as the 'formula of Traub', postmortem values of glucose and lactate found in the cerebrospinal fluid or vitreous humor are considered indicators of antemortem blood glucose levels. However, because the lactate concentration increases in the vitreous and cerebrospinal fluid after death, some authors postulated that using the sum value to estimate antemortem blood glucose levels could lead to an overestimation of the cases of glucose metabolic disorders with fatal outcomes, such as diabetic ketoacidosis. The aim of our study, performed on 470 consecutive forensic cases, was to ascertain the advantages of the sum value to estimate antemortem blood glucose concentrations and, consequently, to rule out fatal diabetic ketoacidosis as the cause of death. Other biochemical parameters, such as blood 3-beta-hydroxybutyrate, acetoacetate, acetone, glycated haemoglobin and urine glucose levels, were also determined. In addition, postmortem native CT scan, autopsy, histology, neuropathology and toxicology were performed to confirm diabetic ketoacidosis as the cause of death. According to our results, the sum value does not add any further information for the estimation of antemortem blood glucose concentration. The vitreous glucose concentration appears to be the most reliable marker to estimate antemortem hyperglycaemia and, along with the determination of other biochemical markers (such as blood acetone and 3-beta-hydroxybutyrate, urine glucose and glycated haemoglobin), to confirm diabetic ketoacidosis as the cause of death.

Differential diagnostics of adrenal incidentalomas

We have analysed the results of radiological investigations (USI, CT, and MRT) involving 177 patients given surgical treatment at the Endocrinological Research Centre during 2006-2010. In addition, the study included measurement of cortisol levels in the dexamethasone suppression test, fractionated metanephrins, and the relationship between aldosterone levels and plasma rennin activity (in the patients presenting with arterial hypertension). Twenty two patients underwent tumour puncture. Seventy six (55.9%) of the 136 patients having incidentalomas were found to have no indications for the surgical intervention (because of the absence of hormonal activity and low malignancy potential of the neoplasm). The follow-up period averaged 24.9±19 months. The choice of indications for the surgical treatment should be based on the results of standardized hormonal studies and the determination of malignancy potential using the native CT density above 20 UH as the principal criterion. Differential diagnostics by USI, MRT, and descriptive CT is believed to be inadequate. USI may be applied as a highly specific method for the detection of cysts and myelolopomas. Native CT density should be taken into consideration for the interpretation of the results of fractionated metanephrin measurements. Diagnosis of pheochromocytoma is very unlikely in the patients presenting with low CT density. Puncture biopsy is indicated only when the presence of metastases in the adrenal glands is suspected.

Prediction of Malignant Middle Cerebral Artery Infarction Using Computed Tomography-Based Intracranial Volume Reserve Measurements

Early decompressive surgery in patients with malignant middle cerebral artery (MCA) infarction improves outcome. Elevation of intracranial pressure depends on both the space occupying brain edema and the intracranial volume reserve (cerebrospinal fluid [CSF]). However, CSF volume was not investigated as a predictor of malignant infarction so far. We hypothesize that assessment of CSF volume in addition to admission infarct size improves early prediction of malignant MCA infarction. Stroke patients with carotid-T or MCA main stem occlusion and ischemic lesion (reduced cerebral blood volume [CBV]) on perfusion CT were considered for the analysis. The end point malignant MCA infarction was defined by clinical signs of herniation. Volumes of CSF and CBV lesion were determined on admission. Receiver-operator characteristics analysis was used to calculate predictive values for radiological and clinical measurements. Of 52 patients included, 26 (50%) developed malignant MCA infarction. Age, a decreased level of consciousness on admission, CBV lesion volume, CSF volume, and the ratio of CBV lesion volume to CSF volume were significantly different between malignant and nonmalignant groups. The best predictor of a malignant course was the ratio of CBV lesion volume to CSF volume with a cut-off value of 0.92 (96.2% sensitivity, 96.2% specificity, 96.2% positive predictive value, and 96.2% negative predictive value). Based on admission native CT and perfusion CT measurements, the ratio of ischemic lesion volume to CSF volume predicts the development of malignant MCA infarction with higher accuracy than other known predictors, including ischemic lesion volume or clinical characteristics.

Is contrast enhancement required to visualize a known breast tumor in a pre-operative CT scan?

Background and purposeA pre-operative CT scan with contrast enhancement (CE) has recently been proposed to improve tumorbed delineation in breast conserving therapy. However, it is not clear whether CE is required for visualization of a known breast tumor. The main aims of this study were to compare the sensitivity of a CE-CT scan with a native CT scan (i.e. without CE) and to identify characteristics predictive for the requirement of CE. Patients and methodsBoth a CE-CT and a native CT were made in 58 breast cancer patients (age 37–75yr), prior to breast conserving surgery. Visibility of the tumor on CT was scored by three observers (clearly visible/doubtful/not visible). Age, tumor size, palpable tumor yes/no, histology, and visibility on mammography were analyzed with respect to the visibility of the tumor on the native CT. ResultsThe sensitivity for tumor detection was better for CE-CT (95%) than for native CT (83%) (p<0.001). Only mammographic visibility scores appeared to be significantly correlated with the visibility of the tumor on the native CT (p=0.013). ConclusionIn most patients CE is not required to visualize a known breast tumor. Mammographic visibility is a good parameter to decide on the use of CE.

