Evaluating Signs of Pulmonary Hypertension on Computed Tomography and Correlating With Echocardiography: A Study at a Tertiary Care Hospital

Introduction: Pulmonary hypertension (PH) is a threatening condition, and it is far more common than previously assumed, especially after the COVID pandemic. Its outcome is not good; if detected late, and can lead to right ventricular failure, which can be fatal. Our goal was to evaluate CT signs of PH, correlate them with echocardiography, and identify the cut-off values of these signs in our population.

Method: In this study, 160 patients having both CT and echocardiography with a maximum gap of one month were assessed from June to November 2021. The association between CT signs and echocardiography to diagnose PH was investigated. The Pearson and Spearman correlation and area under receiver operating curve (AUROC) tests were performed in the analysis. Receiver operating characteristic curve analysis was also used to assess CT’s diagnostic capability and cut-off values.

Result: The correlation between main pulmonary artery (MPA) diameter and main pulmonary artery to aorta ratio (MPA/AO) with mean pulmonary artery pressure (mPAP) was weak but statistically significant (r = 0.316 and r = 0.321, p<0.001). However, there was a very weak correlation between the right and left pulmonary artery and mPAP with correlation coefficients (r) of 0.155 and 0.138, respectively. For the first time in our population, we measured the cut-off values of MPA and MPA/AO ratios for PH which were 26 and 0.88 mm, respectively.

Conclusions: The CT signs of PH correlate with echocardiography; however, should not be used solely; the cut-off values should be used according to race and population.

Relationship Between Greyscale Ultrasound Grading of Hepatic Steatosis and Attenuation Imaging

Background

Non-alcoholic fatty liver disease (NAFLD) has been rising worldwide due to the rising public health threat of metabolic syndrome. Because non-alcoholic steatohepatitis can proceed to liver fibrosis and cirrhosis, early identification and monitoring are critical for management. For the examination of NAFLD, greyscale ultrasound has been frequently employed. A relatively new technique, attenuation imaging (ATI), can quantitatively evaluate and compute the attenuation coefficient (AC). Our goal was to evaluate the performance and cutoff values of attenuation imaging to identify hepatic steatosis. As a reference standard, greyscale ultrasound was employed.

Method

A total of 207 patients were assessed from June to November 2021 after getting informed consent. The association between ATI values and greyscale grading to diagnose hepatic steatosis was investigated, and the Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY, USA) was used to analyze the data. In the analysis, the Spearman correlation and area under the receiver operating characteristic curve (AUROC) tests were performed. Receiver operating characteristic curve analysis was also used to assess ATI’s diagnostic capability and cutoff values.

Result

The correlation between ATI values and hepatic steatosis grades on greyscale was statistically significant (p < 0.05). Greyscale grading and ATI levels have a correlation coefficient (r) of 0.85, indicating a strong association. Steatosis grades 1, 2, and 3 had threshold ATI values of 0.65, 0.73, and 0.96 dB/cm/MHz, respectively. According to greyscale, the diagnostic ability of ATI for steatosis grades 1, 2, and 3 were 0.948 (95% CI: 0.917-0.979), 0.978 (95% CI: 0.961-0.995), and 1.000 (95% CI: 1.000-1.000), respectively.

Conclusions

Attenuation imaging is a reliable method for identifying liver steatosis, with great performance and a strong association with the greyscale ultrasound.

Factors Responsible for Non-Diagnostic Cytology on Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules

Introduction

Fine-needle aspiration (FNA) is a well-recognized procedure for the diagnosis of thyroid nodules, with the advantage of being safe and inexpensive. Fine-needle aspiration cytology (FNAC) is mainly performed for nodules showing suspicious sonographic features that may require thyroidectomy. Even when FNAC is performed under sonographic guidance, the cytological specimen obtained may be inadequate, leading to a non-diagnostic outcome. The aim of this study is to determine the sonographic and technical factors influencing the outcome of FNAC.

