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Purpose The aim of the present study was to correlate computed tomography appearances with clinical severity and outcome using a total lung disease (TLD) score in patients with acute respiratory distress syndrome (ARDS) related to influenza A H1N1 infection. Materials and Methods Chest computed tomographic scans of 33 patients admitted in the intensive care unit with ARDS related to influenza A H1N1 were retrospectively reviewed. Total lung disease was calculated from the combined extent of consolidation (TLC) and ground glass (TLGG) in the anterior, middle, and posterior segments of the lungs at 3 different levels (apex, hila, and base) using the method described by Goodman et al ( Radiology . 213:545-552;1999). Total lung disease, TLC, and TLGG were statistically correlated with demographic characteristics, requirement for extracorporeal membrane oxygenation (ECMO) treatment, and patient outcome. Results Total lung disease is higher in patients who require ECMO treatment ( P = .016). It is significantly higher ( P = .003) in the posterior segments and significantly lower ( P = .0001) in the anterior segments compared with TLGG. Total consolidation significantly increases ( P = .0001), whereas TLGG significantly decreases ( P = .0001) from the anterior toward the posterior segments. There is also a significant increase in TLD ( P = .0001), TLC ( P = .0001), and TLGG ( P = .004) from the apices to the lung bases. There is a negative correlation between TLD and age ( P = .01), and TLGG and body mass index ( P = .014). Total consolidation is higher ( P = .013) and TLGG is lower ( P = .012) in patients with a body mass index greater than 30 kg/m 2 . Conclusion A greater extent of air-space disease in ARDS related to influenza A H1N1 infection is associated with progression to ECMO treatment and, therefore, clinical severity. The extent of total air-space disease is greater in younger patients, and obesity is related to a more extensive consolidation.

This review describes the broad spectrum of findings found in atrial isomerism, suggesting a sequential approach to image evaluation, and illustrates the most common situs disorders, for example, polysplenia and asplenia.

We report a 6-year old girl with recurrent and non-resolving left-sided "pneumonia" over a 3-year period who was diagnosed with an endobronchial low-grade fibrosarcoma. This highlights the importance of considering underlying localized airway obstruction in any case of clinically or radiologically atypical pneumonia in a child and therefore the need for careful follow-up of all but the most typical cases.

Introduction Cardiac imaging is an emerging application of multidetector computed tomography (MDCT). This review summarizes the current capabilities, possible applications, limitations and developments of cardiac CT. Sources of data Relevant publications in peer reviewed literature and national and international guidelines are used to discuss important issues in cardiac CT imaging. Areas of agreement and controversy There is broad consensus that coronary CT angiography is indicated in patients with an intermediate pre-test probability of coronary artery disease (CAD) when other non-invasive tests have been equivocal. In this context, CT can reliably exclude significant CAD. Cardiac CT also has an established role in the evaluation of bypass grafts and suspected coronary anomalies. Radiation exposure from CT procedures remains a concern, although techniques are now available to reduce the X-ray dosage without significantly compromising the image quality. However, with the current level of knowledge, the cardiac CT examinations are not justified to screen for CAD in asymptomatic individuals. Neither is it considered appropriate in patients with a high pre-test probability of CAD, for whom invasive catheter coronary angiography is usually of more benefit. Growing points and areas timely for developing research The ability to reconstruct the volumetric cardiac CT data set opens up avenues for advanced physiological analyses of the heart. For example, if CT myocardial perfusion assessment becomes a reality, there is potential to revolutionize the practice of MDCT imaging. Research is also ongoing to investigate whether cardiac CT has a role in the appropriate triage of patients with chest pain in the emergency department.

