Significant Computed Tomography Findings Research Articles

Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department

BackgroundBariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. MethodsWe conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. ResultsWe included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). ConclusionThis is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.

CT findings in idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) and comparison to other colitides.

The purpose of this study is to determine computed tomography (CT) findings that aid in differentiating idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) from other colitides. Retrospective review of histiologic proven cases of IMHMV (n = 12) with contrast enhanced CT (n = 11) and/or computed tomography angiography (CTA) (n = 9) exams. Control groups comprised of CT of infectious colitis (n = 13), CT of inflammatory bowel disease (IBD) (n = 12), and CTA of other colitides (n = 13). CT exams reviewed by 2 blinded gastrointestinal radiologists for maximum bowel wall thickness, enhancement pattern, decreased bowel wall enhancement, submucosal attenuation value, presence and location of IMV occlusion, peripheral mesenteric venous occlusion, dilated pericolonic veins, subjective IMA dilation, maximum IMA diameter, maximum peripheral IMA branch diameter, ascites, and mesenteric edema. Presence of early filling veins was an additional finding evaluated on CTA exams. Statistically significant CT findings of IMHMV compared to control groups included greater maximum bowel wall thickness, decreased bowel enhancement, IMV occlusion, and peripheral mesenteric venous occlusion (p < 0.05). Dilated pericolonic veins were seen more frequently in IMHMV compared to the infectious colitis group (64% versus 15%, p = 0.02). Additional statistically significant finding on CTA included early filling veins in IMHMV compared to the CTA control group (100% versus 46%, p = 0.008). IMHMV is a rare chronic non-thrombotic ischemia predominantly involving the rectosigmoid colon. CT features that may aid in differentiating IMHMV from other causes of left-sided colitis include marked bowel wall thickening with decreased enhancement, IMV and peripheral mesenteric venous occlusion or tapering, and early filling of dilated veins on CTA.

Diagnostic Accuracy of Computed Tomography by Fungal Sinusitis: A Case-control Study

Introduction: Recent decades show a considerable increase in fungal infections, hence can lead to fungal sinusitis. Immunosuppression, post organ transplant, diabetes mellitus, and Human Immunodeficiency Virus (HIV) infection have led to a rise in the incidence of fungal infections. Recent advances in nasal endoscopy, Computed Tomography (CT), and Histopathological Examination (HPE) Techniques have led to better detection of fungal aetiology. Aim: To determine the most significant CT findings in fungal sinusitis or combination of findings in comparison to HPE. Materials and Methods: This retrospective case-control study was done at Sri Manakula Vinayagar Medical College and Hospital, Puducherry from January 2017 to December 2020. Total number of patients were 90. Total 50 cases of fungal sinusitis confirmed with histopathological confirmation and available non contrast CT Paranasal Sinus (PNS) images where time interval between CT and Functional Endoscopic Sinus Surgery (FESS) not exceeding ten days were included. The control group had 40 patients with chronic sinusitis with HPE negative results. CT PNS were performed on PHILIPS 16 slice scanner without contrast administration. Data was entered into Microsoft excel and analysed using Statistical Package for the Social Sciences (SPSS) 22.0 version software. Results: Mean age of the cases (fungal sinusitis) were 46.7±17 years and 39±13.1 years of controls. Of the total 90 subjects, heterogeneous mucosal thickening was seen in 41 (45.6%), intrasinus hyperattenuation in 36 (40%), bone sclerosis in 44 (48.9%), bone erosion in 36 (40%), sinus expansion in 23 (25.6%) subjects. Fungal sinusitis patients had more proportion of these findings when compared to control group and hence p-value was significant. Conclusion: The CT diagnostic features of the fungal sinusitis are heterogeneous mucosal thickening, intrasinus hyperattenuation, bone sclerosis, bone erosion and sinus expansion which were significant. These findings help to differentiate fungal sinusitis from non fungal sinusitis.

