Use Of CT Research Articles

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine.

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine.

What are the strongest indicators of intracerebral hemorrhage in mild traumatic brain injury?

BackgroundAlthough there are eight factors known to indicate a high risk of intracranial hemorrhage (ICH) in mild traumatic brain injury (TBI), identification of the strongest of these factors may optimize...

Utilization of computerized tomography and magnetic resonance imaging for diagnosis of traumatic C-Spine injuries at a level 1 trauma center: A retrospective Cohort analysis

BackgroundComputerized tomography (CT) is a common imaging modality for trauma patients, but there is debate regarding the role of magnetic resonance imaging (MRI) in cervical (C)-spine clearance. We aim to investigate the utilization of CT and MRI imaging in traumatic C-spine clearance and associated outcomes on patients who undergo both imaging modalities. MethodsA 4-year retrospective review was performed to evaluate the trauma patient imaging algorithm at our institution. The algorithm required CT as a screening examination for traumatic injury patients who are unexaminable because of distracting injury, altered mental status, an abnormal neurological examination, and/or central neck pain. MRI was performed after CT in patients with C-spine injuries identified on CT, those who remained unexaminable, had an abnormal neurological examination, or experienced persistent central neck tenderness. Univariate analyses and adjusted multivariate logistic regression were performed with significance defined as p < 0.05. Results805 patients were analyzed. Compared to MRI, CT had a sensitivity of 50.2%, specificity of 76.6%, positive predictive value of 69.7%, and negative predictive value of 59.0% in detecting C-spine injuries. CT and MRI differed significantly in their ability to detect C-spine soft tissue injuries and C1 vertebral fractures (p < 0.05). ConclusionsMRI is more capable of detecting soft tissue injuries whereas CT is superior in detecting vertebral fractures. Our findings support the need to utilize CT and MRI in conjunction to detect both bony and soft tissue C-spine injuries in traumatically injured patients, who are either unexaminable, have an abnormal neurologic examination, or ongoing central neck tenderness.

Cumulative radiation doses from recurrent PET-CT examinations.

Positron emission tomography (PET–CT) is an essential imaging modality for the management of various diseases. Increasing numbers of PET–CT examinations are carried out across the world and deliver benefits to patients; however, there are concerns about the cumulative radiation doses from these examinations in patients. Compared to the radiation exposure delivered by CT, there have been few reports on the frequency of patients with a cumulative effective radiation dose of ≥100 mSv from repeated PET–CT examinations. The emerging dose tracking system facilitates surveys on patient cumulative doses by PET–CT because it can easily wrap up exposure doses of PET radiopharmaceuticals and CT. Regardless of the use of a dose tracking system, implementation of justification for PET–CT examinations and utilisation of dose reduction measures are key issues in coping with the cumulative dose in patients. Despite all the advantages of PET/MRI such as eliminating radiation exposure from CT and providing good tissue contrast in MRI, it is expensive and cannot be introduced at every facility; thus, it is still necessary to utilise PET–CT with radiation reduction measures in most clinical situations.

Operational factors associated with emergency department patient satisfaction: Analysis of the Academy of Administrators of Emergency Medicine/Association of Academic Chairs of Emergency Medicine national survey.

Patient satisfaction is a focus for emergency department (ED) and hospital administrators. ED patient satisfaction studies have tended to be single site and focused on patient and clinician factors. Inclusion of satisfaction scores in a large, national operations database provided an opportunity to conduct an investigation that included diverse operational factors. We performed a retrospective analysis of the 2019 Academy of Administrators in Academic Emergency Medicine/Association of Academic Chairs of Emergency Medicine (AAAEM/AACEM) benchmarking survey to identify associations between operational factors and patient satisfaction. We identified 59 database variables as potential predictors of Press Ganey likelihood-to-recommend and physician overall scores. Using random forest modeling, we identified the top eight predictors in the models and described their associations. Forty-three (57.3%) academic departments responding to the AAAEM/AACEM survey reported patient satisfaction scores for 78 EDs. Likelihood to recommend ranged from 30.0 to 93.0 (median= 74.8) and was associated with ED length of stay, boarding, use of hallway spaces, hospital annual admissions, faculty base clinical hours, proportion of patients leaving before treatment complete (LBTC), and provider in triage hours per day. Physician overall score ranged from 53.3 to 93.4 (median= 81.9) and was associated with faculty base clinical hours, x-ray utilization, annual ED arrivals, LBTC, use of hallway spaces, arrivals per attending hour, and CT utilization. ED patient satisfaction was associated with intrinsic and extrinsic factors, some being potentially manageable within the ED but others being relatively fixed or outside the control of ED operations. For likelihood to recommend, patient flow was dominant, with erosion of satisfaction observed with increased boarding and longer LOS. Factors associated with physician overall score were more varied. The use of hallway spaces and base clinical hours greater than 1,500 per year were associated with both lower likelihood-to-recommend and lower physician overall scores.