Comprehensive assessment of pulmonary arterial hypertension (PAH) should identify structural causes and subsequent cardiopulmonary consequences of PAH. This currently requires the use of several imaging modalities. Computed tomography (CT) is routinely used for pulmonary angiography (CTPA). Our aim was to assess whether combined pulmonary and coronary angiography (CTPCA) using ECG-gated, multi-detector CT (MDCT) would allow satisfactory pulmonary angiography, coronary angiography and ventriculography to be combined into a single acquisition using a single imaging modality.We assessed CTPCA in 30 consecutive adult patients (mean age 41+/-11 years) with a diagnosis of PAH. In addition to the standard assessment of lung parenchyma and pulmonary vasculature, we assessed the ability of CT to satisfactorily visualise coronary vessels and biventricular function. Functional analysis included: end-diastolic volume (EDV), end-systolic volume (EDV), stroke volume (SV) and ejection fraction (EF) and mass and these parameters were correlated with same day cardiovascular magnetic resonance (CMR).Lung parenchyma, pulmonary and coronary vessels were fully visualised in all cases. Ventriculography correlated well with same day CMR (RVEDV r=0.94, +19.5+/-49.2 ml, RVESV r=0.93, +11.1+/-46.4 ml, RVSV r=0.60, +8.5+/-41.6 ml, RVEF r=0.77, -0.5+/-21.3% and RV mass r=0.73, -17.3+/-60.4 g, LVEDV r=0.68, +12.2+/-110 ml, LVESV r=0.69, +7.5+/-59.7 ml, LVSV r=0.54, +2.5+/-40.6 ml, LVEF r=0.73, -1.9+/-20.8% and LV mass r=0.87, -20.5+/-22.5 g (all p0.001)). Associated congenital cardiovascular malformations were characterised in 22/30 cases.A CTPCA protocol allows safe, fast, comprehensive, non-invasive assessment of the possible anatomical causes and cardiopulmonary sequelae of PAH in adult patients, demonstrating congenital heart abnormalities, coronary artery disease and cardiac function.

Aim To determine whether similarities exist in both the imaging and histopathological features of congenital cystic lung lesions and whether a more appropriate classification would be to adopt the theory of “malinosculation”. Material and methods From the histopathology and computed tomography (CT) database, 24 patients (16 male, median age 3 years) with congenital cystic lung lesions were identified. CT studies were reviewed for site and characteristics of the lesions, parenchymal features, bronchial anatomy, and the presence of a feeding systemic vessel. Individual histopathological parameters were also correlated with CT data. Results There were five type 1 congenital cystic adenomatoid malformations (CCAMs), six type 2 CCAMs, one type 4 CCAM, one bronchial atresia, four pleuropulmonary blastomas (PPBs), and seven sequestrations. CCAMs (types 1, 2 and 4), sequestrations and PPBs appeared as cystic lesions, with cyst size less than 2 cm in type 2 CCAMs. Sequestrations were distinguished radiologically from CCAMs by systemic vessels. Reduced pulmonary attenuation was seen in bronchial atresia, type 2 CCAMs and in sequestrations. Histopathology showed an overlap in entities with sequestrations demonstrating CCAM type 2 histology and segmental atresia noted in both type 2 CCAMs and sequestrations. PPBs showed histological and imaging overlap with type 4 CCAMs and were distinguished on histology by the presence of blastematous proliferation. Conclusions This study demonstrates overlap in the CT appearances of congenital cystic lesions. The similarity in CT and histopathology findings across the spectrum of developmental lesions supports the hypothesis of a common aetiology.

Background. Cardiac computed tomography (CCT) has the potential to assess both coronary anatomy and ventricular function in a single study. We examined the agreement between CCT and myocardial perfusion scintigraphy (MPS) for the assessment of global and regional ventricular function. Methods and Results. Research CCT was performed in 52 patients with a low to intermediate likelihood of coronary artery disease referred for MPS. Left ventricular enddiastolic volume, left ventricular end-systolic volume, left ventricular ejection fraction (LVEF), and myocardial wall motion and thickening were compared between techniques. In addition, myocardial contrast attenuation on CCT was compared with radiotracer uptake on MPS. LVEF values agreed well (mean difference, 4.1%; SD, 15.13%), but CCT left ventricular end-diastolic volume was greater compared with MPS (mean difference, 46.0 mL; SD, 33.34 mL) (P

Adult congenital heart disease is an increasingly prevalent condition with more than 135,000 patients affected in England alone. With this increased patient population and an increase in interventional procedures being performed on them, traditional imaging techniques such as cardiac magnetic resonance (CMR) may be unavailable locally or contra-indicated. Cardiac multidetector computed tomography (MDCT) is rapidly emerging as an alternative imaging method for the investigation of these patients and this review highlights the broad application of cardiac MDCT to this population and makes recommendations on the standardized reporting of complex congenital heart disease.

