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Background Thyroid storm is a rare condition with well-known cardiovascular manifestations including tachycardia, atrial fibrillation, heart failure, and myocardial infarction (MI). Several uncommon conditions that can mimic MI are associated with thyrotoxicosis and discussed in this case. Case summary A 23-year-old previously healthy male presented after the onset of generalized weakness and inability to rise from bed in the setting of 35 kg of unintentional weight loss, and was found to have profound hypokalaemia, elevated thyroid hormone, and suppressed thyroid-stimulating hormone consistent with thyrotoxicosis secondary to Grave’s disease. Following hospital admission, he developed worsening tachycardia with dynamic anteroseptal ST-segment elevations and elevated cardiac biomarkers concerning for MI. He was treated with aspirin, ticagrelor, and a heparin infusion, but was unable to tolerate beta-blockade acutely due to hypotension. Echocardiography demonstrated a severely dilated left ventricle (left ventricular end-diastolic volume index 114 mL/m2) and severely reduced systolic function (ejection fraction 23%) with global hypokinesis. Following initiation of propylthiouracil, iodine solution, and stress-dosed steroids his tachycardia and ST-elevations resolved. Computed tomography (CT) coronary angiography demonstrated no evidence of coronary stenosis. He was discharged on methimazole, metoprolol, and lisinopril and found to have recovered left ventricular systolic function at 2-month follow-up. Discussion Thyrotoxicosis can rarely cause coronary vasospasm, stress cardiomyopathy, and autoimmune myocarditis. These conditions should be suspected in hyperthyroid patients with features of MI and normal coronary arteries. Workup should include laboratory evaluation, electrocardiography (ECG), echocardiography, and non-invasive or invasive ischaemic evaluation.

As the relationship between CT scout landmarks and chest CT boundaries is not known, the selected scan length is often greater than necessary for the CT scan, resulting in increased radiation dose to the neck and upper abdomen. The purpose of this study is to establish the relationship between CT scout landmarks with the superior and inferior boundaries of the lungs on chest CT. Retrospective comparison of the location of the top of the first rib on frontal scout and the most inferior costophrenic angle on lateral scout to the chest CT slice just above and below the lungs. The percent of scans that would exclude part of the lung based on CT initiated at several distances above or below these landmarks was calculated. There was 2.7 times greater variability between scout landmarks and lung boundaries inferiorly than superiorly on chest CT (p

Lung cancer at its earliest stage is typically manifested on computed tomography as a pulmonary nodule, which could be detected by low-dose multidetector computed tomography technology and the use of thinner collimation. Within the last 2 decades, computer-aided detection (CAD) of pulmonary nodules has been developed to meet the increasing demand for lung cancer screening computed tomography with a larger set of images per scan. This review introduced the basic techniques and then summarized the up-to-date applications of CAD systems in clinical and research programs and in the low-dose lung cancer screening trials, especially in the detection of small pulmonary nodules and missed lung cancers. Many studies have already shown that the CAD systems could increase the sensitivity and reduce the false-positive rate in the diagnosis of pulmonary nodules, especially for the small and isolated nodules. Further improvements to the current CAD schemes are needed to detect nodules accurately, particularly for subsolid nodules.

This pictorial essay presents cases of congenital coronary artery anomalies, including congenital anomalies of origin, course, and termination. Familiarity with atypical coronary anatomy and clinical presentation may facilitate appropriate diagnosis and management, particularly as cardiac and thoracic computed tomographic utilization increases.

Objective To assess causative factors, associated imaging findings, and CT course of round atelectasis (RA). Materials and methods We retrospectively reviewed CT reports for “round” or “rounded atelectasis” over a 5-year time frame. Patients with at least 2 CT scans a minimum of 6 months apart were included. Electronic medical records and clinical and imaging follow-up was reviewed for all cases. Results Study population included 50 individuals with mean age of 63 years, and 59 unique instances of RA. The most commonly associated etiologies were hepatic hydrothorax (26%, n = 13) and asbestos exposure (26%), followed by post-infectious pleural inflammation (22%), congestive heart failure (12%), and end stage renal disease (8%). RA was found in the right lower lobe in over half of cases (n = 30). Association with one or more pleural abnormality was identified in all cases, including thickening (88%), fluid (60%), or calcification (40%). Nearly one third (n = 19) demonstrated intra-lesional calcification. In those who underwent PET/CT (20%), lesions demonstrated an average SUV of 2.2 (range 0–7.8). CT course over mean follow up of 32 months (range 6–126 months), demonstrated RA to remain stable (n = 26) or decrease (n = 26) in size in the majority (88%) of cases. Conclusion Round atelectasis may arise from diverse etiologies beyond asbestos, and will most often decrease or remain stable in size over serial exams. Accurate identification may obviate the need for added diagnostic interventions.

Aorto-atrial fistulas are a rare diagnosis with limited reports in the clinical literature. These findings are often characterized by echocardiography alone; however, the advent and increased availability and use of CT angiography to diagnose cardiac abnormalities provides improved anatomic visibility of potential defects. We are reporting a case of a 76-year-old male with decompensated heart failure secondary to a fistula between the aorta and left atrium after remote history of bioprosthetic aortic valve replacement.

