Thoracic Imaging 2003 - Society of Thoracic Radiology

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MONDAY 114 available about the epidemiology of VTE may help the radiologist to guide clinicians in interpreting results of any study for PE or DVT. It is hoped that continued improvement in the noninvasive diagnosis of VTE will lead to better understanding of the range of presentations of VTE and its epidemiology, and will eventually result in better prevention and lower morbidity and mortality. REFERENCES : 1. Wagenvoort CA. Pathology of pulmonary thromboembolism. Chest 1995;107(1 Suppl):10S-17S. 2. Heit JA, Silverstein MD, Mohr DN, Petterson TM, Lohse CM, O'Fallon WM, et al. The epidemiology of venous thromboembolism in the community. Thrombosis & Haemostasis. 2001;86(1):452-63. 3. Oger E. Incidence of venous thromboembolism: a communitybased study in Western France. EPI-GETBP Study Group. Groupe d'Etude de la Thrombose de Bretagne Occidentale. Thrombosis & Haemostasis. 2000;83(5):657-60. 4. Pineda LA, Hathwar VS, Grant BJB. Clinical suspicion of fatal pulmonary embolism. Chest 2001;120(3):791-795. 5. Heit JA. Venous thromboembolism epidemiology: implications for prevention and management. Seminars in Thrombosis & Hemostasis 2002;2:3-14. 6. Dalen JE. Pulmonary embolism: What have we learned since Virchow? Chest 2002;122:1440-1456. 7. Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al. Value of assessment of pretest probability of deepvein thrombosis in clinical management. Lancet 1997;350(9094):1795-8. 8. Sheiman RG, McArdle CR. Clinically suspected pulmonary embolism: use of bilateral lower extremity US as the initial examination--a prospective study. Radiology 1999;212(1):75-8. 9. Nicolaides AN, Kakkar W, Field ES, Renney JT. The origin of deep vein thrombosis: a venographic study. Br J Radiol 1971;44(525):653-63. 10. Smith TP. Pulmonary embolism: what's wrong with this diagnosis? AJR. American Journal of Roentgenology 2000;174(6):1489-97. 11. Gotthardt M, Schipper M, Franzius C, Behe M, Barth A, Schurrat T, et al. Follow-up of perfusion defects in pulmonary perfusion scanning after pulmonary embolism: are we too careless? Nuclear Medicine Communications 2002;23(5):447- 52. 12. Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Current concepts: chronic thromboembolic pulmonary hypertension. N Engl J Med 2001;345(20):1465-1472.
Multi-channel Pulmonary CTA: New Techniques, Observations, and Concepts James F. Gruden, M.D. FCCP Associate Professor of Radiology and Internal Medicine, Emory University School of Medicine, Adjunct Professor of Biomedical Engineering, Georgia Institute of Technology Director, Cardiothoracic Imaging Division, Emory Healthcare, Medical Director, Biomedical Imaging Laboratory, Emory University Hospital and Clinic OBJECTIVES 1. Understand the fundamental differences and similarities between single and multi-channel helical CT angiography and the advantages each has over conventional angiography and scintigraphy and to know the scientific basis for these advantages. 2. Identify current areas of research in image display and processing of large volumetric data sets that may enhance our ability to diagnose thromboembolic disease. 3. Understand the concept of the accuracy of a diagnostic test and the limitations of accuracy as a measure of true test utility. 4. Reconsider the current understanding of venous thromboembolism and its recommended therapy. 5. Understand the recent clinical literature and its limitations. BACKGROUND During the period 1984-1991, an average of 50,000 cases of pulmonary embolism were diagnosed each year in the hospitalized Medicare population alone with a mortality rate of at least 10% [1]. Definitive diagnosis is of paramount importance because of both the seriousness of the condition itself and because complications of anticoagulant therapy are frequent and can be severe. The definitive diagnosis or exclusion of venous thromboembolic disease (PE and DVT) remains problematic, and there are few areas of medicine with such a significant level of uncertaintly and confusion with regard to accurate diagnosis and therapy. One autopsy study found that only 10% of patients 70 years of age and older with PE had a correct diagnosis before death [2]. Missed diagnosis is not the only problem; of all patients with an ICD-9 discharge diagnosis of PE in one series, 28% had no objective evidence of either PE or deep venous thrombosis (DVT) [3]. These diagnostic inaccuracies exist for two major reasons. First, the clinical signs and symptoms associated with PE are nonspecific, as are laboratory investigations, electrocardiograms, and chest radiographs. Clinical studies show a high prevalence of symptoms in patients with PE because diagnostic testing is initiated by the clinical scenario; however, 26-38% of patients with high-probability ventilation-perfusion (VQ) scans in the setting of known DVT are asymptomatic [4, 5]. Clinical estimates of the probability of PE are clearly not sufficient for individual patient management decisions. The second reason for imprecision is that the widely used tests and algorithms for suspected venous thromboembolism (which includes both DVT and PE) are limited in accuracy and inconsistently applied. The ideal diagnostic test should be accurate, direct (objective), rapid, safe, readily available, and of reasonable cost. Only approximately 30% of patients (probably much less in the current medicolegal climate) with clinically suspected PE