AIM: To describe the computed tomography (CT) features of human immunodeficiency virus (HIV)-associated Castleman's disease.MATERIALS AND METHODS: Nine HIV-positive patients with biopsy-proven Castleman's disease were studied. Clinical and demographic data, CD4 count, histological diagnosis and human herpes type 8 (HHV8) serology or immunostaining results were recorded. CT images were reviewed independently by two radiologists.RESULTS: CT findings included splenomegaly (n = 7) and peripheral lymph node enlargement (axillary n = 8, inguinal n = 4). All nodes displayed mild to avid enhancement after intravenous administration of contrast material. Hepatomegaly was evident in seven patients. Other features included abdominal (n = 6) and mediastinal (n = 5) lymph node enlargement and pulmonary abnormalities (n = 4). Patterns of parenchymal abnormality included bronchovascular nodularity (n = 2), consolidation (n = 1) and pleural. effusion (n = 2). On histotogical examination eight patients (spleen n = 3, lymph node n = 9, lung n = 1 bone marrow n = 1) had the plasma cell variant and one had mixed hyaline-vascular/plasma cell variant. The majority had either positive immunostaining for HHV8 or positive serology (n = 8).CONCLUSION: Common imaging features of multicentric Castleman's disease in HIV infection are hepatosplenomegaly and peripheral lymph node enlargement. Although these imaging features may suggest the diagnosis in the appropriate clinical context, they lack specificity and so biopsy is needed for diagnosis. In distinction from multicentric Castleman's disease in other populations the plasma cell variant is most commonly encountered, splenomegaly is a universal feature and there is a strong association with Kaposi's sarcoma. (C) 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

What are the diff erential diagnoses for never smokers who present with ground glass opacities on CT? What are the management options? How are CT detected lung nodules classifi ed at present? What has changed in the classifi cation of lung adenocarcinoma? What are the clinical implications for personalised molecular targeted treatments in lung cancer? Test your diagnostic and management skills in Grand Rounds from the Royal Brompton Hospital and listen to experts inform and discuss the new issues that are raised.

Pulmonary lacerations are an uncommon injury typically associated with high-impact trauma. Most cases occur as a result of high-speed road traffic collisions. Although chest wall and pleural injuries are commonly associated with sports-related thoracic trauma, pulmonary injuries are far less common. There are only a few reported cases of significant pulmonary trauma associated with sports injuries, the majority of which have described pulmonary contusions occurring as a result of thoracic injury sustained while playing high-impact contact sports such as American football. Pulmonary laceration occurring as result of soccer-related thoracic trauma has never previously been reported.

T.K. Mittal , E.D. Nicol ⁎, S.P. Harden , C.A. Roobottom , S.P. Padley , G. Roditi , C.R. Peebles , A. Taylor , M.C. Hamilton , G.J. Morgan-Hughes , R.W. Bury , on behalf of the British Society of Cardiovascular Imaging a Royal Brompton and Harefield NHS Foundation Trust, London, UK b University Hospital Southampton NHS Foundation Trust, Southampton, UK c Plymouth Hospitals NHS Trust, Plymouth, UK d Glasgow Royal Infirmary, Glasgow, UK e Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital, London, UK f Bristol Royal Infirmary, Bristol, UK g Blackpool Victoria Infirmary, Blackpool, UK