The degree and appropriateness of computed tomography utilization for diagnosis of headaches in Ghana

IntroductionHeadache is a common and sometimes debilitating medical condition. Patients presenting with no neurologic anomaly, nontraumatic primary headache require careful evaluation before neuroimaging. National Guidelines standardizing exploitation of Computed Tomography (CT), the most utilized imaging modality in this clinical scenario, has not been established in Ghana, a developing country with limited healthcare resources. The country has not also adopted existing guidelines such as the National Institute for Health and Care Excellence (NICE) of the United Kingdom or the Appropriateness Criteria (AC) of the American College of Radiologists (ACR). The purpose of this review was to analyze the propensity of CT utilization for diagnosing headaches against the AC of the ACR and discuss some of the socio-economic inferences thereof. MethodsThis study retrospectively reviewed CT imaging records and clinical data of all patients referred for head CT scans between 1st January 2016 and 31st December 2018 at five major health facilities (four tertiary government hospitals and one private hospital) across Ghana. We isolated all head CT scans performed for the diagnosis of headache for analysis. We analyzed the type of presenting headache, CT findings, gender distribution, pattern of referrals, and head CT appropriateness against the AC of the ACR. ResultsA total of 44,218 patients were referred to the five facilities for head CT secondary to diverse indications for the period. All non-trauma cases were 41.7%; trauma cases were 31.6%, the majority (72.3%) were from road traffic accidents. The majority (64.9%) of trauma casualties were males. A total of 11,806 (26.7%) patients were referred for a head CT scan for the diagnosis of headache. The private hospital recorded the highest referrals for head CT scan for diagnosis of headache. The gender distribution of all headache patients was 57.6% females, and 42.4% were males. The age distribution showed 19.3% were children, 71.2% were adults, and the aged constituted 9.4%. The results showed 2.8% significant cranial CT findings of all reviewed headache patients. Pathological findings among the cohort of children were 0.6%.The sources and pattern of referrals showed 57.3% were from the Outpatient Department, 26.6% from the Emergency Department, in-patients’ referrals were 9.4%, and specialist consultation was 7.1%. Analysis of CT scans performed against the AC of the ACR, showed 69.0% of headache patients were likely scanned inappropriately. ConclusionsThere is a need to implement international best practice guidelines or develop a national neuroimaging policy to protect patients. Unjustified CT utilization for diagnosis of headaches exposes patients to unnecessary ionizing radiation that can instigate cancer and unnecessary expenditure. Head CT scan for some headache patients with normal neurologic findings may be unnecessary in an emerging country like Ghana. Clinicians must, therefore, be discerning in CT scan requests for the diagnosis of headache.

Prognostic CT findings of malignant bowel obstruction in patients with advanced ovarian cancer.

To evaluate computed tomography (CT) findings able to predict outcome in patients with ovarian cancer (OC) and concomitant bowel occlusion. This institutional review board-approved retrospective study included 31 patients with OC and clinical evidence of bowel occlusion who underwent CT at presentation between February 2013 and June 2015. Two radiologists recorded various qualitative CT features. Correlations between CT and survival data were made with Mann-Whitney test, Wilcoxon test, and χ2 test, as appropriate. Receiver operating characteristic curves were generated for statistically significant CT findings using logistic regression model. Two of 31 patients (6.5%) were alive at the end of this study; 29 patients (93.5%) died of disease. Median overall survival was 90 days. CT features associated with short life expectancy were bowel mural thinning (p=0.03), mesenteric tumor deposits (p=0.009), mesenteric infiltration (p=0.02), and ascites (p=0.04). Area under the curve was 0.728 (p=0.03) for mesenteric tumor deposits in predicting malignant bowel obstruction. Accurate interpretation of CT features may guide decisions in care of women with OC and bowel obstruction.

