Imaging differentiation of pathologic fractures caused by primary and secondary bone tumors

Objective

To describe pre-treatment imaging features of pathologic fractures caused by primary bone tumors (PBTs) and metastatic bone tumors (MBTs) and determine if radiographic or cross-sectional features can differentiate the underlying pathologies associated with the fractures.

Methods

Sixty-nine patients with a diagnosis of a pathologic fracture were enrolled. Biopsy established PBT as the cause of the pathologic fracture in 16 (23%) cases and MBT in 53 (77%) cases. The radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of the subjects were retrospectively reviewed for the presence of multiple imaging features.

Results

Compared to pathologic fractures caused by MBTs, the fractures caused by PBTs demonstrated a higher incidence of lytic bone cortex, mineralization and a soft-tissue mass on radiographs, mineralization and a soft-tissue mass on CT scans, and periosteal abnormality on MRI scans (P < 0.01). These features also exhibited a high negative predictive value in supporting the diagnosis of an underlying PBT over MBT.

Conclusion

Pathologic fractures caused by PBT and MBT may be differentiated by a few specific radiographic and CT imaging features, though MRI was poor for characterization of the underlying lesion. Such knowledge may assist radiologists in raising the possibility of a PBT as the cause of a pathologic fracture.     

A vast increase in the use of CT scans for investigating occult hip fractures

Background

Early diagnosis in neck of femur fractures has been shown to improve outcome. The National Institute for Clinical Excellence recommends if an occult hip fracture is suspected then an MRI should be performed and if not available within 24 h a CT should be considered. At our centre, emergency MRI is rarely available and so CT is commonly used.

Objectives

Our study aims to analyse the trends in CT use over a five year period for the diagnosis of neck of femur fractures.

Methods

Both the number of patients with a hip fracture and those undergoing a CT hip to diagnose an occult injury were identified across two district general hospitals between 2006–2007 and 2010–2011. The time from initial radiograph to CT and initial radiograph to operation were calculated.

Results

In 2006–2007, of 547 hip fractures, 20 CT hips were performed and 6 reported as a fractured neck of femur (30%). In 2010–2011, of 499 hip fractures, 239 CT hips were performed and 65 fractures were recognised (27%). The mean time from radiograph until CT scan was 2.0 days in 2007 and 3.2 days in 2011, which was a statistically significant difference (p < 0.001). For those diagnosed using a CT scan the mean time from admission X-ray to surgery was 1.2 days in 2007 and 3.6 days in 2011.

Conclusion

Clinicians are becoming increasingly reliant on CT for the diagnosis of hip fractures with our data suggesting further imaging is one factor that can delay time to diagnosis and theatre.     

The anterior tilt angle of the proximal tibia epiphyseal plate: A significant radiological finding in young children with trampoline fractures

Objective

Evaluation of the anterior tilt angle of the proximal tibia epiphyseal plate in young children, which suffered a trampoline fracture in comparison with a normal population.

Materials and methods

62 children (31 females, 31 males) between 2 and 5 years of age (average 2 years 11 months, standard deviation 11 months) with radiographs in two views of the tibia were included in this retrospective study. 25 children with proximal tibia fractures were injured with a history of jumping on a trampoline. All other causes for tibia fractures were excluded. A normal age-mapped control cohort of 37 children was compared. These children had neither evidence of a trampoline related injury nor a fracture of the tibia. The anterior tilt angle of the epiphyseal plate of the tibia was defined as an angle between the proximal tibia physis and the distal tibia physis on a lateral view. Two radiologists evaluated all radiographs for fractures and measured the anterior tilt angle in consensus. An unpaired Student's t-test was used for statistical analysis (SPSS). Original reports were reviewed and compared with the radiological findings and follow-up radiographs.

Results

In the normal control group, the average anterior tilt angle measured −3.2°, SD ± 2.8°. The children with trampoline fractures showed an anterior tilt of +4.4°, SD ± 2.9°. The difference was statistically significant, P < 0.0001. In 6 patients (24% of all patients with confirmed fractures) the original report missed to diagnose the proximal tibial fracture.

