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ABSTRACT |
Wednesday, May 9, 1:30 PM–3:30 PM
Abstracts 175-186
Moderator(s): Gautham Reddy and Vince Ho
1:30 PM
175. Impact of Emergency Department Chest CT on Clinical Management of Immunocompetent Patients with Chest Radiographic Findings of Pneumonia
Banker P. D.1*; Jain V. R.2; Haramati L. B.2 1. Albert Einstein College of Medicine, Bronx, NY; 2. Montefi ore Medical Center, Bronx, NY
Address correspondence to P. Banker (PBanker{at}aecom.yu.edu)
Objective: Clinical suspicion for pneumonia (PNA) is a common indication for chest imaging, with chest radiograph (CXR) as the usual initial tool. Literature supports the use of CT in immunocompromised patients to narrow the differential diagnosis (ddx) and strengthen clinical decision making. The utility of chest CT for the diagnosis of PNA in immunocompetent patients, however, is uncertain. The purpose of this study is to assess the utility of chest CT in the emergency department (ED) in immunocompetent patients with suspected PNA on CXR by evaluating its impact on clinical decision making.
Materials and Methods: We retrospectively identified 1373 chest CTs over 12 months (7/05–6/06) from a single ED. CXR (<24 hours before CT) reports were reviewed to narrowly define the study population to those with findings of PNA. CXR with a ddx of noninfectious etiologies or in which CT was recommended were excluded. Fifty-one immunocompetent patients met inclusion criteria: 26 women, 25 men, mean age 60 (range 29–103) years. Immunocompetent age and sex matched controls with ED CXR findings of PNA who did not undergo CT were identified. Charts were reviewed for clinical management and follow-up. The patients and controls were compared using Fisher's exact and t-test.
Results: Significant differences between patients and controls were found for presenting signs and symptoms (s/s) and management. The patients (n = 51) were a sicker group than controls (n = 51). Patients had significantly more s/s than controls, respectively: auscultation abnormalities 64% (33/51) vs 47% (24/51); abnormal sputum 32% (16/51) vs 0%; hypoxemia 22% (11/51) vs 2% (1/51); weight loss 20% (10/51) vs 4% (2/51); and night sweats 16% (8/51) vs 2% (1/51), (p < 0.05, each). Management differed significantly between patients and controls, respectively: antibiotics initiated in 82% (41/51) vs 47% (24/51); change in antibiotics in 29% (15/31) vs 0%; procedures performed in 24% (12/51) vs 0%; and length of stay 8 days vs < 1 day, (p < 0.05, each). 24% (12/51) of patients had an alternative/additional diagnosis to PNA based on CT findings, including tuberculosis (n = 4), pulmonary embolus, lung cancer, multiple myeloma, renal cell carcinoma, small bowel obstruction, lung nodules, hypersensitivity pneumonitis, and neoplasm vs TB, (n = 1, each).
Conclusion: Immunocompetent ED patients with CXR findings of PNA who underwent chest CT were a sicker group than those who were not imaged with CT. Significant alternative/additional diagnoses on CT often guided clinical management in nearly one quarter of patients.
* Will present paper 176. Ranges of Attenuation for Remote and Infarcted Myocardium Assessed with 64-Slice CT
Maffei E.1; Palumbo A.1; Pugliese F.2; Damiani L.1; La Fata L.1; Mollet N. R.2; Cademartiri F.1* 1. Azienda Ospedaliero-Universitaria, Parma, Italy; 2. Erasmus Medical Center, Rotterdam, The Netherlands
Address correspondence to F. Cademartiri (filippocademartiri{at}hotmail.com)
Objective: To evaluate the ranges of attenuation of the left myocardium during the arterial and delayed phase after IV administration of iodinated contrast material during 64-slice CT coronary angiography (CT-CA) in a population of patients with myocardial infarction.