Isolated LOC in head trauma associated with significant injury on brain CT scan

BackgroundA report of loss of consciousness (LOC) is frequently considered reason enough to obtain a computed tomography (CT) scan in the evaluation of head trauma. We conducted this study to reduce exposure to radiation from CT, while still not overlooking clinically significant injuries.ObjectiveThe objective of the study is to determine the correlation between LOC status and brain CT scan results in patients with blunt head trauma and to determine whether there is a subset of patients for whom CT scan need not be performed, without missing clinically significant intracranial injuries.MethodsThis is a retrospective study conducted in the emergency department of an inner-city hospital. The patient population included patients ranging between 13 and 35 years of age, with blunt head trauma, who presented to the emergency department (ED) between January 2010 and December 2013. Patients were divided into two groups: “LOC” group and “no LOC” group. The results of brain CT scans from each group were compared with LOC status. For study purposes, “clinically significant” were those that required interventions or ICU hospitalization of at least 24 h or extended hospitalization. The results were analyzed using chi-square calculations.ResultsDuring the study period, 494 patients were identified as having suffered head trauma. Of these, 185 (37.5%) reported LOC and 309 (62.5%) did not lose consciousness. In the LOC group, 15 (8.1%) had significant CT findings compared to 1.3% (4/309) of those without LOC (p < .001). Of the 4 who had no LOC and had significant brain CT findings, all 4 patients had positive physical findings of head, neck, or facial trauma. In the LOC group, only 1/15 (6.7%) had significant CT findings with a normal GCS of 15 and no physical signs of the head, neck, or facial trauma.ConclusionsA small proportion of patients with LOC had CT finding requiring intervention. Head trauma patients with no physical injuries to the head, neck, or face and a normal GCS had no significant brain CT findings. This raises the question of whether a routine brain CT scan should be obtained in patients with LOC, no physical findings, and a normal GCS after blunt head trauma.

Computed tomography findings in young children with minor head injury presenting to the emergency department greater than 24 h post injury

BackgroundLarge studies which developed decision rules for the use of Computed tomography (CT) in children with minor head trauma excluded children with late presentation (more than 24h). ObjectiveTo assess the prevalence of significant traumatic brain injury (TBI) on CT in infants with head trauma presenting to the emergency department (ED) more than 24h from the injury. MethodsA retrospective chart review of infants less than 24 months old referred for head CT because of traumatic brain injury from January 2004 to December 2014 in Assaf-Harofeh medical center was conducted. We used the PECARN definitions of TBI on CT to define significant CT findings. Results344 cases were analyzed, 68 with late presentation.There was no significant difference in the age between children with late and early presentation (mean 11.4 (SD 5.6) month vs 10. 5 (SD 7.0) month, P=0.27). There was no significant difference between the groups in the incidence of significant TBI (22% vs 19%, p=0.61). Any TBI on CT (e.g. fracture) was found in 43 (63%) patients with late presentation compared with 116 (42%) patients with early presentation (p=0.002, OR 2.37, 95% CI 1.37–4.1). ConclusionA similar rate of CT-identified traumatic brain injury was detected in both groups.‏ There was no significant difference in the incidence of significant TBI on CT between the groups.‏ Young children presenting to the ED more than 24 hours after the injury may have abnormal findings on CT.

Role of contrast CT for the diagnosis and the prognosis of suspected LVAD thrombosis.

There is an urgent need for further studies evaluating the role of imaging modalities in the management of left ventricular assist device (LVAD) thrombosis. This study reviews the role of computed tomography (CT) in the diagnosis of suspected LVAD thrombosis. All contrast chest CTs performed in patients with suspected LVAD thrombosis at the University of Minnesota between January 2008 and April 2014 were reviewed. Significant CT findings were identified, operative notes were reviewed, and patient outcomes were reported. A total of 32 contrast chest CT examinations were performed in 24 patients with suspected LVAD thrombosis. LVAD thrombus was identified on CT in two patients (one in the outflow graft and one in the inflow cannula), and complications were found in two patients (one with inflow cannula malposition and one with outflow graft stenosis at aortic anastomosis site). Thirteen patients (67%) underwent LVAD explantation for clinically presumed LVAD thrombosis (LVAD exchange in seven, orthotopic heart transplant in six). LVAD thrombus was confirmed at the time of surgery in eight patients (62%; six in the motor, two in the outflow graft). CT has a low sensitivity but high specificity for detecting LVAD thrombus. The sensitivity is higher, but still modest for the detection of thrombus in the outflow cannula.

Utility of Emergency Department Use of Abdominal Pelvic Computed Tomography in the Management of Crohn's Disease.