The aim of this study was to assess the relationship of the extent of atherosclerosis on coronary computed tomographic angiography to the extent of secondhand tobacco smoke (SHTS) exposure in asymptomatic never smokers.A dose-related association between SHTS and coronary artery calcium has been reported, but the total extent of atherosclerosis has not been investigated.A total of 268 never smokers, ages 40 to 80 years, completed a questionnaire assessing risk factors and extent of lifetime SHTS exposure, providing a total SHTS exposure score. Ordinal coronary artery calcium scores were derived from low-dose nongated computed tomographic scans, followed by computed tomographic angiography. Analyses of the prevalence, extent, and plaque characteristics of atherosclerosis were performed, and the independent contribution of SHTS, adjusted for other documented risk factors, was determined.Coronary atherosclerosis was noted in 48% and was more frequent with low to moderate and high versus minimal SHTS exposure (48% and 69% vs. 25%; p 0.0001). Adjusted odds ratios for any atherosclerosis were 2.1 (95% confidence interval: 1.0 to 4.4; p = 0.05) for low to moderate and 3.5 (95% confidence interval: 1.4 to 8.5; p = 0.01) for high exposure versus minimal SHTS exposure and were not significant for standard risk factors of diabetes (p = 0.56), hyperlipidemia (p = 0.11), hypertension (p = 0.65), and renal disease (p = 0.24). With increasing SHTS exposure, the percentage of major vessel (14%, 41%, and 45%; p = 0.0013) with any plaque or stenosis increased, as did the number with 5 or more involved segments (0%, 39%, and 61%; p = 0.0001). Also the average number of involved segments increased (0.82, 1.98, and 3.49; p 0.0001), with calcified plaques alone (0.25, 0.77, and 1.52; p 0.0001), with calcified and partially calcified plaques (0.28, 0.82, and 1.58; p 0.001), but not with noncalcified plaques alone (p = 0.11).The presence and extent of atherosclerosis were associated with the extent of SHTS exposure even when adjusted for other risk factors, further demonstrating the causal relationship of SHTS exposure and coronary disease.

A 67-year-old man presented with complaints of intermittent episodes of mild exertional dyspnea and substernal chest pain that improved by resting. He had a history of essential hypertension, cigarette smoking, moderate congenital pulmonic stenosis, and severe pulmonary artery dilatation. Physical examination showed a grade 3 systolic murmur in the apex and left upper sternal border, without other anomalies. His diagnostic work-up included an ECG that demonstrated left ventricular hypertrophy and inverted T waves in the anterolateral leads (particularly in leads V4 and V5), as well as a stress echocardiogram without evidence of ischemia and with moderate-to-severe thickening of …

The idiopathic interstitial pneumonias (IIPs) are a group of diffuse lung diseases that share many similar radiologic and pathologic features. According to the revised 2013 American Thoracic Society-European Respiratory Society classification system, these entities are now divided into major IIPs (idiopathic pulmonary fibrosis, idiopathic nonspecific interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, desquamative interstitial pneumonia, cryptogenic organizing pneumonia, and acute interstitial pneumonia), rare IIPs (idiopathic lymphoid interstitial pneumonia, idiopathic pleuroparenchymal fibroelastosis), and unclassifiable idiopathic interstitial pneumonias. Some of the encountered radiologic and histologic patterns can also be seen in the setting of other disorders, which makes them a diagnostic challenge. As such, the accurate classification of IIPs remains complex and is best approached through a collaboration among clinicians, radiologists, and pathologists, as the treatment and prognosis of these conditions vary greatly.

Backgrounds: To evaluate the response of persistent ground glass nodules (GGNs) in patients with lung adenocarcinoma treated with platinum-based chemotherapy on computed tomography (CT). Methods: We retrospectively studied patients with GGNs that met the following criteria: (I) GGNs found in patients with lung adenocarcinoma, which persist for more than 3 months; (II) patients treated with platinum-based (cisplatin or carboplatin) chemotherapy for at least 2 cycles; (III) ground glass proportion ≥50%. For each patient, if more than two CTs satisfied the inclusion criteria, then the baseline and last CTs were used for analysis, defined as CT1 and CT2. A total of 91 persistent pulmonary GGNs in 51 patients fulfilled the inclusion criteria. We defined growth as a nodule ≥2 mm increase in diameter or showing up a solid portion. GGN response to therapy was assessed and compared with the baseline CT. Differences in CT findings were analyzed using a paired t-test and Pearson χ 2 test. Results: Between 2010 and 2015, 25 of the 51 (49%) were male and 26 of the 51 (51%) were female. The average age at time of detection of a GGN was 63.8 (range, 36–84) years. Mean follow-up duration was 24.1±17.9 months. During the follow-up periods, on a per-nodule basis, 94.5% of GGNs (n=86) remained unchanged in size. Only 5.5% GGNs (n=5) in 5 patients increased in size. The nodules CT feature in each lung adenocarcinoma clinical stage show no difference. No significant difference was found in the size, attenuation, volume, and mass of GGN between baseline and post-treatment measurements, regardless of the type of chemotherapy (P>0.05). Conclusions: The clinical course of GGNs in patients with lung adenocarcinoma is predominantly indolent, and platinum-based chemotherapy may have no effect on the growth of persistent GGNs.