Cardiac computed tomography (CCT) is a non-invasive imaging technique for the diagnosis of coronary artery disease (CAD). The National Institute for Health and Clinical Excellence (NICE) recommend CCT for selected patients in the assessment of chest pain of recent onset.To assess the feasibility and utility of CCT in a nurse-led, protocol-based assessment of chest pain.Patients admitted over 4 months with suspected angina were assessed for eligibility for CCT by a specialist nurse. Eligibility was defined by: a likelihood of CAD90%, no features of acute coronary syndrome, no contra-indications to the scanning process, and the ability to give written consent. An age and sex-matched historical cohort (for whom CCT was unavailable) was compared with the CCT cohort with regard to the diagnosis or exclusion of CAD at 3 months post-discharge from hospital.Of 198 patients admitted, 98 were identified as eligible for CCT. Of these, 37 were recommended for alternative management on cardiologist review, 18 declined consent, 23 were unable to be scanned within 24 h prior to discharge and 14 underwent CCT. CAD was diagnosed or excluded in 14/14 patients undergoing CCT. CAD was diagnosed or excluded in 11/14 patients investigated without CCT, leaving 3/14 patients with no clear diagnosis.This study suggests nurses may be trained to assess patients for CCT within agreed protocols. In the UK it is likely these protocols will be based on NICE guidance. Despite potential diagnostic utility, CCT appears likely to form a small percentage of cardiac investigations undertaken.

CT coronary angiography (CTA) with 64 slice multi-detector CT (64-MDCT) has assumed an increasing role in clinical practice; however the high radiation dose associated with retrospective ECG-gated CTA has led to suggestions that a low dose prospectively gated strategy may be more appropriate. This study aims to assess the feasibility of this proposed strategy amongst standard referral for CTA in our centre.We retrospectively analyzed 200 consecutive clinical CTA studies assessing the number of cardiac phases required to allow full diagnostic visualisation of the coronary tree. We assessed whether the pre-test likelihood of coronary disease, heart rate, heart rate variability and range, current beta-blockers use, coronary calcium score, breathing artefact or study quality affected the number of phases required.125/200 patients (62.5%) required only a single phase for full diagnostic visualisation of the coronary tree [most commonly 65% of the R-R interval-109/125 (87.2%)]. A successful diagnostic single cardiac phase was most likely in patients with a low heart rate (Heart rate70 bpm OR = 2.64; p = 0.003 and heart rate60 bpm OR = 4.81; p0.001 respectively) and low likelihood of coronary disease [OR = 1.97 95% CI (1.09, 3.58) p = 0.025].High image quality is possible using single phase analysis in those patients with low likelihood of coronary disease, low heart rates and full cooperation with inspiratory breath hold. In patients with HR of60, prospective ECG-gated acquisitions reduce radiation dose but may be non-diagnostic in as many as one third. Careful patient selection is therefore essential.

Objectives: To assess intraobserver and interobserver variation in computed tomography coronary angiography (CTA) in 3 patient cohorts at very low, low-to-intermediate, and intermediate-to-high likelihood of coronary artery disease (CAD).Methods: One hundred thirty-three patients underwent 64-channel CTA. Coronary arteries were analyzed by 2 experienced blinded observers and reported as having 0%, 1% to 29%, 30% to 49%, 50% to 69%, 70% to 99%, or 100% stenosis. Intraobserver and interobserver agreement was calculated at cohort level and combined.Results: Overall intraobserver and interobserver agreement was good (kappa = 0.74 and kappa = 0.78, respectively). Segmental agreement for stenoses 50% or greater and 70% or greater was greater than 96%. Disagreements were more likely in the presence of noneccentric calcification for both intraobserver (odds ratio = 0.45 and 0.22) and interobserver (odds ratio 0.40 and 0.10) measurements.Conclusions: Interobserver and intraobserver variability for the detection of coronary stenoses on CTA is good and justifies routine clinical use, The presence of noneccentric calcium and mixed plaque morphology are important causes of disagreement.

