Subsequent Computed Tomography Angiography Research Articles

Polyarteritis nodosa: a case report of isolated large bowel involvement and surgical intervention

Polyarteritis nodosa (PAN) is a necrotizing vasculitis commonly affecting small-sized vessels and medium-sized vessels. We present the case of surgical resection for ischemic colitis secondary to PAN. A 26-year-old woman presented with left lower quadrant pain, diarrhea and bloody stools. Colonoscopy showed diffuse circumferential ulceration and necrotic lining from the sigmoid colon to the splenic flexure. A subsequent computed tomography angiography (CTA) revealed left colonic wall thickening, hypoenhancement and multiple inferior mesenteric artery aneurysms, concerning for vasculitis. Ensuing laboratory workup all returned negative. Worsening pain, left-sided peritonitis, tachycardia and rising white blood cell necessitated a colectomy from the proximal descending to upper rectum with an end colostomy. Surgical pathology showed features consistent with PAN. The patient improved significantly after surgery and was discharged on a steroid taper and later started on mycophenolate mofetil. This case is a unique presentation of isolated large intestinal involvement and was treated with both medical and surgical interventions.

Detrimental consequences after intimal disruption of subclavian artery during transcathether aortic valve implantation

BackgroundTAVI via the left subclavian artery is considered a bail-out strategy in cases where a transfemoral approach is not feasible. However, since this route is only scarcely used, major complications can arise. We describe such an adverse course and present our proceeding.Case presentationA 65-year-old man with severe aortic valve stenosis (AS) was referred for transcatheter aortic valve implantation (TAVI) via left subclavian artery. After uneventful deployment of the TAVI prosthesis, consequent valve assessment with transeosophageal echocardiography and angiography showed a highly mobile and tubular structure shifting within the valve. We went for a surgical extraction via sternotomy on cardiopulmonary bypass (CPB). A 6 cm longish intimal cylinder was hassle-free extracted. 4 days postoperatively the left sided radial pulse was missing. In a subsequent computed tomography angiography (CTA) scan a proximal dissection as well as an intimal flap, causing a subtotal stenosis of the left subclavian artery, was detected. Consecutively the intimal cylinder was removed using a Fogarty-balloon. Pre-discharge control revealed recurrence of peripheral radial pulse and an unimpeded function of the TAVI prosthesis. The patient presented no sequela at discharge.ConclusionThough TAVI is a well-advanced technique complications are not completely avertable. It is thus advisable to have patients discussed in the heart team encompassing all potentially involved specialties.

Regional left ventricle scar detection from routine cardiac computed tomography angiograms using latent space classification

Objectives:The aim of this study is to develop an automated method of regional scar detection on clinically standard computed tomography angiography (CTA) using encoder–decoder networks with latent space classification. Background:Localising scar in cardiac patients can assist in diagnosis and guide interventions. Magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) is the clinical gold standard for scar imaging; however, it is commonly contraindicated. CTA is an alternative imaging modality that has fewer contraindications and is widely used as a first-line imaging modality of cardiac applications. Methods:A dataset of 79 patients with both clinically indicated MRI LGE and subsequent CTA scans was used to train and validate networks to classify septal and lateral scar presence within short axis left ventricle slices. Two designs of encoder–decoder networks were compared, with one encoding anatomical shape in the latent space. Ground truth was established by segmenting scar in MRI LGE and registering this to the CTA images. Short axis slices were taken from the CTA, which served as the input to the networks. An independent external set of 22 cases (27% the size of the cross-validation set) was used to test the best network. Results:A network classifying lateral scar only achieved an area under ROC curve of 0.75, with a sensitivity of 0.79 and specificity of 0.62 on the independent test set. The results of septal scar classification were poor (AUC < 0.6) for all networks. This was likely due to a high class imbalance. The highest AUC network encoded anatomical shape information in the network latent space, indicating it was important for the successful classification of lateral scar. Conclusions:Automatic lateral wall scar detection can be performed from a routine cardiac CTA with reasonable accuracy, without any scar specific imaging. This requires only a single acquisition in the cardiac cycle. In a clinical setting, this could be useful for pre-procedure planning, especially where MRI is contraindicated. Further work with more septal scar present is warranted to improve the usefulness of this approach.