Conclusion

Young children between 2 and 5 years of age are at risk for proximal tibia fractures while jumping on a trampoline. These fractures may be very subtle and difficult to detect on initial radiographs. Measurement of the anterior tilt angle of the proximal tibia epiphyseal plate on lateral radiographs is supportive for interpreting correctly trampoline fractures.     

Sternal fracture in the emergency department: diagnostic value of multidetector CT with sagittal and coronal reconstruction images

Background

Multidetector CT (MDCT) is being increasingly used for patients with traumatic injuries in the emergency room. This is the first study to evaluate the diagnostic performance of MDCT for sternal fracture.

Patients and methods

For 87 patients who had motor vehicle accidents, we evaluated the diagnostic performance of MDCT for the sternal fractures. For 31 patients who underwent both MDCT and lateral radiography for the sternum, we compared the diagnostic performance of two examinations for the evaluation of sternal fracture.

Results

Thirty-two patients had sternal fractures and all the sternal fractures (sensitivity = 100%) were detected on MDCT, especially on the sagittal reconstruction images. However, the axial and coronal images detected 65% and 59% of all sternal fractures, respectively. For 31 patients who underwent both MDCT and lateral radiography for the sternum, MDCT showed superior diagnostic performance compared to that of radiography (accuracy = 97% and 77%, respectively, P = .02). For the one case that showed false positivity for sternal fracture on MDCT due to respiratory artifact, the lateral radiography enabled making the correct diagnosis.

Conclusion

Sternal fracture is frequently seen in patients who have blunt trauma injury secondary to motor vehicle accidents. MDCT, particularly sagittal images detect all of the sternal fractures, is superior to lateral radiography for diagnosis of sternal fracture. In the limited case that CT has severe motion artifact, additional radiography could help the diagnosis of sternal fracture.     

A careful evaluation of scout CT lateral radiograph may prevent unreported vertebral fractures

Objectives

Our purpose was to review scout CT lateral radiographs to reveal osteoporotic vertebral fractures unreported by radiologists and to explore scout CT as a potential diagnostic tool in the detection of vertebral fractures.

Methods

We considered 500 patients (303 males, 197 females, age 64.6 ± 13.5 year-old). Our investigation was firstly focused on scout CT lateral images to detect vertebral fractures with a combined semiquantitative and quantitative diagnostic approach. Findings addressed to vertebral fracture were subsequently confirmed by multiplanar sagittal CT reconstructions. Whenever a vertebral fracture was discovered the radiologist report was read and a collection of patient anamnesis followed to understand whether fractures were already known.

Results

In 44/500 patients (8.8%) the evaluation on scout CT was incomplete or limited for patient/technical-based conditions, and 15 were excluded from the analysis. In 67/485 patients (13.8%) 99 vertebral fractures were detected. Among 67 fractured patients only 18 (26.9%) were previously diagnosed by radiologists. However, in the clinical history of 32 patients vertebral fractures were already known.

Conclusions

The perception and sensibility to vertebral fractures among radiologists are still poor when the assessment of the spine is not the aim of the examination. Short time spent for the evaluation of scout CT lateral radiographs could improve our accuracy.     

Role of postoperative multislice computed tomography in assessment of pedicle screw placement in spinal surgical fixation

Objective

To evaluate the role of three-dimensional (3D) volume rendering computed tomography (CT), in the postoperative assessment of pedicle screw placement.

Methods

Ninety-eight patients with previous spinal fixation surgery were included. All inserted screws were evaluated post operatively within the first month using CT. Degree of misplacement and difference between CT images were recorded.

Results

Seventy six, 68 and 39 misplaced screws were detected in 3D reformatted image, coronal reconstruction and axial CT images, respectively. Dorsal spine had the higher rate of violation of 46 (9.95%) with the highest rate at T4 (12.8%) compared with lumbar of 32 (6.9%). Statistically significant differences were found between lateral and medial violation (P value −0.03), between findings of 3D CT reformatted and axial images (P = 0.04), and also in detecting end plate perforation and anterior vertebral encroachment in different CT images (P value −0.013). Sensitivity for 3D reformatted image and axial image compared with surgical finding in six revised screws was 100% and 95.8% and specificity was 100% and 88.7%, respectively. Highly momentous agreement is reported with Kappa coefficient = 0.95 ± <0.001.