Materials and Methods: Forty-two patients with previous myocardial infarction underwent 64-slice CT-CA (Sensation 64 Cardiac, Siemens) with standard retrospectively ECG gated protocol. The scan was performed after the IV administration of a bolus of 100 ml of iodinated contrast material (iomeprol 400 mgI/ml, 100 cc @ 4 ml/s). When possible IV beta-blockers and sublingual nitrates were administered to lower the heart rate and increase the diameter of the coronary arteries, respectively. In all patients a delayed CT scan (DE-CT) was performed with same parameters used for the CT-CA scan 15 min after the IV administration of contrast material. The attenuation was measured with ROIs in the CT-CA and DE-CT phases at the level of: infarcted myocardium, remote myocardium, no reflow zone (when present).
Results: The attenuation of remote myocardium was 93.8 ± 28.7 HU and 62.7 ± 20.2 HU in the CT-CA and in the DE-CT phase, respectively. The attenuation of infarcted myocardium was 45.9 ± 22.7 HU and 81.0 ± 20.3 HU in the CT-CA and in the DE-CT phase, respectively. The attenuation of no reflow zone (n. 5; 12.8%) was -35.1 ± 20.2 HU and -32.7 ± 20.5 HU in the CT-CA and in the DE-CT phase, respectively. The values of attenuation were all significantly different (p < 0.01), except for the no reflow zone which showed similar attenuation in the CT-CA and in the DE-CT phase (p = 0.90).
Conclusion: Infarcted myocardium has significantly different attenuation from remote myocardium on CT, both in arterial and delayed contrast enhancement phases. The no reflow zone remains constantly hypodense in all contrast enhancement phases.
177. CRICKET: The Coronary Artery Calcification (CAC) in Chronic Kidney Disease (CKD) Using Multidetector Row Spiral Computed Tomography (MDCT)
Mullens F. E.3*; Wessman D.3; Brenner L.2; Sharma A.1; Parker R.3 1. Boise Kidney and Hypertension Institute, Boise, ID; 2. Genzyme, Cambridge, MA; 3. Naval Medical Center, San Diego, CA
Address correspondence to F. Mullens (femullens{at}nmcsd.med.navy.mil)
Objective: Single-center, longitudinal, observational study to examine the temporal association between renal function, cardiovascular disease (CVD) risk factors, and coronary artery calcification (CAC).
Materials and Methods: Subjects included adults aged 18–65 years old without preexisting coronary artery disease. Chronic kidney disease was defined as glomerular filtration rate (GFR) < 60 ml/min using the Modification of Diet in Renal Disease formula. Laboratory measurements and multidetector row computed tomography (MCDT) scans using the Agatston method of coronary artery calcium scoring were performed at baseline and after one year.
Results: Novel CVD risk factors and the average intact parathyroid hormone (iPTH) level were significantly greater in the CKD group. Baseline CAC scores of the CKD group were twice the value of the control group and increased significantly in the one-year study interval. No statistically-significant relationship between the change in CAC and the change in any of the other variables was observed over one year.
Conclusion: CRICKET is one of the first studies to use MDCT to measure CAC in CKD patients. CAC begins in earlier stages of CKD. Novel CVD risk factors and iPTH may promote the development of CAC in CKD patients. Prevention of CVD in the CKD population should target novel CVD risk factors and hyperparathyroidism. The subjects will be followed for another two years in an effort to identify any clinically significant relationships.
178. Variability of Coronary Calcium Scores at Different Image Reconstruction Intervals Using 64-slice CT
Weininger M.*; Ritter C.; Beer M.; Hahn D.; Beissert M. University Hospital of Wuerzburg, Wuerzburg, Germany
Address correspondence to M. Weininger (weininger{at}roentgen.uni-wuerzburg.de)
Objective: To evaluate the variability of coronary calcium scores depending on the image reconstruction interval using a 64-slice CT scanner with a fast gantry rotation time of 330msec.
Materials and Methods: 21 patients (12 men, 9 women, mean age 56 ± 11 years) with a mean heart rate of 68 ± 7 beats per minute (bpm) underwent coronary calcium scoring using a 64-slice CT scanner (Siemens, Germany) and a standardized scanning protocol (collimation 1.5 mm, rotation time 0.33 sec, 120 kV, 190 mAs eff). Oral ß-blockers were administered to 12 patients with a baseline heart rate >70 bpm. Image reconstruction (slice thickness 3 mm, increment 1.5 mm) was performed in 10% increments from 0–100% of the RR-interval. Two blinded experienced observers independently calculated Agatston (AS), calcium mass (MS) and volume scores (VS) for every reconstructed image series using syngo CaScoring software (Siemens).