have the disease [6]. A diagnostic test able to provide information regarding the presence and significance of other chest disease would also be desirable. None of the common tests in use (other than CT) meet all or even most of these criteria. The use of CT angiography (CTA) in the assessment of patients with possible thromboembolic disease has coincided with the development of rapid helical (spiral) scanners, which enable angiogram-like images of the pulmonary circuation in a single breath-hold. This technique has revolutionized the approach to the patient with possible PE and offers significant and important improvements over the traditional diagnostic approach (chest radiograph and VQ scan) in the initial assessment of these patients. New “multi-channel” or “multi-detector” scanners acquire 4 or even 8 channels of data simultaneously and faster (16, 32 channels) scanners are in development. These multi-channel scanners have significant advantages over single channel helical CT; these will be outlined and illustrated after a brief review of pertinent issues in pulmonary CTA. There is no question that multi-channel CT (MCCT) is the new gold standard in the diagnosis of PE and it is unethical to perform randomized trials that exclude some patients from MCCT or force conventional angiography to be performed after clearly negative or positive MCCT studies. SINGLE CHANNEL HELICAL CT ANGIOGRAPHY Nearly all of the published literature in CT pulmonary angiography refers to studies obtained with single channel helical CT, and a basic understanding of this information is essential to an understanding of the significant impact of MCCT in this setting. All helical data sets are volumetric and permit image reconstructions at overlapping intervals, improving density discrimination between small adjacent structures of different attenuation (such as thrombi within enhancing arteries). The central thorax can also be scanned in a single breath hold (no respiratory motion) on these scanners; these features in concert enable high quality multiplanar reconstructions. Helical pulmonary CT angiography has become the method of choice in the assessment of patients with suspected venous thromboembolism even prior to the developmant of multi-channel technology. Images should be reviewed on a workstation, in cine mode, and multiplanar reconstructions performed in difficult cases at commercially available workstations. Examples will be shown. With single channel scanners, we use a collimation of 3 mm and a pitch of 2 with a reconstruction interval of 2 mm after acquiring data from the diaphragm up during a single 20-25 second breath-hold. If necessary, scans can be performed during either quiet respiration or two distinct breath-holds separated by a short (5-10 seconds) interval although this introduces motion and limits assessment of smaller, peripheral vessels. Few patients have difficulty tolerating the examination. We use 100- 150 cc of low osmolar, nonionic contrast (30-48% iodine) injected at a rate of 2.5-3 cc/sec. Although we formerly achieved optimal opacification of the pulmonary vasculature through the use of a "timing run" or by using the Smart Prep (General Electric Medical Systems, Milwaukee) program, we now use a fixed delay of 20 seconds from the start of the injection to imaging. This is easier to reproduce, introduces less potential for error during the exam, and enables more predictable timing of the leg vein image acquisition (see below). The thinly-collimated overlapping images permit detailed assessment of the central airways, hilar and mediastinal lymph nodes, and of the lungs and pleural surfaces. This ancillary information is not provided by any other diagnostic test commonly used in the assessment of patients with suspected venous thromboembolism and is of importance in the symptomatic patient with an unknown diagnosis. We perform a half-mA scan of the entire chest prior to contrast injection as well since the entire thorax cannot be scanned with single channel helical machines using the above parameters. CT, like pulmonary angiography, directly depicts thrombi within the opacified arterial lumen as intravascular filling 115 MONDAY
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The Society of Thoracic Radiology T
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Dear Friends, Welcome to Miami Beac
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Continuing Medical Education Credit
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Warren B. Gefter, MD University of
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Ernest M. Scalzetti, MD SUNY Upstat
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Registration Hours Saturday, March
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Program Committee Ella A. Kazerooni
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Small Airway Disease Americana 3 Mo
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Benjamin Felson Memorial Lecture Am
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Session 2-B Concurrent Session Clin
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Workshops (choose 1) 1:00 - 1:45 D1
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Sunday
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March 2, 2003 General Session Sunda
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SUNDAY 46 One type of direct-readou
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CT-PET Imaging Suzanne Aquino, M.D.
