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PURPOSE: To assess if dual-energy computed tomographic pulmonary angiography (DECTPA) derived lobar iodine quantification can provide an accurate estimate of lobar perfusion in patients with severe emphysema, and offer an adjunct to single-photon emission CT perfusion scintigraphy (SPECT-PS) in assessing suitability for lung volume reduction (LVR). MATERIALS AND METHODS: Patients with severe emphysema (forced expiratory volume in 1 s

PurposeTo describe the incidence of pulmonary artery thrombosis in COVID-19 versus influenza pneumonia using CT angiography and to assess whether it may increase the risk of pulmonary hypertension.Materials and MethodsSingle and dual energy CT pulmonary angiography of age- and gender-matched patients with influenza and COVID-19 pneumonia, referred for extra-corporeal membrane oxygenation (ECMO) and/or mechanical ventilation from January 2016 to January 2021, were retrospectively evaluated. Two independent observers qualitatively and quantitively assessed clot burden and Qanadli CT Obstruction Index. Two consensus observers calculated pulmonary artery volume and right to left ventricular diameter ratio (Terarecon, California, USA) to diagnose pulmonary hypertension. Pulmonary infarct volume and perfused blood volume relative enhancement were also calculated (Syngo via, Siemens Healthineers, Forchheim, Germany). All radiologic parameters were correlated with clinical data. To assess if in situ thrombosis could be visualised on CT, isolated segmental and subsegmental filling defects were used as an imaging surrogate. For statistical analyses, Graphpad Prism9 and IBM SPSS v27.0 software were used.ResultsThe incidence of either central PE or DVT was equal between patients with COVID-19 and influenza pneumonia (20%). The incidence of isolated segmental and subsegmental filling defects was higher in COVID-19 but without statistical significance (44% vs 32%;p=0.5607). Right to left ventricular diameter and pulmonary artery to aorta ratios were higher in COVID-19 compared to influenza (1.01 vs 0.866 and 1.04 vs 0.904;p=0.0071 and p=0.0023, respectively).ConclusionIn a comparable group of patients with severe COVID-19 and influenza pneumonia, CT features of pulmonary hypertension are more often present in patients with COVID-19 pneumonia despite an equal clot burden on CT. This is not attributable to pulmonary thrombosis visible on CT and supports the hypothesis that micro- rather than macrovascular obstruction is the cause of severe hypoxia in COVID-19 pneumonia.

Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary support primarily used in cardiothoracic and intensive care unit (ICU) settings. The purpose of this review is to familiarise radiologists with the imaging features of ECMO devices, their associated complications and appropriate imaging protocols for contrast-enhanced CT imaging of ECMO patients. This paper will provide a brief introduction to ECMO and the imaging modalities utilised in ECMO patients, followed by a description of the types of ECMO available and cannula positioning. Indications and contraindications for ECMO will be outlined followed by a description of the complications associated with ECMO, which radiologists should recognise. Finally, the imaging protocol and interpretation of contrast-enhanced CT imaging in ECMO patients will be discussed. In the current clinical climate with millions of COVID-19 cases around the world and tens of thousands of critically ill patients, many requiring cardiopulmonary support in intensive care units, the use of ECMO in adults has increased, and thus so has the volume of imaging. Radiologists need to be familiar with the types of ECMO available, the correct positioning of the catheters depending on the type of ECMO being utilised, and the associated complications and imaging artefacts.

Background Pilot lung cancer screening programmes in England have utilised a lung health check (LHC) model, comprising a nurse-led respiratory consultation, spirometry and a lung cancer risk calculation. We report the short-term outcomes of recommendations made to primary care for management of non-cancer incidental findings in a screening pilot. Methods 1542 participants from 17 general practice (GP) surgeries attended for a LHC between August 2018 and April 2019. Lung nodules, significant incidental lung findings on computed tomography (CT), unexplained respiratory symptoms, and suspected non-lung malignancies were managed within the screening programme. Participants with: i) ‘red-flag’ symptoms without lung cancer, ii) unexplained obstructive spirometry and respiratory symptoms, iii) significant coronary artery calcification (CAC) on CT, who were not known to have previously undergone cardiovascular risk stratification, and iv) significant, but non-urgent, non-lung incidental findings on CT, were referred to primary care. GP records were evaluated to establish outcomes. Results 165 primary care recommendations were made in 157/1542 (10.2%) individuals. Results below are from 16 GP practices and will be updated at the time of presentation. 49/1542 (3.2%) were referred to their GP for suspected undiagnosed chronic obstructive pulmonary disease (COPD), of whom 19/49 (38.8%) had a community-based respiratory review. 12/49 (24.5%) were newly diagnosed with COPD, and 5/49 (10.2%) commenced inhaler therapy. Of 52/1145 (4.5%) scanned participants with heavy CAC but without known ischaemic heart disease, 26/52 (50.0%) had a QRISK2 score (all >10%). Lipid-lowering therapy was commenced in 21/52 (40.4%). Echocardiography was recommended for 22/1542 (1.4%) participants with suspected cardiac disease, largely aortic valve calcification. 7/22 (31.8%) underwent echocardiography. Only 1/22 (4.5%) was deemed to require intervention for significant aortic stenosis. 7/1542 (0.5%) recommendations were made for other non-urgent/non-cardiothoracic incidental findings; none required further intervention. Conclusions A minority of participants required primary care management for incidental findings based on the West London lung screening study protocol. Although not all recommendations were implemented, incidental findings infrequently led to changes to patient management overall. Changes to patient management most commonly occurred as a result of recommendations for assessment for COPD and cardiovascular risk.