Functional Cardiac Ct In Pediatric And Adult Patients With Congenital And Acquired Heart Diseases.

Introduction: The aim of the study was to assess the utility of the functional Cardiac CT in evaluating the cardiac function and morphology in patients with congenital and acquired heart diseases. Cardiac anatomy is well delineated by CT as compared to other available imaging modalities. Evaluation of cardiac function by CT has been a challenge. However with latest generation 320 detectors/640-multi slice CT machine it is now possible to assess cardiac anatomy and cardiac function.

Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy

Goals and backgroundThe utility of routine head CT (HCT) in hepatic encephalopathy (HE) evaluation is unclear. We investigated HCT yield in detecting acute intracranial abnormalities in cirrhotic patients presenting with...

Predicting Histology of Tracheobronchial Neoplasms: A CT Based Differentiation Model

Background: Tracheobronchial (TB) tumors follow same pathological classification as lung neoplasms; however, some entities are known to favor airways. Distinction of pathological types is necessary for suggesting appropriate management strategy.Purpose: To evaluate utility of multidetector CT (MDCT) in differentiation of primary TB tumors; and assess validity of a scoring system based on imaging biomarkers to differentiate tumor types.Methods: MDCT features of 45 patients were analyzed for location, shape, calcification, attenuation, parenchymal changes, bronchoceles, extraluminal extension, lymphadenopathy, metastases. The two largest groups were compared with each other and remaining entities using Chi square tests. Six-point scoring system combining the differentiating features was devised and receiver operating characteristic curve analysis performed.Results: The most frequent type was neuroendocrine tumors (NET) (51.1%), followed by salivary gland tumors (SGT) (20%); including adenoid cystic carcinoma (ACC) (13.3%) and mucoepidermoid carcinoma (MEC) (6.7%). Comparing NETs with other entities as a whole, and independently with SGTs, significant difference was found among location (p = 0.05 and 0.001 respectively), shape (p < 0.001), calcification (p = 0.038 and 0.041 respectively), attenuation (p = 0.001 and 0.019 respectively), bronchoceles (p = 0.013 and 0.010 respectively). Significant difference was found among ACC and MEC in location (p = 0.01) and morphology (p < 0.001).On receiver operating characteristic (ROC) curve analysis of the score, areas under curve for NET, SGT and ACC were 0.913, 0.872 and 0.962 respectively. Suggested cut-off values were >3.5 for carcinoid (sensitivity 70%, specificity 91%), <2.5 for SGT (sensitivity 78%, specificity 75%), <1.5 for ACC (sensitivity 83%, specificity 92%).Conclusion: Use of a scoring system enables maximum diagnostic accuracy in MDCT differentiation of TB tumors.

Semi-supervised learning for an improved diagnosis of COVID-19 in CT images.