A Rare Case of Contained Chronic Rupture of Abdominal Aortic Aneurysm Associated With Vertebral Erosion: Pre- and Post-operative Findings on Computed Tomography and a Narrative Review.

Contained chronic rupture of aortic aneurysm (CCR-AA) is a rare condition that can be associated with vertebral body erosion (VBE) and is often a diagnostic challenge; in fact, CCR-AAs are in general hemodynamically stable and the patients tend to present with a non-specific low-back pain syndrome secondary to vertebral involvement. Furthermore, the differential diagnosis of a retroperitoneal mass can be difficult on medical imaging. We discuss the case of a 79-years-old man, heavy smoker without history of cardiovascular diseases, admitted to the emergency department with signs of left lower limb ischemia. The patient was hemodynamically stable and the medical examination revealed a pulsatile abdominal mass. Doppler ultrasound showed the presence of aneurysmal dilatation of infra-renal abdominal aorta and chronic femoropopliteal occlusion on the left side. The subsequent computed tomography angiography (CTA) demonstrated a voluminous retroperitoneal mass continuous with the infra-renal aorta, which infiltrated the psoas muscles and caused vertebral bodies erosion of the anterior wall in L2, L3 and L4 suspected for CCR-AA or mycotic aortic aneurysm. Furthermore, the examination confirmed the occlusion of the peripheral arterial circulation of the left lower limb. The patient underwent a successful open replacement of the infra-renal abdominal aorta through aorto-aortic prosthetic graft insertion; the visualization during the surgical procedure of a posterior vessel wall opening in continuity with the eroded vertebral bodies associated with negative microbiological culture of the thrombotic material sample, led to the definitive diagnosis of CCR-AA. The post-operative CTA showed successful open vascular treatment. A bypass surgery of the left lower limb was then performed with positioning saphenous graft between femoral common artery and posterior tibial artery. The patient was finally discharged in good clinical conditions.

Vasospasm Surveillance by a Simplified Transcranial Doppler Protocol in Traumatic Brain Injury

To detect post-traumatic vasospasm in patients with traumatic brain injury (TBI), we implemented a simplified transcranial Doppler (TCD) surveillance protocol in a neurointensive care setting. In this study, we evaluate the yield of this protocol. Adult patients with TBI admitted to the neurointensive care unit were examined with TCD by 2 intensive care nurses trained in TCD examinations. Flow velocities of the middle cerebral arteries were recorded. TCD suspected vasospasm was defined as the mean flow velocity >120 cm/s, and when detected, the protocol recommended a supplementary computed tomography angiography. The rate of detection of TCD suspected vasospasm and the subsequent rate of radiological diagnosis of vasospasm were recorded. In multivariate logistic regression analysis, we evaluated age, initial Glasgow Coma Scale, craniotomy, and decompressive craniectomy as potential predictors of developing increased TCD velocity. A total of 84 patients with TBI with a median initial Glasgow Coma Scale score of 6 were examined by TCD. TCD suspected vasospasm was found in the middle cerebral arteries of 18% of examined patients. Two-thirds of patients with TCD suspected vasospasm were investigated with a subsequent computed tomography angiography, and 80% of these patients received a radiological diagnosis of vasospasm. In logistic regression analysis, decompressive craniectomy was significantly associated with increased risk of developing TCD suspected vasospasm (odds ratio: 11.57, 95% confidence interval: 2.59-51.73, P= 0.001). The implementation of a simplified TCD surveillance protocol in a neurointensive care setting yielded an 18% detection rate of TCD suspected vasospasm. In our cohort of patients with TBI, decompressive craniectomy was associated with increased risk of developing TCD suspected vasospasm.