Recent developments in computed tomography (CT) technology permit imaging of the coronary arteries. Non-enhanced CT is used to perform coronary artery calcium scoring, which is useful to stratify the risk of future coronary events but does not allow assessment of stenosis. Contrast-enhanced CT enables angiographic evaluation of the coronary artery lumen. The high negative predictive value of coronary CT angiography (CTA) makes it a useful test to rule out the presence of significant coronary stenoses, especially in those patients with an intermediate pre-test likelihood of coronary artery disease. Coronary CTA also has potential to aid triage of patients with acute chest pain in the emergency depart-ment. Coronary artery bypass grafts can be assessed reliably using CT. Intracoronary stents are difficult to image due to artefacts caused by metal, often precluding detection of in-stent restenosis. There is emerging evidence supporting the ability of CT to characterize atherosclerotic plaque, potentially allowing identification of those plaques at most risk of rupture. Myocardial perfusion imaging using cardiac CT is also the subject of current investigation.

We validate a method of calcium scoring on CT coronary angiography (CTCA) and propose an algorithm for the assessment of patients with stable chest pain. 503 consecutive patients undergoing coronary artery calcium score (CACS) and CTCA were included. A 0.1 cm2 region of interest was used to determine the mean contrast density on CTCA images either in the left main stem (LM) or right coronary artery. Axial 3 mm CTCA images were scored for calcium using conventional software with a modified threshold: mean LM contrast density (HU) + 2SD. A conversion factor (CF) for predicting CACS from raw CTCA scores (rCTCAS) was determined using a multivariable regression model adjusted for model over-optimism (1,000 bootstrap samples). Accuracy of this method was determined using weighted kappa for NICE recommended CACS groupings (0, 1–400, >400) and Bland–Altman analysis for absolute score. With the CF applied: CACS = (1.183 × rCTCAS) + (0.002 × rCTCAS × threshold), there was excellent agreement between methods for absolute score (mean difference 5.44 [95 % limits of agreement −207.0 to 217.8]). The method discriminated between high (>400) and low risk (

In patients with transposition of the great arteries, the identification of coronary anatomy is fundamental to optimal surgical outcome. A number of classifications describing the coronary vessels' origin and course in transposition of the great arteries have been published. However, all are limited to operative or pathological case series. They are often alphanumeric classifications that do not lend themselves to clinical practice; they do not consider certain important anatomical variations that may increase surgical morbidity and mortality, nor do they fully delineate coronary anatomy or define the relationship to adjacent structures seen with cardiovascular computed tomography. Using cardiovascular computed tomography for illustrative purposes, we propose and validate a universal sequential descriptive classification and an associated alphanumeric classification that may be used for all coronary anomalies with or without associated congenital heart disease.

Chest radiography is the most commonly performed diagnostic imaging test, but in unselected acute medical admissions it offers low diagnostic yield and high case-finding costs. There has been a trend towards the use of targeted radiological investigation. Advances in computed tomography technology, with improvements in spatial and temporal resolution, have facilitated detailed cardio-pulmonary imaging within a single breath hold. Advances in ultrasound technology have improved the accurate delineation of small thoracic structures with the added advantages of portability, repeatability. Real-time, dynamic ultrasound imaging is particularly useful for ‘point-of-care’ testing. The targeted use of radiological investigations early in clinical assessment has the potential to reduce diagnostic time and costs, improve diagnostic yield and facilitate prompt treatment.