Coronavirus disease 2019 (COVID-19) has been spread out all over the world. Although a real-time reverse-transcription polymerase chain reaction (RT-PCR) test has been used as a primary diagnostic tool for COVID-19, the utility of CT based diagnostic tools have been suggested to improve the diagnostic accuracy and reliability. Herein we propose a semi-supervised deep neural network for an improved detection of COVID-19. The proposed method utilizes CT images in a supervised and unsupervised manner to improve the accuracy and robustness of COVID-19 diagnosis. Both labeled and unlabeled CT images are employed. Labeled CT images are used for supervised leaning. Unlabeled CT images are utilized for unsupervised learning in a way that the feature representations are invariant to perturbations in CT images. To systematically evaluate the proposed method, two COVID-19 CT datasets and three public CT datasets with no COVID-19 CT images are employed. In distinguishing COVID-19 from non-COVID-19 CT images, the proposed method achieves an overall accuracy of 99.83%, sensitivity of 0.9286, specificity of 0.9832, and positive predictive value (PPV) of 0.9192. The results are consistent between the COVID-19 challenge dataset and the public CT datasets. For discriminating between COVID-19 and common pneumonia CT images, the proposed method obtains 97.32% accuracy, 0.9971 sensitivity, 0.9598 specificity, and 0.9326 PPV. Moreover, the comparative experiments with respect to supervised learning and training strategies demonstrate that the proposed method is able to improve the diagnostic accuracy and robustness without exhaustive labeling. The proposed semi-supervised method, exploiting both supervised and unsupervised learning, facilitates an accurate and reliable diagnosis for COVID-19, leading to an improved patient care and management.

Implementing Coronary CT for Routine Annual Surveillance of Cardiac Allograft Vasculopathy in Heart Transplant Patients

<h3>Purpose</h3> Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects heart transplant (HT) patients. Routine surveillance for CAV is warranted. We evaluated the feasibility, utility and safety of cardiac CT to screen for CAV in HT patients. <h3>Methods</h3> From Feb 2018 to Jul 2019 all HT patients >four years post-HT were converted from using stress myocardial perfusion imaging for the annual CAV surveillance to cardiac CT (calcium score scan and CT angiography (CTA)). All first scans were included. Scans were scored for image quality (non-diagnostic, moderate, good, excellent), Agatston calcium score and coronary stenosis (0%, <50% or ≥50%). CAV score (similar to ISHLT guidelines) based on CT findings was compared to the most recent CAV score (based on invasive angiography and perfusion imaging). Major adverse cardiovascular events (MACE) were scored one-year post-CT. <h3>Results</h3> In total, 141 CT scans were included. CTA was performed in 140 out of 141 patients who were planned for cardiac CT (55 (43-64) years, 66% men, and 11 (8-16) years post-HT). One patient only had a calcium score due to no IV access. Mean heart rate during CTA was 75±11 beats per minute with beta-blockers given in 90 patients. Image quality was good/excellent in 124 (89%) scans. Median radiation dose was 2.1 (1.6-2.9) mSv. Median Agatston calcium score was 4 (0-73), 56 (40%) patients had no detectable calcium. CTA showed new obstructive coronary disease (≥50% stenosis) in 25 (18%) patients (Figure 1). CTA reclassified CAV score in 49 (35%) patients (p<0.001). There were 78 CAV0, 30 CAV1, 15 CAV2 and 17 CAV3 patients. MACE occurred in 8 (6%) patients in the year post-CCTA (2 deaths (rejection + cancer), 5 CVAs, 2 myocardial infarctions (type 4 MI + NSTEMI in known CAV)). <h3>Conclusion</h3> Cardiac CT can be performed successfully in HT patients with good/excellent image quality and low radiation dose. CTA successfully detects significant CAV which leads to substantial reclassification of CAV grades.

Association between clinical, laboratory findings and chest CT in COVID-19 in a secondary hospital in Jakarta, Indonesia.

A new emerging infectious disease caused by SARS-CoV-2 has caused a global pandemic. Early diagnosis is essential to prevent and halt the spread of the disease, patient management and isolation. In this study, we aimed to reveal correlations between clinical and laboratory findings with chest CT. This in an observational case series single center study in a secondary hospital in Jakarta, Indonesia. Patients were included if they had typical symptoms and positive RT-PCR for SARS-CoV-2. Forty-two patients with positive RT-PCR were included in this study. Typical CT findings were present in 33 (78.6%). We found a positive correlation between patients in whom the imaging was performed after the 4th day of symptoms and chest CT findings (r=0.365 p<0.05). In receiver operating characteristic analysis of this parameter, the area under curve (AUC) was 0.678, and the sensitivity and specificity were 0.96 and 0.44, respectively. Early diagnosis of COVID-19 is essential to promptly isolate and treat suspected patients. Utilization of chest CT to help diagnosis in this pandemic era needs to be considered by healthcare facilities especially if RT-PCR is limited.

