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ABSTRACT |
Vargas D.; El-Merhi F.; Ocazionez D.; Marmol A.; Jimenez A.; Restrepo C. S. The University of Texas Health Science Center at San Antonio, San Antonio, TX
Address correspondence to D. Vargas (vargasd2{at}uthscsa.edu)
Background: The right ventricle is an often overlooked structure when the radiologist evaluates cross-sectional studies. In part this is due to the low incidence of primary intrinsic abnormalities of the right ventricle; the vast majority of abnormal findings in the right ventricle are secondary to pulmonary hypertension. However, there is a myriad of entities that affect the right ventricle, some of which are unique to this anatomic structure, with distinctive imaging features that facilitate their prompt diagnosis. In addition to cardiac CT, we emphasize the use of emergent modalities such as cardiac MRI, which has proven useful in the diagnosis and evaluation of pathologies such as right ventricular infarction.
Key Issues: This exhibit will address the most commonly encountered right ventricular pathologies as seen on cross-sectional studies, along with clinical correlation. These include primary neoplasms such as rhabdomyoma, angiosarcoma and myxoma; congenital anomalies such as Ebstein's anomaly, arrythmogenic right ventricular cardiomyopathy (dysplasia) and double-chambered right ventricle; common pitfalls such as intraventricular thrombi; and postsurgical scenarios such as corrected tetralogy of Fallot. Special attention is dedicated to the evaluation of right ventricular dysfunction, right ventricular infarction and traumatic injuries on MRI and CT.
Format: Didactic in the form of PowerPoint with a short quiz at the end. Organizational structure to be done by pathology.
Teaching Points: Upon completing this exhibit, the individual should be familiar with the spectrum and imaging and clinical findings of right ventricular disease. The viewer should be able to determine how CT and MRI confer vital information in the diagnosis of right ventricular processes.
E048. Noncompaction Syndrome of the Myocardium: Pathophysiology and Imaging Pearls
Zenooz N. A.1; Zahka K.1; Siwik E.1; Johnson M.; Gilkeson R. C.1, Gupta P.2 Case Western Reserve University, Cleveland, OH; MacNeal Hosptial, Berwyn, IL
Address correspondence to N. Zenooz (navid.zenooz{at}case.edu)
Background: Noncompaction syndrome of the myocardium (NCSM), also referred to as "spongy myocardium," was thought to be very rare, but it has recently been more frequently reported. This syndrome appears as excessive and prominent trabeculations with deep intertrabecular recesses within the ventricular walls, usually involving the left ventricle (LV). It is seen in both genders and all races.
Key Issues: Patients may present with cardiac arrhythmias (the major cause of death), thromboembolic events, or LV failure. Associations with other diseases, including neurologic or other cardiac syndromes, have been noted. NCSM is primarily diagnosed by Doppler echocardiography; however, CT scan and MRI are useful tools for determining case severity and patient's prognosis. With these methods, high-resolution images of the myocardium are obtained that enable better recognition of the areas over which the trabeculae are distributed. Early diagnosis can improve the patient's survival by premature heart transplantation or implantation of a defibrillator. Also, since there are many reports of occurrence of this syndrome in several members of the same family (mainly X-linked inheritance), upon accurate and early diagnosis, the patient's family can be further screened.
Format: This didactic presentation is organized to: 1) review the pathophysiology of NCSM; 2) focus on imaging features of NCSM in cross-sectional modalities (CT and MRI); 3) discuss the value of early diagnosis and treatment of NCSM and also the importance of screening of the family members.
Teaching Points: We hope to make the reader more familiar with: (1) pathophysiology of NCSM; (2) clinical presentation and associations of this syndrome; and (3) characteristic imaging features of NCSM, which are helpful in diagnosis and prognostication of this syndrome.
E049. Imaging Features of Anomalous Coronary Arteries
Vilvendhan R.; Ersoy H.; Rybicki F. Brigham and Womens Hospital, Boston, MA
Address correspondence to R. Vilvendhan (rvilvendhan{at}partners.org)
Objective: To retrospectively analyze the imaging features of anomalous coronary arteries.
Materials and Methods: We retrospectively reviewed the medical and imaging records of 13 patients (1/2005–9/2006, M = 6, age range = 17–62 yrs, mean age = 46.1 yrs) diagnosed with anomalous coronary arteries by 64 slice CT (Siemens Sensation 64, Erlangen, Germany). The CT protocol used 0.6 x 0.4 mm slice thickness, and retrospective gating was used, with reconstruction between 40% and 85% of the cardiac cycle (5% increment). 60–90 cc of iodinated contrast media was administered (370 mgI/cc), followed by normal saline. Coronary anomalies were categorized as follows: origin, course (i.e. myocardial bridge), and termination (including coronary fistulae). Medical record review documented clinical presentation, angiographic findings, and nuclear imaging when available.
Results: Fourteen anomalous vessels were identified in 13 patients. All anomalous origins were coronary arteries that arose from the incorrect sinus of Valsalva. There were 2 anomalous left main (1 interartial, and 1 anterior to pulmonary artery), 2 anomalous right main (2 interartial) and 3 anomalous LCX (retroaortic). Three patients presented with myocardial bridges, with 4 bridged arteries (1 patient with bridge of both LAD and RCA). There were 3 anomalies of termination, both coronary artery to coronary sinus fistulas: one from the RCA, and two from the circumflex. Volume rendered images were useful in depicting the relationship between the anomalous arteries and myocardium. Oblique and curved planar reformatted images were useful in delineating anomalies.
Conclusion: 64-slice CT noninvasively delineates anomalous coronary anatomy. Volumetric and reformatted images were useful in interpretation. Classification into anomalous origin, course and termination can be performed with CTA.
E050. Getting To the Point: Imaging Lesions of the Cardiac Apex
Pantelic M.; Poopat C.; Song T.; Abdul-Nour K. Henry Ford Hospital, Detroit, MI
Address correspondence to M. Pantelic (milan{at}rad.hfh.edu)
Background: The heart can be involved by a wide spectrum of disease processes, including those of developmental, inflammatory, ischemic, neoplastic and acquired or iatrogenic cause. While some entities may have uniform manifestations, many are more protean, and still others may have particular predilection for or more unique features at the apical myocardium.
Key Issues: This exhibit will depict how global as well as local diseases of the heart manifest their involvement in the apical myocardium. The spectrum of diseases reviewed will include: normal variation; congenital and developmental abnormalities, including arrythmogenic dysplasia, hypertrophic and noncompaction states; inflammatory disease; ischemic disease, including infarction and thrombosis; iatrogenic injury and neoplastic involvement. A brief overview of relevant pathophysiology will be followed by presentation of correlative multimodality imaging by MRI, CT and echocardiography. Imaging findings will be stressed over details of imaging technique, although in some cases relevant technical pearls will be described.
Format: Predominantly didactic PowerPoint exhibit with some interactive navigation features, organized by pathologic subtype grouping and presenting diagnostic imaging in both static and dynamic (cine/movie) formats.
Teaching Points: The viewer will: • Gain an appreciation for the spectrum of disease involving the cardiac apex. • Become familiar with features of apical myocardial involvement in specific diseases, and their appearance on imaging modalities presented. • Appreciate strengths and weaknesses of the imaging modalities of CT, MRI and echocardiography. • Learn how to use this knowledge in the differential diagnosis of apical lesions.
E051. How Coronary CT Angiography can be used in the Preoperative Evaluation of Patients for Cardiac Surgery
Gupta R. T.1; Schwartz R. S.3; Gupta P. K.2; Kshettry V. R.3; Kirshenbaum K. J.1 1. Advocate Illinois Masonic Medical Center, Chicago, IL; 2. MacNeal Hospital, Berwyn, IL; 3. Minneapolis Heart Institute, Minneapolis, MN
Address correspondence to R. Gupta (Rajan.Gupta-MD{at}advocatehealth.com)
Background: The data that will be presented will be primarily from Minneapolis Heart Institute and will address the current and future utility of coronary CT angiography (CTA) and its advantages over conventional angiography. It will detail how this imaging modality can be used in lieu of conventional angiography in certain patient populations. It will also show how this can be an invaluable tool for the cardiac surgeon and other healthcare providers.
Key Issues: 1. To examine the role of cardiac imaging in preoperative evaluation of the cardiac surgery patient. 2. To understand advantages/disadvantages of coronary CTA and conventional angiography. 3. To show how one major center is using coronary CTA in place of conventional angiography. 4. To identify additional uses of coronary CTA in the future.
Format: The format of the exhibit will be didactic. Sample topic headings follow: 1. Overview of coronary CTA. 2. Coronary CTA vs. conventional angiography: What information does each provide? 3. How coronary CTA is being used currently in preoperative evaluation of patients for cardiac surgery at one major center. 4. How coronary CTA could obviate the need for conventional angiography in certain patient populations. 5. Utilization of coronary CTA: Its current uses and its additional potential applications in the future.
Teaching Points: The major teaching points of this exhibit are: 1. To show how coronary CTA and conventional angiography can be utilized to provide a detailed evaluation of the heart and coronary vessels in preoperative planning for cardiac surgery. 2. To identify the possible advantages of coronary CTA over conventional angiography. 3. To identify the patient populations most likely to benefit from coronary CTA vs. conventional angiography. 4. To provide examples of how coronary CTA can obviate the need for conventional angiography in certain groups.