The primary aim of this study was to determine predictors of clinically significant computed tomography (CT) scans, paying particular attention to findings of previous CT scans. Use of CT to assess patients with Crohn's disease (CD) in the Emergency Department (ED) is both costly and exposes patients to high levels of ionizing radiation while not clearly improving outcomes. Patients with CD who underwent CT scan in the Emergency Department from 2008 to 2011 at a tertiary referral center were assessed for clinically significant findings. A multivariable generalized estimating equation model with logit link and exchangeable working correlation structure was constructed to assess for independent predictors of CT scans with clinically significant findings. A total of 118 patients with CD underwent 194 CT scans. Ninety-two of 194 (47%) CT scans demonstrated clinically significant findings. Predictors of clinically significant CT scans included ileal disease involvement [odds ratios (OR) 3.47, P=0.01] and white blood cell count >12 (OR 2.1, P=0.03). Most notably, patients with a CT scan without clinically significant findings performed in the preceding month were significantly less likely to have a clinically significant CT scan (OR 0.23, P=0.005). Patients with CD who had a CT scan without significant findings the month prior are unlikely to have clinically significant CT findings. Ileal disease and an elevated white blood cell are predictive of clinically significant CT scans.

Unenhanced Computed Tomography to Visualize Hollow Viscera and/or Mesenteric Injury After Blunt Abdominal Trauma

To identify and describe the major features of unenhanced computed tomography (CT) images of blunt hollow viscera and/or mesenteric injury (BHVI/MI) and to determine the value of unenhanced CT in the diagnosis of BHVI/MI.This retrospective study included 151 patients who underwent unenhanced CT before laparotomy for blunt abdominal trauma between January 2011 and December 2013. According to surgical observations, patients were classified as having BHVI/MI (n = 73) or not (n = 78). Sensitivity, specificity, P values, and likelihood ratios were calculated by comparing CT findings between the 2 groups.Six significant CT findings (P < 0.05) for BHVI/MI were identified and their sensitivity and specificity values determined, as follows: bowel wall thickening (39.7%, 96.2%), mesentery thickening (46.6%, 88.5%), mesenteric fat infiltration (12.3%, 98.7%), peritoneal fat infiltration (31.5%, 87.1%), parietal peritoneum thickening (30.1%, 85.9%), and intra- or retro-peritoneal air (34.2%, 96.2%).Unenhanced CT scan was useful as an initial assessment tool for BHVI/MI after blunt abdominal trauma. Six key features on CT were correlated with BHVI/MI.

Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis.

The purpose of this study was twofold: (1) to determine the incidence of positive computed tomography (CT) findings in patients presenting to the emergency department (ED) with non-traumatic headache at our institution and (2) to examine follow-up exams, including lumbar puncture, non-enhanced CT, CT angiogram, CT venogram, and magnetic resonance imaging (MRI), to see how often the use of further testing changes the diagnosis. With IRB approval, 865 patients were identified through ED requisitions for CT head with the indication of headache during the calendar year 2011. Exclusion criteria included head trauma, prior intracranial surgery, focal neurologic symptoms, and known intracranial mass. CT results were divided into three categories: P0, P1, and P2. Negative studies were graded as P0. Positive studies were subdivided into clinically insignificant or P1 and clinically significant or P2. Clinically significant was defined as requiring medical treatment. Subsequently, the electronic medical records and picture archiving and communication system (PACS) were reviewed to determine the incidence of follow-up exams, including lumbar puncture or imaging. The secondary tests were divided into the same P0, P1, and P2 categories. There were 254 positive studies: P1 clinically insignificant (27.1%, 235/865) and P2 clinically significant (2.2%, 19/865). Of 257 follow-up exams performed, the majority were lumbar punctures (36.0%) or CT angiograms (29.5%). In 19/257 exams or 7.4%, the additional testing changed the clinically insignificant (P0/P1) diagnosis to a significant (P2) result. At our institution, there was a 2.2% incidence of significant positive CT findings in patients presenting to the ED with non-traumatic headache. Follow-up testing was variable and resulted in a 7.4% increase in the severity of diagnosis compared to the initial negative CT scan.

Utility of CT in the emergency department in patients with ulcerative colitis.