Conclusion

We conclude that postoperative evaluation of pedicle screw using 3D CT reconstruction was a reliable method.     

The "communication line" suggests occult posterior malleolar fracture associated with a spiral tibial shaft fracture

Objectives

To demonstrate radiographical characteristics of the relationship between distal spiral tibial shaft fractures and associated occult posterior malleolar fractures (PMF) that confirmed by CT and MRI.

Materials and methods

X-rays for a ninety-six patients with spiral tibia fracture and associated PMF were reviewed. All patients additionally had an ankle CT. Patients with a negative CT scans underwent an ankle MRI. Radiographic observations included fracture location, characteristics, and a presence of a fracture line between the two injuries.

Results

The spiral tibia fracture line was contiguous with PMF in 89 of 96 cases after evaluation with the CT and MRI. The line connecting the two injuries, which occurs between the medial inferior apex of the spiral tibia fracture line and the posterior superior apex of the PMF was identified as the “communication line”. In 47 of the 89 conjunction fractures, the “communication line” was detectable preoperatively and in 12 cases postoperatively by anteroposterior radiograph. By using the CT and MRI scans, we found that no “communication line” was present in only 7 cases.

Conclusion

It is important to understand the nature of the association between distal spiral tibial shaft fractures and occult posterior malleolar fractures for optimal stabilization of the fracture and for appropriate rehabilitation. The “communication line” is a useful diagnostic clue for early recognition the occult PMF and alerts a closer evaluation of the lateral view and further CT examination.     

Comparison of diagnostic accuracy of Magnetic Resonance Imaging and Multidetector Computed Tomography in the detection of pelvic fractures

Objective

To compare diagnostic accuracy and interobserver reliability of Magnetic Resonance Imaging (MRI) and Multidetector Computed Tomography (MDCT) in the detection of acute pelvic fractures.

Materials and methods

In 38 consecutive patients (mean age 74.7 years) with a positive finding of anterior pelvis fracture in the conventional X-rays, pelvic MRI and MDCT were performed for further evaluation of pelvic ring fractures. Two radiologists independently read all data sets. Sensitivity and specificity were calculated based on mean scores for each method. Sensitivities of CT and MRI were compared using a paired proportion test (McNemar). Diagnostic validity of both methods was assessed by the interobserver variability using kappa statistics. Combined clinical data and findings from all imaging studies served as the reference standard.

Results

122 fractures were identified in the reference standard (37 sacral, 58 pubic, 22 acetabular, 1 ischial, 4 ilial). On average, MRI detected 96.3% whereas CT detected 77% of all fractures. With regard to sensitivity, MRI proved to be significantly better compared to MDCT (observer 1, p = 0.0009; observer 2, p = 0.0003 by observer 2). In particular, MRI performed better in the depiction of sacral fractures, reaching a sensitivity of 98.6% compared to 66.1% at CT. The interobserver variability was determined to be very good (k = 0.955 for MRI and 0.902 for MDCT).

Conclusion

MRI reaches a significantly higher sensitivity than CT in the detection of acute pelvic fractures, particularly of the sacrum. Especially in elderly patients with suspicion of a sacral fracture and negative results at MDCT, MRI may be considered as the next step in diagnostic workup.     

Under-reporting of osteoporotic vertebral fractures on computed tomography

Purpose

Osteoporotic vertebral fractures are frequently asymptomatic. They are often not diagnosed clinically or radiologically. Despite this, prevalent osteoporotic vertebral fractures predict future osteoporotic fractures and are associated with increased mortality and morbidity. Appropriate management of osteoporosis can reduce future fracture risk. Fractures on lateral chest radiographs taken for other conditions are frequently overlooked by radiologists. Our aim was to assess the value of computed tomography (CT) in the diagnosis of vertebral fracture and identify the frequency with which significant fractures are missed.