Magnetic resonance imaging-based diagnosis of aortitis preceding development of a thoracic aneurysm in a patient with giant cell arteritis: a case report

BackgroundInflammatory manifestation in the aortic arch can be a complication of giant cell arteritis (GCA), potentially requiring surgical therapy in the case of aneurysmatic dilatation.Case summaryWe report the case of a 73-year-old female patient with GCA in whom a typical appearance of arteritis was visualized on magnetic resonance imaging of the superficial temporal arteries. Additionally, ectasia (4.7 cm) of the ascending aorta with a mural rim of increased contrast media uptake was detected at the time of the initial diagnosis, which is an indicator of aortitis. While the diameter had only minimally increased in a computed tomography angiography (CTA) examination after 8 months, a subsequent CTA revealed an increased diameter of 5.8 cm and maximum at the level of the ascending aorta another 22 months later, indicating urgent surgery to replace the ascending aorta.DiscussionMagnetic resonance imaging can detect silent, generalized manifestations of GCA such as severe aortitis, which may possibly lead to aneurysmatic dilatation, urging closer follow-up imaging. Detection of the ongoing process and subsequent follow-up imaging protects patients by avoiding rupture.

Visual Diagnosis: Abnormal Behavior in a 2-month-old Boy.

Visual Diagnosis: Abnormal Behavior in a 2-month-old Boy.

Abstract No. 164 Influence of emergency department clinical presentation on speed of diagnosis for patients with suspected acute gastrointestinal bleeding

In patients with suspected acute gastrointestinal bleeding rapid diagnosis is essential to avoid significant morbidity and mortality. The purpose of this study was to assess whether initial clinical evaluation is associated with differences in time between emergency department (ED) presentation and computed tomography angiography (CTA). A retrospective, single health system, multi-hospital study reviewed charts from 2009 to 2019 for patients admitted to the ED with suspected GI bleeding and subsequent CTA. 81 patients with active extravasation on CTA were matched to 93 patients by age, gender and date of CTA scan without active extravasation. Presenting symptoms, vitals, medications, time of ED arrival and CTA were collected. Mean time from ED arrival to CTA was compared using unpaired t-tests. The mean patient age was 69.5 (range, 24-100) and 91 were female. Faster time from admission to CTA was noted in patients on anticoagulation (315 vs 377 mins; P = 0.008) and with heart rate >100 beats/min (314 vs 378 mins; P< 0.001). Hematochezia (330 vs 435 minutes; P = 0.057) was non-significant but trended toward faster time to CTA. No difference was noted based on systolic blood pressure < 110 mmHg (362 vs 343 mins; P = 0.79). Overall, time from ED admission to CTA was significantly faster in patients with active extravasation (297 vs 423 minutes; P = .009). In patients with suspected gastrointestinal bleeding accurate clinical assessment drives faster time to confirmation of hemorrhage on CTA.

Postpartum vertebral artery dissection: case report and review of the literature

BackgroundHypertensive disorders of pregnancy are associated with vascular complications, including ischemic stroke and cervical artery dissection. Vertebral artery dissection (VAD), however, is rare. We describe a 31-year-old female who presented with vertigo, nausea, and vomiting and was found to have a VAD. In addition, we discuss the presentation, differential diagnosis, and pathogenesis of this uncommon but clinically significant vascular event and summarize other cases of vertebral artery dissection described in the medical literature.Case presentationA 31-year-old Hispanic woman presented 10 days postpartum with a one-day history of vertigo, nausea, vomiting, and frontal headache. The patient’s pregnancy course had been complicated by preeclampsia, chorioamnionitis, and iron-deficiency anemia, and her delivery was complicated by acute hemorrhage. Physical examination was significant for left leg ataxia. Laboratory studies showed marked thrombocytosis. Emergent computed tomography (CT) scan of the head was obtained and revealed a left cerebellar ischemic large vessel stroke. Subsequent CT angiography of the head and neck showed a left VAD. Based on correlation of the clinical history and laboratory and imaging findings, a diagnosis of vertebral artery dissection secondary to reactive (secondary) thrombocytosis from overlapping iron-deficiency anemia and acute hemorrhage was established. The patient was started on a heparin infusion and experienced significant improvement after a four-day hospitalization.ConclusionVAD is a rare but important cause of neurologic symptoms in the postpartum period and should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women aged 30 years or older and those with a history of a hypertensive disorder of pregnancy are at particularly high risk. Prompt diagnosis and management of VAD is essential to ensure favorable outcomes.