Computed tomography (CT) is used in the emergency department (ED) for triage of patients with gastrointestinal complaints. Patients with inflammatory bowel disease undergo radiologic studies for gastrointestinal symptoms and are at risk for excessive ionizing radiation exposure; however, the utility of CT in the ED in patients with ulcerative colitis (UC) is not clear. In this study, we assess the frequency and risk factors for clinically significant CT findings in patients with UC in the ED. We retrospectively reviewed 163 consecutive cases of patients with UC who presented to a tertiary care ED and underwent abdominopelvic CT between June 2008 and December 2011. Using logistic regression, we identified predictors of significant CT findings and derived a model to predict CT scans without clinically significant findings. Of note, 63.2% (103/163) of CT scans had no clinically significant findings. Less than 2% of scans revealed complications related to UC. Predictors of CT scans without clinically significant findings included rectal bleeding or diarrhea (P < 0.001), use of 5-aminosalicylate (P = 0.011), or immunomodulator (P = 0.032). Alternatively, predictors of clinically significant CT findings included nausea and vomiting (P < 0.001), history of colectomy (P < 0.001), history of abdominal or pelvic surgery (P < 0.001), surgery within 1 month (P < 0.001), age (P = 0.004), elevated white blood cell count (P = 0.003), and no UC medications (P = 0.001). Most patients with UC who presented to the ED and underwent CT had no clinically significant findings. We devised a model to predict lack of clinically significant CT findings, which may assist in reducing cost and radiation exposure in patients with UC.

Risk Stratification of Emergency Department Patients With Crohn's Disease Could Reduce Computed Tomography Use by Nearly Half

Computed tomography (CT) is a useful tool for assessing disease activity and excluding complications in patients with Crohn's disease (CD). However, excessive radiation increases risk for malignancy. We aimed to identify automatable algorithms with high negative predictive values for significant CT findings in patients with CD who present at the emergency department. We conducted a retrospective review of a tertiary center's medical records to identify adults diagnosed with CD who presented from 2000 through 2011. Logistic regression was used to model complications (perforations, abscesses, or other serious findings) and inflammation. There were 1095 visits made by 613 individuals that included a CT scan within 24 hours of arrival. The average number of CT scans was 1.8 (range, 1-31). Complications of CD were observed in 16.8% of CT scans, inflammation in 54.5%, and new/worse findings in 67.2%. On the basis of 10-fold cross-validation, the area under the receiver operating characteristic curve value for the complications model was 0.80 (95% confidence interval, 0.74-0.86) and for the inflammation model was 0.71 (95% confidence interval, 0.68-0.74). Scanning only patients with model-predicted complications would reduce scans by 43.0%, with a miss rate of 0.8% (4 of 491). Patients presenting to the emergency department with CD are frequently assessed by CT. However, no significant findings are observed in 32.8%, and only 17% have complications from CD. We created models to identify patients not likely to have significant findings from CT with high negative predictive values; these could aid physicians in avoiding CT scans for many patients. Studies are needed to validate these models beyond a single center.

CT of Preoperative and Postoperative Acetabular Fractures Revisited

We compared preoperative and postoperative computed tomography (CT) versus radiographic imaging in the evaluation of acetabular fractures (AFs). Fifty-four patients who underwent imaging for AFs were retrospectively evaluated. Postoperative reduction quality was assessed on radiographs and CT scan by 2 observers. Rate of reintervention was noted. Radiation exposure from CT was calculated. After reduction, 24 patients had significant findings on postoperative CT. Five patients required reintervention, all of whom had significant postoperative CT findings and complex fractures. Notably, only 1 of the 5 patients had an indication for reintervention based on radiographs alone.The average dose for preoperative/postoperative CT study was 11.5/12.3 mSv, respectively, with a cumulative average dose of 23.8 mSv. Although reoperation rate is low after fixation of AFs, CT is required to identify those requiring reintervention. However, postoperative CT should be used judicially, only in patients presenting with complex acetabular fractures.