Cardiac magnetic resonance (CMR) has demonstrated its utility in the noninvasive diagnosis of cardiac amyloidosis (CA). Our aim was to evaluate the ability of standard Look-Locker sequences to quantify amyloid deposition in CA.Consecutive patients referred for CMR for possible CA were retrospectively evaluated. Positive cardiac biopsy and/or typical pattern of late gadolinium enhancement were required for the diagnosis of CA. Postcontrast T1 values were obtained from Look-Locker sequences and correlated with markers of severity of disease and major events. When cardiac biopsies were available, histological validation was determined. A total of 174 patients were included. A final diagnosis of CA was reached in 37.4%. Myocardial and endocardial T1 times, as well as the respective ratios with blood and skeletal muscle, were lower among patients with CA and demonstrated good diagnostic performance. The best parameters were myocardial/blood (area under the curve 0.83; P .001) and endocardial/blood (area under the curve 0.84; P .001) T1 ratios. Among patients with CA, no associations were found between T1 ratios either with markers of amyloid burden or with prognostic variables. However, all T1 indexes showed significant correlations with histological quantification of amyloid deposition.Look-Looker derived postcontrast T1 shows good diagnostic accuracy to detect CA and correlation with histological amyloid burden.

Objectives This study sought to assess patterns and functional consequences of mitral apparatus infarction after acute myocardial infarction (AMI). Background The mitral apparatus contains 2 myocardial components: papillary muscles and the adjacent left ventricular (LV) wall. Delayed-enhancement cardiac magnetic resonance (DE-CMR) enables in vivo study of inter-relationships and potential contributions of LV wall and papillary muscle infarction (PMI) to mitral regurgitation (MR). Methods Multimodality imaging was performed: CMR was used to assess mitral geometry and infarct pattern, including 3D DE-CMR for PMI. Echocardiography was used to measure MR. Imaging occurred 27 ± 8 days after AMI (CMR, echocardiography within 1 day). Results A total of 153 patients with first AMI were studied; PMI was present in 30% (n = 46 [72% posteromedial, 39% anterolateral]). When stratified by angiographic culprit vessel, PMI occurred in 65% of patients with left circumflex, 48% with right coronary, and only 14% of patients with left anterior descending infarctions (p Conclusions Papillary muscle infarction is common after AMI, affecting nearly one-third of patients. Extent of PMI parallels adjacent LV wall injury, with lateral infarction—rather than PMI—associated with increased severity of post-AMI MR.

Background— Cardiac magnetic resonance (CMR) typically quantifies LV mass (LVM) by means of manual planimetry (MP), but this approach is time-consuming and does not account for partial voxel components— myocardium admixed with blood in a single voxel. Automated segmentation (AS) can account for partial voxels, but this has not been used for LVM quantification. This study used automated CMR segmentation to test the influence of partial voxels on quantification of LVM. Methods and Results— LVM was quantified by AS and MP in 126 consecutive patients and 10 laboratory animals undergoing CMR. AS yielded both partial voxel (AS PV ) and full voxel (AS FV ) measurements. Methods were independently compared with LVM quantified on echocardiography (echo) and an ex vivo standard of LVM at necropsy. AS quantified LVM in all patients, yielding a 12-fold decrease in processing time versus MP (0:21±0:04 versus 4:18±1:02 minutes; P FV mass (136±35 g) was slightly lower than MP (139±35; Δ=3±9 g, P P =0.73) and hypertrophy ( P =1.00). Regarding partial voxel segmentation, AS PV yielded higher LVM (159±38 g) than MP (Δ=20±10 g) and AS FV (Δ=23±6 g, both P PV and AS FV correlated with larger voxel size (partial r =0.37, P r =0.28, P =0.002) and total LVM ( r =0.19, P =0.03). Among patients, AS PV yielded better agreement with echo (Δ=20±25 g) than did AS FV (Δ=43±24 g) or MP (Δ=40±22 g, both P PV and ex vivo results were similar (Δ=1±3 g, P =0.3), whereas AS FV (6±3 g, P P =0.02) yielded small but significant differences with LVM at necropsy. Conclusions— Automated segmentation of myocardial partial voxels yields a 14–17% increase in LVM versus full voxel segmentation, with increased differences correlated with lower spatial resolution. Partial voxel segmentation yields improved CMR agreement with echo and necropsy-verified LVM.

Rationale and Objectives The aim of this study was to compare effective radiation doses between prospective and retrospective electrocardiographic gating during coronary computed tomographic angiography for coronary artery bypass grafting evaluation. Materials and Methods Fifty consecutive coronary computed tomographic angiographic exams for coronary artery bypass grafting evaluation, 25 prospectively gated and 25 retrospectively gated, were reviewed from January 8, 2008, to June 16, 2009. Body mass index and image quality were also compared between the two groups. To minimize the potential bias introduced by differences in torso length, the effective radiation dose from each exam was measured and normalized to a 24-cm z -axis scan length for all patients. Pooled t tests were used to compare the prospectively and retrospectively gated groups. Results The average effective doses delivered in the retrospective and prospective groups were 40.8 mSv (standard error [SE], 1.8 mSv) and 8.6 mSv (SE, 0.7 mSv), respectively. When normalized to the average z -axis scan length of 24 cm, the effective dose in the retrospective group, 38.4 mSv (SE, 1.3 mSv), was still >4 times greater than that in the prospective group, 9.1 mSv (SE, 0.7 mSv) ( P Conclusions Effective radiation dose in coronary computed tomographic angiography for coronary artery bypass grafting evaluation is very high because of long scan lengths. Prospective electrocardiographic gating significantly reduces effective radiation dose by an average of 76% compared to retrospectively gated scans (9.1 vs 38.4 mSv). In the coronary artery bypass grafting population, prospective electrocardiographic gating should be used whenever ventricular functional assessment is not required.