A74 INCREASING RATES OF CT IMAGING IN THE EMERGENCY DEPARTMENT AMONG PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract Background Computed tomography (CT) imaging of the abdomen is often performed in the emergency department (ED) to exclude urgent pathology in patients with Inflammatory Bowel Disease (IBD). However, concerns over excessive radiation exposure from repeated use have led to expert consensus guidelines advising against CT imaging unless there is suspicion of complications (obstruction, perforation, abscess) or a non-IBD cause for symptoms. Aims Our study aimed to determine trends in abdominal CT utilization and findings among patients with IBD in the ED. Methods We performed a retrospective cohort study between 01/01/2009 and 31/12/2018 at a single academic center. We identified ED encounters for adults (age ≥17 years) with a pre-existing diagnosis of IBD from our institutional database and determined the proportion resulting in an abdominal CT scan within 72 hours of presentation. IBD subtypes were classified based on ICD-10 claims: K50.90* for Crohn’s disease (CD), K51.90* for Ulcerative colitis (UC) and IBD undifferentiated (IBDU) for patients with both claims. A time trend analysis was performed using a generalized linear model that assumed a Poisson distribution. CT scans were classified according to the dominant imaging finding. For this part we excluded studies performed within 1-month of surgery or those re-assessing a known abscess or malignancy. Results A total of 14783 encounters were identified. Among these encounters 3000 CT scans were performed: 2000 for patients with CD (21.9%), 652 for UC (16.5%) and 348 for IBDU (20.4%). The rates of CT utilization significantly increased by 2.7% (95% CI, 1.2–4.3; p=0.0004) in patients with CD, by 4.2% (95% CI, 1.7–6.7; p=0.0009) in patients with UC and by 6.3% in patients with IBDU (95% CI, 2.5–10.0; p=0.0011). Among the eligible CT scans performed for CD, the following dominant findings were reported: normal (25%), inflammation (23%), obstruction (23%), penetrating (18%) and unrelated to IBD (8.6%). In contrast, the following findings for patients with UC were reported: normal (20%), inflammation (39%), obstructive (19%), penetrating (8%) and unrelated to IBD (15%). Conclusions In this single center study, a steady increase in CT utilization in the ED was observed in patients with IBD. Interestingly, only a small proportion of the CT scans demonstrated urgent findings. Future studies are required to determine the factors that contribute to the ongoing increase in CT utilization in this patient population. Funding Agencies None

Isolated subarachnoid hemorrhage in mild traumatic brain injury: is a repeat CT scan necessary? A single-institution retrospective study.

Traumatic brain injury (TBI) with isolated subarachnoid hemorrhage (iSAH) is a common finding in the emergency department. In many centers, a repeat CT scan is routinely performed 24 to72 h following the trauma to rule out further radiological progression. The aim of this study is to assess the clinical utility of the repeat CT scan in clinical practice. We reviewed the medical charts of all patients who presented to our institution with mild TBI (mTBI) and isolated SAH between January 2015 and October 2017. CT scan at admission and control after 24 to 72h were examined for each patient in order to detect any possible change. Neurological deterioration, antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries, and length of stay in hospital were analyzed. Of the 649 TBI patients, 106 patients met the inclusion criteria. Fifty-four patients were females and 52 were males with a mean age of 68.2years. Radiological iSAH progression was found in 2 of 106 (1.89) patients, and one of them was under antiplatelet therapy. No neurological deterioration was observed. Ten of 106 (9.4%) patients were under anticoagulation therapy, and 28 of 106 (26.4%) were under antiplatelet therapy. ISAH in mTBI seems to be a radiological stable entity over 72h with no neurological deterioration. The clinical utility of a repeat head CT in such patients is questionable, considering its radiation exposure and cost. Regardless of anticoagulation/antiplatelet therapy, neurologic observation and symptomatic treatment solely could be a reasonable alternative.