Material and methods

This cross-sectional study was conducted prospectively at the radiology department, Dr. Ziauddin Hospital, Karachi, from January 1, 2019, to December 31, 2020. This study was approved by the Ethical Review Committee (ERC) of Ziauddin University. All the patients undergoing ultrasound (US)-guided FNAC of thyroid nodules were included. Patients with a history of previous thyroid surgery, very large thyroid lesions (>5 cm), and those with adjacent soft tissue pathology obscuring the assessment of thyroid nodules were excluded from this study.

Result

Out of 176 nodules studied, 14 were non-diagnostic and 162 were diagnostic. A 22G needle was used in most of the patients, i.e. 102 (57.3%), which demonstrated no relationship with the non-diagnostic results. According to Bethesda, 136 (77.3%) patients were benign, 22 (12.5%) had lesions with atypia/follicular lesions of undetermined significance, 14 (8%) were non-diagnostic and four (2.3%) were suspicious for malignancy. A subset, including 76 nodules, was categorized according to Thyroid Imaging Reporting and Data System (TIRADS) as follows: 28 (36.8%) nodules were moderately suspicious, 24 (31.6%) were mildly suspicious, 20 (26.3%) were not suspicious, and four (5.3%) nodules were benign. It was also observed that none of the hypoechoic nodules yielded non-diagnostic cytology.

Conclusion

This study concludes that radiologists must be aware of the technical details, cytologic preparation, and procedure-related complications associated with US-guided FNA to optimize patient care and the diagnostic outcome.

Comparison of Maximum Intensity Projection and Volume Rendering in Detecting Pulmonary Nodules on Multidetector Computed Tomography

Introduction Lung cancer is the most common cancer overall, and the foremost cause of cancer-related mortality. Almost all lung cancers evolve from pulmonary nodules. As multidetector CT (MDCT) scanners are now widely available, there is an increased rate of detection of pulmonary nodules. It is of utmost importance to evaluate pulmonary nodules to rule out the possibility of neoplastic diseases. With advancements in technology, there are various manual and automatic analytic software providing a wide range of post-processing techniques. Maximum intensity projection (MIP) and volume rendering (VR) techniques have been analyzed previously regarding pulmonary nodules but there is a scarcity of data in terms of low-density nodules. This study aims to delineate the comparison and supremacy of both techniques in terms of low-density nodules. Methodology The current prospective study was conducted from June 2019 to June 2020 in the Radiology Department at Dr. Ziauddin Hospital, Karachi. Chest CT scans were performed on 16 slice MDCT (Alexion 16 Multi-slice, Toshiba Medical System Corporation, Houston, TX). A consultant radiologist of six years experience and a postgraduate trainee of three years experience analyzed each patient on a workstation (Vitrea 6.2.0, Vital Images, Minnetonka, MN). SPSS 23.0 (SPSS Inc., Chicago, IL) was incorporated for data analysis. Data were expressed in the median and interquartile range (IQR). Data collected for this study were analyzed using analyzing the median difference in nodule count using Wilcoxon's signed-rank test. A p-value of <0.05 was considered significant. Results After informed consent, 236 patients were recruited for the study. MIP outperformed VR in terms of nodule detection and low-density nodules at each evaluated slab thicknesses (p<0.001). A 10-mm MIP was superior to all other techniques in terms of detection of pulmonary nodules and low-density nodules (p<0.001). MIP was also considered an easier technique as there was excellent inter-rater reliability and agreement. Conclusion This study is robust evidence regarding the supremacy of MIP. MIP outperformed VR on every slab thicknesses. The 10-mm MIP technique was superior to all others evaluated and was recorded to be an easier analyzing technique.

Ultrasound-Guided Transthoracic Mediastinal Biopsy: A Safe Technique for Tissue Diagnosis in Middle- and Low-Income Countries

Background and objectives

The high cost of video-assisted transthoracic procedures precludes their use in the diagnostics of mediastinal masses in low- and middle-income countries (LMICs). This study aims to assess the technical success rate and diagnostic yield of ultrasound-guided transthoracic mediastinal biopsies at a tertiary care hospital.