Materials and methods

The thoracic CT scans of 100 consecutive male and 100 consecutive female patients over 55 years were reviewed. CT images were acquired on General Electric Lightspeed multi-detector (MD) CT scanners (16 or 32 row) using 1.25 mm slice thickness. Midline sagittal images were reconstructed from the 3D volume images. The presence of moderate (25–40% height loss) or severe (>40% height loss) vertebral fractures between T1 and L1 was determined using an established semi-quantitative method and confirmed by morphological measurement. Results were compared with the formal CT report.

Results

Scans of 192 patients were analysed (95 female; 97 male); mean age 70.1 years. Thirty-eight (19.8%) patients had one or more moderate to severe vertebral fractures. Only 5 (13%) were correctly reported as having osteoporotic fractures in the official report. The sensitivity of axial CT images to vertebral fracture was 0.35.

Conclusion

Incidental osteoporotic vertebral fractures are under-reported on CT. The sensitivity of axial images in detecting these fractures is poor. Sagittal reformations are strongly recommended to improve the detection rate.     

The Assessment of Anemia From Attenuation Values of Cranial Venous Drainage on Unenhanced Computed Tomography of the Head

Objective

To determine if prediction of anemia is possible from quantitative analyses of unenhanced cranial computed tomography (CT) images.

Methods

A retrospective chart review revealed 101 patients who had hemoglobin and hematocrit levels obtained within 24 hours of an unenhanced cranial CT. Regions of interest were the place on the torcular Herophili (confluence of sinuses) and the left and right transverse sinuses. Attenuation values were correlated with hemoglobin and hematocrit to investigate any possible relationship.

Results

Hemoglobin levels were correlated with torcular and transverse sinus attenuation levels. For every 10 Hounsfield unit (HU) increase in torcular attenuation, hemoglobin levels increased by 16.3 g/L (P < .001). When subgroup analysis was performed, by sex, for every 10 HU increase in torcular attenuation, hemoglobin levels increased by 22.6 g/L (P < .001) in men and 8.96 g/L (P < .05) in women.

Conclusion

The attenuation values for venous drainage on unenhanced cranial CT constitute a practical adjunct in the assessment of anemia. Given the number of individuals undergoing CT without blood work, this rapid assessment technique for anemia is a convenient means for narrowing possible diagnoses.     

The role of multi detector computerized tomography in evaluation of maxillofacial fractures

Objective

The purpose of our study was to assess the role of multi-detector CT in the evaluation of maxillofacial fractures.

Subjects and methods

The study included 30 patients complaining from facial trauma with suspected facial fractures referred from the emergency unit of the El-Minia University Hospital. All patients subjected to non contrast MDCT in axial cuts and images are transferred to workstation then they underwent coronal, sagittal reconstructed images and 3-D volume rendering that are of benefit in final diagnosis.

Results

A total of 30 patients were included (their mean age 26 years). It was found that the nasal bone is most common to be fractured (found in 19 cases), followed by maxillary bone (17 cases), zygomatic bone (10 cases), mandibular bone (8 cases) and the pterygoid plates are least frequent to be fractured (6 cases). Also, concerning the complex facial fractures; the orbital wall fractures are the most frequent (found in 22 cases), followed by zygomatico-maxillary complex fractures (8 cases), the naso-orbito-ethmoid fractures (6 cases), and lastly comes the Le Forte fractures (found in 4 cases).

Conclusion

The use of MDCT is mandatory for the accurate classification of maxillo-facial fractures and so the management decision.     

T2WI MRI and MRI-MDCT correlations of the osteoporotic vertebral compressive fractures

Purpose

The purpose of this study was to present the various vertebral bone signal and configuration patterns on T2WI MRI in osteoporotic benign fractures. The appearances were also assessed with thin slice MPR CT images.

Materials and methods

66 patients (43 women, 23 men; age range, 34–97 years; mean age, 76 years) with 100 vertebral compression fractures due to osteoporosis were included in our study. All cases are acute or subacute phase fractures which occurred within 1 month. Multiple fractures were observed in 29 patients, in 8 cases multiple concurrent fractures were proved by past radiograph or MRI. Three planes of T2WI (sagittal, coronal, axial) section images were correlated with the corresponding MDCT images.

