Emergency Radiology最新文献

Purpose: Septic arthritis is a dangerous medical condition requiring prompt diagnosis, often via arthrocentesis. A "dry tap" occurs when no fluid is aspirated. We hypothesized that the absence of a joint effusion on pre-procedure advanced imaging would reliably predict a dry tap and exclude septic arthritis.

Methods: A cohort of 217 arthrocentesis cases of large joints (hips, shoulders, knees) from our institution, with pre-procedure advanced imaging (CT, MR, US) of the same joint performed within the previous 48 h, was analyzed. Exclusion criteria included non-native joints or inadequate imaging of the affected joint. These cases underwent blinded review by 4 radiologists who measured the deepest pocket of joint fluid on the pre-procedure imaging. Wilcoxon rank-sum test was performed comparing joint fluid pocket size to outcomes of successful aspiration and final diagnosis.

Results: A smaller average joint pocket fluid size was present on advanced imaging in both dry taps compared with successful arthrocenteses (p < .0001), and in uninfected joints compared with septic joints (p = .0001). However, the overlap of values was too great to allow for a perfectly predictive cutoff. 29% (5/17) of patients with no visible joint fluid on pre-aspiration imaging underwent successful arthrocentesis, one case representing septic arthritis.

Conclusion: Volume of joint fluid on advanced pre-arthrocentesis imaging cannot reliably predict subsequent dry tap nor exclude septic arthritis.

Purpose: In this cross-sectional study, we aimed to characterize how frequently the anatomy of interest (AOI) was excluded when evaluating genital pathology using the current CT pelvis protocol recommended by the American College of Radiology and evaluate how AOI exclusion affects patient management.

Methods: We retrospectively reviewed medical records, using diagnosis and CPT codes, of patients admitted with genital pathology who obtained a CT scan at our institution from July 1, 2020-April 30, 2023. Baseline patient demographics were included. Data about each index CT scan (scan obtained at our institution) were recorded and assessed for exclusion of the AOI. Statistical analysis was performed to determine the rate of AOI exclusion and to compare patient management between patients with AOI excluded versus those without AOI exclusion.

Results: 113 presentations for genital pathology included an index CT scan and were included for analysis. Patients were primarily men (98%) with a mean age of 53.1 years (SD 13.9). The most common diagnoses were Fournier's gangrene (35%), scrotal abscess (22%) and unspecified infection (19%). 26/113 scans (23%) did not capture the entire AOI. When the AOI was missed during the index scan, there was a higher rate of obtaining additional scans (38% vs. 21%), but a similar rate of intervention (77% vs. 63%) when compared to index scans that captured the entire AOI. 35 scans (31%) had protocol-extending instructions; index scans that captured the entire AOI were more likely to have specific protocol-extending instructions (38% vs. 8% p < 0.01).

Conclusions: Creating a specific CT protocol for genital pathology could decrease the amount of inappropriate irradiation and improve AOI capture rates without relying on specific request for protocol deviation.

Background: Splenic sequestration crisis is a potentially fatal complication of sickle cell disease, mainly seen in young children. Only a few case series describe the acute splenic sequestration crisis in adults and its management, which primarily consists of supportive care and, in some cases, splenectomy. Splenic artery embolization has seldom been described in sickle cell disease. This is probably the first case in which an adult with sickle cell disease presented with an acute splenic sequestration crisis was managed successfully through splenic artery embolization.

Results: This 22-year-old female, a known case of sickle cell disease, presented with severe pain in the abdomen and low-grade intermittent fever for two days, secondary to an acute splenic sequestration crisis. The diagnosis of acute splenic sequestration was made based on clinical and blood parameters, ultrasonography, and computed tomography. Even with adequate supportive care and blood transfusions, the patient's condition worsened with a rapid fall in the hemoglobin and total platelet count. Considering splenectomy to be a high-risk procedure for this patient, a decision of rescue splenic artery embolization was taken, which was successful.

Conclusion: Splenic artery embolization may be considered a lifesaving procedure in patients with acute splenic sequestration, where the risk of splenectomy can be high. Adequate post-procedure supportive care is vital for preventing complications.

Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment.

Purpose: We hypothesize that delayed phase imaging does not provide additional diagnostic information in patients who undergo multi-phasic CTA for suspected active bleeding.