Intensive Doppler Ultrasonography for Early Detection of Hepatic Artery Thrombosis After Adult Living Donor Liver Transplantation.

BackgroundEarly hepatic artery thrombosis (eHAT) is a severe arterial complication leading to biliary complications and graft failure in living donor liver transplantation (LDLT). This study sought to early identify the abnormal waveforms of eHAT by using intensive Doppler ultrasonography (DUS) after LDLT and to assess the clinical outcome in these eHAT patients.Material/MethodsDUS for 419 adult LDLT recipients was performed twice after vascular anastomosis during liver transplantation and once a day at the bedside for at least 2 weeks.ResultsNine adult LDLT recipients with eHAT were identified by using bedside DUS with subsequent computed tomography angiography (CTA). All eHAT cases were noted in the first 2 weeks. Five patients with CTA findings of partial thrombus with the small visualized intrahepatic hepatic artery (HA) were treated with intravenous thrombolysis (IVT) (medical group). Another 4 patients with CTA findings of extrahepatic HA occlusion and nonvisualization of intrahepatic HAs were treated by arterial re-anastomosis (surgical group). The prevalence of long-term non-anastomotic biliary strictures was 33.3% in the surgical group. Intensive post-LDLT DUS is a convenient and sensitive tool for eHAT detection.ConclusionsSubsequent CTA gives valid information on occluded arteries and associated findings, which impact decision-making and are correlated with patient outcome. Our protocol of DUS has high sensitivity and diagnostic accuracy for use in in eHAT patients with partial occlusion, and it can be applied for IVT treatment, avoiding the need for reoperation and preventing long-term biliary complications.

Not aString, not aTangle, not an Aneurysm : Emerging Pattern of Large Parenchymal Bleeding in Younger Patients Associated with Abnormal Vessels on Imaging.

PurposeIntracerebral hemorrhage (ICH) accounts for up to 20% of all strokes, and there is a high rate of associated morbidity and mortality. Computed tomography (CT) findings, such as a spot sign have been shown to be an independent predictor of poor outcome. We have recently encountered a succession of ICH patients who presented with a peculiar imaging finding, which we term the spot on a string sign. This is a rare imaging finding, and interestingly, all these patients presented to our institution over the last few weeks.MethodsThis was a single high-volume center series of patients who presented to our institution between 1 April and 21 May 2020. All patients underwent initial non-contrast CT brain and subsequent CT angiography (CTA). We also present laboratory and clinical data. Our primary measure was the presence of the spot on a string sign on the CTA. We also report the clinical course of these patients.ResultsIn this study seven large-volume ICH patients with this imaging sign were identified, with a median age of 48 years (range 30–68 years). All had tested negative for coronavirus disease 19 (COVID-19).ConclusionWe have described an unusual imaging finding in a cohort of younger patients with large-volume ICH, all of whom presented in a 2-month period to a high-volume neurovascular unit. The cause of these ICH presentations and associated imaging findings are unclear, but we encourage other clinicians to be aware of and vigilant for this rare phenomenon, especially in younger patients with such a bleeding pattern.

Point-of-care ultrasound diagnosis of thoracic aortic aneurysm in a patient presenting with hemoptysis

IntroductionHemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions.Case ReportA 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day.DiscussionThe vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Hemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions. A 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day. The vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Figure 1. POC-US of suprasternal notch view showed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma (arrow). Figure 2. CTA of the aorta revealed proximal ruptured thoracic aortic aneurysm with adjacent hematoma.•Sun D, Mehta S. Hemoptysis caused by erosion of thoracic aortic aneurysm. CMAJ. 2010; 182:186.•Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg 1985; 89:50.•Nair G, Jindal S, Chandra A, Swami S, Garg P. Haemoptysis - a rare presentation of aortic aneurysm. Lung India. 2008;25:20.