An automatic left ventricle (LV) segmentation algorithm is presented for quantification of cardiac output and myocardial mass in clinical practice. The LV endocardium is first segmented using region growth with iterative thresholding by detecting the effusion into the surrounding myocardium and tissues. Then the epicardium is extracted using the active contour model guided by the endocardial border and the myocardial signal information estimated by iterative thresholding. This iterative thresholding and active contour model with adaptation (ITHACA) algorithm was compared to manual tracing used in clinical practice and the commercial MASS Analysis software (General Electric) in 38 patients, with Institutional Review Board (IRB) approval. The ITHACA algorithm provided substantial improvement over the MASS software in defining myocardial borders. The ITHACA algorithm agreed well with manual tracing with a mean difference of blood volume and myocardial mass being 2.9 +/- 6.2 mL (mean +/- standard deviation) and -0.9 +/- 16.5 g, respectively. The difference was smaller than the difference between manual tracing and the MASS software (approximately -20.0 +/- 6.9 mL and -1.0 +/- 20.2 g, respectively). These experimental results support that the proposed ITHACA segmentation is accurate and useful for clinical practice.

Blood suppression in the lower extremities using flow-reliant methods such as double inversion recovery may be problematic due to slow blood flow. T(2) mapping using fast spin echo (FSE) acquisition was utilized to quantitate the effectiveness of double inversion recovery blood suppression in 13 subjects and showed that 25 +/- 12% of perceived vessel wall pixels in the popliteal arteries contained artifactual blood signal. To overcome this problem, a flow-insensitive T(2)-prepared inversion recovery sequence was implemented and optimal timing parameters were calculated for FSE acquisition. Black blood vessel wall imaging of the popliteal and femoral arteries was performed using two-dimensional T(2)-prepared inversion recovery-FSE in the same 13 subjects. Comparison with two-dimensional double inversion recovery-FSE showed that T(2)-prepared inversion recovery-FSE reduced wall-mimicking blood artifacts that inflated double inversion recovery-FSE vessel wall area measurements in the popliteal artery.

The objectives of this study were to prospectively evaluate changes in tumor perfusion after chemoradiation therapy and to investigate the feasibility of perfusion CT for prediction of early tumor response and prognosis of non-small cell lung cancer.Perfusion CT was performed on an MDCT scanner with 50 mL of iodinated contrast material injected at 4 mL/s. The quality of each functional map was rated from 0 to 3 for 123 patients with confirmed lung cancer. A subset of images was independently reviewed by two radiologists to measure interobserver and intraobserver variability. Perfusion parameters and tumor response were assessed for 35 patients with non-small cell lung cancer who underwent chemoradiation therapy. Progression-free survival and overall survival were analyzed for 22 patients who underwent repeated perfusion CT after therapy.Image quality was graded 2 (moderate) or 3 (good) in 68.2% of cases. High interobserver and intraobserver correlations of perfusion parameters were found on qualified images. The patients who responded to chemoradiation therapy had significantly greater blood flow (p = 0.023) than patients who did not respond. The median progression-free survival period of the patients with an increased permeability-surface area product was 4.7 months, significantly lower than the median progression-free survival period of 19.0 months among patients with a decreased permeability-surface area product (p0.001). The median overall survival period was 10.6 months for the group with an increased permeability-surface area product, significantly lower than the 19.3 months for the group with a decreased permeability-surface area product (p = 0.004).Non-small cell lung cancer with higher perfusion is more sensitive to chemoradiation therapy than that with lower perfusion. After chemoradiation therapy, findings at perfusion CT are a significant predictor of early tumor response and overall survival among patients with non-small cell lung cancer.

ObjectivesThis study sought to compare contrast-enhanced anatomic imaging and contrast-enhanced tissue characterization (delayed-enhancement cardiac magnetic resonance [DE-CMR]) for left ventricular (LV) thrombus detection.BackgroundContrast echocardiography (echo) detects LV thrombus based on anatomic appearance, whereas DE-CMR imaging detects thrombus based on tissue characteristics. Although DE-CMR has been validated as an accurate technique for thrombus, its utility compared with contrast echo is unknown.MethodsMultimodality imaging was performed in 121 patients at high risk for thrombus due to myocardial infarction or heart failure. Imaging included 3 anatomic imaging techniques for thrombus detection (contrast echo, noncontrast echo, cine-CMR) and a reference of DE-CMR tissue characterization. LV structural parameters were quantified to identify markers for thrombus and predictors of additive utility of contrast-enhanced thrombus imaging.ResultsTwenty-four patients had thrombus by DE-CMR. Patients with thrombus had larger infarcts (by DE-CMR), more aneurysms, and lower LV ejection fraction (by CMR and echo) than those without thrombus. Contrast echo nearly doubled sensitivity (61% vs. 33%, p < 0.05) and yielded improved accuracy (92% vs. 82%, p < 0.01) versus noncontrast echo. Patients who derived incremental diagnostic utility from DE-CMR had lower LV ejection fraction versus those in whom noncontrast echo alone accurately assessed thrombus (35 ± 9% vs. 42 ± 14%, p < 0.01), with a similar trend for patients who derived incremental benefit from contrast echo (p = 0.08). Contrast echo and cine-CMR closely agreed on the diagnosis of thrombus (κ = 0.79, p < 0.001). Thrombus prevalence was lower by contrast echo than DE-CMR (p < 0.05). Thrombus detected by DE-CMR but not by contrast echo was more likely to be mural in shape or, when apical, small in volume (p < 0.05).ConclusionsEcho contrast in high-risk patients markedly improves detection of LV thrombus, but does not detect a substantial number of thrombi identified by DE-CMR tissue characterization. Thrombi detected by DE-CMR but not by contrast echo are typically mural in shape or small in volume.