Predictors of Significant CT Findings in Patients with Ulcerative Colitis Who Present to the Emergency Department

Purpose: The use of abdominopelvic computed tomography (CT) plays an important role in the diagnosis and management of patients with inflammatory bowel disease (IBD), and its use in the emergency department (ED) has increased the last decade. A previous study demonstrated that the use of CT in the ED in patients with Crohn's disease detected significant findings in one-third of patients. We sought to assess the use of CT in patients with ulcerative colitis (UC) in the ED. Methods: We identified 92 cases of patients with UC who presented to the ED between January, 2010 and December, 2011 and underwent abdominal and/or pelvic CT. We reviewed the medical records of these visits to determine the prevalence of significant CT findings, defined as those that required urgent or emergent clinical intervention. We then assessed for potential predictors of significant CT findings. We analyzed the significance of these factors through single and multiple logistic regression. Results: A total of 92 ED visits were reviewed. Fifty-two percent were female, 79% Caucasian, and the median age was 50 years. Significant findings were seen in 44.6% (41/92) of cases. 10% (9/92) of patients had significant UC-related findings, including perforation, abscess, large bowel obstruction, and malignancy. In 34.7% (32/92) of patients, CT scans identified significant non-UC findings; the most common were small bowel obstruction (7, 21.9%), appendicitis (3, 9.38%), and diverticulitis (3, 9.38%). 55.4% (51/92) of patients had no significant CT findings, which were either UC-related inflammation (31, 33.7%) or no acute process (20, 21.7%). Predictors of significant findings on CT were a chief complaint of nausea and vomiting (odds ratio [OR] 5.31 [1.73-16.28]), history of abdominal surgery (OR 4.43 [1.79-10.95]), and no UC medications at presentation (OR 3.79 [1.59-9.03]). Predictors of non-significant findings were chief complaints of rectal bleeding (OR 20.29 [4.42-93.04]) or diarrhea (OR 7.69 [2.75-21.49]), and a 5-aminosalicylic acid medication (OR 2.98 [1.21-7.33]). On multivariate analysis, the predictors of significant findings that remained statistically significant were rectal bleeding (aOR 0.05 [0.1-0.28]), nausea and vomiting (aOR 4.25 [1.1-16.28]), and no UC medications (aOR 4.38 [1.52-12.62]) at the time of presentation. Conclusion: Less than half of patients with ulcerative colitis who present to the emergency department and undergo CT have significant findings on imaging. Understanding predictors of significant findings could alter management, and may help to minimize cost and radiation exposure in patients with UC.

Chronic destructive pulmonary tuberculosis: assessment of disease activity by computed tomography

Determination of disease activity of chronic destructive pulmonary tuberculosis (TB) on imaging studies can be difficult because several imaging findings due to disease chronicity such as a residual cavity can be misinterpreted as an active disease. To evaluate computed tomography (CT) findings to predict active disease in patients with chronic destructive pulmonary TB. CT findings of 36 patients with chronic active destructive pulmonary TB and 78 patients with chronic inactive destructive pulmonary TB were reviewed and their patterns of lung lesions were compared. Statistical comparisons were performed using chi-square and Student's T tests for univariate analyses, and a stepwise logistic regression method was used for multivariate analysis. Based on univariate analyses, cavitary destruction (P = 0.015), non-branching centrilobular nodules (P < 0.001), tree-in-bud pattern (P < 0.001), airspace nodules (P < 0.001), and cavities in other lobes (P = 0.001) were more frequently seen in chronic active destructive pulmonary TB. A stepwise logistic regression analysis demonstrated that tree-in-bud pattern (odds ratio, 52.3; 95% confidence interval, 6.2-437.2; P < 0.001) were significant CT findings associated with active disease. Tree-in-bud pattern were the most characteristic CT findings to predict active disease in patients with chronic destructive pulmonary TB.

Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study

The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Can We Predict the Site of Entry Tear by Computed Tomography in Patients With Acute Type A Aortic Dissection?

