1
|
Qi Y, Ma X, Li G, Ma X, Wang Q, Yu D. Three-Dimensional Visualization and Imaging of the Entry Tear and Intimal Flap of Aortic Dissection Using CT Virtual Intravascular Endoscopy. PLoS One 2016; 11:e0164750. [PMID: 27760170 PMCID: PMC5070738 DOI: 10.1371/journal.pone.0164750] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/02/2016] [Indexed: 01/02/2023] Open
Abstract
AIMS Conventional computed tomography (CT) approaches provides limited visualization of the entire endoluminal changes of aortic dissection (AD), which is essential for its treatment. As an important supplement, three-dimensional CT virtual intravascular endoscopy (VIE) can show relevant details. This study aims to determine the value of VIE in displaying the entry tear and intimal flap of AD. METHODS AND RESULTS Among 127 consecutive symptomatic patients with suspected AD who underwent CT angiography (CTA), 84 subjects were confirmed to have AD and were included in the study. Conventional CT and VIE images were observed and evaluated. From the 92 entry tears revealed via conventional CT, 88 (95.7%) tears appeared on VIE with round (n = 26), slit-shaped (n = 9), or irregular (n = 53) shapes, whereas the intimal flaps were sheetlike (n = 34), tubular (n = 34), wavelike (n = 13), or irregular (n = 7) in shape. The VIE also showed the spatial relationship between the torn flap and adjacent structures. Among 58 entry tears with multiple-line type flap shown on conventional CT, 41 (70.7%) appeared with an irregular shape on VIE, whereas among 30 tears with single-line type flap, 17 (56.7%) appeared as round or slit-shaped on VIE. These results demonstrated a significant difference (P < 0.05). The poor display of tears on VIE was related to the low CT attenuation values in lumen or in neighboring artifacts (P < 0.01). CONCLUSION CT VIE presents the complete configurations and details of the intimal tears and flaps of AD better than conventional CT approaches. Accordingly, it should be recommended as a necessary assessment tool for endovascular therapy and as part of strategy planning in pre-surgical patients.
Collapse
Affiliation(s)
- Yafei Qi
- Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Xiaoyuan Ma
- Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Gang Li
- Radiology Department, Jiaotong Hospital of Shandong Province, Jinan, Shandong Province, China
| | - Xiangxing Ma
- Radiology Department, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Qing Wang
- Radiology Department, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Dexin Yu
- Radiology Department, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
- * E-mail:
| |
Collapse
|
2
|
Sawyer KN, Shah P, Qu L, Kurz MC, Clark CL, Swor RA. Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department. West J Emerg Med 2015; 16:677-82. [PMID: 26587090 PMCID: PMC4644034 DOI: 10.5811/westjem.2015.6.25958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/01/2015] [Accepted: 06/30/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. Methods This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. Results A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6mSv). No patient in either group had a related 30-day revisit. Conclusion Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.
Collapse
Affiliation(s)
- Kelly N Sawyer
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Payal Shah
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Lihua Qu
- William Beaumont Hospital, Research Institute Center for Outcomes Research, Royal Oak, Michigan
| | - Michael C Kurz
- University of Alabama School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Carol L Clark
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Robert A Swor
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| |
Collapse
|
3
|
Sentz A. The Role of CTA, MRA, and Sonography in Aortic Dissection. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2015. [DOI: 10.1177/8756479315586026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aortic dissection is an emergent condition requiring rapid diagnosis and immediate treatment. Patients with aortic dissection typically present with complaints of a sudden onset of severe abdominal and back pain. Patients with a suspected dissection may undergo a variety of imaging tests such as computed tomography angiography, sonography, and/or magnetic resonance angiography. The role of these diagnostic imaging modalities for aortic dissection is examined in detail in this literature review. These imaging modalities are compared and contrasted by reviewing their advantages, disadvantages, and overall effectiveness for aortic dissection.