Purpose To develop and evaluate an automated left ventricle (LV) segmentation algorithm using Graph searching based on Intensity and Gradient information and A priori knowledge (lvGIGA). Materials and Methods The lvGIGA algorithm was implemented with coil sensitivity correction and polar coordinate transformation. Graph searching and expansion were applied for extracting myocardial endocardial and epicardial borders. LV blood and myocardium intensities were estimated for accurate partial volume calculation of blood volume and myocardial mass. Cardiac cine SSFP images were acquired from 38 patients. The lvGIGA algorithm was used to measure blood volume, myocardial mass, and ejection fraction, and compared with clinical manual tracing and the commercial MASS software. Results The success rate for segmenting both endocardial and epicardial borders was 95.6% slices for lvGIGA and 37.8% for MASS (excluding basal slices that required manual enclosure of ventricle blood). The lvGIGA segmentation result agreed well with manual tracing, within −2.9 ± 4.4 mL, 2.1 ± 2.2%, and −9.6 ± 13.0 g, for blood volume, ejection fraction, and myocardial mass, respectively. Conclusion The lvGIGA algorithm substantially improves the robustness of LV segmentation automation over the commercial MASS software, agrees well with clinical manual tracing, and may be a useful tool for clinical practice. J. Magn. Reson. Imaging 2008;28:1393–1401. © 2008 Wiley-Liss, Inc.

Transthoracic needle biopsy of the indeterminate pulmonary nodule is a well-established, highly accurate, and minimally invasive diagnostic procedure. A pulmonary nodule in virtually any location is accessible to transthoracic needle biopsy. A solid understanding of special biopsy techniques enables the operator to overcome the commonly encountered challenges, including small, mobile, and partly obscured nodules. Because biopsy-related complications can be reduced but not completely eliminated, a familiarity with such complications and the procedures used to manage them is essential. A close partnership with the cytology team is crucial in achieving a high diagnostic accuracy during transthoracic needle biopsy. In the future, biopsy-derived microarray analysis may play a greater role in guiding treatment and predicting treatment outcomes.

BACKGROUND Accurate quantification of left ventricular mass and ejection fraction is important for patients with left ventricular hypertrophy. Although cardiac magnetic resonance imaging has been proposed as a standard for these indices, prior studies have variably included papillary muscles and trabeculae in myocardial volume. This study investigated the contribution of papillary muscles and trabeculae to left ventricular quantification in relation to the presence and pattern of hypertrophy. METHODS Cardiac magnetic resonance quantification was performed on patients with concentric or eccentric hypertrophy and normal controls (20 per group) using two established methods that included papillary muscles and trabeculae in myocardium (method 1) or intracavitary (method 2) volumes. RESULTS Among all patients, papillary muscles and trabeculae accounted for 10.5% of ventricular mass, with greater contribution with left ventricular hypertrophy than normals (12.6 vs. 6.2%, P < 0.001). Papillary muscles and trabeculae mass correlated with ventricular wall mass (r = 0.53) and end-diastolic volume (r = 0.52; P < 0.001). Papillary muscles and trabeculae inclusion in myocardium (method 1) yielded smaller differences with a standard of mass quantification from linear ventricular measurements than did method 2 (P < 0.001). Method 1 in comparison with method 2 yielded differences in left ventricular mass, ejection fraction and volume in all groups, especially in patients with hypertrophy: the difference in ventricular mass index was three-fold to six-fold greater in hypertrophy than normal groups (P < 0.001). Difference in ejection fraction, greatest in concentric hypertrophy (P < 0.001), was independently related to papillary muscles and trabeculae mass, ventricular wall mass, and smaller ventricular volume (R = 0.56, P < 0.001). CONCLUSION Established cardiac magnetic resonance methods yield differences in left ventricular quantification due to variable exclusion of papillary muscles and trabeculae from myocardium. The relative impact of papillary muscles and trabeculae exclusion on calculated mass and ejection fraction is increased among patients with hypertrophy-associated left ventricular remodeling.

OBJECTIVE. The purpose of this study was to compare whole-heart acquisition with targeted-volume acquisition in 3-T navigator coronary MR angiography with parallel imaging.SUBJECTS AND METHODS. The right and left coronary arteries of 20 subjects were imaged with axial whole-heart acquisition and two oblique targeted-volume acquisitions.RESULTS. Both whole-heart and targeted-volume acquisitions were completed with similar navigator efficiencies (≈ 50%) and depicted similar coronary artery diameters (≈ 3 mm) (p ≥ 0.06). The lengths of the coronary arteries were not significantly different (p = 0.07–0.45) for the whole-heart and targeted-volume approaches. Depiction of the sharper coronary arteries (p ≤ 0.04) and overall image quality (p < 0.02) were better with the targeted-volume approach.CONCLUSION. For current 3-T navigator parallel-imaging coronary MR angiography, targeted-volume acquisition yields sharper coronary images than does whole-heart acquisition.