Effects of Sublingual Glyceryl Trinitrate Administration on the Quality of Preprocedure CT Angiography Performed to Plan Prostate Artery Embolization

PurposeTo determine the effects of sublingual glyceryl trinitrate (GTN) on the quality of planning computed tomography (CT) angiography performed prior to prostate artery embolization (PAE). Materials and MethodsA retrospective cohort study was performed on patients who had previously undergone CT angiography before a procedure for PAE at our institution. Early CT angiography studies for PAE at our single center had initially been performed without GTN. These were compared to subsequent CT angiography studies that had been performed with GTN, after a previously implemented change in practice. Prostate arteries were examined by 2 blinded observers for peak enhancement (Hounsfield units [HU]) and lumen diameter. In addition, assessors’ interpretation of the prostate artery origin from CT angiography was compared with the true anatomy demonstrated at the time of procedure. ResultsA total of 16 patients, corresponding to 32 prostate arteries, were examined on CT angiography. Mean diameter of the prostate artery was found to be significantly greater in those receiving GTN (2.2 mm vs. 1.6 mm, P < .001). Peak prostate artery enhancement was also greater in the GTN group (218 HU vs 173 HU, P = 0.042). Observers correctly identified the prostate artery origin more frequently in the GTN group; however, this difference was not statistically significant (56% vs 25%, odds ratio = 3.9, P = .149). ConclusionsThe administration of sublingual GTN immediately prior to CT angiography is associated with a significant increase in prostate artery diameter and peak opacification. This was not associated with a statistically significant increase in the ability of observers to correctly identify the origin of the prostate artery.

Syphilitic Bilateral Coronary Artery Ostial Stenosis Presenting as Acute Coronary Syndrome

Syphilis is an infectious disease which occurs through a series of frequently overlapping stages. It can impair the cardiovascular and neurological systems. In approximately 30% of non-treated patients, syphilis develops its tertiary form. We report a case of a 41-year male patient admitted due to acute coronary syndrome presented as unstable angina. Coronary angiography showed a 100% ostial lesion of left main coronary artery and 90% occlusion of the right coronary artery ostium. Subsequent Computed Tomography Angiography (CTA) scan showed prominent thickening of the aortic wall. The Venereal Disease Research Laboratory (VDRL) test was titrated to 1/16. The patient was referred for coronary artery bypass graft (CABG). Key words: Syphilis, Acute Coronary Syndrome, unstable angina, Coronary Angiography, Left Main Coronary Artery, Right Coronary Artery, Coronary ostial stenosis, Computed Tomography Angiography.

Utility of Repeat Cerebrovascular Imaging among Hospitalized Stroke Patients

The purpose of this study is to evaluate the frequency and clinical utility of repeat cerebrovascular imaging with computed tomography angiography (CTA) of the head after contrast-enhanced magnetic resonance angiography (CE-MRA) of the head in acute stroke patients. All stroke patients admitted to 2 academic medical centers from January 1, 2012 through December 31, 2014 were identified as part of prospective radiology database if they underwent CE-MRA of the head followed by subsequent CTA of the head within 7 days. Two vascular neurologists blinded to CTA results retrospectively reviewed medical records including documented indications for imaging studies and clinical changes in patients to determine necessity of CTA. Of 1355 acute stroke patients who underwent CE-MRA of the head, 195 (14%) patients underwent subsequent CTA of the head within 7 days, including 33 patients with nondiagnostic CE-MRA because of motion artifact. Of the remaining 162 (12%) patients, 69 (43%) were considered to have an unnecessary CTA of the head. Multivariable logistic regression analysis identified (1) absence of new neurologic examination changes [OR 7.29; 95% CI 1.92-27.63] and (2) same documented indication for both studies [OR 6.47; 95% CI 3.04-13.78] as significant predictors of an unnecessary CTA. Changes in clinical management after CTA were significantly more common in necessary CTAs compared with studies determined to be unnecessary (42% versus 7%, P < .0001). The utility of repeat cerebrovascular imaging with CTA of the head following a diagnostic CE-MRA is low when there is no change in neurologic examination or when ordered for the same indication.

Management of aneurysmal subarachnoid hemorrhage: State of the art and future perspectives.