Results: Excellent interobserver agreement was achieved (
= 0.98). Mean values and mean coefficients of variation among all
patients were as follows: AS, 224 ± 396, 77%; MS, 40 ± 68, 70%;
VS, 200 ± 362, 81%. Image reconstruction interval dependent analysis
displayed mean coefficients of variation of 81% (AS), 79% (VS) and 74% (MS),
respectively. No statistical significant difference in variations depending on
the image reconstruction interval could be found for AS, VS and MS (p
> 0.05).
Conclusion: Our results show that by using a 64-slice scanner with fast gantry rotation values for VS, AS and MS display a wide range of variability depending on the image reconstruction interval. Our findings are in concordance with prior studies using 4- and 16-slice CT scanners and reporting similar results. We could not identify a specific image reconstruction interval displaying a significant lesser variability. This indicates that for accurate and reproducible quantification of coronary calcium scores still more than one reconstruction interval needs to be evaluated.
179. MRI Perfusion Changes in the Hypothermic Isolated Porcine Heart: Implications for Extended Donor Heart Preservation for Cardiac Transplantation
Rivard A. L.2*; Swingen C. M.3; Kamdar F. D.4; Cordova E. J.4; Foker J. E.3; Jerosch-Herold M.1; Bianco R. W.3; John R.3 1. Oregon Health Sciences Center, Portland, OR; 2. University of Florida, Gainesville, FL; 3. University of Minnesota, Department of Surgery, Minneapolis, MN; 4. University of Minnesota, Medical School, Minneapolis, MN
Address correspondence to A. Rivard (andrewrivard{at}hotmail.com)
Objective: Preservation of the donor heart is currently limited by known ischemic changes. We chose MR imaging to determine the changes in myocardial perfusion with prolonged hypothermic storage. Peak contrast enhancement was used as a measurement of viable microvasculature.
Materials and Methods: Porcine hearts were excised (n = 24), flushed with Ribosol cardioplegic and stored at 7°C for either 6.1 ± 0.6 hours (n = 13) or 15.6 ± 0.6 hours (n = 11). T1-weighted imaging was performed in the short axis view. Approximately 80 serial images were acquired at a rate of 1/sec during administration of 0.006 mmol/mL Gd-DTPA (500 ml, 1 L/min). Signal intensity versus time curves were generated for each heart to determine the percent contrast enhancement of the myocardium as compared to a reference.
Results: Peak myocardial contrast enhancement at 15.6 hours was much less than at 6.1 hours (30% vs. 67%, p < 0.005). No correlation of peak up-slope of the intensity curve (as a surrogate of flow) to storage time was found. Scanner time averaged 16 minutes.
Conclusion: Global assessment of the donor heart is possible using perfusion MRI technology. This allows a practical and feasible myocardial evaluation of the donor heart using the same modality used in post transplant follow-up.
180. Cardiac Contrast-enhanced MRI for Noninvasive Detection of Myocardial Fibrosis in Patients with Aortic Valve Stenosis
Weininger M.*; Ritter C.; Koestler H.; Weidemann F.; Hahn D.; Beer M. University Hospital of Wuerzburg, Wuerzburg, Germany
Address correspondence to M. Weininger (weininger{at}roentgen.uni-wuerzburg.de)
Objective: To investigate whether contrast-enhanced MRI can noninvasively detect myocardial fibrosis in patients with aortic stenosis.