Purpose To develop a rapid navigator-gated three-dimensional (3DNAV) delayed-enhancement MRI (DE-MRI) sequence for myocardial viability assessment, and to evaluate its performance with breathhold two-dimensional (2DBH) DE-MRI sequence as the reference standard. Materials and Methods 2DBH DE-MRI was initiated 10 minutes after contrast administration and followed by 3DNAV DE-MRI in 23 patients at 1.5 T. Comparison was performed using three qualitative criteria (image quality score, diagnostic outcome, relative diagnostic confidence score) in all patients, and three quantitative criteria (infarct volume, infarct signal-to-noise ratio [SNRinf], and infarct-viable myocardium contrast-to-noise ratio [CNRinf-myo]) in patients with hyperenhanced myocardium. Results Compared to 2DBH DE-MRI, 3DNAV DE-MRI provided slightly better image quality, the same final diagnostic outcomes, and better relative diagnostic confidence score with 79% SNRinf improvement (P = 0.002) and 90% CNRinf-myo improvement (P = 0.004) in 39% less scan time (414 ± 118 seconds for 2DBH and 251 ± 93 seconds for 3DNAV). The measured infarct volumes demonstrated excellent correlation (18.9 ± 19.0 mL for 2DBH DE-MRI vs. 17.6 ± 19.0 mL for 3DNAV DE-MRI, r2 = 0.998, P < 0.001, N = 7) and narrow limits of agreement (–1.3 ± 1.8 mL). Conclusion 3DNAV DE-MRI provides improved image quality and similar infarct detection in less scan time compared to the standard 2DBH DE-MRI. J. Magn. Reson. Imaging 2008. © 2008 Wiley-Liss, Inc.

Among patients that present with cardiac masses, thrombus is an important diagnostic consideration that affects both clinical management and prognosis. Although thrombus can occasionally be difficult to diagnose using structural criteria alone, it can be distinguished from other structures according to tissue characteristics. Because thrombus is inherently avascular, absence of contrast uptake was used as a highly specific identifying feature. Delayed-contrast cardiac computed tomography (CT) imaging has been previously used for myocardial tissue characterization, distinguishing between viable and infarcted myocardium based upon differences in contrast uptake. This technique also offers potential diagnostic utility for assessment of thrombus. In this report, we describe a case of a patient with a giant left atrial mass in whom delayed-contrast CT was employed as a useful diagnostic technique for identification of cardiac thrombus.

To assess the incremental increase in thromboembolic disease detection at indirect computed tomographic (CT) venography versus CT pulmonary angiography and to determine the importance of scan interval for indirect CT venography on the basis of thrombus length.Institutional review board approval was obtained, and informed consent was not required. The study included 1590 consecutive patients undergoing CT pulmonary angiography for the suspicion of pulmonary embolism. Two minutes after completion of pulmonary angiography, a contiguous indirect CT venography was performed from the iliac crest to the popliteal fossa. The presence of pulmonary embolism or deep venous thrombosis (DVT) was recorded for all patients. The lengths of all deep venous thrombi found in the first 378 consecutive patients were recorded.Pulmonary embolism was detected in 243 (15%) of 1590 patients at CT pulmonary angiography, and DVT was detected in 148 (9%) patients at indirect CT venography. Among 148 patients with DVT, pulmonary embolism was detected in 100 patients at CT pulmonary angiography. Thus, the addition of indirect CT venography to CT pulmonary angiography resulted in a 20% incremental increase in thromboembolic disease detection compared with that at CT pulmonary angiography alone (99% confidence interval: 17%, 23%). Among the 378 patients, DVT was present in 33 patients at indirect CT venography. Two (6%) of 33 patients had clots measuring 2 cm or less, six (18%) had clots measuring 3-4 cm, and 25 (76%) had clots measuring more than 4 cm in length.The addition of indirect CT venography to CT pulmonary angiography incrementally increases the detection rate of thromboembolic disease by 20%. Performance of indirect CT venography by using contiguous section intervals, with a section width of 1 cm, is recommended to accurately detect DVT.

46 year old female with history of progressive shortness of breath for 3 years associated with recurrent right lung infiltrates and hemoptisis. A computed tomography of the chest showed a left atrial mass suggestive of atrial myxoma confirmed with transesophageal echocardiogram. Contrary with findings from a dedicated EKG gated cardiac computed tomography suggestive of cor triatriatum with associated thrombus and less likely a neoplasm; findings later on confirmed during surgery. Cardiac CT offers superior spatial resolution and multi-planar image reconstructions, allowing improved characterization of cardiac structures and cardiac masses compared to other traditional cardiovascular imaging modalities.

The original version of this article unfortunately contained a mistake. The conflict of interest was incorrect.