Collapse
Affiliation(s)
- Amanda Sentz
- Adventist University of Health Sciences, Orlando, FL, USA
| |
Collapse
|
4
|
Polacco M, Sedati P, Arena V, Pascali VL, Zobel BB, Oliva A, Rossi R. Visualization of myocardial infarction by post-mortem single-organ coronary computed tomography: a feasibility study. Int J Legal Med 2014; 129:517-24. [PMID: 25249224 DOI: 10.1007/s00414-014-1085-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/03/2014] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Post-mortem imaging is increasingly used in forensic field in cases of natural deaths related to cardiovascular diseases, which represent the most common causes of death in developed countries. While radiological examination is generally considered to be a good complement for conventional autopsy, it was thought to have limited application in cardiovascular pathology. The aim of this study was to investigate the role of post-mortem multidetector coronary artery computed tomography in cases of sudden death in adults. MATERIALS AND METHODS We have enrolled 11 cases, all of whom were negative for macroscopic extra-cardiac lethal findings after standard autopsy procedure. Later, from the same individuals, isolated single-organ post-mortem computed tomography coronarography (PMCTA), using an iodinated non-ionic contrast medium, was achieved. After computed tomography examination, all the isolated hearths were carried to the forensic pathologist, and a conventional histology assessment was performed on them. RESULTS In 7 out of 11 of cadavers, a final diagnosis of myocardial infarction was made after a complete autopsy and histology procedures. Isolated hearts underwent PMCTA scanning and was confirmed in 6/11 cases, with the autopsy findings showing the presence and the localization of occlusions or severe stenoses and the extension of the myocardial hypoxic area by the extravasation of contrast medium as well. CONCLUSION Isolated single-organ PMCTA could be considered a valid and useful tool in addition to traditional autopsy investigation (macroscopic sections and histology) in identifying the cause of death by recognizing the presence and degree of coronary artery disease and myocardial infarction area visualization.
Collapse
Affiliation(s)
- Matteo Polacco
- Institute of Public Health, Section of Legal Medicine, Catholic University, Rome, Italy
| | | | | | | | | | | | | |
Collapse
|
5
|
CT Diagnosis of a Thoracic Aort Aneurysm with Type B Aortic Dissection Clinically Misdiagnosed as Acute Pulmonary Embolism. Case Rep Med 2012; 2012:720394. [PMID: 22991520 PMCID: PMC3444002 DOI: 10.1155/2012/720394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 08/15/2012] [Indexed: 11/17/2022] Open
Abstract
A 54-year-old man was admitted to the emergency department, presenting with an acute onset of chest pain and severe respiratory distress symptoms. He was medicated with intravenous analgesia and antihypertensive drugs. The patient was subjected to a chest X-ray which revealed a prominent widening of the mediastinum and pleural effusion on the left side. In laboratory tests-d-dimer level was highly elevated. The patient was clinically interpreted as having an acute pulmonary embolism and referred to the radiology clinic to perform a computed tomography (CT) examination. Contrast-enhanced CT demonstrated that there was no abnormality related to the pulmonary vasculature, but a huge thoracic aorta aneurysm measuring 11 × 8.1 × 7.7 cm in diameter was detected. Accompanying the aneurysm, an intimal flap was also present in the proximal descending thoracic aorta, distal to the origin of the left subclavian artery and extending into the bifurcation level. The patient was therefore diagnosed as having a type B aortic dissection as well. Once these serious conditions were detected, he was immediately transferred to a cardiovascular thoracic surgery hospital for endovascular repairment operation.
