Fleischner lines and pulmonary emboli

Initial findings in chest X-rays as predictors of worsening lung infection in patients with COVID-19: correlation in 265 patients

Background and aims

We aimed to analyze the relationship between the initial chest X-ray findings in patients with severe acute respiratory syndrome due to infection with SARS-CoV-2 and eventual clinical worsening and to compare three systems of quantifying these findings.

Material and methods

This retrospective study reviewed the clinical and radiological evolution of 265 adult patients with COVID-19 attended at our center between March 2020 and April 2020. We recorded data related to patients’ comorbidities, hospital stay, and clinical worsening (admission to the ICU, intubation, and death). We used three scoring systems taking into consideration 6 or 8 lung fields (designated 6A, 6B, and 8) to quantify lung involvement in each patient’s initial pathological chest X-ray and to classify its severity as mild, moderate, or severe, and we compared these three systems. We also recorded the presence of alveolar opacities and linear opacities (fundamentally linear atelectasis) in the first chest X-ray with pathologic findings.

Results

In the χ2 analysis, moderate or severe involvement in the three classification systems correlated with hospital admission (P = .009 in 6A, P = .001 in 6B, and P = .001 in 8) and with death (P = .02 in 6A, P = .01 in 6B, and P = .006 in 8). In the regression analysis, the most significant associations were 6B with alveolar involvement (OR 2.3; 95%CI 1.1.–4.7; P = .025;) and 8 with alveolar involvement (OR 2.07; 95% CI 1.01.–4.25; P = .046). No differences were observed in the ability of the three systems to predict clinical worsening by classifications of involvement in chest X-rays as moderate or severe.

Conclusion

Moderate/severe extension in the three chest X-ray scoring systems evaluating the extent of involvement over 6 or 8 lung fields and the finding of alveolar opacities in the first pathologic X-ray correlated with mortality and the rate of hospitalization in the patients studied. No significant difference was found in the predictive ability of the three classification systems proposed.

Initial findings in chest X-rays as predictors of worsening lung infection in patients with COVID-19: correlation in 265 patients

Antecedentes y objetivos

El propósito de este estudio en 265 pacientes con síndrome respiratorio agudo severo por coronavirus 2 (SARS-CoV-2) es establecer una relación entre la cuantificación inicial de los hallazgos en la radiografía de tórax en pacientes con COVID-19 y un eventual empeoramiento clínico, así como comparar tres sistemas de cuantificación que se proponen.

Material y métodos

En este estudio retrospectivo se revisó la evolución clínica y radiológica de 265 pacientes adultos con infección por COVID-19 atendidos en nuestro centro entre marzo y abril de 2020, registrándose la presencia de comorbilidades, así como datos de estancia hospitalaria y empeoramiento clínico (ingreso en unidad de cuidados intensivos/intubación y fallecimiento). La afectación en la radiografía de tórax inicial patológica de cada paciente se cuantificó siguiendo tres sistemas de puntuación diferentes sobre 6 u 8 campos pulmonares (denominados 6 A, 6 B y 8) para determinar una afectación leve, moderada o grave y establecer comparación entre dichos sistemas. También se registró la presencia de opacidades alveolares y opacidades lineales (fundamentalmente atelectasia laminar) en la primera radiografía patológica.

Resultados

La afectación moderada o grave en los tres sistemas de cuantificación (6 A, 6 B y 8) mostró correlación en el estudio de χ² con la variable ingreso hospitalario (p = 0,009, 0,001, 0,001, respectivamente) y fallecimiento de los pacientes (p = 0,02, 0,01, 0,006, respectivamente). El estudio de regresión mostró como más significativas las asociaciones 6 B + afectación alveolar [odds ratio (OR) 2,3, p = 0,025, intervalo de confianza (IC) al 95% 1,1-4,7) y clasificación 8 + afectación alveolar (OR 2,07, p = 0,046, IC 95% 1,01-4,25). La afectación moderada o grave en la radiografía de tórax no mostró diferencias significativas entre los tres sistemas de cuantificación en el estudio predictivo de empeoramiento clínico.

Conclusión

La extensión moderada/grave en los tres sistemas de puntuación de la radiografía de tórax valorando la extensión de enfermedad sobre 6 y 8 campos pulmonares y la existencia de opacidades alveolares en la primera radiografía patológica se correlacionaron con la mortalidad y la tasa de hospitalización en los pacientes estudiados. No se apreció una diferencia significativa en la capacidad predictiva de los tres sistemas de cuantificación propuestos.

Linear Atelectasis around the Hilum on Chest Radiography: A Novel Sign of Early Lung Cancer

BACKGROUND

Linear atelectasis is a focal area of subsegmental atelectasis with a linear shape. Linear atelectasis may occur as a consequence of subsegmental bronchial obstruction.

AIMS

We propose an early roentgen sign of obstructing lung tumors, namely perihilar linear atelectasis, and ascertain whether this phenomenon could be used as a sign to detect radiographically occult primary lung cancer.

MATERIALS AND METHODS

We performed a retrospective review of 45,000 posteroanterior chest radiographs to determine the frequency of appearance and characteristics of perihilar linear atelectasis. The perihilar region of chest radiographs was evaluated for the presence of linear atelectasis. When linear atelectasis was found, the total thickness was measured. Student's t-test was used to evaluate statistical significance, correlating the thickness of atelectasis and the presence of obstructing central primary lung cancer.

RESULTS

Perihilar linear atelectasis was demonstrated in 58 patients. Atelectasis was caused by an obstructing tumor in 21 (36%) cases and a variety of other conditions in 37 (64%) patients. A statistically significant relationship (P < 0.001) was observed between the dimension of perihilar linear atelectasis and primary lung cancer, with 16 of 19 patients with thick (>5.5 mm) perihilar linear atelectasis found to have primary lung cancer.

CONCLUSION

Thick perihilar linear atelectasis is a new diagnostic roentgen sign that suggests subsegmental bronchial obstruction. In this patient subgroup, who are otherwise asymptomatic, a persistent linear atelectasis can be due to primary lung cancer.

Historical Evolution of Imaging Techniques for the Evaluation of Pulmonary Embolism

As we celebrate the 100th anniversary of the founding of the Radiological Society of North America (RSNA), it seems fitting to look back at the major accomplishments of the radiology community in the diagnosis of pulmonary embolism. Few diseases have so consistently captured the attention of the medical community. Since the first description of pulmonary embolism by Virchow in the 1850s, clinicians have struggled to reach a timely diagnosis of this common condition because of its nonspecific and often confusing clinical picture. As imaging tests started to gain importance in the 1900s, the approach to diagnosing pulmonary embolism also began to change. Rapid improvements in angiography, ventilation-perfusion imaging, and cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging have constantly forced health care professionals to rethink how they diagnose pulmonary embolism. Needless to say, the way pulmonary embolism is diagnosed today is distinctly different from how it was diagnosed in Virchow's era; and imaging, particularly CT, now forms the cornerstone of diagnostic evaluation. Currently, radiology offers a variety of tests that are fast and accurate and can provide anatomic and functional information, thus allowing early diagnosis and triage of cases. This review provides a historical journey into the evolution of these imaging tests and highlights some of the major breakthroughs achieved by the radiology community and RSNA in this process. Also highlighted are areas of ongoing research and development in this field of imaging as radiologists seek to combat some of the newer challenges faced by modern medicine, such as rising health care costs and radiation dose hazards.