Aims This study was designed to assess the accuracy of coronary artery calcium scans (CACS) acquired at radiation doses below mammography and low-dose lung scanning, compared with standard-dose CACS. Methods and results CACS was performed in 102 consecutive patients at 120 kVp; all were imaged at standard-dose mAs levels ranging from 30 to 80 mAs determined by their weight, with iterative reconstruction (IR) level 3, and at 50% of the standard-dose mAs with IR level 7 to compensate for the expected increased noise with lower mAs. The low- vs. standard-dose mAs was 24.5 ± 8.8 vs. 48.5 ± 17.8 mAs ( P < 0.0001), and the radiation exposure was 0.37 ± 0.16 vs. 0.76 + 0.34 mSv ( P < 0.0001). The Agatston score correlation between the low and high dose was excellent ( r = 0.998, P < 0.0001) over a range of scores from 0 to 2512. The weighted kappa for agreement of standard CAC risk categories was 0.95 (95% CI 0.83–0.97). The mean of the differences between individual low- and standard-dose Agatston scores was 17.4 ± 25.8, lower than the reported variability of two scans performed with the same mAs. Conclusion There was excellent agreement of CACS-based risk classification at low and standard doses, with lower interscan variability than with reported identical doses. The low-dose CACS radiation exposure was less than the approved screening tools of mammography and low-dose lung scanning. [10.1093/ehjci/jeu220][1] [1]: /lookup/doi/10.1093/ehjci/jeu220

Background Cardiac amyloidosis (CA) is associated with typical morphological features on echocardiography, including concentric LV hypertrophy (LVH). Cardiac magnetic resonance (CMR) can accurately depict anatomy in different cardiomyopathies. Our aim was to describe the morphological features and remodelling patterns of CA with CMR, and establish their diagnostic accuracy, as well as the value of traditional diagnostic criteria derived from echocardiography and electrocardiography. Methods Consecutive patients referred for CMR for possible CA were retrospectively evaluated. The diagnosis of CA was established in the presence of a positive cardiac biopsy and/or a typical pattern of myocardial late gadolinium enhancement. Morphological parameters were obtained from standard cine sequences. The presence and distribution of LVH, relative wall thickness (RWT) and LV remodelling patterns were determined. Results 130 patients (92 males (70.8%), age 64±13 years) were included. CA was diagnosed in 51 (39.2%). Patients with CA had increased LV wall thickness and LV mass index. An LV remodelling pattern different from concentric LVH was found in 42% of patients with CA, and asymmetric LVH was noted in 68.6%. A model including RWT, asymmetric LVH, and LVMI showed diagnostic accuracy of 88%, sensitivity of 67% and specificity of 86% for CA detection. Traditional diagnostic criteria for CA showed high specificity but poor sensitivity. Conclusions Asymmetric LVH and remodelling patterns different from concentric LVH are common in CA. Increased LV mass index, increased RWT, and asymmetric LVH are independently associated with the diagnosis. Traditional diagnostic criteria show poor sensitivity.

Multidetector CT angiography is now the reference standard for the diagnosis of acute pulmonary embolism (PE).1 However, recognising the radiographic changes associated with PE remains important, as the imaging available early in the diagnostic process is still likely to be a plain film radiograph of the chest. We describe a case in which one of the radiographic signs of PE prompted a CT angiogram even though PE was not initially considered a strong differential consideration. A patient presented to the emergency room with a 4-day history of right-sided pleuritic chest pain and shortness …

Background Dynamic contrast enhanced (DCE) cardiovascular magnetic resonance (CMR) is increasingly used to quantify microvessels and permeability in atherosclerosis. Accurate quantification depends on reliable sampling of both vessel wall (VW) uptake and contrast agent dynamic in the blood plasma (the so called arterial input function, AIF). This poses specific challenges in terms of spatial/temporal resolution and matched dynamic MR signal range, which are suboptimal in current vascular DCE-CMR protocols. In this study we describe a novel dual-imaging approach, which allows acquiring simultaneously AIF and VW images using different spatial/temporal resolution and optimizes imaging parameters for the two compartments. We refer to this new acquisition as SHILO, Simultaneous HI-/LOw-temporal (low-/hi-spatial) resolution DCE-imaging. Methods In SHILO, the acquisition of low spatial resolution single-shot AIF images is interleaved with segments of higher spatial resolution images of the VW. This allows sampling the AIF and VW with different spatial/temporal resolution and acquisition parameters, at independent spatial locations. We show the adequacy of this temporal sampling scheme by using numerical simulations. Following, we validate the MR signal of SHILO against a standard 2D spoiled gradient recalled echo (SPGR) acquisition with in vitro and in vivo experiments. Finally, we show feasibility of using SHILO imaging in subjects with carotid atherosclerosis. Results Our simulations confirmed the superiority of the SHILO temporal sampling scheme over conventional strategies that sample AIF and tissue curves at the same time resolution. Both the median relative errors and standard deviation of absolute parameter values were lower for the SHILO than for conventional sampling schemes. We showed equivalency of the SHILO signal and conventional 2D SPGR imaging, using both in vitro phantom experiments (R2 =0.99) and in vivo acquisitions (R2 =0.95). Finally, we showed feasibility of using the newly developed SHILO sequence to acquire DCE-CMR data in subjects with carotid atherosclerosis to calculate plaque perfusion indices. Conclusions We successfully demonstrate the feasibility of using the newly developed SHILO dual-imaging technique for simultaneous AIF and VW imaging in DCE-CMR of atherosclerosis. Our initial results are promising and warrant further investigation of this technique in wider studies measuring kinetic parameters of plaque neovascularization with validation against gold standard techniques.