Materials and Methods: 11 patients (mean age 70 ± 9 years, 6 men, 5 women) with valvular aortic stenosis (AHA classification; mild: n = 1; moderate: n = 3; severe: n = 7) according to echocardiography were examined using a 1.5-T MR scanner. In all patients cine-MRI (SSFP), flow quantification (SSFP) and late enhancement imaging (PSIR) were performed. In the same MRI exam degree of stenosis and impairment of ventricular function were determined. Prior to MRI, coronary artery disease was ruled out in 5 patients by conventional coronary angiography. Presence and absence of late enhancement (LE) as parameter for myocardial fibrosis was correlated to left ventricular morphological and functional data. According to the presence of LE patients were divided into two groups (G1, LE; G2, no LE).
Results: In 73% of our patients LE was detected (G1; 8/11; 5 men, 3 women), ranging from small focal spots to larger areas with a strong preference for basal segments. Mean value for left ventricular mass was 165 ± 52 g (G1, 168 ± 59 g; G2, 157 ± 27 g), for ejection fraction 58 ± 18% (G1, 54 ± 19%; G2, 67 ± 13%), for orifice area 0.8 ± 0.5 cm2 (G1, 0.8 ± 0.6 cm2; G2 0.8 ± 0.1 cm2). Additional findings included significant aortic regurgitation (G1, n = 4; G2, n = 2) and mitral regurgitation (G1, n = 2; G2, n = 1).
Conclusion: Our results show that a high percentage of patients with aortic stenosis display myocardial late enhancement. The dedicated focal patchy pattern of LE and its preference for basal segments could be characteristic and a differentiator from LE caused by infarction-related scarring. Our data furthermore indicate that myocardial fibrosis is associated with a clear tendency to left ventricular functional impairment and additional valvular diseases.
181. Quantitative Perfusion Measurements of the Healthy Human Lung by Using Contrast-enhanced MRI
Weininger M.*; Oechsner M.; Koestler H.; Hahn D.; Beissert M.; Beer M. University Hospital of Wuerzburg, Wuerzburg, Germany
Address correspondence to M. Weininger (weininger{at}roentgen.uni-wuerzburg.de)
Objective: To evaluate contrast-enhanced pulmonary perfusion by comparing a pre-bolus approach to single bolus measurements using different contrast agent quantities.
Materials and Methods: 11 healthy volunteers (8 men, 3 women, mean age 25 ± 2 years) were examined using a 1.5-T MR scanner. Perfusion images were acquired in expiratory breath-holds with saturation-recovery TrueFISP. We compared first-pass boluses (0.5/1.0/2.0/3.0 ml) to pre-bolus approaches with 2 ml and 3 ml. A ROI was positioned in the left pulmonary artery to evaluate the arterial-input-function (AIF). The AIF for the 2-ml and 3-ml bolus was constructed from 1 ml AIF. Signal-time courses of the lung parenchyma were taken from ROIs over the right and left lung. Perfusion values were calculated deconvoluting the lung's signal-time courses with the AIF and an exponential function as residuum. Perfusion maps were generated fitting the lung pixel by pixel. Lung volume (2D-HASTE) and heart-time-volume (TrueFISP) were measured to derive the global lung perfusion (GLP) as correlation.
Results: Mean perfusion values were as follows: 0.5 ml: 190 ± 73 ml/min/100 ml; 1 ml: 221 ± 68 ml/min/100 ml; 2 ml: 263 ± 87 ml/min/100 ml; 3 ml: 365 ± 148 ml/min/100 ml; pre-bolus 1 ml/2 ml: 192 ± 70 ml/min/100 ml; pre-bolus 1 ml/3 ml: 165 ± 52 ml/min/100 ml. Mean value for GLP was 187 ± 34 ml/min/100 ml. Single bolus measurements with contrast quantities = 2 ml result in increased pulmonary perfusion, due to saturation effects of the AIF. Calculated perfusion maps resulted in improved fit quality and smoother maps using the pre-bolus approach.
Conclusion: Our data indicate that lung perfusion using single boluses (0.5 ml, 1.0 ml) and pre-boluses (2 ml, 3 ml) display higher correlation to GLP. Furthermore the pre-bolus technique seems to be preferable to single boluses as it achieved smoother and less noisy perfusion maps due to higher SNR.