Objectives: To assess intraobserver and interobserver variability in cardiac computed tomographic measurements of global biventricular function, left ventricular (LV) regional wall motion, systolic wall thickening, and first pass perfusion in 3 patient cohorts at very low, low to intermediate, and intermediate to high cardiac risk. Methods: One hundred thirty-three patients underwent 64-channel cardiac computed tomography. Images were analyzed by 2 experienced, blinded observers. Intraobserver and interobserver agreements were calculated for each cohort and were combined for patients with structurally normal hearts. Results: Intraobserver and interobserver agreements were good for all global and regional LV parameters with narrow levels of agreement. Right ventricular ejection fraction agreement was also good, but other right ventricular parameters showed wide levels of agreement. Conclusions: Biventricular ejection fraction, LV regional wall motion, and systolic wall thickening, volume, and mass show good reproducibility for use in standard clinical practice. Right ventricular volumetric and mass data in patients with congenital heart disease should be interpreted with caution.

There is currently much debate around the limited positive predictive value (PPV) of CT coronary angiography (CTA). There remain no published studies comparing different thresholds to define significant visual stenoses on CTA compared to the gold standard quantitative coronary angiography (QCA). The spatial resolution for ICA is (0.1 mm)(3) compared with (0.5 mm)(3) in clinical CTA and direct comparison introduces a systematic overestimation of stenosis severity by CTCA. Assessing both ≥ 50% and ≥ 70% visual stenoses on CTA with QCA we found that the negative predictive value (NPV) of CTA is equally high for both. The PPV of CTA improves using ≥ 70% but with a loss of sensitivity. Using ≥ 70% stenosis on CTA for referral for ICA would reduce the number of ICA that does not lead to percutaneous intervention (PCI) but a functional test for intermediate lesions (visual stenoses of 50%-69%) on CTA is recommended to overcome the reduction in sensitivity.

Aim To describe the CT features of fibrosing mediastinitis. Materials and methods The clinical notes, histology, and CT images from 12 patients with fibrosing mediastinitis were reviewed. Clinical data regarding the presentation and suspected aetiology were correlated with location of mediastinal disease, calcification, effect on mediastinal structures, and additional pulmonary findings on computed tomography (CT). Results The mean age was 40.5 years, with seven female and five male patients. The most common presenting symptom was shortness of breath. Fibrosing mediastinitis diffusely infiltrated the mediastinum in five patients and was localized in seven. Calcification was present in two cases. Eleven of 12 cases had narrowing of mediastinal structures, including five with pulmonary artery narrowing, five with superior vena cava obstruction, four with bronchial narrowing, three with tracheal narrowing, and one with narrowing of the pulmonary vein. The disease was considered idiopathic in seven cases with a demonstrable aetiology in five cases. Eight out of 12 patients had additional pulmonary findings, including all patients with a known aetiology. Conclusions In the present series of patients, fibrosing mediastinitis more commonly presented as a localized mediastinal mass than as diffuse mediastinal disease, with the anterior mediastinal compartment most frequently involved. Most cases were idiopathic compared with the majority of previous cases at this institution being ascribed to tuberculosis. There is a high incidence of concomitant pulmonary findings, in particular when an identifiable aetiology is present. Obstruction of vital structures frequently gives rise to complications.

Aim To document the pulmonary vascular changes on thin-section computed tomography (CT) in patients with Eisenmenger syndrome and idiopathic pulmonary arterial hypertension, and to determine whether there is any correlation with pulmonary arterial pressures or the aetiology of pulmonary hypertension. Material and methods From the National Pulmonary Hypertension Database, we identified eight patients with idiopathic pulmonary arterial hypertension and 20 patients with Eisenmenger syndrome (secondary to a ventriculoseptal defect) who had also undergone contrast-enhanced thin-section CT. CT studies were reviewed for the presence of centrilobular nodules, mosaicism, neovascularity, and bronchial artery hypertrophy. Haemodynamic data were also reviewed. Results Centrilobular nodules, mosaicism, and neovascularity were seen in both patient groups (p > 0.05). A significantly higher number of enlarged bronchial arteries were seen in patients with Eisenmenger syndrome. There was no correlation with pulmonary arterial pressures. Conclusion Patients with idiopathic pulmonary arterial hypertension and Eisenmenger syndrome demonstrated similar pulmonary vascular changes on CT. These changes did not predict the underlying cause of pulmonary hypertension or its severity.