E052. Assessment of Left Ventricular Hypertrophy and Dilation on Nongated Chest CT: Correlation with Echocardiography
Srinivasan A.2; Nallamshetty L.1; Aggarwal A.2; Gohari A.2 1. Bay State Medical Center, Springfi eld, MA; 2. State University of New York Health Science Center at Brooklyn, Brooklyn, NY
Address correspondence to A. Srinivasan (abhay.srinivasan{at}downstate.edu)
Objective: Left ventricular (LV) volume and wall thickness are important predictors of LV performance. Given the increasing role of CT in cardiac imaging, this study examines the validity of nongated chest CT in incidental determinations of LV hypertrophy or dilation, using echocardiography as the standard of reference.
Materials and Methods: 32 contrast-enhanced CT scans of 30 patients who recently underwent echocardiography were studied. Cardiac slice selection was standardized for maximum diastole, and a protocol was established for the measurement of the LV short axis diameter, inter-ventricular septum, and LV posterior wall. Measurements were made on Fusion eFilm v. 2.0 workstations (Merge Healthcare). Repeated CT measurements were obtained by three independent observers, blinded to each other and to the results of echocardiography. CT data were compared to M-mode echocardiographic measurements of LV end diastolic diameter (LVEDD, range 3.4 cm–6.9 cm, median 4.8 cm), posterior wall thickness (PWT, range 0.6 cm–1.4 cm, median 1.0 cm) and septum thickness (ST, range 0.6 cm–1.4 cm, median 1.0 cm). LV mass (LVM, range 106 g–320 g, median 170 g) was calculated from determinants LVEDD, ST and PWT using the American Society of Echocardiography formula. Analogous calculations were made using CT data. Correlation was evaluated using linear regression (Pearson's correlation coefficient, r) with statistical significance (Ho: r = 0) if p < 0.05.
Results: Correlation of LVM was moderate, r = 0.56 (p = 0.006). However, correlation plots showed stronger linkage at lower LVM values. The PWT and ST parameters demonstrated poor correlation, with r = 0.27 (p = 0.188) and r = 0.34 (p = 0.373), respectively. However, LVEDD correlation was strong between the two modalities, with r = 0.76 (p < 0.001), and r > 0.74 for each individual observer. Interobserver concordance for this parameter, defined by Cohen's kappa statistic, was 0.92, with a 95% confidence interval of [0.85, 0.96].
Conclusion: Non-gated chest CT is not a valid modality in evaluating left ventricular hypertrophy. This is predominantly attributed to inaccuracy (and imprecision) in measurement of the posterior wall and the septum. Results demonstrate that the 1.2 cm septal thickness cutoff that has traditionally been used to suggest LV hypertrophy on chest CT is not a valid criterion. However, good correlation between LV short axis on CT and LVEDD on echocardiogram suggests that chest CT may be useful in the incidental evaluation of dilated cardiomyopathy.
E053. Multislice CT Imaging of Coronary Fistulae
Pen V.; Provost Y.; Paul N. S. University of Toronto, Toronto, Canada
Address correspondence to V. Pen (penv{at}hotmail.com)
Background: Multidetector row CT (MDCT) provides a comprehensive, non invasive assessment of the coronary arteries. The aim of this exhibit is to review the spectrum of coronary artery fistulae and emphasize key features that influence surgical planning and follow up.
Key Issues: We reviewed all the coronary artery fistulae documented by MDCT angiography at our institution, a tertiary referral center, from February 2003 to August 2006. Eleven patients were identified; the electronic medical charts were accessed to document relevant symptoms and signs and the impact of the CT findings on clinical management.
Format: Didactic power point presentation combined with a quiz. Organizational structure: by imaging technique.
Teaching Points: 1. The definition and pathophysiology of coronary artery fistulae 2. The optimal MDCT protocol; data acquisition and post processing techniques used to depict the abnormal coronary vasculature and help to plan potential intervention as well as follow-up. 3. MDCT Coronary Angiography provides accurate depiction of the origin, the caliber and the site of drainage of coronary artery fistulae. 4. To differentiate coronary artery fistulae from mimickers.
E054. CT Coronary Angiography: The Importance and Application of EKG Editing
Pereira A. M.; Provost Y.; Doyle D.; Pen V.; Paul N. University Health Network/Mount Sinai Hospital, Toronto, Canada
Address correspondence to A. Pereira (andre.pereira{at}uhn.on.ca)
Background: The development of 64-row MDCT with faster gantry rotation has enabled a comprehensive assessment of the coronary arteries. Optimal speed and cardiac cycle synchronization are yet to be achieved, especially in cases with sinus tachycardia or development of arrhythmias during data acquisition. ECG editing is a feasible and valuable post processing tool which minimizes motion artifacts caused by mild cardiac arrhythmias (atrial fibrillation, premature ventricular contractions, bradycardia), especially in patients unable to receive pharmacological rate modification prior to examination.
Key Issues: This presentation aims to describe the fundamental essential anatomy and physiology of the normal cardiac conducting system and the characteristic EKG tracing of abnormal rhythms occurring in each region of the conducting system. The corresponding EKG editing technique required will be described in detail.
Format: The information will be presented in didactic format. First the viewer will be conducted through a review of the main abnormal rhythms. This will be followed by a description of the EKG editing techniques specifically used for abnormal rhythm. Comparative examples of coronary CT angiograms with and without EKG editing will be used to illustrate the clinical importance of this technique.
Teaching Points: 1. An understanding of the cardiac conducting system. 2. Recognition of the principle cardiac arrhythmias likely to occur during coronary CT. 3. To determine which EKG editing technique is required in order to maximize CT coronary angiogram quality.
E055. The A-Z of Coronary Angiography with 64-row MDCT
Paul N. S.2; Verschuur I.2; Walczynski R.1; Pereira A.2; Doyle D.2; Pen V.2; Santiago S.2; Spiller N.2; Provost Y.2 1. Toshiba Medical Systems (Canada), Markham, Canada; 2. University Health Network and Mount Sinai Hospital, Toronto, Canada
Address correspondence to N. Paul (narinder.paul{at}uhn.on.ca)
Background: CT coronary angiography (CTCA) is a rapidly evolving technology in the assessment of coronary artery disease. A robust and reproducible technique is vital to the success of this examination. There are numerous pitfalls and artifacts that can simulate disease and if unrecognized, reduce the accuracy of the technique.
Key Issues: The aim of this presentation is to provide a comprehensive review of the steps required to successfully perform, process and report CTCA using a 64-row MDCT. We aim to familiarize the reader with a spectrum of commonly encountered coronary artery abnormalities, artifacts and technical challenges.
Format: The presentation will include a glossary of terms linked to the relevant section in the body of the text. The presentation will be organized as a step wise logical sequence of events which aim to lead the reader from the process of patient selection and preparation through to post processing techniques used to identify artifacts and pitfalls.
Teaching Points: 1. Familiarity with technical terms related to CTCA. 2. A greater understanding of the intricacies related to successful CT coronary angiography.
E056. Evaluation of the Effectiveness of Oral Beta Blockade in Patients for Coronary CT Angiography
Pannu H.; Sullivan C.; Lai S.; Fishman E. K. Johns Hopkins Medical Institutions, Baltimore, MD
Address correspondence to H. Pannu (hpannu1{at}jhmi.edu)
Objective: To determine the effectiveness of oral beta blockade in lowering the heart rate prior to coronary CT angiography.
Materials and Methods: Nursing records for 238 consecutive patients having coronary CT angiography over 7 months were reviewed. 21 patients were excluded for lack of IV access, pacemakers, incomplete records or for contraindications to beta blockers. The heart rate (HR) was noted on arrival to CT and 30 and 60 minutes after oral beta blocker dosing.
Results: 94 of the 217 patients (43.3%) were not given beta blockers in the department and on arrival had a mean HR of 60.7 ± 5.3 bpm and during CT had a mean HR of 56.9 ± 7.6 bpm. 123 of the 217 patients (56.6%) were given rate controlling medication after arrival for CT. On arrival, these patients had a mean HR of 78.3 ± 9.4 bpm and during CT had a mean HR of 59.0 ± 7.7 bpm. 122 patients were given oral metoprolol in the following amounts - 114 got 50 mg, 7 got 100 mg and 1 got 25 mg; one patient got 30 mg of oral diltiazem. 68 (55.2%) patients were monitored by nursing for <1 hour and had a baseline HR of 73.1 ± 5.1 bpm, a 9.8 ± 4.7 bpm decrease in HR at 30 minutes and an HR of 56.5 ± 7.2 bpm during CT. 39 patients (31.7%) were monitored by nursing for 1 hour and had a baseline HR of 81.3 ± 7.2 bpm, a 9.8 ± 7.4 bpm decrease in HR at 30 minutes, a 16.9 ± 6.3 bpm decrease in HR at 60 minutes, and an HR of 59.8 ± 4.8 bpm during CT. 16 patients were given oral beta blocker, monitored by nursing for 1 hour and then given intravenous metoprolol. These patients had a baseline HR of 93.5 ± 8.9 bpm, a 13.1 ± 6.4 bpm decrease in HR at 30 minutes and a 15.9 ± 6.8 bpm decrease in HR at 60 minutes. There were no complications from the metoprolol.