182. Mediastinal Mass: Assessment with Diffusion-weighted Single Shot Echo-planar MR Imaging
Abdel Razek A.*; Elshafeay M.; Elhadedy T. Mansoura Faculty of Medicine, Mansoura, Egypt
Address correspondence to A. Abdel Razek (arazek{at}mans.eun.eg)
Objective: To assess the clinical usefulness of diffusion-weighted single shot echo-planar MR imaging in patients with mediastinal mass.
Materials and Methods: This prospective study was conducted on 37 consecutive patients (19M, 18F aged 5–67 years: mean 34 years) with mediastinal mass. They underwent single shot echo planar diffusion-weighted MR imaging of the mediastinum with b-factor of 0,300 and 600 sec/mm2. The scanning parameters were: TR = 10,000 ms, TE = 108 ms, bandwidth = 125 kHz, slice thickness = 4 mm. Apparent diffusion coefficient (ADC) maps were reconstructed. The ADC value of the mediastinal mass was calculated and correlated with the surgical finding or biopsy.
Results: The mean ADC value of malignant tumors was 1.02 ± 0.13 x 10-3 mm2/sec in bronchogenic tumor, 1.02 ± 0.13 x 10-3 mm2/sec in lymphoma, 1.02 ± 0.13 x 10-3 mm2/sec in malignant thymoma. The mean ADC value of benign lesions was 1.47 ± 0.07 x 10-3 mm2/sec in benign thymic tumors, 1.61 ± 0.11 x 10-3 mm2/sec in neurogenic tumor and 02 ± 0.13 x 10-3 mm2/sec in mediastinal cyst. There was significant different in ADC value between benign and malignant mediastinal masses (p < 0.003) and within mediastinal malignancy (p < 0.002). When apparent diffusion coefficient value of 1.25 x 10-3 mm2/sec was used as a threshold value for differentiating malignant from benign mediastinal mass, the best results were obtained with an accuracy of 95%, sensitivity of 93%, specificity of 90%, positive predictive value of 86% and negative predictive value of 98%.
Conclusion: Apparent diffusion coefficient map is a new imaging modality used for characterization of mediastinal mass as it can differentiate benign mediastinal mass from malignant tumor and offer useful information for assessment of the histologic type of mediastinal malignancy.
183. Cardiopulmonary Assessment in Pectus Excavatum Patients Using MRI
Saleh R.*; Finn J. P.; Fenchel M.; Abrazado M.; Krishnam M.; Nyborg G.; Ton A.; Fonkalsrud E. W.; Cooper C. B. UCLA, Los Angeles, CA
Address correspondence to R. Saleh (rsaleh{at}mednet.ucla.edu)
Objective: To use MRI for detecting cardio-respiratory patho-physiologic abnormalities in pectus excavatum patients prior to corrective surgery, in comparison with healthy, normal subjects.
Materials and Methods: MRI studies in 23 patients (m = 18, M ± SD:19 ± 4 years) with PE were compared with age matched normal volunteers (m = 18, M ± SD: 24 ± 3.6 years), with no chest deformity or cardiopulmonary symptoms. All studies were performed on a 32-channel 1.5-T scanner (Avanto, Siemens). A complete cardio-respiratory protocol included SSFP survey images for chest wall indices (pectus severity index [PSI], chest and cardiac flatness [ChF, CaF]), multiplanar SSFP cardiac cine for quantitative hemodynamic indices, 3D time-resolved dynamic angiography and high spatial resolution 3D MRA for assessment of anatomy and transit times, flow quantification through the main pulmonary artery and individual lung volumetric by SSFP imaging. In addition, to validate the MRI-derived lung volume, Plethysmography was done for both groups. Angiographic and cardiac studies were assessed by two radiologists for evaluation anomalies. A two-tailed t-test, Pearson correlation, and agreement tests were used for above measurements between the two-matched groups.