Background Correct differentiation of a cardiac tumor from a thrombus remains important in clinical practice as the prognosis and therapeutic approach vary substantially. Techniques such as echocardiography may have limitations due to reduced image quality and poor tissue characterization. Cardiac magnetic resonance (CMR) has emerged as a promising tool in this regard; however, studies assessing its value are scarce. Methods We retrospectively analyzed the CMR of patients with a definite cardiac mass. Thrombus was defined as a noninfiltrating mass that fulfilled any of the following criteria: a) adjacent to an akinetic or dyskinetic myocardial segment (typically infarcted) or central catheter, b) located in the atrial appendage in patients with atrial fibrillation, c) experienced a significant reduction in size under anticoagulation therapy, or d) had surgical and/or pathological confirmation. Tumor was defined as a mass that did not fulfill any of the above criteria plus a) was infiltrative, or b) located in the left aspect of the fossa ovalis with typical features of myxoma, or c) had surgical and/or pathological confirmation. Mass features on common CMR sequences (cine image, T1-weighted [T1w] and T2 weighed [T2w] spin-echo, contrast first pass perfusion, post-contrast TI scout, and late gadolinium enhancement (LGE)) were analyzed. Categorical data were summarized as frequencies and percentages, and continuous variables were expressed as mean ± SD. Difference in CMR characteristics between thrombi and tumors were compared by Chi-square, Fisher’ so r t-student tests as appropriate. A two sided P-value of

Background Post-contrast myocardial T1-mapping with cardiac magnetic resonance (CMR) has shown usefulness in the diagnosis of cardiac amyloid. A lower value indicates increase in extracellular volume and thereby amyloid deposition. The aim of this study is to assess the association between the amount of amyloid deposition as estimated by the degree of post-contrast myocardial T1 reduction and the severity of left ventricular (LV) involvement in cardiac amyloidosis. Methods Consecutive patients referred for 3.0 Tesla CMR with a final diagnosis of cardiac amyloidosis (defined as positive cardiac biopsy and/or typical diffuse, predominantly subendocardial pattern of delayed contrast enhancement) were retrospectively evaluated. The septal E/E’ ratio as an index of LV filling pressures was measured with doppler echocardiography (n=18, 69%). Indexed LV volumes and mass, LV ejection fraction, and LV basal anteroseptal and inferolateral wall thicknesses were determined from cine CMR. Hemodynamic data from cardiac catheterization and brain natriuretic peptide (BNP) serum levels were available in 9 (36%) and 14 (54%) patients. respectively. Myocardial, endocardial, blood, and skeletal muscle were quantified after Gd-DTPA administration on a previously validated Look-Locker sequence using dedicated software. Correlations between myocardial T1 values and other indices of cardiac involvement were performed using Pearson correlation coefficients. Results We included 26 patients (17 males [65.4%], age 68±13 years) with a final diagnosis of cardiac amyloid. There was an inverse correlation between myocardial/blood T1 ratio and basal anteroseptal (r=-0.519, p=0.008) and inferolateral (r=-0.498, p=0.011) wall thickness. Similarly endocardial/blood T1 ratio was inversely correlated with basal anteroseptal (r=-0.595, p=0.002; Figure) and inferolateral (r=-0.429, p=0.032) wall thickness. No significant associations were noted with LV volumes, ejection fraction, or mass. Otherwise, myocardial and endocardial T1 time showed an inverse correlation with BNP (r=-0.659, p=0.014 and r=-0.610, p=0.027 respectiveley). In addition, myocardial/skeletal muscle T1 ratio showed

Summary Lateral wall infarction on DE-CMR, independent of papillary muscle involvement, confers increased risk for ischemic mitral regurgitation. Background The mitral apparatus contains two myocardial components - papillary muscles and the adjacent left ventricular (LV) wall. Delayed enhancement CMR (DE-CMR) enables in-vivo study of potential contributions of LV wall and papillary muscle infarction (PMI) to MR. This study examined the relative impact of papillary muscle and LV wall infarction on mitral regurgitation (MR) following ST elevation MI (STEMI). Methods Multimodality imaging was prospectively performed among patients with first STEMI: DE-CMR (IR-GRE, acquired 10-30 minutes post gadolinium [0.2 mmol/kg]) was used to assess LV infarct pattern - including PMI (graded by location and extent - complete or partial, stratified using threshold of >50% papillary myocardium) and LV wall infarction (17 segment model, 5 point score/segment). Cine-CMR (SSFP) was analyzed for cardiac function and geometry - including LV chamber size, regional wall motion (5 point score/segment), and mitral annular diameter. Echocardiography (echo) was used to quantify MR (0-4+ grade) using established consensus criteria. Each imaging modality was read independently.

Detection of small pulmonary nodules has markedly increased as computed tomography (CT) technology has advanced and interpretation evolved from viewing small CT images on film to magnified images on large, high-resolution computer monitors. Despite these advances, determining the etiology of a lung nodule short of major surgery remains problematic. Initial nodule size is a major criterion in evaluating the risk for malignancy, and the majority of CT detected nodules are

Tube and line interpretation in portable chest radiographs was assessed using a new visualization method. When using the new method, radiologists' interpretation time was reduced by 30% vs. standard modality processing and window and level (23 vs. 33 s). For pulmonary ICU physicians, reading time was essentially unchanged. There was more than a 50% reduction in the use of inferential language in the dictation for both reader groups when using the new method, suggesting greater interpretation confidence.