Conclusion: Oral metoprolol can be given safely for cardiac CT and effectively lowers the heart rate in approximately one hour.
E057. Cardiac MDCT Evaluating Chest Pain in the Emergency Room
Kim D.2; Byun J.1 1. Chosun University Hospital, Gwangju, South Korea; 2. Chosun University, College of Medicine, Gwangju, South Korea
Address correspondence to D. Kim (kdhoon{at}chosun.ac.kr)
Objective: The objectives of our exhibition are to show various gated or nongated MDCT images and to determine whether MDCT can provide a comprehensive assessment of cardiac and noncardiac causes of chest pain in emergent patients.
Materials and Methods: Patients with chest pain between March 2005 and July 2006 were approached for recruitment in this retrospective study. Each patient underwent enhanced ECG-gated or nongated16-slice MDCT. The images were evaluated for cardiac (coronary calcium scoring and stenosis, perfusion, wall motion and ejection fraction) and significant noncardiac (pulmonary embolism, aortic dissection, pneumonia and non traumatic pneumothorax etc.) causes of chest pain. Correlation was made between the presence of significant cardiac and noncardiac findings on CT and the final clinical diagnosis based on history, examination, and any subsequent work-up.
Results: The 264 patients who complete the chest pain protocol included 147 men (56%) and 117 women (44%) with a mean age of 58 years (range, 27–88 years). 192 patients (73%) had no significant CT findings and a final diagnosis of clinically insignificant chest pain. 72 (27%) had significant CT findings (cardiac causes in 15 patients and noncardiac causes in 57 patients) concordant with the final diagnosis. CT failed to suggest a diagnosis in 5 patients (5/72, 7%), three of whom proved to have clinically significant coronary artery stenoses and two proved to have pulmonary thromboembolism clinically. Overall sensitivity for all other cardiac and noncardiac causes were 80% and 96%, respectively.
Conclusion: Gated or nongated MDCT scanning in emergent patients with chest pain is a feasible and a useful modality for evaluating cardiac and noncardiac causes of chest pain.
E058. Prevalence and Significance of Incidental Findings on Cardiac MRI
Laxpati M. J.2; McKenna D. A.1; Colletti P. M.1 1. Keck School of Medicine, Department of Radiology, Los Angeles, CA; 2. Keck School of Medicine, University of Southern California, Los Angeles, CA
Address correspondence to M. Laxpati (laxpati{at}gmail.com)
Objective: The purpose of this study is to determine the prevalence and significance of incidental extracardiac thorax and upper abdominal findings on cardiac MR exams.
Materials and Methods: 132 elderly participants enrolled in an ongoing prospective observational study, underwent a screening cardiac MRI exam between November 23, 2005 and July 20, 2006, using a standard 7 sequence protocol. Participants had a mean age of 74.2 years (range, 61–89 years), and were composed of 127 men and 5 women. All images were retrospectively reviewed by a radiologist, specifically assessing for noncardiac findings. Visualized abnormalities were noted and categorized according to significance. Clinically significant findings were defined as those requiring further clinical or radiological work-up, with moderately significant findings defined as those that may affect patient care depending on medical history or symptoms. Remaining findings were considered clinically insignificant.
Results: Within the group, 107 volunteers (81%) had extracardiac findings, with 63 (48%) having multiple findings. A total of 224 incidental findings were visualized, with at least one clinically significant and moderately significant finding found in 23 (17%) and 43 (33%) of the subjects, respectively. Clinically significant findings included pulmonary and pleural nodules, solid or complex lesions in the kidneys, liver, and thyroid, and aortic aneurysms and dissection. The most prevalent incidental findings were benign appearing renal cysts, hepatic cysts, hemangiomas, and atelectasis. The SSFSE coronal and axial localizer, and short axis oblique sequences were most sensitive at detecting incidental findings with 47%, 46%, and 41% of all findings visualized on each of the views, respectively.
Conclusion: In total, 81% of our volunteers had extracardiac findings, of which 17% had clinically significant findings, necessitating further work up. We believe that these numbers may appear elevated secondary to the fact that we specifically reviewed studies for incidental findings, but may actually be close to the true prevalence for this reason. It is therefore important that physicians look beyond the heart when reviewing cardiac MRI studies and carefully assess the entire field of view for abnormalities.
E059. Postoperative MR Imaging in Congenital Heart Disease— An Increasing Category of Patients in Cardiac MRI
Schneider G.2; Massmann A.2; Lindinger A.3; Schäfers H.1; Fries P.2 1. Department of Thoracic and Cardiovascular Surgery, Homburg, Germany; 2. Department of Diagnostic and Interventional Radiology, Homburg, Germany; 3. Department of Pediatric Cardiology, Homburg, Germany
Address correspondence to G. Schneider (ragsne{at}uniklinik-saarland.de)
Background: Survivors of congenital heart disease (CHD) who underwent corrective surgical procedures are more and more a common referral in cardiac MRI. The aim of this exhibit is to teach postsurgical anatomy and related short and long term complications in MRI.
Key Issues: This exhibit reviews technical aspects and clinical considerations in MRI of patients post surgery for CHD. Whereas some of the patients are still in the pediatric age group others reached the adult age and now present with heart insufficiency or other long term problems related to the corrective surgical procedures which make it necessary to tailor MR studies to the specific clinical problems. Case studies illustrate how MRI can complement data from other imaging modalities.
Format: One of the well-established applications of MRI is the evaluation of CHD in the pediatric age group. However increasing interest is gained in the follow-up of patients with CHD who underwent corrective surgical procedures. In this context adult CHD represents an increasing category of patients and radiologists should be aware of the common postsurgical anatomy and associated short and long term complications.
Teaching Points: The aim of this exhibit is to demonstrate postoperative MRI in long term survivors of congenital heart disease.
E060. MRI of Cardiac and Paracardiac Masses: A Pictorial Review
Schneider G.3; Fries P.3; Boehm M.2; Schaefers H.1; Kindermann I.2 1. Department of Thoracic and Cardiovascular Surgery, Homburg, Germany; 2. Department of Cardiology, Homburg, Germany; 3. Department of Diagnostic and Interventional Radiology, Homburg, Germany
Address correspondence to G. Schneider (ragsne{at}uniklinik-saarland.de)
Background: Although cardiac masses are most frequently detected on echocardiography, MRI is the method of choice to accurately evaluate and further characterize cardiac tumors.
Key Issues: MRI is a valuable tool in evaluation of cardiac and paracardiac masses. The maximum information is gained if all clinical information together with results of other imaging modalities are taken into consideration. The minimal MR protocols to characterize a lesion should be understood to add important information in the work-up of cardiac and paracardiac masses.
Format: An overview of imaging techniques in cardiac MRI together with proposed protocols to evaluate cardiac masses will be presented. Based on MRI findings and other clinical data algorithms that give the reader a large spectrum of information to characterize cardiac and paracardiac masses will be presented. Case studies include common and rare benign and malignant as well as tumor-like lesions with typical and atypical manifestation and will be correlated with histology and surgical images.
Teaching Points: The purpose of this exhibit is to present MRI findings in both benign and malignant cardiac tumors as well as tumor-like lesions. When helpful CT imaging, catheter angiography and echocardiography as well as histologic specimens are presented in addition and important findings for diagnosis, staging and therapy planning will be highlighted.
E061. Cardiac Magnetic Resonance of Patients with Tetralogy of Fallot Following Surgical Repair
Chapman V. M.; Larson D.; Rader S.; Strain J. The Childrens Hospital, Denver, CO
Address correspondence to V. Chapman (vernon.chapman{at}riaco.com)
Background: Advances in the medical and surgical management of patients with Tetralogy of Fallot (TOF) has led to an increased number of these patients surviving into adulthood. Cardiac magnetic resonance (CMR) is an excellent noninvasive means of following these patients.
Key Issues: Following surgical repair of TOF, patients experience varying degrees of pulmonary regurgitation and right ventricular dilation/dysfunction. In addition, the pulmonary arteries may exhibit stenoses as a consequence of hypoplasia or prior surgical intervention (such as Blalock-Taussig shunt). CMR allows both anatomic and functional characterization and assists in determining the appropriate timing for surgical intervention.
Format: The format for this presentation will be didactic. The following topics will be reviewed: (1) anatomy of uncorrected TOF, (2) types of initial surgical repair, (3) Imaging protocol, (4) Important imaging findings and functional parameters, and (5) timing and types of subsequent surgical intervention.
Teaching Points: Cardiac magnetic resonance is an excellent noninvasive means of evaluating patients with Tetralogy of Fallot following surgical repair. CMR allows quantification of pulmonary regurgitation, right ventricular size and systolic function and assists in determining to appropriate timing of surgical intervention.
E062. MRI of Left Ventricular Thrombus
Colletti P. M.; Sarma R. J. University of Southern California, Los Angeles, CA
Address correspondence to P. Colletti (colletti{at}usc.edu)
Background: This exhibit demonstrates the cardiac MRI findings in left ventricular thrombus
Key Issues: Organization is by cardiac MRI findings on localizers, cine, perfusion imaging, and delayed contrast enhancement views.
Format: 10 cases are presented as unknowns with history, correlative echocardiograms and follow-up. Each case has teaching points emphasized.