Results: Chest wall indices were significantly higher in PE patients (PSI in PE patients 9.1 ± 4.8 vs. 2.8 ± 0.3 p < 0.001). RVEF (%) for PE patients were significantly lower (patients 54 ± 9.6 vs. 62.2 ± 8.4 in the control group, p = 0.009). All chest wall indices did not show significant correlation with RV EF or LV EF. Comparison of Plethysmography between pectus patients and normal controls for functional residual capacity, total lung capacity, residual volume and vital capacity (FRC = 3.9 ± 1.6 vs3 ± 0.6 vs, TLC = 5.6 ± 1.5 vs. 5.8 ± 0.9 RV = 1.4 ± 0.4 vs. 1.5 ± 0.5, VC = 4.2 ± 1.2 vs. 4.4 ± 0.9, respectively) yielded no significant difference (p < 0.05) in PE patients compared to the control group. MRI derived lung volumetric measurements for above measurements were not significant between patients and control group (TLC = 5.5 ± 1.5 vs. 6 ± 0.8; RV = 2.1 ± 0.5 vs. 2.2 ± 0.4; VC = 3.4 ± 1 vs. 3.8 ± 0.4; p > 0.05). There was no significant difference for average and peak pulmonary flow and velocity (p < 0.05). Pulmonary vasculature was assessed normal in all patients with PE, assessment of cine images by two radiologists demonstrated more prominent trabeculation of the right ventricle in the PE group (k = 0.71).
Conclusion: These initial results with MRI are consistent with the view that PE patients have cardiovascular impairment and not pulmonary function impairment.
184. CT Image Quality in Patients Unable to Lift Arms Overhead: Comparison of Two Modified Arm Positions
Litmanovich D.*; Raptopoulos V.; Pianykh O.; Tognolini A.; Spirn P.; Boiselle P. Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Address correspondence to D. Litmanovich (dlitmano{at}bidmc.harvard.edu)
Objective: CT scans of the chest are ideally performed with patients' arms raised overhead, but some patients are unable to achieve this position resulting in suboptimal imaging caused by severe streak artifacts. It has been suggested that the. The purpose of this study was to assess whether interposition of a pillow between the arms and the torso would improve image quality by decreasing these artifacts.
Materials and Methods: The degree of streak artifacts was assessed on CT scans of the chest in patients with their arms raised above their head (arms-raised group; n = 23), down by their side (arms-down group; n = 18) and over a pillow placed on their chest (arms-on-pillow group; n = 27).Patients with other known potential causes for streak artifact (such as indwelling or overlying metallic devices or oral contrast medium) were excluded. Each CT was evaluated by consensus by 2 radiologists who graded streak artifact using a 5-point scale (1 = no artifact, 5 = severe artifact) at two anatomical levels: aortic arch and right inferior pulmonary vein. Median artifact scores at each level were compared between the subgroups using Mann-Whitney rank sum test.
Results: The median (1–3rd quartiles) grade for the arms-raised group was 2 (1.25–2). This was statistically significantly different compared with the arms-down group 3 (2–3), p < 0.001, and for the arms-on-pillow group 2 (2–3), p = 0.0011. However the difference between the arms-down and arms-on-pillow group was not statistically significant (p = 0.14) but a trend for artifact reduction with the use of pillow was noticed (median 3 vs. 2), p = 0.14. On individual locations, the arms-raised position was statistically superior to both other groups in both locations. There was no difference in grading at the level of the aortic arch between the arms-down and arms-on pillow groups (medians 2 for both), p = 0.44. However, there was a trend towards improvement at the inferior pulmonary vein location (medians 3 vs. 2), p = 0.13.
Conclusion: Inability to raise arms overhead significantly reduces CT image quality. However, a modified position with arms placed over pillows has the potential to reduce the severity of streak artifact compared to positioning with arms by patients' sides.
185. Discordant Lung Motion: The Disturbed Pleura
Rafat Zand K.*; Rakheja R.; Kosiuk J.; Mesurolle B. McGill University Health Center, Montreal, Canada
Address correspondence to K. Rafat Zand (k_r_zand{at}yahoo.com)
Objective: To describe "discordant lung motion" in the absence of diaphragmatic paralysis: a phenomenon seen on multislice MDCT pulmonary CT angiography studies, resulting in significant image degradation.