Collapse
|
6
|
Ross SG, Thali MJ, Bolliger S, Germerott T, Ruder TD, Flach PM. Sudden death after chest pain: feasibility of virtual autopsy with postmortem CT angiography and biopsy. Radiology 2012; 264:250-9. [PMID: 22570504 DOI: 10.1148/radiol.12092415] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the potential of minimally invasive postmortem computed tomographic (CT) angiography combined with image-guided tissue biopsy of the myocardium and lungs in decedents who were thought to have died of acute chest disease and to compare this method with conventional autopsy as the reference standard. MATERIALS AND METHODS The responsible justice department and ethics committee approved this study. Twenty corpses (four female corpses and 16 male corpses; age range, 15-80 years), all of whom were reported to have had antemortem acute chest pain, were imaged with postmortem whole-body CT angiography and underwent standardized image-guided biopsy. The standard included three biopsies of the myocardium and a single biopsy of bilateral central lung tissue. Additional biopsies of pulmonary clots for differentiation of pulmonary embolism and postmortem organized thrombus were performed after initial analysis of the cross-sectional images. Subsequent traditional autopsy with sampling of histologic specimens was performed in all cases. Thereafter, conventional histologic and autopsy reports were compared with postmortem CT angiography and CT-guided biopsy findings. A Cohen κ coefficient analysis was performed to explore the effect of the clustered nature of the data. RESULTS In 19 of the 20 cadavers, findings at postmortem CT angiography in combination with CT-guided biopsy validated the cause of death found at traditional autopsy. In one cadaver, early myocardial infarction of the papillary muscles had been missed. The Cohen κ coefficient was 0.94. There were four instances of pulmonary embolism, three aortic dissections (Stanford type A), three myocardial infarctions, three instances of fresh coronary thrombosis, three cases of obstructive coronary artery disease, one ruptured ulcer of the ascending aorta, one ruptured aneurysm of the right subclavian artery, one case of myocarditis, and one pulmonary malignancy with pulmonary artery erosion. In seven of 20 cadavers, CT-guided biopsy provided additional histopathologic information that substantiated the final diagnosis of the cause of death. CONCLUSION Postmortem CT angiography combined with image-guided biopsy, because of their minimally invasive nature, have a potential role in the detection of the cause of death after acute chest pain.
Collapse
Affiliation(s)
- Steffen G Ross
- Centre for Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Berne, Bern, Switzerland
| | | | | | | | | | | |
Collapse
|
7
|
Valente T, Rossi G, Lassandro F, Marino M, Tortora G, Muto R, Scaglione M. MDCT in diagnosing acute aortic syndromes: reviewing common and less common CT findings. Radiol Med 2011; 117:393-409. [PMID: 22095416 DOI: 10.1007/s11547-011-0747-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 04/11/2011] [Indexed: 12/19/2022]
Abstract
Nontraumatic acute thoracic aortic syndromes (AAS) describe a spectrum of life-threatening aortic pathologies with significant implications on diagnosis, therapy and management. In this context, multidetector computed tomography (MDCT) is the gold standard due to its intrinsic diagnostic value; its performance approaches 100% sensitivity and specificity, and it is accepted as a first-line modality for suspected acute aortic disease. MDCT allows early recognition and characterisation of acute aortic syndromes as well as the presence of any associated complications - findings that are essential for optimising treatment and improving clinical outcomes. Although classic CT findings have long been known, other unusual signs are continually reported in the medical literature. We reviewed the classic and less common CT findings, correlating them with pathophysiology, timing and management options, to achieve a definite and timely diagnostic and therapeutic definition.
Collapse
Affiliation(s)
- T Valente
- Dipartimento d Diagnostica per Immagini, Servizio di Radiologia, A.O.R.N. V. Monaldi, Napoli, Italy
| | | | | | | | | | | | | |
Collapse
|
8
|
Reeps C, Pelisek J, Bundschuh RA, Gurdan M, Zimmermann A, Ockert S, Dobritz M, Eckstein HH, Essler M. Imaging of Acute and Chronic Aortic Dissection by 18F-FDG PET/CT. J Nucl Med 2010; 51:686-91. [DOI: 10.2967/jnumed.109.072298] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
9
|
Hamilton MCK, Nightingale AK, Masey S, Stuart AG, Angelini G, Hopkins R, McGann G. A case report of a normal aorta misdiagnosed as type A dissection by modern multidetector computed tomography. Eur Radiol 2010; 20:1856-8. [PMID: 20306083 DOI: 10.1007/s00330-010-1748-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 12/31/2009] [Accepted: 01/09/2010] [Indexed: 11/29/2022]
Abstract
Computed tomography (CT) is generally considered the investigation of choice to exclude acute aortic syndrome. We report an important potentially disastrous misdiagnosis using a modern 32 slice multidetector CT system.
Collapse
Affiliation(s)
- M C K Hamilton
- Department of Radiology, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK.
| | | | | | | | | | | | | |
Collapse
|
10
|
The Importance of Imaging Assessment Before Endovascular Repair of Thoracic Aorta. Eur J Vasc Endovasc Surg 2009; 38:408-21. [DOI: 10.1016/j.ejvs.2009.06.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 06/22/2009] [Indexed: 11/23/2022]
|