Usefulness of Staging Chest CT in Breast Cancer: Evaluating Diagnostic Yield of Chest CT According to the Molecular Subtype and Clinical Stage.

The aim of this study is to investigate the clinical utility of staging chest CT in breast cancer by evaluating diagnostic yield (DY) of chest CT in detection of metastasis, according to the molecular subtype and clinical stage. This retrospective study included 840 patients with 855 breast cancers from January 2017 to December 2018. The number of patients in clinical stage 0/I, II, III and IV were 457 (53.5%), 298 (34.9%), 92 (10.8%) and 8 (0.9%), respectively. Molecular subtype was identified in 841 cancers and there were 709 (84.3%) luminal type, 55 (6.5%) human epidermal growth factor receptor 2 (HER2)-enriched type and 77 (9.2%) triple-negative (TN) type. The DYs in clinical stage 0/I, cII, cIII and cIV were 0.2% (1/457), 1.7% (5/298), 4.3% (4/92) and 100.0% (8/8), respectively. The DYs in luminal type, HER2-enriched type and TN type were 1.7% (12/709), 3.6% (2/55) and 2.6% (2/77), respectively. Clinical stage was associated with the DY (p = 0.000). However, molecular subtype was not related to the DY (p = 0.343). Molecular subtype could not provide useful information to determine whether staging chest CT should be performed in early-stage breast cancer. However, chest CT should be considered in advanced breast cancer.

Dual-Layer Detector CT With Virtual Noncalcium Imaging: Diagnostic Performance in Patients With Suspected Wrist Fractures.

OBJECTIVE. The purpose of this study was to evaluate the diagnostic utility of dual-layer CT (DLCT) for evaluating wrist injuries and to compare it with MRI. MATERIALS AND METHODS. The cases of 62 patients with suspected wrist fractures who underwent imaging with both DLCT and MRI from January 2018 through February 2019 were retrospectively reviewed. By means of a calcium suppression algorithm, virtual noncalcium (VNCa) image reconstruction was performed, and the images were reviewed by two readers to identify fractures, bone contusions, and nontraumatic lesions in the radius, ulna, and carpal bones. Sensitivity, specificity, PPV, and NPV were calculated and compared between standard CT and VNCa images with a combination of standard CT and MRI as the reference standard. RESULTS. Use of DLCT with VNCa reconstruction increased the sensitivity of diagnosis of fractures in the radius and carpal bones over that of standard CT alone; occult fractures were detected that were not seen with standard CT. The sensitivity and specificity for detecting radius fracture were 98.1% and 93.8% for DLCT and 96.3% and 93.8% for standard CT. For detecting carpal bone fracture, sensitivity and specificity were 100% and 98.9% for DLCT and 93.8% and 100% for standard CT. VNCa reconstruction also had good diagnostic accuracy with regard to diagnosing nonfracture bone contusions in carpal bones. The accuracy was comparable to that of MRI with sensitivity of 92.9% and specificity of 94.5%. Interreader agreement in interpreting VNCa images was generally good to excellent. CONCLUSION. DLCT with VNCa reconstruction is a promising tool for identifying occult wrist fractures and nonfracture contusion injuries in patients with wrist trauma.

Data That Support Removing the Mysticism for Radiologist's Performance of Cardiac CT and MRI.

Data That Support Removing the Mysticism for Radiologist's Performance of Cardiac CT and MRI.

Incidental Findings: A Survey of Radiologists and Emergency Physicians.