Background:Aneurysmal subarachnoid hemorrhage (SAH) accounts for 5% of strokes and carries a poor prognosis. It affects around 6 cases per 100,000 patient years occurring at a relatively young age.Methods:Common risk factors are the same as for stroke, and only in a minority of the cases, genetic factors can be found. The overall mortality ranges from 32% to 67%, with 10–20% of patients with long-term dependence due to brain damage. An explosive headache is the most common reported symptom, although a wide spectrum of clinical disturbances can be the presenting symptoms. Brain computed tomography (CT) allow the diagnosis of SAH. The subsequent CT angiography (CTA) or digital subtraction angiography (DSA) can detect vascular malformations such as aneurysms. Non-aneurysmal SAH is observed in 10% of the cases. In patients surviving the initial aneurysmal bleeding, re-hemorrhage and acute hydrocephalus can affect the prognosis.Results:Although occlusion of an aneurysm by surgical clipping or endovascular procedure effectively prevents rebleeding, cerebral vasospasm and the resulting cerebral ischemia occurring after SAH are still responsible for the considerable morbidity and mortality related to such a pathology. A significant amount of experimental and clinical research has been conducted to find ways in preventing these complications without sound results.Conclusions:Even though no single pharmacological agent or treatment protocol has been identified, the main therapeutic interventions remain ineffective and limited to the manipulation of systemic blood pressure, alteration of blood volume or viscosity, and control of arterial dioxide tension.

Thrombosis of Inferior Vena Cava Diagnosed Using Point-of-Care Ultrasound After Pediatric Near-Syncope

BackgroundVenous thromboembolism (VTE) is extremely rare but under recognized in the pediatric population. Although the literature on the use of ultrasound to detect VTEs in adults is plentiful, little has been documented on its use in the pediatric population. Case ReportWe present a case of a healthy 16-year-old female who presented to our emergency department with 3 months of dyspnea on exertion and one episode of near-syncope. Point-of-care cardiac ultrasound identified an inferior vena cava thrombosis. Subsequent computed tomography angiography diagnosed concurrent bilateral pulmonary emboli (PE). The patient's identical twin sister presented with similar symptoms shortly thereafter and was also diagnosed with VTE and bilateral PE. Why Should an Emergency Physician Be Aware of This?This case demonstrates an instance of VTE and pulmonary embolism in twin adolescent girls. Physical examination findings, electrocardiogram, chest x-ray study, and several previous evaluations did not reveal the diagnosis. Point of care ultrasound was used to correctly diagnosis VTE and for heightened concern for a pulmonary embolism.

Prediction of Rupture Sites in Abdominal Aortic Aneurysms After Finite Element Analysis

Purpose: To associate regions of highest local rupture risk from finite element analysis (FEA) to subsequent rupture sites in abdominal aortic aneurysms (AAA). Methods: This retrospective multicenter study analyzed computed tomography angiography (CTA) data from 13 asymptomatic AAA patients (mean age 76 years; 8 men) experiencing rupture at a later point in time between 2005 and 2011. All patients had CTA scans before and during the rupture event. FEA was performed to calculate peak wall stress (PWS), peak wall rupture risk (PWRR), rupture risk equivalent diameters (RRED), and the intraluminal thrombus volume (ILTV). PWS and PWRR locations in the prerupture state were compared with subsequent CTA rupture findings. Visible contrast extravasation was considered a definite (n=5) rupture sign, while a periaortic hematoma was an indefinite (n=8) sign. A statistical comparison was performed between the 13-patient asymptomatic AAA group before and during rupture and a 23-patient diameter-matched asymptomatic AAA control group that underwent elective surgery. Results: The asymptomatic AAAs before rupture showed significantly higher PWRR and RRED values compared to the matched asymptomatic AAA control group (median values 0.74 vs 0.52 and 77 vs 59 mm, respectively; p<0.0001 for both). No statistical differences could be found for PWS and ILTV. Ruptured AAAs showed the highest maximum diameters, PWRR, and RRED values. In 7 of the ruptured AAAs (2 definite and 5 indefinite rupture signs), CTA rupture sites correlated with prerupture PWRR locations. Conclusion: The location of the PWRR in unruptured AAAs predicted future rupture sites in several cases. Asymptomatic AAA patients with high PWRR and RRED values have an increased rupture risk.