Methods

This descriptive cross-sectional study was conducted in patients presenting with mediastinal masses referred to radiology services at Dr. Ziauddin University Hospital. Karachi, Pakistan. Ultrasonography was performed using Toshiba Xario 200 & Aplio 500 using convex and linear probes accordingly. Biopsy was performed using a combination of 18G semiautomatic trucut and 17G co-axial needles. Complications and overall diagnostic yields were determined.

Results

In all 70 patients referred, the procedure was completed successfully with an overall procedural yield of 95.7%. Inconclusive biopsies due to inadequate specimen were seen in two (4.2%) patients. No post-procedure major complication or mortality was observed. Minor complications were seen in three (4.2%) out of 70, including hematoma (<3 cm) in one patient and small pneumomediastinum in two patients.

Conclusion

Ultrasound-guided transthoracic mediastinal biopsy may be the pragmatic technique of choice in LMICs for the diagnosis of mediastinal masses as they provide real-time visualization and is cost-effective and safe.

Role of CT Imaging With Three-Dimensional Maximum Intensity Projection Reconstruction in the Evaluation of Portal Vein Variants at a Tertiary Care Hospital

INTRODUCTION

Portal vein (PV) is the principal blood vessel transporting blood from the alimentary tract and spleen to the liver. The aim of this study is to determine the prevalence of PV anatomical variations in our population using multidetector CT with maximum intensity projection (MIP) technique at a tertiary care hospital.

METHODS

This cross-sectional study was prospectively conducted from November 2018 to June 2019 in the Department of Radiology at a tertiary care hospital in Karachi. After informed consent, all the patients with no known hepatic pathology undergoing routine abdomen CT were included in this study. Patients with previous hepatic resection surgeries, undiagnosed large hepatic tumors/metastasis, and those with PV thrombosis were excluded.

RESULTS

A total of 500 patients (256 males and 244 females) were included in the study; the mean age of female patients was relatively higher as compared to the male patients (53.80 ± 18.44 vs. 44.15 ± 19.94 years; p = 0.000). Standard PV anatomy (type 1) was found in 438 patients (87.6%). Trifurcation (type 2) occurred in 18 patients (3.6%). Right posterior portal vein as the first branch of main PV (type 3) was found in 22 patients (4.4%). A separate branch of the right portal vein (RPV) to segment VII (type 4) and separate branch of the RPV to segment VI (type 5) were found in 6 (1.2%) and 16 (3.2%) patients, respectively.

CONCLUSION

Our study displayed a relatively higher frequency of standard PV anatomy (type 1) compared to previous studies. We highlight the role of MIP in the analysis of hepatic venous anatomy with its utility demonstrating improved detection of variations.

Diagnostic Accuracy of CT Scan in Diagnosing Paranasal Fungal Infection

OBJECTIVE

To assess the diagnostic accuracy of CTscan in detecting paranasal sinus fungal infections.

STUDY DESIGN

Cross-sectional, observational study.

PLACE AND DURATION OF STUDY

Department of Radiology, Ziauddin University Hospital, Karachi, from April to September 2014.

METHODOLOGY

Patients with clinical suspicion of fungal sinusitis were included in this study. Patients with already diagnosed or history of recurrent fungal infections were excluded. All these patients underwent CTscan examination of paranasal sinuses. Findings were recorded. Final diagnosis was based on smear analysis for fungal culture. Accuracy analysis was conducted for CTdiagnosis using smear analysis as the gold standard. Kappa analysis was conducted to determine agreement.

RESULTS

Out of the 120 patients, 71 (59%) were male. The sensitivity, specificity, positive predictive value and negative predictive value of CTwere 96.19%, 93.33%, 99.01%, 77.77%, respectively. The diagnostic accuracy was 95.83%. Kappa statistics showed 82% agreement beyond chance.

CONCLUSION

CTscan is highly accurate in diagnosing and characterizing fungal infection of paranasal sinuses. It also determines the extent of disease which eventually aids in deciding the surgical approach to be used.