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 three children with an unusual radiological sign: "trachea with an air fluid level." We suggest this is related to paucity of cough leading to recurrent chest infections. Voluntary cough suppression as a cause of chronic lower respiratory tract infection is recorded in adults (The Lady Windermere Syndrome) but has not previously been reported in children. We propose that in these children impaired airway mucus clearance may be also be caused by voluntary cough suppression. However, the complex physiology of coughing means it is difficult to distinguish between true voluntary cough suppression and paucity of cough due to a subtle neurological deficit. In two patients, the cycle has led to permanent lung damage with bronchiectasis and reduced lung function. In the third, early diagnosis and multidisciplinary intervention has so far delayed progression to bronchiectasis. With greater awareness of this phenomenon in children, there is potential for effective early intervention with medical, physical, and psychological therapies.

ARTICLE Sir, We thank George and Chattopadhyay for their detailed appraisal1 of our recent paper,2 and we note with interest their extensive references to our data in their recent publication.3 While they raise some interesting issues, we dispute a number of their assertions. To address their points in turn: 1. The study determines the likelihood of CAD in all subjects, at odds with guidance. We agree that it would have been ideal to exclude patients with known coronary artery disease (CAD) from further assessment in our study; however, the reasons for not doing so were multiple and compelling. The foremost issue was how to define CAD to generate an appropriate exclusion criterion. Traditionally, significant CAD has been defined by a history of myocardial infarction, ‘positive’ angiography or coronary revascularization. With advancing biomarker technology (e.g. highly sensitive troponin) and radiological techniques (e.g. cardiac computed tomography), detection of early CAD may now precede the development of symptoms and there is debate as to the implications of these occult findings. Enhanced diagnostic sensitivity for ischemic myocardial injury may also come at the expense of specificity, especially …

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.

Desai S, Dusmet M, Ladas G, Pomplun S, Padley S P G, Griffin N, Badreddine J, Goldstraw P & Nicholson A G (2010) Histopathology 57, 121–127 Secondary vascular changes in pulmonary sequestrations Aims: Whilst parenchymal changes in pulmonary sequestrations are well described, there are comparatively little data on associated vascular changes and their extent. The aim of this study was to retrospectively review morphological changes within sequestrations, concentrating on vascular changes and associations with clinical parameters. Methods and results: Twenty-seven resected cases of sequestrations (intralobar n = 20, extralobar n = 7) showed a male predominance (n = 16) and an age range of 2 months–60 years (average 13 years). Plexogenic vascular changes (medial hypertrophy and intimal fibrosis) were seen in 15 of 27 cases, as well as plexiform lesions in seven cases. Patients with plexogenic changes had a higher mean age compared with those lacking vascular changes (19 versus 6 years) and were more commonly female. Respiratory tract infections were associated solely with intralobar sequestrations. No other associations between presenting symptoms and histopathological parameters were identified. Adjacent lung showed lesser plexogenic changes in six of 22 intralobar cases. There were features of type 2 congenital cystic adenomatoid lesions in 63% of cases. Dissection of the supplying systemic artery (n = 1), intralesional aspergilloma (n = 1) and coexistent lymphangiomatosis (n = 1) were also identified. Conclusions: Hypertensive vascular changes are not uncommon in both intrapulmonary and extrapulmonary sequestrations, although their relative severity seems unrelated to presenting symptoms.

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.

Transbronchial fine needle aspiration (TBNA) is a simple technique for sampling mediastinal lymph nodes and may provide additional information in patients with suspected lung cancer. However, the technique is still under-utilized, and the objective of this study was to evaluate the value of TBNA as part of an integrated pathway for the assessment of patients with suspected lung cancer. All patients referred to the lung cancer services of our institutions were prospectively evaluated. TBNA was performed in all patients with evidence of mediastinal lymphadenopathy. TBNA of one or more lymph node sites were performed in 129 of these patients. TBNA was the sole diagnostic modality in 23% of patients and provided positive staging information for 49% of patients, with adequate sampling in 71% of patients. Among patients with mediastinal adenopathy, the number of patients who required a TBNA performed to diagnose one patient with malignancy in patients suspected with lung cancer (number needed to diagnose) was 1.47 (95% confidence interval, 1.47–1.76). No complications were observed in patients who underwent TBNA. TBNA improves the diagnostic yield and staging of patients with lung cancer. Moreover, it is a simple, low-cost, and safe test, which should be incorporated into the diagnostic pathway of patients with suspected lung cancer.

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.