Teaching Points: Left ventricular thrombi: 1. Are often not detected by echocardiology. 2. May occur with or without LV aneurysm. 3. Can be detected on localizer images, with cine functional studies, during perfusion exams, and on delayed contrast-enhanced views. 4. May be small (<5 ml) or large (>20 ml) 5. May be plaque-like, sessile, or pedunculated. 6. Can regress with anticoagulation or embolize and cause arterial occlusion.
E063. Differences in Clinical Information Gained From Imaging Modalities Including MR, CT, and Nuclear Studies
Sachdev K.2; Hoffmann U.1 1. Massachusetts General Hospital, Boston, MA; 2. St Francis Hospital, Evanston, IL
Address correspondence to K. Sachdev (karinasachdev{at}yahoo.com)
Background: Noninvasive imaging of the heart is a very important application because coronary artery disease is one of the leading killers worldwide.
Key Issues: This exhibit will address advances in MRI, CT (including CT angio and cardiac calcium scoring), and nuclear studies in imaging of the heart with comparisons to cardiac cath and echo.
Format: Format will be both didactic and quiz format with organizational structure by imaging technique - tables will contrast disadvantages and advantages of various techniques.
Teaching Points: I will hope the viewer will get a feel for the advantages of noninvasive imaging of the heart, comparing and contrasting each separate modality.
E064. Cardiac Imaging–Are We There Yet?
Kapoor V. Bayhealth Medical Center, Kent General Hospital, Dover, DE
Address correspondence to V. Kapoor (vibhu{at}kapoorv.us)
Background: Coronary artery disease is one of the leading causes of morbidity and mortality in developed countries such as the United States. Perpetual cardiac motion critical to sustaining life has been a challenge to noninvasively image the morphology and function of the heart. Recent advances in gated multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) have made it possible to study the function and anatomy of the heart.
Key Issues: This electronic presentation has two parts: Part I reviews the principles of gated cardiac imaging; the rational and technique for optimal contrast administration; and parameters/sequences for performing cardiac imaging with MDCT and MRI. Part II reviews the cardiac anatomy, clinical applications and limitations of both these imaging techniques.
Format: The educational exhibit is presented in a PowerPoint didactic format. It is organized as follows: Part I: Principles of gated cardiac imaging; optimizing contrast delivery for coronary artery imaging; parameters for cardiac MDCT; sequences for cardiac MRI. Part II: Coronary artery anatomy–normal and abnormal; multiplanar cross-sectional anatomy of cardiac chambers; anatomical and functional cardiac imaging with MDCT/MRI.
Teaching Points: 1. Enable reader to understand and implement the protocols to evaluate morphology and function of the heart including coronary arteries, cardiac chambers, myocardial perfusion and viability and valvular heart disease 2. Review the clinically pertinent CT and MRI anatomy of the heart 3. Provide guidelines for interpretation of cardiac studies.
E065. Ventricular Assist Devices. A Pictorial Review
Hameed T. Indiana University, Indianapolis, IN
Address correspondence to T. Hameed (thameed{at}iupui.edu)
Background: Ventricular assist devices are utilized in the management of patients with advanced heart failure. These are commonly used as a temporary measure awaiting transplantation. These may also be used for long term care as myocardial replacement or as a bridge to myocardial recovery. With recent technological developments, the use of these devices is increasing and it is important for the radiologists to be familiar with these devices.
Key Issues: This exhibit describes various types of ventricular assist devices, their basic mechanism and expected connections within the body, imaging findings in patients with the devices and associated complications.
Format: Format will be didactic. Organizational structure will be by the types of devices followed by imaging appearance of the devices and complications.
Teaching Points: 1. The basic mechanism and types of the ventricular assist devices. 2. Appearance of ventricular assist devices on imaging. 3. Imaging findings of complications related to ventricular assist devices.
E066. Influence of Sex and Somatotype on Aortic Root Diameter
Adamu A. A. Rostov State Medical University, Rostov-on-Don, Russia
Address correspondence to A. Adamu (scorpion68kd{at}yahoo.com)
Objective: This study aimed to examine the effect of sex and body habitus on aortic root diameter in healthy individuals.
Materials and Methods: 165 healthy individuals in the age range 17 to 23 years (85 women and 80 men) underwent anthropometry and M-mode echocardiography. Using the method of R.N. Dorokhov and V.G. Petrukhin (1989), the individuals were grouped according to somatotype into nanosomic (I), microsomic (II), micromesosomic (III), mesosomic (IV), mesomacrosomic (V), macrosomic (VI) and megalosomic (VII). Aortic root diameter was measured in centimeters using the parasternal long axis view during the diastolic phase of the cardiac cycle. Echocardiography was synchronized with electrocardiography.
Results: In this study, no individuals with types I and VII somatotypes were found. Aortic root diameter is higher in men than in women (3.04 ± 0.04 and 2.75 ± 0.03 cm, respectively). In women the values obtained for the different somatotypes are -2.61 ± 0.04 (II); -2.70 ± 0.07 (III); -2.78 ± 0.06 (IV); -2.75 ± 0.08 (V); 2.79 ± 0.07 (VI). There is no apparent change in the obtained values with changing body habitus. However, in men we observed a progressive rise in aortic root diameter with increasing body habitus -2.80 ± 0.06, 2.89 ± 0.06, 2.97± 0.12, 3.08 ± 0.06, 3.20 ± 0.07.
Conclusion: Aortic root diameter is higher in men than women; it also increases with increasing body size in men but not in women. The influence of sex and somatotype on aortic root diameter needs to be evaluated as it is sometimes necessary to delineate between higher limit of normality and early manifestation of disease.
E067. Multimodality Imaging of Azygous Vein Anomalies
Saghari H.; Stringfellow G.; Richardson R. R.; Mitchell C. l. St. Joseph's Hospital and Medical Center, Phoenix, AZ
Address correspondence to H. Saghari (Sagharih{at}yahoo.com)
Background: Azygous vein anomalies are commonly encountered on MDCT and MR of the chest and abdomen. Although the majority of these anomalies are incidental and of little clinical significance some can be symptomatic such as the fistulous communication with the left atrium and some may be part of a heterotaxy syndrome. The major anomalies of the azygous vein include congenital absence of the azygous, azygous lobe and azygous continuation of the IVC. Less common azygous anomalies include interruption of the azygous vein with reconstitution, fistulous communication of the azygous vein with the left atrium and a double azygous arch
Key Issues: We retrospectively reviewed 120 cardiac MRAs and 150 CTAs in approximately 230 patients. MRA was performed using double dose contrast with 3D time of flight GRE sequences. CTA was performed using 3 cc/kg nonionic contrast at 3 cc/sec and 1 mm axial slices at 11 sec and 16 sec delays. Raw data was used to construct multiplanar and 3D reformatted images. Correlation with angiography was obtained when the anatomy was out of the ordinary. We encountered five cases of azygous continuation of the IVC. One case demonstrated in utero IVC clot and showed enlargement of the azygous system at birth with the IVC difficult to follow below the liver on MRI. Four out of five cases of azygous continuation of the IVC had other common situs anomalies with associated congenital heart disease. Additionally, there were two cases of congenital absence of the azygous vein and two cases of an accessory azygous vein. Of the less common anomalies, we found one case of a double azygous arch, and 2 cases of interruption of the azygous with blood return from the lower azygous to the left atrium and reconstitution of the azygous vein forming an arch and emptying into the SVC.
Format: MRA and CTA are excellent imaging modalities for evaluation of venous anomalies in chest and abdomen. The most common type of azygous anomaly associated with other congenital anomalies is azygous continuation of the IVC, in which we found 6 cases in 230 patients. The two cases of fistulous communication of the azygous vein with the left atrium are important to recognize because they represent right to left shunts and could be the source of emboli. The other encountered anomalies represent interesting anatomic variants that are important for radiologists and clinicians to recognize to avoid diagnostic pitfalls.
Teaching Points: Most common types of azygous anomaly and association with other anomalies
E068. CTA and MRA Evaluation of Left Superior Vena Cava Anomalies
Saghari H.; Stringfellow G. B.; Richardson R. R.; Trahan A. M.; Mitchell C. L. St. Joseph's Hospital and Medical Center, Phoenix, AZ
Address correspondence to H. Saghari (sagharih{at}yahoo.com)
Background: A left superior vena cava (SVC) is a commonly encountered vascular anomaly seen on MDCT and MR of the chest. Although the majority of these anomalies are incidental and are of little clinical significance some can be symptomatic and may be part of a congenital heart disease complex. The left SVC typically inserts into the coronary sinus returning blood to the right atrium. We found one left SVC that passed under the aorta back to the right SVC. A left SVC may connect directly to the left atrium and can be a cause of cyanosis. Finally the left SVC can be a conduit for the pulmonary venous return in patients with total anomalous pulmonary venous return.