In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention. There are reliable indirect computed tomography (CT) findings to predict the entry site. In 83 patients with type A AAD whose primary entry tears were identified surgically between 2003 and 2009, we retrospectively examined the diagnostic CT scans regarding pericardial effusion, the largest short-axial diameter of the aorta, widths of true and false lumens, and false lumen thrombosis at 6 levels of thoracic aorta from the aortic root to the descending aorta. The primary entry sites identified intraoperatively were proximal ascending in 21 patients, middle ascending in 21, distal ascending in 21, arch in 17, and descending or unknown in 16. The multivariate logistic analysis revealed that pericardial effusion (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.2-3.4, P < 0.001) and dilated ascending aorta (OR: 1.6, 95% CI: 1.1-2.4, P = 0.012) were the significant CT findings to predict the entry tear in the ascending aorta. It also revealed that the significant CT finding to predict the entry tear distal to the aortic arch was nonthrombosed false lumen in the descending aorta (OR: 1.2, 95% CI: 1.1-2.1, P = 0.048). We can predict the primary entry site by the preoperative CT findings in patients with type A AAD, considering pericardial effusion, aortic diameter, widths of true and false lumens, and false lumen thrombosis at different anatomic levels.

What is the clinical utility of a 6-month computed tomography in the follow-up of endovascular aneurysm repair patients?

A drawback of endovascular aneurysm repair (EVAR) is the need for ongoing surveillance. Follow-up schedules including 1-, 6-, and 12-month computed tomography (CT) established by regulatory trials have been carried into clinical practice without critical assessment. The utility of a 6-month CT, with its associated radiation exposure and contrast toxicity, obtained after a normal result at 1-month CT has not been established. All EVAR patients from 1996 to 2004 at one institution with complete local 1-year follow-up were reviewed for clinically significant CT findings at 1, 6, and 12 months. Before 2000, all patients underwent 1-, 6-, and 12-month CT. In 2000, a policy of omitting the 6-month CT in patients who had a normal result on the 1-month scan was adopted. During the study period, 573 patients underwent EVAR, and 376 patients who had complete local 1-year follow-up were included in this review. All had a 1-month CT scan and the result was abnormal in 40 (10.6%): five had type 1 leaks (1.3%), 34 had type 2 leaks (9.0%), and one had a type 3 leak (0.3%); all were followed with 6-month CT. The 1-month CT scan result was normal for 336 (89.4%) patients. Of these, group I (130 patients, 67 treated after 2000) underwent routine 6-month CT, with only two abnormalities noted (1.5%); both were type 2 endoleaks not associated with sac growth. No 6-month CT in this group demonstrated findings warranting intervention. The 6-month CT was omitted in group II (206 patients, all treated after 2000), and follow-up was only at 1 year. In this group, no patient's management would have been altered by findings on a 6-month CT. No patient in either group experienced aneurysm sac growth by 1 year. Clinical complications occurred in three group I patients (2.3%): seroma, limb occlusion, and main body thrombosis. Only one group II patient (0.5%) experienced a complication <or=1 year, a limb occlusion at 9 months. After EVAR, a 6-month CT after a normal 1-month CT result does not identify any clinically significant findings warranting intervention and can be omitted safely from the follow-up schedule.

SHOULD THE PELVIS BE INCLUDED IN ABDOMINAL COMPUTED TOMOGRAPHY SCANS OF CHILDREN WITH UPPER-ABDOMINAL PRIMARY MALIGNANT TUMORS?

INTRODUCTION: There is increasing awareness of the potential risk associated with ionizing radiation in pediatric radiology. Children with abdominal cancer undergo multiple computed tomography (CT) scans both at diagnosis and for follow-up. OBJECTIVE: We sought to estimate the potential contribution of pelvis CT findings in the management of children with upper-abdominal tumors in correlation with the effective radiation dose. METHODS: Three hundred forty-two children (aged 1 day to 16 years) with histologically proven upper-abdominal primary malignant tumors (children with lymphoma were not included) were examined during the last 15 years in our department. Their upper- and lower-abdominal CT scans were reviewed retrospectively for clinically significant pelvic abnormalities. The effective radiation dose for each abdominal area was calculated. RESULTS: Nine children (2.63%) showed CT pelvic abnormalities that did not change clinical management, and 7 (2.04%) showed findings that affected tumor staging. Thirty-nine percent of the total effective radiation dose was from pelvic CT scans. CONCLUSIONS: Our data indicate that clinically significant pelvic CT findings are rare in children with upper-abdominal primary malignant tumors. We suggest that the pelvis should not be routinely included in abdominal CT scans unless indicated by other clinical or laboratory findings, given the high level of effective radiation dose.