Initial screening test for blunt cerebrovascular injury: Validity assessment of whole-body computed tomography

Our whole-body computed tomography protocol (WBCT), used to image patients with polytrauma, consists of a noncontrast head computed tomography (CT) followed by a multidetector computed tomography (40- or 64- slice) that includes an intravenous, contrast-enhanced scan from the face through the pelvis. WBCT is used to screen for blunt cerebrovascular injury (BCVI) during initial CT imaging of the patient with polytrauma and allows for early initiation of therapy with the goal of avoiding stroke. WBCT has not been directly compared with CT angiography (CTA) of the neck as a screening tool for BCVI. We hypothesize that WBCT is a valid modality to diagnose BCVI compared with neck CTA, thus screening patients with polytrauma for BCVI and limiting the need for subsequent CTA. A retrospective review of the trauma registry was conducted for all patients diagnosed with BCVI from June 2009 to June 2013 at our institution. All injuries, identified and graded on initial WBCT, were compared with neck CTA imaging performed within the first 72hours. Sensitivity was calculated for WBCT by the use of CTA as the reference standard. Proportions of agreement also were calculated between the grades of injury for both imaging modalities. A total of 319 injured vessels were identified in 227 patients. On initial WBCT 80 (25%) of the injuries were grade I, 75 (24%) grade II, 45 (14%) grade III, 41 (13%) grade IV, and 58 (18%) were classified as indeterminate: 27 vertebral and 31 carotid lesions. Twenty (6%) of the 319 injuries were not detected on WBCT but identified on subsequent CTA (9 grade I, 7 grade II, 4 grade III); 6 vertebral and 14 carotid. For each vessel type and for all vessels combined, WBCT demonstrated sensitivity rates of over 90% to detect BCVI among the population of patients with at least one vessel injured. There was concordant grading of injuries between WBCT and initial diagnostic CTA in 154 (48% of all injuries). Lower grade injures were more discordant than higher grades (55% vs 13%, respectively; P<.001). Grading was upgraded 8% of the time and downgraded 25%. WBCT holds promise as a rapid screening test for BCVI in the patient with polytrauma to identify injuries in the early stage of the trauma evaluation, thus allowing more rapid initiation of treatment. In addition, in those patients with high risk for BCVI but whose WBCT results are negative for BCVI, neck CTA should be considered to more confidently exclude low-grade injuries.

Number of Entry Tears Is Associated With Aortic Growth in Type B Dissections

Aortic growth rate in acute type B aortic dissection (ABAD) is a significant predictor for aortic complications and death. To improve the overall outcome, radiologic predictors might stratify patients who benefit from successful medical management vs those who require intervention. This study investigated whether the number of identifiable entry tears in ABAD patients is associated with aortic growth. ABAD patients with uncomplicated clinical conditions and therefore treated with medical therapy were evaluated. Those with a computed tomography angiography (CTA) obtained at clinical presentation and a subsequent CTA obtained at least 90 days after medical treatment were included (2005 to 2010). The CTAs were investigated for the number of entry tears between the true and false lumen. Diameters of the dissected aortas were measured at five levels on the baseline and on the last available follow-up CTA, and annual aortic growth rates were calculated. The number of entry tears in these patients and the location in the aorta were compared with the aortic growth rate. Included were 60 patients who presented with 243 dissected segments. Mean growth rates during follow-up (median, 23.2; range, 3 to 132 months) were significantly higher in patients with 1 entry tear (5.6 ± 8.9 mm) than in those with 2 (2.1 ± 1.7 mm; p = 0.001) and 3 entry tears (mean 2.2 ± 4.1; p = 0.010). The distance of the primary entry tear from the left subclavian artery did not have an effect on the aortic growth rate (median, 38; interquartile range, 24 to 137 mm; p = 0.434). The number of entry tears in ABAD patients detected on the first CTA after clinical presentation is a significant predictor for aortic growth. Patients with 1 entry tear at presentation show a higher growth rate than other patients and might benefit from more strict surveillance or early prophylactic intervention.