Key Issues: We retrospectively reviewed 120 cardiac MRAs and 150 CTAs in approximately 230 patients. MRA was performed using double dose contrast with 3D time of flight GRE sequences. CTA was performed using 3 cc/kg nonionic contrast at 3 cc/sec and 1mm axial slices at 11-sec and 16-sec delays. Raw data was used to construct multiplanar and 3D reformatted images. Conventional angiography was performed in 5 patients. Correlation with angiography was obtained when the anatomy suggested a symptomatic lesion
Format: We found a left SVC in 31 patients. Of these, 25 were of the classic left SVC type with blood return to the right atrium via the coronary sinus. Three of the patients had a left SVC that connected directly to the left atrium and had symptoms of cyanosis or low oxygen saturations. One patient had total anomalous pulmonary venous return (TAPVR) with the left SVC serving as a conduit to return blood from the lungs back to the right SVC and right atrium. One patient had blood return to the coronary sinus but also had a partial anomalous pulmonary venous return (PAPVR) from the left upper lobe. Finally one patient had a left SVC that passed under the aorta and connected to the right SVC, which may make this an aberrant left brachiocephalic vein rather than a left SVC. There were no false positives or false negatives when correlating with conventional angiography. MRA and CTA are excellent imaging modalities for evaluation of venous anomalies in the chest with excellent correlation with conventional angiography. The most common type of left SVC returns blood to the right atrium via the coronary sinus. It is important to always trace the blood flow of a left SVC as they may return blood to the left atrium or serve as a conduit for pulmonary blood flow in PAPVR or TAPVR.
Teaching Points: Role of CTA and MRA in evaluation of venous anomalies.
E069. The Lateral Chest Radiograph Revisited: Normal Anatomy with 3D CT Correlation
Christensen J.; Wandtke J. University of Rochester, Rochester, NY
Address correspondence to J. Christensen (Jared_Christensen{at}urmc.rochester.edu)
Background: Although the use of chest CT has greatly increased over the past several years, chest radiography remains the most frequently performed imaging examination. While emphasis is placed on the frontal projection, the lateral chest radiograph is an important adjunct in the diagnosis of cardiothoracic disease, particularly in the evaluation of "blind" areas not well visualized on the frontal view and in further localizing pathology. A sound understanding of normal anatomy and common variants is essential for the accurate interpretation of the lateral chest radiograph.
Key Issues: Evaluation of the lateral chest radiograph is challenging in several respects: it is more susceptible to distortion from improper patient positioning than the frontal projection; anatomic structures from both lungs are superimposed; and interfaces between aerated lung and lesions are not easily seen. Notwithstanding, there are key anatomic structures, landmarks, and spaces which should routinely be identified on systematic review to facilitate interpretation; the absence or variation in such may indicate pathology. Imaging correlation with chest CT is beneficial in further defining and reinforcing these anatomic relationships. The information obtained on chest CT supports, rather than supplants, that obtained from skilled interpretation of the lateral chest radiograph.
Format: The exhibit will focus on the normal anatomy of the lateral chest radiograph with axial and multiplanar CT reconstructions for correlation. A detailed anatomic didactic review of the following will be presented: heart and vasculature; mediastinum (anterior, middle, and posterior structures); hila; spaces (retrosternal, retrocardiac, and retrotracheal); lobes and pulmonary segments; fissures; trachea and bronchi; hemidiaphragms; and osseous structures. Each section includes interactive components, examples of common pathology, and a final user quiz at the conclusion of the exhibit.
Teaching Points: 1. Understand the benefits as well as the limitations of the lateral chest radiograph. 2. Review normal thoracic and cardiac anatomy on the lateral chest radiograph with 3D CT correlation. 3. Apply a systematic approach to facilitate interpretation of anatomic subtleties. 4. Demonstrate overall proficiency in the identification of normal lateral thoracic anatomy through an interactive quiz.
E070. Collage Of Pulmonary Artery Anomalies
Berkowitz E. A.; Ferguson E. C.; Oldham S. A. University of Texas-Houston Health Sciences Center, Houston, TX
Address correspondence to E. Berkowitz (eugberkowitz{at}yahoo.com)
Background: Anomalies of the pulmonary arteries encompass several categories: congenital, vascular, neoplastic, infectious/granulomatous, and traumatic. The history, clinical context and radiographic appearance will point one toward the appropriate diagnosis.
Key Issues: Pulmonary artery pseudoaneurysm occurs secondary to trauma, infection or iatrogenic. Pulmonary artery aneurysm is rare but may been seen with Takayasu's arteritis, giant cell arteritis, Behcet's disease, William's Syndrome, prenatal varicella, pulmonary arterial hypertension, traumatic/mycotic, or catheter complication. Pulmonary arterial hypertension causes a pressure overload and manifests as an enlarged main (>33 mm), right/left (>22 mm) main pulmonary arteries, peripheral vessel tapering, and RVH. Calcification of the wall of the pulmonary arteries is diagnostic of PAH. Intracardiac and extracardiac left to right shunts cause increased vascularity secondary to volume overload, enlarging the pulmonary arteries with large vessels extending to periphery. The knuckle sign refers to the dilatation and abrupt termination of a pulmonary artery upstream of an obstructing pulmonary thrombus. Neoplasms of the pulmonary arteries include myxoma and sarcoma which is rare polyploid enhancing intravascular mass within a central pulmonary artery. Tumor embolism is rarely seen but has been reported with hepatocellular carcinoma and renal cell carcinoma. Pulmonary artery anatomic variants include pulmonary sling, an aberrant origin of the left pulmonary artery from the right pulmonary artery which crosses between the trachea and esophagus. Truncus arteriosus is classified by origin of pulmonary artery from a common truncus. Intrinsic abnormalities of the pulmonary arteries include: pulmonary artery agenesis, pulmonary hypoplasia, hypogenetic lung syndrome (Scimitar Syndrome) and Swyer-James Syndrome. These anomalies are a spectrum of abnormal bronchopulmonary and bronchovascular development. Lastly, fibrosing/granulomatous mediastinitis is a progressive accumulation of collagen and fibrous tissue which encases and compresses mediastinal structures such as SVC, trachea/main bronchi, esophagus and pulmonary arteries/veins.
Format: A didactic format will subdivide the anomalies into five categories. Specific examples will be shown utilizing radiography and CT/MR to illustrate each case.
Teaching Points: Recognize and categorize a pulmonary artery anomaly based on imaging characteristics to narrow the differential diagnosis.
E071. CT Venography in Suspected Venous Thromboembolism: Findings, Pitfalls, and Controversies
Katz D. S.2; Hoffmann J.2; Choi A. Y.2; Loud P. A.1; Hon M.2; Grossman Z.1 1. Roswell Park Cancer Institute, Buffalo, NY; 2. Winthrop-University Hospital, Mineola, NY
Address correspondence to D. Katz (dsk2928{at}pol.net)
Background: CT venography (CTV), combined with CT pulmonary angiography, has utility, for a variety of reasons, for the diagnosis or exclusion of deep venous thrombosis (DVT), as well as for the determination of the extent of clot burden and its location and chronicity, in the lower extremities and in the abdomen and pelvis. The purpose of this exhibit is to review our experience at two institutions over the past ten years with CT venography which we routinely perform in patients undergoing CT pulmonary angiography for suspected venous thromboembolism.
Key Issues: The latest literature on CTV will be reviewed in some detail, as will controversies including the appropriate and optimal technique and strategies to minimize radiation dose.
Format: Findings on positive and negative CT venograms will be demonstrated from case material from the past decade. Pitfalls, variants, uncommon and unusual findings, and alternative diagnoses will all be shown and discussed. The literature on the yield of CT venography combined with CT pulmonary angiography compared with CT pulmonary angiography alone, including the recent PIOPED II data, will be reviewed.
Teaching Points: Radiologists performing CT venography in conjunction with CT pulmonary angiography should be familiar with routine and uncommon and unusual findings on CTV, as well as pitfalls and controversies regarding the technique.
E072. CT of Venous Anomalies in the Thorax
Tsai P.; Chen J.; Lai H.; Shen W. China Medical University Hospital, Taichung, Taiwan
Address correspondence to P. Tsai (jeonhc{at}uci.edu)
Objective: CT angiography (CTA) is an important tool to exclude significant vascular diseases and obviating the need for invasive catheterization. In venous anomalies of the chest, CTA can depict various anomalies in the bronchial-cephalic vein, SVC, pulmonary vein, IVC, and azygous vein. The purpose of this study is to describe the CT imaging features of venous anomalies in the thorax.
Materials and Methods: In a period of two years, 5000 CTA of the chest were performed and reviewed. The nonenhanced images were acquired followed by contrast-enhanced images. For CTA, we administered 100 ml iodinated contrast agent at 3 to 4 ml/sec by using a power injector. The time delay was achieved using automatic triggering with a contrast-monitoring cursor placed on distal descending thoracic aorta. Contrast scanning was initiated when attenuation in the aorta reached 120 HU. The SDCT were performed by using Picker 5000 or Picker 2000. The MDCT were performed by using a LightSpeed Ultrafast 16. Patients were requested to hold their breath during the examination. Sections were reconstructed at 1.25-mm intervals. Reconstruction data were determined on a commercially available external workstation. All CT images, including transverse reconstructions, volume renderings, shaded-surface displays, maximum intensity projections, and curved planar reformations were reviewed.