Incidental findings (IFs) are defined as a “mass or lesion, detected by an imaging examination performed for an unrelated reason” [ 1 Berland L.L. Overview of white papers of the ACR incidental findings committee ii on adnexal, vascular, splenic, nodal, gallbladder, and biliary findings. J Am Coll Radiol. 2013; 10: 672-674 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar ]. Approximately a quarter of imaging tests will identify an IF, with nearly a third of CT scans revealing one [ 2 O’Sullivan J.W. Muntinga T. Grigg S. Ioannidis J.P.A. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018; 361: 1-13 Google Scholar , 3 Lumbreras B. Donat L. Hernández-Aguado I. Incidental findings in imaging diagnostic tests: a systematic review. Br J Radiol. 2010; 83: 276-289 Crossref PubMed Scopus (201) Google Scholar ]. As CT utilization has grown since the 1970s, the prevalence and burden of IFs have increased [ 1 Berland L.L. Overview of white papers of the ACR incidental findings committee ii on adnexal, vascular, splenic, nodal, gallbladder, and biliary findings. J Am Coll Radiol. 2013; 10: 672-674 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar ]. The ACR IF Committee has published white papers outlining imaging and clinical criteria for follow-up of IFs that may represent early cancer [ 4 Publications by the ACR IF Committee. Available at: https://publish.smartsheet.com/42d18e874a164318a0f702481f2fbb70. Accessed September 11, 2020. Google Scholar ]. However, institutional programs enabling tracking follow-up recommendations and assurance of follow-up tests’ completion for IFs remain sparse [ 5 Wandtke B. Gallagher S. Reducing delay in diagnosis: multistage recommendation tracking. AJR Am J Roentgenol. 2017; 209: 970-975 Crossref PubMed Scopus (17) Google Scholar ]. Relevance of Physician Attitudes Toward Incidental Findings for Radiology PracticeJournal of the American College of RadiologyVol. 18Issue 10PreviewWe share the concerns of Moore et al on the need to consider differing attitudes among radiologists and clinicians toward incidental findings (IFs) when seeking to improve the quality of care, and we extend the idea [1]. It has also been our experience that IFs are commonly encountered, particularly in examinations involving CT, and are often of potential clinical significance [2]. Failure to appropriately follow up or further investigate IFs represents a risk to physicians (at both ends) and to patients. Full-Text PDF

Utility of Multiparametric CT for Identification of High-Risk NAFLD.

OBJECTIVE. The purpose of this study was to evaluate the utility of laboratory and CT metrics in identifying patients with high-risk nonalcoholic fatty liver disease (NAFLD). MATERIALS AND METHODS. Patients with biopsy-proven NAFLD who underwent CT within 1 year of biopsy were included. Histopathologic review was performed by an experienced gastrointestinal pathologist to determine steatosis, inflammation, and fibrosis. The presence of any lobular inflammation and hepatocyte ballooning was categorized as nonalcoholic steatohepatitis (NASH). Patients with NAFLD and advanced fibrosis (stage F3 or higher) were categorized as having high-risk NAFLD. Aspartate transaminase to platelet ratio index and Fibrosis-4 (FIB-4) laboratory scores were calculated. CT metrics included hepatic attenuation, liver segmental volume ratio (LSVR), splenic volume, liver surface nodularity score, and selected texture features. In addition, two readers subjectively assessed the presence of NASH (present or not present) and fibrosis (stages F0-F4). RESULTS. A total of 186 patients with NAFLD (mean age, 49 years; 74 men and 112 women) were included. Of these, 87 (47%) had NASH and 112 (60%) had moderate to severe steatosis. A total of 51 patients were classified as fibrosis stage F0, 42 as F1, 23 as F2, 37 as F3, and 33 as F4. Additionally, 70 (38%) had advanced fibrosis (stage F3 or F4) and were considered to have high-risk NAFLD. FIB-4 score correlated with fibrosis (ROC AUC of 0.75 for identifying high-risk NAFLD). Of the individual CT parameters, LSVR and splenic volume performed best (AUC of 0.69 for both for detecting high-risk NAFLD). Subjective reader assessment performed best among all parameters (AUCs of 0.78 for reader 1 and 0.79 for reader 2 for detecting high-risk NAFLD). FIB-4 and subjective scores were complementary (combined AUC of 0.82 for detecting high-risk NAFLD). For NASH assessment, FIB-4 performed best (AUC of 0.68), whereas the AUCs were less than 0.60 for all individual CT features and subjective assessments. CONCLUSION. FIB-4 and multiple CT findings can identify patients with high-risk NAFLD (advanced fibrosis or cirrhosis). However, the presence of NASH is elusive on CT.

Added value of deep learning-based liver parenchymal CT volumetry for predicting major arterial injury after blunt hepatic trauma: a decision tree analysis.