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Page 35 and 36: SUNDAY 62 17. Sewell PE, Vance RB.
Page 37 and 38: SUNDAY 64 cal ventilation will be r
Page 39 and 40: SUNDAY 66 radiologic, and histopath
Page 41 and 42: SUNDAY 68 application. The untreate
Page 43 and 44: SUNDAY 70 The Expanded Spectrum of
Page 45 and 46: SUNDAY 72 Hypersensitivity Pneumoni
Page 47 and 48: SUNDAY 74 Small Airway Diseases Mic
Page 49 and 50: SUNDAY 76 The “Head-cheese Sign
Page 51 and 52: SUNDAY 78 “Holes” in the Lung:
Page 53 and 54: SUNDAY 80 Pleural Effusions Gerald
Page 55 and 56: SUNDAY 82 Asbestos Related Pleural
Page 57 and 58: SUNDAY 84 Other Pleural Neoplasms S
Page 59 and 60: SUNDAY 86 Image-Guided Therapy of M
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Page 63 and 64: March 3, 2003 General Session 7:00
Page 65 and 66: Cardiac MRI: Established Indication
Page 67 and 68: Cardiac MRI: New Developments Gauth
Page 69 and 70: 5. The volume of contrast medium re
Page 71 and 72: Acute Aortic Syndrome Ernest M. Sca
Page 73 and 74: as well as separation of the cusps
Page 75 and 76: Pulmonary Veins: Imaging for Radiof
Page 77 and 78: Imaging of Cardiopulmonary Support
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Page 87 and 88: CT Strucural and Functional Imaging
Page 89 and 90: curves (TDCs) are generated by manu
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Page 95 and 96: 127 MONDAY
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Page 99 and 100: REFERENCES Bergin CJ, Rios G, King
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Page 103 and 104: March 4, 2003 General Session 7:00
Page 105 and 106: Adult Manifestations of Congenital
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Page 109 and 110: Imaging of the Pericardium Paul L.
Page 111 and 112: Cardiomyopathy Martin J. Lipton, M.
Page 113 and 114: TUESDAY 150 Nuclear Cardiology Upda
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The Spectrum of Pulmonary Infection
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Immune deficiency occurs frequently
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TUESDAY 180 The Internet and the Pr
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TUESDAY 182 Workshop A1: Lymphoma:
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TUESDAY 184 Digital Images: Camera
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TUESDAY 186 Analysis of Mediastinal
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Unusual Manifestations of Lung Canc
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Wednesday
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March 5, 2003 General Session Wedne
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WEDNESDAY 208 principle is that “
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WEDNESDAY 210 years and a current o
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WEDNESDAY 212 lesions generally mim
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WEDNESDAY 214 capable of studying t
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WEDNESDAY 216 Small T1 Lung Cancer:
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WEDNESDAY 218 REFERENCES Seely JM,
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WEDNESDAY 220 Therefore, radiologis
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WEDNESDAY 222 sectional area varies
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WEDNESDAY 224 Lung Cancer Staging A
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Metastatic Disease to Lung Gordon L
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Thoracic Metastates from Osteosarco
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STR tutorial: Use of MD CT reconstr
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ogenic edema, fat embolism, heroin
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WEDNESDAY 236 Pulmonary Arterial Hy
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WEDNESDAY 238 pathological process,
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Thursday
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THURSDAY 250 Pulmonary Tuberculosis
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THURSDAY 252 1. Clinical criteria:
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THURSDAY 254 AIDS patients are also
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THURSDAY 256 Viral Infection on HRC
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THURSDAY 258 Imaging of Coccidioido
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THURSDAY 260 from the laryngeal sur
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THURSDAY 262 Inflammatory Diseases
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Virtual Endoscopy in the Thorax: Pr
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Notes 269 THURSDAY
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SECOND LEVEL THIRD LEVEL
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