Results: The following major categories of venous anomalies were identified by CTA: 1) anomalous left bronchial-cephalic vein (LBCV) and SVC, including LBCV posterior to aortic arch, double LBCV, LBCV to accessory azygous and azygous, presence of LBCV to Sappey, bilateral SVC, and narrowing of LBCV with collateral circulation; 2) asplenia and polysplenia; 3) anomalous pulmonary vein, including TAPVR, PAPVR, pul. vein to azygous, pul. AVM and varix, isolated Rb2 and Rb6, common channel of pulmonary vein, Rb6 to RUL vein, isolated RML and LIL pulmonary vein, and thrombus in pulmonary vein and LA; 4) anomalous IVC, including IVC and azygous vein thrombosis, absence of infrarenal IVC, absence of suprarenal IVC with right renal vein to azygous to SVC, absence of suprarenal IVC with right renal vein to hemiazygous to SVC, circum-aortic left renal vein, and azygous vein in azygous fissure.
Conclusion: CTA can depict various venous anomalies in the chest. It helps us either to find out the significant clinical problems or to have a better understanding of the normal variants of venous drainage noninvasively.
E073. Evaluation of Large Airway Disease with CT Virtual Endoscopy
Thomas B. P.; Donnelly E. F.; Strother M. K.; Worrell J. A. Vanderbilt University Medical Center, Nashville, TN
Address correspondence to B. Thomas (bradley.thomas{at}vanderbilt.edu)
Background: CT virtual endoscopy can be used in many contexts including evaluation of vascular, bowel and airway diseases. This postprocessing tool is easy to learn and takes little time at the CT workstation. Virtual laryngoscopy and tracheobronchoscopy take advantage of the excellent contrast resolution of large airways and provide complimentary visual images to the endoscopist, assisting in diagnosis and treatment planning.
Key Issues: Multiplanar imaging, surface rendering and other 3D techniques can help delineate the extent of disease and provide lesion localization for operative planning. This educational exhibit gives an overview of large airway abnormalities from an endoscopic viewpoint.
Format: Techniques of CT virtual endoscopy and its utility in evaluation of large airway disease is presented in a PowerPoint tutorial. A review of pertinent anatomy and examples of pathology are included.
Teaching Points: This exhibit: 1) Reviews laryngeal and large airway anatomy, from an endoscopic viewpoint. 2) Demonstrates focal and diffuse pathological processes that involve the large airways. 3) Outlines the clinical presentation and imaging evaluation of various large airway diseases.
E074. Bony Thorax: Spectrum of Radiologic Features of Various Etiologies
Kim K.; Lee K.; Yang D.; Choi P.; Roh M. Dong-A University Hospital, Busan, South Korea
Address correspondence to K. Kim (knkim{at}dau.ac.kr)
Background: Although the radiologic manifestations of a variety of pathologic condition of the bony thorax frequently overlap, the awareness of these entities is helpful to make a specific diagnosis and to avoid mistakes in clinical practice.
Key Issues: The ribs are essential structure of the osseous thorax and provide information that aids in the interpretation of radiologic images. A variety of pathologic condition of the bony thorax may be overlooked at chest radiography. Careful observation of the bony thorax is often rewarding.
Format: 1. primary neoplasm–benign and malignant neoplasm; 2. metastasis; 3. infectious diseases; 4. miscellaneous diseases.
Teaching Points: A wide variety of pathologic processes affect the bony thorax. Many diseases have characteristic radiographic, CT, or MR imaging appearances that can allow differentiation from other entities. Understanding the morphologic characteristic of these disorders may facilitate recognition of their various radiologic appearances, accurate diagnosis, and optimal treatment.
E075. Pulmonary Tuberculosis Involving the Right Middle Lobe of the Lung: CT and Clinical Characteristics
Jeon K.; Bae K. Gyeongsang National University Hospital, Jinju, South Korea
Address correspondence to K. Jeon (knjeon{at}gsnu.ac.kr)
Objective: The purpose of this study was to describe CT and clinical features of tuberculosis involving the right middle lobe of the lung.
Materials and Methods: Over the past three years, among patients diagnosed with pulmonary tuberculosis at our hospital 21 (male: female = 4: 17, mean age: 72 years) with the CT and chest radiographs showing mainly right middle lobe involvement were reviewed for radiological and clinical presentation.
Results: Middle lobe collapse and/or consolidation (n = 21) and bronchial stenosis or obstruction without soft tissue masses (n = 20) were the main findings on CT. Enlarged mediastinal or hilar lymph nodes with or without calcification (n = 20), and cavities within consolidated tissue (n = 2) were noted. Ill-defined centrilobular nodules (n = 16), a tree-in-bud appearance (n = 13), segmental or focal consolidations (n = 8) and well-defined small nodules (n = 5) were found in the adjacent lung. All patients were older than 64 years and most complained of nonspecific symptoms such as dyspnea or general weakness. The sputum smear for acid-fast bacilli was positive in four of the 21 patients. After completion of antituberculous chemotherapy, a variety of changes were seen on follow-up chest radiographs.
Conclusion: A diagnosis of tuberculosis, in the right middle lobe of the lung is suggested in older patients with the following CT findings: 1) typical findings of middle lobe collapse and/or consolidation, 2) middle lobe bronchus stenosis or obstruction without soft tissue mass, 3) mediastinal lymphadenopathy with or without calcification, 4) cavities within consolidation, centrilobular nodules with branching linear structure in adjacent lungs. Further evaluation such as bronchoscopy is recommended for confirmation even when the sputum smear for acid fast bacilli is negative.
E076. Imaging Findings in 18 Patients with Eosinophilic Pneumonia
Bakhshayesh Karam M.; Montazami N.; Zahiri Fard S.; Tahbaz M. O.; Ashtarian M. National Research Institute of Tuberculosis and Lung Diseases - Dr. Massih Daneshvari Medical Center, Tehran, Iran
Address correspondence to M. Bakhshayesh Karam (mehrdadbakhshayesh{at}yahoo.com)
Objective: Eosinophilic pneumonia (EP) includes distinct individual syndromes characterized by eosinophilic pulmonary infiltrates and, commonly, peripheral blood eosinophilia.
Materials and Methods: In this study, we surveyed radiological findings of 18 patients with confirmed diagnosis of eosinophilic pneumonia in Massih Daneshvari Medical Center in Tehran. We retrospectively reviewed the documents of 18 patients with EP. Diagnostic criteria were based on clinical, laboratory and imaging findings.
Results: The most important findings in CXR and CT scan of the patients were patchy and nonsegmental consolidations in the middle and upper zones. The opacities are usually in apical or axillary location.
Conclusion: It seems favorable statistical outcomes of imaging findings in patients with EP, which can be distributed to the entire population of our country, need further long-term studies, and needs chest X rays and CT scans data recording for all these patients in other medical and research centers.
E077. Imaging of Castleman's Disease with Histopathologic Correlation
Chang H.; Bhatt S.; Simon R.; Dogra V. University of Rochester Medical Center, Rochester, NY
Address correspondence to H. Chang (hannah_chang{at}urmc.rochester.edu)
Background: Castleman's disease is a rare, benign disorder of unknown etiology which can be seen as abnormal enlargement of lymph nodes. Either one or multiple lymph node groups can be affected. Two main histologic subdivisions are noted including the more common localized hyaline vascular disease versus disseminated plasma cell type. Mimics may include Hodgkin's lymphoma, Kaposi sarcoma, thymoma, sarcoidosis and POEMS syndrome.
Key Issues: Many malignant neoplastic diseases can mimic or sometimes, as in the case of Kaposi sarcoma, coexist with Castleman's disease and tissue sample is needed to establish a definitive diagnosis. Careful review of radiographic findings, such as morphology, location and enhancement pattern, can improve the radiologist's ability to appropriately suggest a diagnosis of Castleman's disease.
Format: Didactic poster presentation with selected imaging demonstrating key findings. A short quiz will be provided at the end to solidify and summarize important points.
Teaching Points: 1. Recognize cross-sectional imaging features of Castleman's disease. 2. Understand and correlate pathologic basis of imaging of Castleman's disease. 3. Describe the differential diagnosis of Castleman's disease.
E078. Rheumatic Diseases and the Lung: With Radiologic—Pathologic Correlation. All You Need to Know
Restrepo C. S.1; Vargas D.1; Jagirdar J.1; Ocazionez D.1; Carrillo J.2; Ojeda P.2 1. The University of Texas Health Science Center at San Antonio, San Antonio, TX; 2. Universidad Nacional de Colombia - Hospital Santa Clara, Bogotá, Colombia
Address correspondence to C. Restrepo (restrepoc{at}uthscsa.edu)
Background: The rationale of this exhibit is to illustrate the wide array of pulmonary manifestations related to the most prevalent rheumatic diseases. Pulmonary involvement is a common finding in the vast majority of these patients, and ranges, depending on the disease, from 1–5% in ankylosing spondylitis to more than 70% in patients with systemic lupus erythematosus (SLE). Pulmonary patterns of involvement expand from simple pleural thickening and/or effusions to the often complex parenchymal and interstitial patterns. The different radiographic and CT findings associated with each of these diseases is presented and include, but are not limited to Caplan syndrome and bronchiolitis obliterans organizing pneumonia (BOOP) in rheumatoid arthritis; interstitial fibrosis and bronchioloalveolar cell carcinoma in systemic sclerosis; acute lupus pneumonitis and alveolar hemorrhage in SLE; honeycombing and nodular pattern in Sjögren's syndrome; cystic changes and vasculitis in mixed connective tissue disorder (MCTD); diffuse alveolar damage and pleuroparenchymal irregularities in dermato- and polymyositis; apical fibrosis and aspergillosis associated with ankylosing spondylitis.