Results

In our retrospective study, various signals and forms of vertebral body fractures were observed. The fracture zone (line) was classified 3 signal intensity patterns. (high; n = 24, low to intermediate; n = 16, low intensity; n = 38) on T2WI. The signal of the peri(para) fractured area were high (n = 6), intermediate to low (n = 41), low (n = 53)intensity. With CT correlative study, high, low to intermediate area were considered to be corresponded to the bone marrow edema, fibrous reparative tissue with/without the bony callus formation. The localization were as follows: sub-end plate band like lesion in 53, central in 16, anterior in 13, sub-endplate + anterior in 10, and complete (diffuse) in 8. In 10 cases, adjacent Schmorl's nodules were observed.

Conclusion

The various vertebral body signal patterns were observed in osteoporotic compressive fracture on T2WI. By MRI-CT correlations, high signal and low signal area on T2WI corresponded to the bone marrow edema, and the fibrous tissue or callus formation respectively.     

Screening and detection of blunt vertebral artery injury in patients with upper cervical fractures: The role of cervical CT and CT angiography

Objective

To evaluate the clinical utility of nonenhanced CT (NECT)-based screening criteria and CTA in detection of blunt vertebral artery injury (BVAI) in trauma patients with C1 and/or C2 fractures.

Methods

We retrospectively reviewed the clinical records of all blunt trauma patients with C1 and/or C2 fractures between 8/2006 and 9/2011. Cervical CTA was prompted by cervical fractures involving/adjacent to a transverse foramen, and/or subluxation on NECT. Two neuroradiologists independently reviewed the CTA studies, and graded the BVAI.

Results

210 patients were included; of these, 124 underwent CTA (21/124 with digital subtraction angiography, DSA), and 2 underwent DSA only. Overall, 30/126 suffered BVAI. Among 21 patients who underwent both CTA and DSA, there was 1 false negative and 1 false positive (both grade 1). There was strong interobserver agreement regarding CTA-based BVAI detection (kappa = 0.93, p < 0.001) and grading (kappa = 0.90, p < 0001). Only 3/30 BVAI patients suffered a posterior circulation stroke; none of the patients who had a negative CTA or were not selected for CTA, based on NECT screening criteria, suffered symptomatic stroke. While C1/C2 comminuted fracture was more common in patients with high grade BVAI (p = 0.039), simultaneous C3–C7 comminuted fracture increased the overall BVAI risk (p = 0.011).

Conclusion

CTA reliably detects symptomatic BVAI in patients with upper cervical fractures. Utilization of NECT-based screening criteria such as transverse foraminal involvement or subluxation may be adequate in deciding whether to perform CTA, as no patients who were not selected for CTA suffered a symptomatic stroke. However, CTA may miss lower grade, asymptomatic BVAI.     

Mandibular fracture patterns consistent with posterior maxillary fractures involving the posterior maxillary sinus,pterygoid plate or both: CT characteristics

Objectives:

The aim of this study was to determine the incidence of posterior maxillary fractures involving the posterior maxillary sinus wall, pterygoid plate or both, unrelated to major midface fractures in patients with mandibular fractures, and to characterize associated fractures.

Methods:

A CT study was performed in patients with mandibular fractures to identify posterior maxillary fractures. Patients aged under 16 years, those with mandibular fractures involving only dentoalveolar components and those with concurrent major midfacial fractures were excluded.

Results:

13 (6.7%) of 194 patients with mandibular fractures also had posterior maxillary fractures (case group). The injury pattern correlated with the external force directed to the lateral side of the mandible (p < 0.001), alcohol consumption (p = 0.049), the presence of multifocal fractures (p = 0.002) and the fracture regions in the symphysis/parasymphysis (p = 0.001) and the angle/ramus (p = 0.001). No significant difference between the case and non-case groups was seen for age, sex or cause of trauma. Non-displaced fractures in the ipsilateral posterior mandible occurred with significant frequency (p = 0.001) when the posterior maxillary fractures involved only the sinus.