Methods: Data on patients who underwent multiphasic CTA (pre-contrast, arterial, porto-venous, and delayed phases) for suspected acute bleed were retrospectively collected between January 2019 and November 2021. CTA images were reviewed by a general radiologist, an interventional radiologist, and a body imaging radiologist independently. Each reader evaluated if delayed phase images provided additional information that would change the final impression of the CTA report. Additional information regarding bleeding location, time needed for delayed image acquisition, and radiation exposure were also obtained.

Results: A total of 104 patients with CTAs were analyzed with an average age of 58 years ± 22. Studies rated with absent additional findings on delayed images were 102 (98.1%) by the interventional radiologist, 101 (97.1%) by the body imaging radiologist, and 100 (96.1%) by the general radiologist with percent agreement of 96.15% (kappa 0.54, p < 0.001). All the findings were characterized as unlikely to be clinically significant. Mean time added to complete a delayed phase images was 3.61 ± 3.4 min. The average CT dose length product (DLP) for the total exam was 3621.78 ± 2129.57 mGy.cm with delayed acquisition adding a mean DLP of 847.75 ± 508.8 mGy.cm.

Conclusion: Delayed phase imaging does not provide significant additional diagnostic information in evaluating patients with suspected active bleeding but is associated with increased examination time and radiation exposure.

Purpose: The goal of our study was to better characterize new CT diagnoses of peritoneal carcinomatosis (PC) in the ED, and to evaluate how to best identify the primary lesion. Prompt identification of the source of the carcinomatosis may allow for the patient to receive early initial care from the correct clinical service.

Methods: All new CT cases of PC-like appearance identified on CT in the ED from January 2017 through July 2020. Each report and corresponding medical record were manually reviewed. Patient demographics, presence/absence of intravenous contrast, source organ predicted by the radiologist in the CT scan report, pathologic diagnosis, and amount of ascites were tabulated. Chi-tests were used to test the statistical significance of differences between groups.

Results: Of the 131 CT cases of new PC-like appearance which received workup, 108 cases had pathologically proven PC and 23 cases had no underlying malignancy yielding a positive predictive value for actual PC of 82%. The most common cause of new PC in women was gynecological (66%), and in men was of GI tract origin (57%). Concordance between radiologist prediction and final pathology was higher with intravenous contrast (58%) compared to without contrast (40%); although this difference was not statistically significant (p = 0.19). A moderate or large amount of ascites was found in more than half of GYN primaries and in adenocarcinoma of unknown primary and there was a statistically significant difference in amount of ascites between cancer primaries (p = 0.01).

Conclusion: A PC-like appearance on CT in the ED will likely be in patients with known malignancy, but of the new cases, there is a high PPV for it to represent new peritoneal carcinomatosis. Gynecological and GI malignancies are the most common cause in women and men, respectively, and this may help in focusing the radiologist's search pattern. Usage of intravenous contrast may help in identifying a primary lesion, and the presence of high-volume ascites should suggest a GYN primary or adenocarcinoma of unknown primary when there is no other obvious primary lesion.

Background: Burnout is a chronic problem prevalent in radiology, with a significant burden on individuals and healthcare systems.

Discussion: A substantial portion of the literature on managing burnout has focused on individual-based remedies. We posit that burnout is a systemic problem and present an overview of some system-based strategies that could be employed to mitigate burnout in radiology. These include managing workload, optimizing work shifts, maximizing autonomy, limiting work-life conflicts, creating opportunities for professional fulfillment, utilizing user-friendly electronic medical records (EMR), deploying efficient picture archiving and communication systems (PACS), building system redundancy, leadership transparency, and fostering a healthy work environment.  CONCLUSION: System-based strategies can help mitigate burnout.

Purpose: This study aimed to identify the radiological CT findings that are significantly correlated with the outcome of conservative management with oral water-soluble contrast medium in patients presenting with Adhesive Small Bowel Obstruction (ASBO) to the Emergency Room.

Methods: In this retrospective single-center study, we considered all consecutive patients admitted to the ER from February 2019 to February 2023 for ASBO with an available contrast-enhanced CT scan performed at diagnosis and treated with conservative management. The investigated CT findings were type and location of transition zone, ASBO degree, fat notch sign, beak sign, small bowel feces sign, presence of peritoneal free fluid and pneumatosis intestinalis. Radiological parameters were analyzed using univariable and multivariable logistic regression to test the significant association between the CT parameters and the target.