Key Issues: Understanding the unique imaging characteristics on plain film, CT and HRCT of the different rheumatic diseases will aid the radiologist in narrowing the spectrum of differential diagnoses when this is uncertain. On the other hand, when the diagnosis has been already confirmed, it will help the radiologist in focusing his/her attention toward the specific findings expected for the disease.
Format: All the key features of the rheumatic diseases and their patterns of pulmonary involvement are reviewed in a didactic PowerPoint presentation. A short quiz is offered at the end of the presentation.
Teaching Points: To develop awareness of the spectrum of pulmonary involvement and recognize the distinctive characteristics of the most prevalent rheumatic diseases, in order to narrow the differential diagnosis and provide the clinician with precise and useful findings when following this population of patients.
E079. Imaging Features of Malignant Solitary Pulmonary Nodule on Helical Dynamic CT Scan
Jin G.1; Han Y.1; Lee Y.1; Lee H.2 1. Chonbuk National University, Medical School, Jeonju, South Korea; 2. Wonkwang University, Oriental Medicine, Iksan, South Korea
Address correspondence to G. Jin (gyjin{at}chonbuk.ac.kr)
Objective: This study was to explore malignant solitary pulmonary nodule features on helical incremental dynamic CT scan.
Materials and Methods: Dynamic CT scan was performed on 70 cases of solitary pulmonary nodule (SPN). Of the 39 cases proved by pathology, 14 were lung carcinoma, 14 were pulmonary tuberculoma, 2 were aspergillosis, 5 were hamartoma, 1 was abscess, 1 was sclerosing hemangioma, and 2 were intrapulmonary lymph node. Dynamic CT was performed by using a helical technique (series of images obtained throughout the nodule at 20, 40, 60, 80, 100, 120 seconds and 3 and 5 minutes) after intravenous injection of contrast medium. For discriminating the benign from malignant SPNs, the maximum relative enhancement ratio (MER) and the slope of the enhancement (SLE) were calculated and then they were statistically compared. With varying the threshold of the two indexes, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. Also, we evaluated percentage peak enhancement interval of SPN on TAC.
Results: The mean SLE of the malignant SPN group was significantly higher than that of the benign SPN group (malignant: 0.019 ± 0.014, benign: 0.007 ± 0.007). The mean MER of the malignant group was not significantly higher than that of the benign SPN group (malignant: 1.47 ± 0.9, benign: 1.59 ± 3.0). However, when hamartoma and sclerosing hemangioma were excluded, the mean MER of the malignant group was significantly higher than that of the benign SPN group (malignant: 1.47 ± 0.9, benign: 0.64 ± 0.82). SPN with 0.57 as the threshold of MER and 0.005 as the threshold of SLE at the same time for distinguishing the malignant SPN group from the benign SPN group, the accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 71.8%, 85.7%, 64%, 57.1%, and 88.9%. SPN with 0.57 as the threshold of MER and 0.005 as the threshold of SLE at the same time for distinguishing the malignant SPN group from the benign SPN group, when hamartoma and sclerosing hemangioma were excluded, the accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 78.8%, 85.7%, 74%, 70.6%, and 85.7%. In between 240–300 seconds after injection, one malignant SPN (7.1%) and eight benign SPNs (32%) showed peak enhancement.
Conclusion: Helical dynamic CT is helpful in differential diagnoses of malignant and benign SPN. Most of the well-enhanced benign SPNs showed more delayed enhancement than malignant SPNs.
E080. Solitary Pulmonary Nodule on Helical Dynamic CT Scan: Enhancement Pattern Analysis Using a Computed-aided Diagnosis (CAD) System
Jin G.1; Lee H.2; Lee Y.1; Han Y.1 1. Chonbuk National University, Medical School, Jeonju, South Korea; 2. Wonkwang University, Oriental Medicine, Iksan, South Korea
Address correspondence to G. Jin (gyjin{at}chonbuk.ac.kr)
Objective: This study was to investigate enhancement patterns of solitary pulmonary nodule (SPN) on dynamic CT scan using a computed-aided diagnosis (CAD) system.
Materials and Methods: This study enrolled the 39 cases proved by pathology using PTNB or open lung biopsy. Dynamic CT was performed by using a helical technique (series of images obtained throughout the nodule at 20, 40, 60, 80, 100, 120 seconds and 3 and 5 minutes) after intravenous injection of contrast medium. We analyzed enhancement pattern of SPN using a computed-aided diagnosis (CAD) system (Lung care, Sensation 16, Siemens, Germany) by expert technician and direct drawing ROI of SPN by expert radiologist simultaneously. We compared a CAD with personal results for Hounsfield Unit (HU) of SPN, enhancement pattern, peak enhancement interval. We used descriptive statistics in this study.
Results: The average size of the technical success group was 19.3 x 15.1 mm, respectively. 21/25 (84%) SPNs showed the same or similar enhancement patterns and peak enhancement interval on a CAD and direct personal draw. However, HU of SPN using a CAD system is lower than direct personal draw (25.2 ± 19.1 to 58 ± 18.2).Technical failure showed more benign SPN (11/25) than malignant SPN (3/14).
Conclusion: A CAD system can be of help in the analysis of the enhancement pattern of SPNs on dynamic CT although this system has a limitation of calculation of small SPNs.
E081. A Meta-Analysis of the Literature about Pulmonary Nodules Computer-Aided-Detection by Comparing CT Low-Dose Protocols and CT Normal-Dose Protocols
Saba L.; Mallarini G. Policlinico Universitario di Monserrato, Radiology, Cagliari, Italy
Address correspondence to L. Saba (gmallarin{at}yahoo.it)
Objective: The purpose of this study was to evaluate the role and the diagnostic efficacy of pulmonary nodules computer-aided detection (CAD) using a CT low-dose protocol. We made a meta-analysis in the literature, and we observed CAD sensitivity and efficacy. We evaluated if CAD by using low-dose CT is comparable with normal-dose CT results.
Materials and Methods: We used as data sources the medical literature database of PubMed, Medline, and Cochrane where we searched for articles published in the English language from January 2001 to August 2006. We performed a comprehensive search of abstracts of English language articles in the MEDLINE and PUBMED database, using the search terms "computer aided detection pulmonary," "computer aided detection lung," "CAD pulmonary," "CAD lung," "pulmonary nodules automated detection." Then we compared sensitivity and specificity in CT normal-dose protocol and CT low-dose protocol.
Results: Eighteen studies met the inclusion criteria and contained a total of more than 700 patients and 2500 pulmonary nodules studied by CAD. We observed sensitivity of 70.7% for the CAD in the CT low-dose protocol and 81.36% for CAD normal-dose protocol.
Conclusion: Results of our study suggest that the use of CAD in CT low-dose protocols produce results smaller than CT normal-dose protocols.
E082. Anterior Mediastinal Masses: Radiologic Spectrum and Pathologic Correlation
Cura M.; Cura A. UTHSCSA, San Antonio, TX
Address correspondence to M. Cura (marcocura{at}yahoo.com)
Background: The anterior mediastinum may be involved by primary or metastatic tumors. Masses of the anterior mediastinum can be divided in three groups, depending on the radiological characteristics: solid, cystic and fatty. The differential diagnosis of solid anterior mediastinal masses is extensive, but there are some radiographic characteristics such as attenuation, calcification and borders/local invasion that can help to narrow the differential diagnosis. When dealing with cystic mediastinal masses, they can further be classified in partially cystic (with solid components) or completely cystic (unilocular or multilocular). On the other hand the differential diagnosis of fatty anterior mediastinal masses is less complex. The use of different imaging modalities to characterize masses of the anterior mediastinum and the correlation of the imaging findings with pathology specimens help to understand the disease process and its radiological presentation. This exhibit correlates the pathology specimens with the imaging appearances of anterior mediastinal masses. Understanding the pathology of the diseases is essential when interpreting diagnostic studies.
Key Issues: This exhibit will describe the radiological findings of anterior mediastinal masses; illustrate them using plain films, computed tomography, positron emission tomography; and correlate them with histological and macroscopic pathology specimens.
Format: The radiological findings and pathology specimens of anterior mediastinal masses are correlated and presented in a didactic format to improve the understanding of these disease processes and the radiological presentation of these masses.
Teaching Points: Learn about disease processes of the anterior mediastinum such as thymic hyperplasia, thymoma, atypical thymoma, thymic carcinoma, teratoma, Hodgkin's disease, Castleman's disease, multilocular thymic cyst, and multinodular goiter. Recognize and categorize imaging findings of masses of the anterior mediastinum. Understand the diseases by correlating radiological and pathologic studies. Demonstrate the correlation between the radiological manifestations of masses of the anterior mediastinum and the pathology specimens. Differentiate between benign and malignant process of the anterior mediastinum.
E083. Evaluation of Solid and Cystic Pleural Based Masses with CT and MRI
Bhoot V.2; Esposito F.2; Chhabra A.1; Mithalal R.2 1. Drexel University–Tenet Hospital, Philadelphia, PA; 2. Mercy Catholic Medical Center, Darby, PA
Address correspondence to V. Bhoot (bhootve{at}yahoo.com)
Background: The differential diagnosis of pleural based masses encompasses many processes. The purpose of this exhibit is to describe key imaging characteristics of solid and cystic pleural based masses on CT and MRI, and to narrow the possibilities to a manageable few which can be correlated with the clinical scenario to arrive at the correct diagnosis.