Conclusions:

Mandibular fractures accompanied by posterior maxillary fractures are not rare. The finding of a unilateral posterior maxillary fracture on CT may aid the efficient radiological examination of the mandible based on possible patterns of associated fractures, as follows: in the ipsilateral posterior region as a direct fracture when the impact is a medially directed force, and in the symphysis/parasymphysis or contralateral condylar neck as an indirect fracture.     

Comparative study of DTS and CT in the skeletal trauma imaging diagnosis evaluation and radiation dose

Purpose

To compare the differences between CT (Computed tomography) and DTS (digital tomosynthesis) in the X-ray radiation dose, and to analyze the sensitivity and specificity of each examination to check the suspected fractures and dislocations cases.

Methods

From May 2010 to February 2012, 46 patients suspected with fractures and/or dislocations were prospectively enrolled to do the CT and DTS examination on the basis of the results of DR examination. Patients were considered ineligible if they were pregnant or lactating (female subjects only). The Yangzhou Regional Ethical Review Board in Jiangsu province, China approved this study. All 46 patients signed the informed consent. To contrast radiation dose between CT and DTS group of the patients and make statistical analysis. Two experienced experts assess the image quality by I–III grade and make statistical analysis. Draw the ROC of reader A and B according to the golden standard of clinical diagnosis.

Results

The average effective dose of CT Group is 5.46 msv, while average effective dose of DTS group is 0.07 msv.There is significant statistical difference (t = 22.89, p < 0.01) between them. Calculate and compare the area under the ROC curve of reader A and B. The area of reader A by CT and DTS is 0.999 ± 0.005, 0.973 ± 0.022. The area of reader B is 0.961 ± 0.026, 0.944 ± 0.032. Both of them perform z test, and P > 0.05. There is no significant difference. Assess the uniformity of two readers with Kappa test. The Kappa value of reader A and B is respectively 0.757 and 0.783. When the value is greater than 0.75, two readers’ uniformity is considered well. The two readers’ sensitivity and specificity in diagnosing hidden skeletal trauma with CT and DTS are respectively 97.06% (reader A), 96.97% (reader B); 91.67% (reader A), 84.62% (reader B). Use the χ² test to them, then get the same result: P > 0.05. There is no statistical significant.

Conclusion

Radiation dose of VolumnRAD DTS only account for 1.5% of CT, but its image can meet the requirements for clinical diagnosis. When fracture and/or dislocation is suspected with DR, VolumnRAD DTS can be recommended firstly as further checks.     

Whole-body MRI vs. CT for staging lymphoma: Patient experience

Objective

To assess and compare patient experience of whole-body magnetic resonance imaging (MRI) to that of computed tomography (CT) for staging newly diagnosed lymphoma.

Materials and methods

A total of 36 patients with newly diagnosed lymphoma prospectively underwent whole-body MRI and CT for staging purposes. Patients were asked to fill in a short questionnaire with regard to the burden and experience of the examination on a Likert scale (range 1–4). Wilcoxon signed rank tests were used to determine statistically significant differences in patient (dis)comfort between the two examinations.

Results

Patients reported to be significantly (P = 0.007) less worried before undergoing whole-body MRI compared to CT. Patients also experienced whole-body MRI as significantly (P = 0.010) less unpleasant and felt significantly (P = 0.003) better shortly after the scan. The necessary preparations before CT scanning (i.e. insertion of intravenous line, drinking of contrast fluid), which are not required for whole-body MRI, were reported to be a considerable burden.

Conclusion

In this study in patients with newly diagnosed lymphoma, whole-body MRI was experienced as a more patient-friendly technique than CT.     

Prognostic evaluation of PET/CT in residual post-chemotherapy masses in patients with diffuse large B-cell lymphoma and its impact on survival

Aim of the work

To evaluate the prognostic value and accuracy of PET/CT in DLBCL patients with post-treatment CT-residual masses with concern in overall (OAS) and progression-free survival (PFS).

Materials and methods

We retrospectively studied 62 patients with DLBCL who had CT documented residual masses (CRu) after completion of chemotherapy.