Results: Among the 106 included patients (median age 74.5 years), conservative treatment was effective in 59 (55.7%) and failed in 47 (44.3%), needing delayed surgery. In the failure group, there was a higher prevalence of patients who had previous ASBO episodes (p = 0.03), a greater proportion of females (p = 0.04) and a longer hospital stay (p < 0.001). At multivariable analysis, two CT findings were significantly correlated with failure of conservative treatment: fat notch sign (OR = 2.95; p = 0.04) and beak sign (OR = 3.42; p = 0.04).

Conclusions: Two radiological signs correlate with failure of non-operative management in ASBO, suggesting their importance in surgical decision-making. Patients presenting with these signs are at higher risk of unsuccessful conservative treatment and may require undelayed surgical intervention.

Purpose: Fifty percent of cranial CT scans performed achieve no benefit and entail risks. Our aim is to determine the yield of non-traumatic urgent cranial-CT and develop a pretest clinical probability scale approach.

Methods: Adult patients seen in our emergency department between 2017-2021 and referred for urgent cranial-CT for non-traumatic reasons were retrospectively recruited and randomly selected. Presenting complaint (PC), demographic variables, Relevant radiological findings (RRF) on the urgent cranial-CT and Relevant clinical-radiological findings (RCRF: admission need or RRF detection on the urgent cranial-CT or cranial CT/MRI in the following three months) were recruited.

Results: We recruited 702 patients, with median age 62 [47-76] years, 363 (51.7%) females. RCRF were observed in 404 (57.55%); of these, 352 (50.1%) required admission. RRF were detected in 190 (27.06%): 36 acute ischemic and 27 acute hemorrhagic lesions, 115 masses, 9 edema, and 27 hydrocephalus. Predictive PC for urgent cranial-CT were motor, speech, sensory deficits, sudden alteration of mental status, epileptic seizure, cognitive impairment, neurological symptoms in cancer patients, acute headache without a prior history and with meningeal signs; nausea, vomiting, or hypertensive crisis; visual deficits, and dizziness. This algorithm provided sensitivity, specificity, positive predictive value, and negative predictive value (NPV, 95%CI in brackets) of 92.1% (89-94.5%), 27.5% (22.5-33.0%), 63.3% (59.2-67.2%), and 71.9% (62.7-80.0%), to diagnose RCRF, and 97.4% (93.4-99.1%), 21.3% (17.8-25.1%), 31.5% (27.7-35.4%), and 95.6% (90.1-98.6%), to diagnose RRF. In patients not requiring admission (n = 350), the NPV for RRF was 98.8% (93.6-100%); the negative likelihood ratio 0.08 (0.01-0.57), and sensitivity remained at 97.8% (82.2-99.9%). Applying it would have avoided performing 85/350 urgent cranial-CT (24.29%). To find one RRF, we would have gone from performing 7.8 (350/45) to 5.9 (265/45) CTs, failing to diagnose 1/45 (2.2%) RRF.

Conclusions: This proposed clinical scale could potentially decrease 24% of urgent cranial-CT.

Purpose: The use of thermal insulations reduces the risk of hypothermia, therefore decreases the risk of death in trauma victims. The aim of the study was to assess whether thermal insulations cause artifacts, which may hinder the diagnosis of injuries, and how the used thermo-systems alter the radiation dose in polytrauma computed tomography.

Methods: Computed tomography scans were made using the road accident victim body wrapped consecutively with 7 different covers. 14 injury areas were listed and evaluated by 22 radiologists. The radiation dose was measured using a dosimeter placed on the victim in the abdominal area.

Results: No significant artifacts in any of the tested covers were observed. The presence of few minor artifacts did not hinder the assessment of injuries. Certain materials increased (up to 19,1%) and some decreased (up to -30,3%) the absorbed radiation dose.

Conclusions: Thermal insulation systems tested in this study do not cause significant artifacts hindering assessment of injuries in CT scans. Concern for artifacts and increased radiation dose should not be a reason to remove patients' thermal insulation during performing trauma CT-scanning.