Key Issues: This exhibit will describe the imaging appearances of various solid and cystic pleural based masses on CT and MRI. The key imaging findings of these pathologies will be outlined in table format with associated imaging characteristics. After following the described step-by-step approach of evaluating these masses on CT and MRI, a concise differential shall be formulated.
Format: This proposed exhibit will be formulated by creating a differential diagnosis table encompassing both solid and cystic pleural based masses. In a table format, key CT and MRI imaging characteristics will be formulated with case examples demonstrating these features.
Teaching Points: The viewer will learn how to approach a pleural based mass, appropriately characterize this lesion as solid/cystic, and formulate a concise differential diagnosis based on key CT and MRI imaging characteristics. Hopefully, after completing this exhibit, the viewer will gain an understanding of various pleural based pathologies and how to properly categorize these various lesions.
E084. Differential Diagnosis of Peripheral Parenchymal Opacity(ies)
Berkowitz E. A.; Ferguson E. C.; Oldham S. A. University of Texas–Houston Health Sciences Center, Houston, TX
Address correspondence to E. Berkowitz (eugberkowitz{at}yahoo.com)
Background: Peripheral opacity(ies), which may be focal or multifocal, are categorized into acute versus chronic consolidation(s)/masses. Acute entities include infection, simple eosinophilic pneumonia, contusion and infarct. Chronic etiologies include rounded atelectasis, COP/OP, chronic eosinophilic pneumonia, alveolar sarcoidosis, bronchoalveolar carcinoma/lymphoma, aspiration/lipoid pneumonia, radiation pneumonitis, and drug toxicity.
Key Issues: Simple eosinophilic pneumonia presents as self-limited, benign, transient, migratory, nonsegmental consolidation(s). Chronic eosinophilic pneumonia presents as a chronic upper lobe peripheral homogeneous consolidation with a reverse "bat wing" distribution. Rounded atelectasis presents as an oval subpleural mass with whorled bronchovascular markings (comet tail sign), volume loss and air bronchograms in patients with prior pleural effusions. Bronchoalveolar cell carcinoma presents as a peripheral nodule or focal/multifocal ground glass opacity/consolidation with air bronchograms. CT angiogram sign is seen with contrast-enhanced vessels through the low attenuation consolidation. PTLD is a spectrum varying from benign infectious mononucleosis to very aggressive lymphomas which can present as peripheral basal nodules/masses or consolidations. Rheumatoid nodules are peripheral nodules which may cavitate and calcify. When associated with Caplan syndrome, these nodules have an upper lobe predilection. Lipoid pneumonia is a low attenuation (HU = -100) consolidation with air bronchograms in the gravity-dependent lobes. Alveolar sarcoid can present as peripheral large nodules which may cavitate and represents confluent sarcoid granulomas in the interstitium with peripheral satellite nodules and air bronchograms. Amiodarone toxicity presents as a high density peripheral consolidation and a diffuse high density liver. Extramedullary hematopoiesis presents as enhancing paravertebral/posterior mediastinal mass secondary to marrow expansion in severe anemias. Radiation fibrosis which occurs 6 weeks to 6 months after treatment produces a linear configuration conforming to the radiation field.
Format: A didactic format starting with a table listing the differential diagnosis of a peripheral opacity with subdivision into acute versus chronic processes. Figures will illustrate the above with examples using radiography and CT.
Teaching Points: Devise a differential diagnosis for a peripheral opacity based on imaging characteristics and clinical data.
E085. Thymic Cysts: Spectrum of Disease and Radiologic–Pathologic Correlation
Ocazionez D.1; Vargas D.1; Carrillo J.2; Ojeda P.2; Restrepo C. S.1 1. The University of Texas Health Science Center at San Antonio, San Antonio, TX; 2. Universidad Nacional de Colombia–Hospital Santa Clara, Bogotá, Colombia
Address correspondence to D. Ocazionez (ocazionez{at}uthscsa.edu)
Background: Thymic cysts are uncommon mediastinal lesions and represent at the most 1–3% of all mediastinal masses. Thymic cysts may be congenital or acquired. The former are less common, arise from a remnant of the thymopharyngeal duct and are usually unilocular. Acquired thymic cysts are more common, are usually multilocular and associated with several conditions, including Sjögren's syndrome, myasthenia gravis, aplastic anemia and following radiation exposure. They have been also related with thymic neoplasms such as thymoma, lymphoma and carcinoma. A novel association has been recently described between multilocular thymic cysts and patients with HIV infection (the majority of which are children), and suggested to form part of the diffuse infiltrative lymphocytosis syndrome (DILS).
Key Issues: The radiologist must be aware of the classification of thymic cysts, and, in the case of multilocular cysts, provide essential information to appropriately guide the clinician toward the probable underlying disease. Employing a broad range of illustrative cases, this exhibit reviews the characteristic appearances of congenital and acquired thymic cysts. Characteristic findings are depicted on plain films, computed tomography, MRI and ultrasound. The association with HIV infection and DILS is addressed, and four new cases of multilocular thymic cysts in adult patients with AIDS are presented. A rational approach to the differential diagnosis of thymic cysts as well as a clinical and pathological correlation is intended.
Format: The format of this exhibit will be didactic with a review of key points using PowerPoint.
Teaching Points: After reviewing this exhibit the reader should: 1. Be familiar with the classification and imaging features of thymic cysts. 2. Learn the differential diagnosis of thymic cysts. 3. Feel comfortable when approaching these lesions on imaging studies. 4. Be aware that multilocular thymic cysts are commonly a manifestation of an underlying disorder, rather than a primary thymic lesion.
E086. Interobserver Variability in the Interpretation of CT Pulmonary Angiography and its Clinical Implications with 4-slice MDCT and 64-slice MDCT Scanners
Krumreich J.; Pierce J. L.; Simons G. H. Naval Medical Center Portsmouth, Portsmouth, VA
Address correspondence to J. Krumreich (jakrumreich{at}mar.med.navy.mil)
Objective: Prior research has demonstrated that there was significant interobserver variability for pulmonary CTA performed at Naval Medical Center Portsmouth (NMCP) from 2000-2002. The purpose of this study is to determine if the interobserver variability is lower with the use of 64 MDCT scanners and new protocols.
Materials and Methods: 160 CT pulmonary angiograms from March 2000 through December 2002 performed at our institution utilizing a 4-slice MDCT with 2.5 mm slice thickness, 150 ml Isovue 300 IV at 4cc per second during breath hold. The studies were double read and the interobserver variability as well as the number of uninterpretable studies were recorded. In November 2005 NMCP began utilizing a 64-detector scanner with 2.5 mm slice thickness, 150 ml of Isovue 370 IV at 4 cc/second with shallow breath hold for Pulmonary CT Angiography. 100 studies were double read and the interobserver variability as well as the number of uninterpretable studies were recorded.
Results: Out of 160 studies analyzed which used 4-slice MDCT technology and Isovue 300, there was interobserver variability in 16.9% (27 of 160) and 8.8% uninterpretable studies secondary to poor contrast bolus. The studies that utilized 64 slice MDCT technology and Isovue 370 are still being analyzed; however, the preliminary data suggest only a 3% interobserver variability and less than 1% uninterpretable studies.
Conclusion: Poor clinical outcomes may occur secondary to the treatment of false positives/nontreatment of false negatives. In the case of the older studies, as presented in 2003 at the RSNA, there were 5 adverse events (3 events) related to treatment/nontreatment of pulmonary emboli at our institution from 2000-2002. As our technology and ability to interpret the studies improve, our interobserver variability decreases, and so should the number of adverse events from over treatment, delayed treatment or lack of treatment.
E087. Lymphoproliferative Disorders of the Chest: Imaging "Twins" and Mimics
Burns J.; Jain V. R.; Haramati L. B. Montefi ore Medical Center, Bronx, NY
Address correspondence to J. Burns (judahburns{at}hotmail.com)
Background: Lymphoproliferative disorders involving the chest are increasingly being recognized. HIV infection and iatrogenic immunosuppression associated with organ transplantation predispose to lymphoma and other unusual lymphoproliferative disorders. Radiologists must be aware of the imaging findings of both common and uncommon lymphoproliferative disorders to guide appropriate biopsy technique, to expedite treatment, and to prevent unnecessary surgery.
Key Issues: Not all abnormal lymph nodes represent lymphoma; similarly, lymphoma can take a variety of forms. Imaging appearances range from simple enlarged lymph nodes to endobronchial, pulmonary parenchymal, peri-cardial, pleural and chest wall masses. These various anatomic sites and appearances each have their own differential diagnosis. Additionally, less common lymphoproliferative disorders may involve the chest including Rosai Dorfman disease, Castleman's disease, lymphocytic interstitial pneumonia, MALT lymphoma, lymphomatoid granulomatosis, leukemia, myeloma, and posttransplant lymphoproliferative disorder (PTLD).
Format: This presentation follows a didactic format, using case examples to introduce differential diagnoses with illustrative examples. Explanatory slides highlight key anatomic, pathologic and radiologic features of lymphoma and r