Background The prevalence of idiopathic scoliosis in the general pediatric population is reported to be between 0.5% and 3.2%. Previous studies have reported an increased prevalence of scoliosis in children with cystic fibrosis (CF). Hypothesis The prevalence of scoliosis in CF children is greater than in the normal population. Methods Chest X-rays of 319 patients attending the Royal Brompton CF Centre were reviewed. The Cobb angle of any spinal lateral curvature was measured. Scoliosis was defined as a Cobb angle of more than 10°. Results Median age of the whole group of patients was 10.9 years (range 1.1–18 years), 53% were females. Seven patients (2.2%) had radiological signs of scoliosis, their mean age was 14.5 ± 2.3 years (range: 11.5–18 years), 5 were females. Age at onset of scoliosis was between 5 and 10 years for three patients and over 10 years for the others. All the curves were thoracic and with right convexity: apices between T7 and T9 for the single curves (n = 5) and between T4 and T5 (n = 2) for the double curves. Conclusion CF patients showed a similar prevalence of scoliosis as in the normal population (2.2% vs. 0.5–3.2%). There was the same gender (female) and side (right-sided) predilection as in normal population. Pediatr Pulmonol. 2013; 48:553–555. © 2012 Wiley Periodicals, Inc.

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.

There are currently no published studies of the impact of CT coronary angiography (CTA) on patient management or cost when compared with other established imaging techniques. We assessed the short term investigation and treatment costs of CTA compared with myocardial perfusion scintigraphy (MPS) using real clinical scenarios. Clinical information with either their CTA or MPS results were presented to 20 cardiologists in a random order. They decided further investigations and treatment required based on these data. Short term cost was calculated for each imaging strategy. Whilst the total number of further investigations requested did not differ between groups patients undergoing CTA were more likely to be referred for invasive coronary angiography, receive aspirin, statins, ACE inhibitors, β-blockers or clopidogrel. Overall cost and investigation costs were similar between CTA and MPS; however treatment costs were higher with CTA. There are significant differences in further clinical management when using CTA compared with MPS, in particular with greater use of secondary preventative medication.

We report on a child with Mycoplasma pneumonia, who developed an unexplained new oxygen requirement. He was found to have an ileo-femoral thrombosis and an acute pulmonary embolus, with positive anti-phospholipid antibodies and acquired activated protein C resistance. These are both acquired risk factors for venous thrombosis. He was successfully anti-coagulated and well at follow-up with disappearance of the anti-phospholipid antibodies, and normalization of his activated protein C activity. Children who present with Mycoplasma infections who run an atypical course should be monitored closely for signs of thrombosis. Thrombosis formation should also be considered in those children with deteriorating respiratory status, but little change in radiographical findings. Children found to have developed thrombi should be investigated with a full thrombophilia screen to elicit both congenital and acquired risk factors, and should be anti-coagulated appropriately.

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

An 83-year-old woman presenting with collapse was found to have an impaired left ventricular ejection fraction (20% predicted). Conventional coronary angiography and magnetic resonance imaging (MRI) were both unable to define the coronary artery anatomy. MRI revealed no previous myocardial infarction or fibrosis. A computed tomographic (CT) coronary angiogram was performed, revealing a single coronary artery (SCA) arising from the right coronary sinus. This vessel quadrifurcated into (i) a normal dominant right coronary artery supplying the posterior circulation, (ii) an anomalous left anterior descending (LAD) artery passing …

We report the case of a fit and healthy 41-year-old man, who presented with significant haemoptysis without a history of recurrent infections. His computed tomography scan showed a dense lesion in the left lower lobe with a feeding vessel arising from the abdominal aorta, characteristic for an intra-pulmonary sequestration. To prevent possible further haemoptysis or infections, a left lower lobectomy was performed. The histological examination showed the typical features of a sequestration. However, within the sequestration, a carcinoid tumour without atypical features was found. There was no lymph node involvement. Sequestrations are congenital lesions without communication with the bronchial tree and with a systemic blood supply. They commonly cause recurrent infection. Fatal haemoptysis has also been described, but is rare. There are very few reports of neoplastic lesions in sequestrations. This case illustrates two unusual aspects of sequestrations. Surgery offers definitive treatment for both pathologies, as opposed to embolisation.

Background Enlargement of the LA is known to increase the risk of atrial fibrillation (AF) and its associated complications. However, the relation between other left atrial (LA) anatomical abnormalities and the risk of developing AF is less well described. Objective The aim of this study was to compare the prevalence of LA anatomical abnormalities between a group of patients with recurrent AF and a group of patients in sinus rhythm (SR) with the use of cardiac computed tomography (CT). Methods The cardiac CT prevalence, location, and size of LA accessory appendages and diverticula were assessed in 200 patients with recurrent AF referred for radiofrequency catheter ablation and compared with a control group of 200 patients in SR. Results The prevalence and mean length and width for diverticula were 23.5%, 8.1 mm, and 8.1 mm, in the AF group and 20.5%, 7.8 mm, and 7.2 mm in the SR group, respectively, and for accessory appendages 6.5%, 8 mm, and 6.3 mm in the AF group and 6.5%, 9.4 mm, and 5.7mm in the SR group, respectively. In both groups, the most common location for a diverticulum or an accessory appendage was the right anterosuperior LA wall. The prevalence, location, and size of accessory appendages and diverticula were not significantly different (P > 0.05) between cohorts. Conclusion This study found no difference in the prevalence and anatomic characteristics of LA accessory appendages and diverticula between patients in recurrent AF and patients in SR.