In patients presenting with blunt hepatic injury (BHI), the utility of CT for triage to hepatic angiography remains uncertain since simple binary assessment of contrast extravasation (CE) as being present or absent has only modest accuracy for major arterial injury on digital subtraction angiography (DSA). American Association for the Surgery of Trauma (AAST) liver injury grading is coarse and subjective, with limited diagnostic utility in this setting. Volumetric measurements of hepatic injury burden could improve prediction. We hypothesized that in a cohort of patients that underwent catheter-directed hepatic angiography following admission trauma CT, a deep learning quantitative visualization method that calculates % liver parenchymal disruption (the LPD index, or LPDI) would add value to CE assessment for prediction of major hepatic arterial injury (MHAI). This retrospective study included adult patients with BHI between 1/1/2008 and 5/1/2017 from two institutions that underwent admission trauma CT prior to hepatic angiography (n = 73). Presence (n = 41) or absence (n = 32) of MHAI (pseudoaneurysm, AVF, or active contrast extravasation on DSA) served as the outcome. Voxelwise measurements of liver laceration were derived using an existing multiscale deep learning algorithm trained on manually labeled data using cross-validation with a 75-25% split in four unseen folds. Liver volume was derived using a pre-trained whole liver segmentation algorithm. LPDI was automatically calculated for each patient by determining the percentage of liver involved by laceration. Classification and regression tree (CART) analyses were performed using a combination of automated LPDI measurements and either manually segmented CE volumes, or CE as a binary sign. Performance metrics for the decision rules were compared for significant differences with binary CE alone (the current standard of care for predicting MHAI), and the AAST grade. 36% of patients (n = 26) had contrast extravasation on CT. Median [Q1-Q3] automated LPDI was 4.0% [1.0-12.1%]. 41/73 (56%) of patients had MHAI. A decision tree based on auto-LPDI and volumetric CE measurements (CEvol) had the highest accuracy (0.84, 95% CI 0.73-0.91) with significant improvement over binary CE assessment (0.68, 95% CI 0.57-0.79; p = 0.01). AAST grades at different cut-offs performed poorly for predicting MHAI, with accuracies ranging from 0.44-0.63. Decision tree analysis suggests an auto-LPDI cut-off of ≥ 12% for minimizing false negative CT exams when CE is absent or diminutive. Current CT imaging paradigms are coarse, subjective, and limited for predicting which BHIs are most likely to benefit from AE. LPDI, automated using deep learning methods, may improve objective personalized triage of BHI patients to angiography at the point of care.

The utility of routine head CT for hemorrhage surveillance in post-craniotomy patients undergoing anticoagulation for venous thromboembolism

Anticoagulation for postoperative venous thromboembolism (VTE) may infer a higher risk of intracranial hemorrhage. We treat patients with VTE using slowly titrating intravenous heparin drip without bolus. When PTT is greater than 60 s, a head CT is obtained to monitor for the development of a intracranial hemorrhage before transition to oral anticoagulation. We evaluated the utility of routine surveillance head CT to monitor for intracranial hemorrhage during anticoagulation. This is a case series of neurosurgical patients in an academic quaternary hospital who developed a VTE after cranial procedures between 2007 and 2017. Over 11,000 patients were screened for the study. Patients’ demographics data, surgical indication, PTT at the time of surveillance CT head, surveillance CT head findings, and patient’s clinical course were reviewed. A total of 83 patients were included. Three patients (3.6%) developed a new subclinical hemorrhage on CT head imaging while on heparin drip. Interval CT head showed stable hemorrhage in all patients. Heparin drip was stopped in two patients and they both progressed from DVT to pulmonary embolism: one patient died due to cardiac arrest, the other patient was transitioned to oral anticoagulation. In the third patient heparin drip was continued uneventfully and transitioned to oral anticoagulation with no further clinical sequalae. Surveillance CT while on heparin drip for VTE management detected subclinical intracranial hemorrhage in a small subset of patients. Patients whose anticoagulation was stopped had progression of VTE. Undertreatment of VTE in the presence of subclinical hemorrhage may lead to significant morbidity and mortality.