To investigate whether asymmetric distribution of acute respiratory distress syndrome (ARDS) following lobectomy is due to compensatory hyperexpansion of the residual lung within the hemithorax operated on and to discern if this distribution reflects true asymmetry of the disease process.Retrospective review of the intensive care unit database was performed over a period of 6 years to identify all cases of lung injury following lung surgery that satisfied the American-European consensus criteria for ARDS. Time to onset following surgery, time of subsequent computed tomographic (CT) examination, patient age and sex, and nature of surgery were recorded, as well as eventual patient status (ie, death or discharge). Availability of both preoperative and postoperative CT scans was required for inclusion for further analysis. These images were analyzed on a commercial CT workstation for the volume of lung resected and the pre- and postoperative volume and density of each lung. Expected postoperative densities (preoperative density adjusted for volume) were compared with observed postoperative densities.Review disclosed 583 patients who underwent lobectomy or segmentectomy. Seventeen patients (2.9%) developed postoperative ARDS. Nine of these patients had pre- and postoperative CT scans available for analysis. In eight of nine cases, density increased more in the nonoperated lung than in the operated lung (P =.01). The degree of density increase in the nonoperated lung was significantly greater (305 mg/mL; range, 48-449 mg/mL) than that in the operated lung (13 mg/mL; range, -198 to 231 mg/mL; P.001).Following lobectomy, there appears to be a truly asymmetric form of ARDS rather than compensatory hyperexpansion of the residual lung on the operated side.

To assess the CT features of tuberculosis of the chest wall, the CT findings in four patients with documented tuberculous chest wall infection were reviewed. Two patients were Caucasian and two were of Chinese origin. All had normal immune status. In two cases tuberculosis involved the ribs, in one the costal cartilage, and in one the sternoclavicular joint. Computed tomography demonstrated osseous and cartilaginous destruction (in four), soft tissue masses with calcification (in two), and rim enhancement following intravenous contrast medium administration (in two). Underlying pleuroparenchymal tuberculosis was present in two cases. Tuberculosis of the chest wall is characterized by bone or costal cartilage destruction and soft tissue masses that may demonstrate calcification or rim enhancement with or without evidence of underlying lung or pleural disease.

An 18-year-old patient with metabolic myopathy due to long-chain fatty acid coenzyme A dehydrogenase-deficiency1 ,2 presented with worsening positional dyspnoea. He had required invasive ventilation via tracheostomy 6 months earlier. Examination revealed respiratory distress, a prolonged inspiratory phase and …

Aim : The high resolution CT (HRCT) characteristics of fibrosing alveolitis and sarcoidosis are well established, and HRCT has been shown to have a high diagnostic accuracy in these two conditions. We report two cases of sarcoidosis with features in common with the usual appearances of cryptogenic fibrosing alveolitis (CFA). Patients and methods : Two adult male patients with sarcoidosis established by transbronchial biopsy or open lung biopsy who had undergone HRCT scanning were reviewed. At presentation both cases had an atypical pattern of radiological abnormality more in keeping with the features of CFA. Two observers independently assessed the CT scans for accepted features of CFA and sarcoidosis. Results : In both cases CFA was the most likely radiological diagnosis based on the accepted HRCT criteria for this condition. In neither patient were the appearances suggestive of sarcoidosis. In both cases the predominant distribution of abnormality was peripheral, subpleural and in the lower lung zones rather than peribronchial, central and in the mid and upper lung zones. Nodular opacities were not present in either case. Conclusion : HRCT is an accurate and reliable method of suggesting or confirming the diagnosis of CFA and sarcoidosis. In a very small number of cases, sarcoidosis may produce HRCT appearances almost identical to CFA.