Materials and Methods: Retrospective evaluation of 103 consecutive pulmonary CTA studies on a 64-slice MDCT scanner (slice thickness 0.625 mm, reconstruction interval 0.5 mm, pitch 0.5 mm, 120 kV/smart mA) was performed. Discordant lung motion was defined as motion artifact on at least three consecutive slices in only one lung. Local paracardiac motion was disregarded. Coexisting thoracic pathologies were recorded. Normal or variable position of diaphragm on the scout film and serial chest X rays was interpreted as evidence of intact diaphragms.
Results: Of the 103 studies, 2 were excluded due to extensive parenchymal disease or severe breathing. Of the remaining 101 studies, unilateral lung motion was seen in 25 (24.7 %), which were all cases with pleural effusions. Sixty-three had no or minimal effusions, none demonstrating the artifact. Twelve had small free effusions, 3 (25%) showing discordant motion. Twenty-three had large free effusions, 22 (95.6%) demonstrating the artifact. Three cases with large loculated effusions showed no discordant motion. The artifact was mostly confined to the cranial third of lung (cranio-caudal acquisition), except in very large effusions. Image degradation of involved slices ranged from minimal to uninterpretable (5 of 22 cases). None of the patients had radiological evidence of diaphragmatic paralysis.
Conclusion: "Discordant lung motion" in the absence of diaphragmatic paralysis is closely associated with pleural space abnormalities, most commonly sizable effusions. Delayed lung expansion due to mechanical uncoupling of visceral and parietal pleura and bulk motion of large effusions could explain this phenomenon. The artifact affects mostly the initial slices of acquisition, as the affected lung catches up with the healthier side and the rattling effusion settles down with time. In cases where a large effusion is noticed on the scout film, this artifact can be minimized by a 2–3 second acquisition delay after patient's deep inspiration prior to a breath-hold.
186. Complete Cartilage Ring Tracheal Stenosis Associated with Anomalous Left Pulmonary Artery (The Ring Sling Complex). Report of Five Cases and Systematic Review of the Literature
Restrepo C. S.3*; Vargas D.3; Varon-Puerta C.4; Reina R.1; Murcia S.2 1. Clinica de Marly, Bogota, Colombia; 2. Fundacion Cardioinfantil, Bogota, Colombia; 3. The University of Texas Health Science Center at San Antonio, San Antonio, TX; 4. University of Southern California, Los Angeles, CA
Address correspondence to C. Restrepo (restrepoc{at}uthscsa.edu)
Objective: To review the imaging findings associated with Ring-Sling Complex, prevalence of associated anomalies, clinical presentation, demographic information and patient outcome.
Materials and Methods: The medical records and imaging files of five patients with Ring-Sling complex were reviewed. A systematic review of literature was done in which additional 52 cases of patients with pulmonary artery (PA) sling with associated tracheal stenosis were identified, for a total of 57 affected individuals. The demographic information, clinical manifestation, and data regarding associated anomalies and patient outcome was extracted. Illustrative images from our own patients are presented.
Results: Affected individuals were more often men (66%) than women (33%), with a 2:1 ratio. All patients had some degree of tracheal stenosis, which more often affected a long segment (73%) rather than a short distal segment (17.8%). Length of stenosis was not specified in 5 patients. The majority of patients presented other congenital malformation (78.6%), with cardiovascular anomalies being the most common (62.5%), followed by pulmonary (12.5%), anorectal (10.7%), and other gastrointestinal (8.9%). The most common cardiovascular anomalies were atrial septal defect (16.1%) and persistent ductus arteriosus (10.7%). The most common associated bronchopulmonary anomaly was a tracheal bronchus to the right upper lobe which was found in 13 of 57 patients (23.2%). All patients developed respiratory symptoms during their first year of life, and tracheal reconstruction was performed in the majority (76.8%). Mortality among affected patients is high (44.6%) from respiratory complications, cardiovascular malformations or associated conditions.
Conclusion: Tracheal stenosis associated with PA sling more often involves a long tracheal segment. Men are affected more often, and associated congenital malformations are common. Despite diverse surgical techniques employed for reconstruction, mortality remains high, thus requiring correct early diagnosis.
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