Results

Forty-four patients with negative PET scan were free of relapse while 4 out of 18 patients with positive scan showed CR, the other 14 patients had developed relapse. PET attained a sensitivity of 100%, a specificity of 91%, a NPV of 100% and a PPV of 77.8% and an accuracy of 93.5%. The median OAS time was 33.59 months in patients with negative scan and 19.00 months in patients with positive scan with highly significant correlation (P value 0.0001) and the median PFS time was 29.53 months in patients with negative scan versus only 4.00 months in patients with positive scan with highly significant correlation (P value 0.0000).

Conclusion

PET/CT plays helpful part in evaluation of therapy response in DLBCL patients with CT residual mass and post-chemotherapy PET could be used as an accurate and good predictor of OAS and PFS.     

Diffuse ischemia in noncontrast computed tomography predicts outcome in patients in intensive care unit

Purpose

In the intensive care unit (ICU), prognosticating patients who are comatose or defining brain death can be challenging. Currently, the criteria for brain death are clinical supported by paraclinical tests. Noncontrast computed tomography (CT) shows diffuse loss of grey-white differentiation consistent with infarction. We hypothesize that the extent of hypodensity is predictive of poor neurologic outcome or brain death.

Materials and Methods

A total of 235 consecutive adult patients with cardiac arrest or with serious trauma admitted to ICU in 1 year were studied. Seventy met inclusion criteria. CT images were reviewed by multiple observers blinded to final outcome who assessed for loss of grey-white conspicuity. A modification of the validated Alberta Stroke Program Early CT Score (ASPECTS) was used to include non–middle cerebral artery territories. Primary outcome was death or functional disability at 3 months. Dichotomized CT scores were correlated with poor clinical status (Glasgow Coma Score < 5 and APACHE [Acute Physiology and Chronic Health Evaluation] score >19) and poor outcome (modified Rankin Scale >2).

Results

The CT score was ≤10 in 7 patients and >10 in 63 patients. The CT score value correlated with the severity of baseline clinical status on the Glasgow Coma Score (r = 0.53, P < .01) and negatively with the APACHE-II score (r = −0.27, P < .05). The CT score value negatively correlated with functional outcome (r = −0.40, P < .01). All the patients with a CT score ≤10 died. The sensitivity of the CT score for functional outcome was 24%, and specificity was 100%. Agreement among observers for the CT score was good (Intraclass correlation coefficient = 0.77).

Conclusion

Diffuse loss of grey-white matter differentiation is subtle but specific for poor neurologic outcome, which may allow earlier prognostication of patients in whom clinical parameters are difficult to assess.     

Contrast-enhanced CT and diffusion-weighted MR imaging: Performance as a prognostic factor in patients with pancreatic ductal adenocarcinoma

Objective

To determine whether contrast enhancement of CT and apparent diffusion coefficient on diffusion-weighted MR imaging are important parameters that can predict outcomes for patients with pancreatic ductal adenocarcinoma.

Materials and methods

Ninety-two patients with histologically confirmed pancreatic ductal adenocarcinoma who underwent quadriphasic CT (including unenhanced, pancreatic parenchymal, portal venous and delayed phases) and fat-suppressed single-shot echo-planar diffusion-weighted MR imaging at 3.0 T were retrospectively analyzed to investigate prognostic factors. Overall survival curves were drawn using the Kaplan–Meier method. Effects on survival of variables including age, sex, tumor location, tumor size, TNM stage, carbohydrate antigen 19-9, carcinoembryonic antigen, treatment, tumor contrast enhancement and apparent diffusion coefficient values were analyzed in univariate analysis using the log-rank test. Variables were analyzed in multivariate analyses using the Cox proportional hazards regression model.

Results

Median survival for the entire patient population was 18.2 months. Higher contrast enhancement during all phases was associated with significantly longer overall survival (P < 0.001 for all phases). The difference in overall survival between groups divided by median apparent diffusion coefficient value was not significant (P = 0.672). TNM stage (P = 0.026) and tumor contrast enhancement on CT (P = 0.027) were significantly related to survival in multivariate analysis.

Conclusions

Poor enhancement of pancreatic adenocarcinomas on enhanced CT is associated with reduced patient survival.