Assessment of Calcified Carotid Plaque Volume: Comparison of Contrast-Enhanced Dual-Energy CT Angiography and Native Single-Energy CT

The purpose of this study was to compare estimates of calcified plaque volume in the carotid arteries based on contrast-enhanced dual-energy CT angiograms with volume estimates based on native CT scans. Detection of hard plaque in the carotid arteries with dual-energy CT angiography was successful in all patients. Estimates of calcified plaque volume based on dual-energy CT angiograms correlated well with those based on native single-energy CT scans but at a lower attenuation threshold (130 HU as opposed to 180 HU) were underestimates compared with those on the native CT scans.

Une lésion laryngée létale

We reported the results of post mortem computed tomography of the liver in 27 subjects dead simultaneously during a flood. The aim of our work was to identify the different patterns of post mortem intrahepatic gas distribution and the timing of its appearance. Although post mortem CT is the method of choice for the evaluation of gas distribution, controversies exist about the first site of appearance of intrahepatic gas (portal veins versus hepatic veins) as well as the timing and steps of intrahepatic gas spreading. In each subject we performed thin slice CT scanner (Somatom Definition, Siemens) and post processing of native CT images with Minimum Intensity Projection technique.Our results show that the first site of appearance of intrahepatic gas is portal veins. Gas in hepatic veins was never seen without the presence of the gas in portal vein. Gaseous cysts in hepatic parenchyma represent a further and usually more tardive pattern of intrahepatic gas distribution.In addition, we demonstrated that differences in timing of gas spreading was statistically significative for exclusive presence of portal veins gas before 48 h as well as for complete substitution of hepatic parenchyma by cysts 64 h after death.In conclusion, our work shows that the CT study of postmortem intrahepatic gas distribution could be a useful complementary tool both in demonstrating the mechanism of intrahepatic gas spreading and in estimating post mortem interval.

Bilaterale Fallhand – zentrale oder periphere Läsion?

The wrist drop, also called carpoptosis or drop hand, is a common clinical presentation in case of peripheral damage to the radial nerve. But what about the picture of a bilateral finger/wrist drop?! We report the case of a 61-year-old female patient who was admitted to the hospital for myocardial infarction. Subsequently she developed a right dominant bilateral wrist drop. Further neurological examination revealed a positive Wartenberg sign pointing towards a central motoric dysfunction. The following native cerebral CT scan demonstrated bilateral hypodense lesions in both hand knobs in the precentral gyri. Subsequent MRI confirmed acute cerebral infarction in these two but also several other, clinically silent, locations. Further diagnostic work-up revealed a hypokinetic cardiac apex suggesting cardiac embolism to be the cause for cerebral thrombembolism and the clinically leading symptom of right-dominant bilateral finger/wrist drop. Besides the case presentation also the differential diagnosis and clinical test for diagnostic work-up of wrist drops are presented and discussed.

Postmortem Imaging-Guided Biopsy as an Adjuvant to Minimally Invasive Autopsy With CT and Postmortem Angiography: A Feasibility Study

Although postmortem CT suffices for diagnosing most forms of traumatic death, the examination of natural death is, to date, very difficult and error prone. The introduction of postmortem angiography has led to improved radiologic diagnoses of natural deaths. Nevertheless, histologic changes to tissues, an important aspect in traditional examination procedures, remain obscure even with CT and CT angiography. For this reason, we examined the accuracy of a minimally invasive procedure (i.e., CT angiography combined with biopsy) in diagnosing major findings and the cause of death in natural deaths. We examined 20 bodies in a minimally invasive fashion-namely, native CT, CT angiography, and biopsy-and compared the results to those obtained at subsequent autopsy and histologic analysis. Regarding the major findings and the cause of death, the minimally invasive examination showed almost identical results in 18 of 20 cases. In one case, the severity of a cardiac ischemia was underestimated; in another case, the iliopsoas muscles were not biopsied, thus missing the diagnosis of discoid muscle necrosis and therefore a death due to hypothermia. In light of increasing objections of the next of kin toward an autopsy and the necessity for medical examiners to assess the manner and cause of death, we think that the minimally invasive procedure described here may present a viable compromise in selected cases.

Percutaneous Vertebroplasty and Pulmonary Cement Embolism: Results from VERTOS II

The reported incidence of PCE during PV varies, depending on the sensitivity of diagnostic tests used. To assess the true incidence of PCE, we performed native chest CT during follow-up in a large proportion of patients from the VERTOS II trial. VERTOS II is a prospective multicenter randomized controlled trial comparing PV with conservative therapy in 202 patients. After a mean follow-up of 22 months (median, 21 months; range, 6-42 months), 54 of 78 patients (69%) with 80 vertebrae treated with PV underwent native chest CT to detect possible PCE. The presence, location, number, and size of PCE were recorded. In addition, the presence of pulmonary parenchymal changes adjacent to PCE was noted. Possible risk factors for PCE, such as age, sex, number of treated vertebrae, cement volume per vertebra, and presence and location of perivertebral cement leakage, were evaluated. PCE was detected in 14 of 54 patients (26% 95% CI, 16%-39%). All patients were asymptomatic. Cement emboli were small and randomly distributed in peripheral small vessels. There were no reactive pulmonary changes. Cement leakage in the azygos vein was the only risk factor for the occurrence of PCE (OR, 43; 95% CI, 5-396). Small and clinically silent PCE occurred in a quarter of patients treated with PV. Cement leakage into the azygos vein was the only risk factor. With time, these small cement emboli remained inert, without inflammatory pulmonary response. Standard postprocedural CT or chest radiographs are not necessary.