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.

The National Institute for Health and Clinical Excellence (NICE) recently released guidelines for the investigation of chest pain of recent onset. There is no published data regarding their impact on out-patient cardiac services.This study was undertaken to assess the likelihood of coronary artery disease (CAD) in Rapid Access Chest Pain Clinic (RACPC) patients and the resultant investigation burden if NICE guidance was applied.Five hundred and ninety-five consecutive patients attending two RACPCs over 6 months preceding release of the NICE guidelines [51% male; median age 55 (range 22-94) years] were risk stratified using NICE criteria and the resultant investigations evaluated.One hundred and six (18%) patients had a likelihood of CAD10%, 123 (21%) between 10% and 29%, 175 (29%) between 30% and 60%, 141 (24%) between 61% and 90% and 50 (8%)90%. NICE would have recommended 443 (74%) patients for no cardiac investigation, 10 (2%) for cardiac computed tomography (CCT), 69 (12%) for functional cardiac testing and 73 (12%) for invasive angiography. Relative to existing practice, there would have been a trend towards reduced functional cardiac testing (-24%, P = 0.06), no significant change in CCT (43%, P = 0.436) and a significant increase in invasive angiography (508%, P 0.001). The cost of investigations recommended by NICE would have been £15,881 greater than existing practice.This study suggests patients attending RACPC will have a greater likelihood of CAD than predicted by NICE. Differences between recommended investigations and existing practice will guide investment in cardiac services. Individual hospitals should assess their RACPC cohorts prior to implementing the NICE guidelines.

Introduction Data from cardiac CT (CCT) is often fused with eletrophysiological maps to allow precise pulmonary vein isolation and can detect left atrial appendage (LAA) thrombus in patients undergoing radio-frequency AF ablation (RFA). We present a complete audit cycle that reduced the prevalence of pseudo-thrombus (caused by poor initial mixing of contrast) in the LAA on CCT following implementation of a new protocol. Methods A standard of 100% positive and negative predictive value for the detection of LAA thrombus in patients undergoing CT assessment pre AF ablation was set. 225 consecutive patients were included with 7 patients excluded due to congential heart disease or previous cardiac surgery. 90 consecutive scans included in the initial audit. The diagnostic accuracy (sensitivity, specificity, positive (PPV) and negative predictive value (NPV)) for LAA thrombus detection was determined. A new 2-phase acquisition protocol (additional 60 second delayed scan) was introduced and the subsequent 128 consecutive cases were re-audited to determine if the standard had been met and compared to the published range in the literature. All patients underwent a TOE (as part of the standard clinical work-up) as the gold-standard reference. The additional radiation burden following the introduction of the delayed scan was determined. Results A total of 8 true LAA thrombi were detected (5 and 3 using standard acquisition and 2-phase, respectively). The use of the 2-phase acquisition significantly reduced pseudo-thrombus detection (30 vs. 0 cases; p Conclusion Implementation of an additional 60 second delayed scan improved the detection of LAA thrombus in patients referred for RFA potentially negating the need for a separate TOE for this purpose. This incurs a minimal additional radiation dose and requires no additional contrast.

Until recently, the bronchial circulation has been relatively ignored in the research and clinical arenas, perhaps because of its small volume and seeming dispensability relative to the pulmonary circulation. Although the bronchial circulation only receives around 1% of the cardiac output in health, it serves functions that are critical to maintaining airway and lung function. The bronchial circulation also plays an important role in many lung and airway diseases; through its ability to increase in size, the bronchial circulation is able to provide lung parenchymal perfusion when the pulmonary circulation is compromised, and more recently the role of the bronchial circulation in the pathogenesis of inflammatory airway disease has been explored. Due to the anatomic variability and small volume of the bronchial circulation, much of the research to date has necessitated the use of animal models and invasive procedures. More recently, non-invasive techniques for measuring bronchial blood flow in the mucosal microvascular network have been developed and offer a new avenue for the study of this circulation in humans. In conjunction with molecular research, measurement of airway blood flow (Q(aw)) may help elucidate the role of the bronchial circulation in inflammatory airway disease and become a useful tool for monitoring therapy.

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.