P4987Long term follow up after comparison of two strategies in a chest pain unit: exercise echocardiography and multidetector computed tomography

Introduction and objectives

Up to 5% patients with acute chest pain present an acute coronary syndrome (ACS). This study aimed to compare peak exercise echocardiography (ExE) and multidetector computed tomography (MCT) in patients referred to a chest pain unit.

Methods

203 patients with ≥1 cardiovascular risk factors, no ischemic ECG changes and negative biomarkers were randomized to ExE (n=103) or MCT (n=100). The endpoints were hard events (cardiovascular death and non-fatal myocardial infarction), combined events (hard events and revascularizations), and combined events plus readmissions during follow-up. Cost of either strategy was also investigated.

Results

Mean age was 64±11 years and 131 patients were male. Hypertension was seen in 71%, hypercholesterolemia in 74%, diabetes mellitus in 28%, and smoking in 21%. Most of the patients had a low TIMI risk score (68% TIMI I and 32% TIMI II). Mean follow-up was 4,7±2,7 years. Invasive angiography due to positive/nonconclusive results was performed in 34 of the patients, 103 submitted to SE and in 27 of the 100 submitted to MCT (33% vs. 27%, p=0.15). A final diagnosis of acute coronary syndrome was achieved in 53 patients (30 [88%] in the ExE group and 23 [85%] in the MCT group, p=0.12). There were no significant differences between groups in hard events (5 [5%] patients in the ExE group and 7 [7%] in the MCT group, p=0,42), combined events (35 patients [34%] in the ExE group and 29 [29%] in the MCT group), and combined events plus readmissions (43 [42%] patients in the ExE group and 41 [41%] in the MCT). The median stay in hospital was 7 (5–10) days in the ExE group and 8 (5–10,25) in the MCT group (p=NS). For patients with negative results by either technique the mean stay was less than 8 hours. There were no differences in the global cost, although it was lower for patients with negative ExE (557 € vs. 706 €, p<0,02) as compared to those with negative TCM.

Conclusions

Both MCT and ExE are equally effective for the stratification of patients with low to moderate probability of ACS admitted to a chest pain unit. The cost was similar with both strategies, although significant lower in ExE when negative studies were compared.

Percutaneous Catheter Drainage of Tuberculous Psoas Abscesses

Six patients with 7 tuberculous psoas or ilio-psoas abscesses were treated by CT-guided catheter drainage and chemotherapy. The abscesses (5 unilateral and 1 bilateral) were completely drained using a posterior or lateral approach. The abscess volume was 70 to 700 ml (mean 300 ml) and the duration of drainage 5 to 11 days (mean 7 days). Immediate local symptomatic improvement was achieved in all patients, and there were no procedural complications. CT follow-up at 3 to 9 months showed normalization in 5 patients, 2 of whom are still on medical therapy. One patient, who did not take the medication regularly, had a recurrent abscess requiring new catheter drainage after which the fluid collection disappeared. Percutaneous drainage represents an efficient and attractive alternative to surgical drainage as a supplement to medical therapy in the management of patients with large tuberculous psoas abscesses.

Benign regenerative nodules with copper accumulation in a case of chronic Budd-Chiari syndrome: CT and MR findings

Budd-Chiari syndrome is a rare disease characterized by hepatic outflow obstruction due to different causes. Hepatic nodules in patients with Budd-Chiari syndrome are rare and can be due to hepatocellular carcinoma and benign regenerative nodules. Imaging descriptions of regenerative nodules in cirrhotic livers are numerous, but the imaging findings of benign regenerative nodules associated with Budd-Chiari syndrome have only recently been reported. We present the computed tomographic and magnetic resonance features of benign regenerative hepatic nodules with copper accumulation in a patient with chronic Budd-Chiari syndrome.

Colonic metastasis from renal cell carcinoma: helical-CT demonstration

Clinically evident colonic metastasis from renal cell carcinoma (RCC) is rare. In the present study a hypervascular sigmoid mass was demonstrated on arterial-phase helical CT using a water enema in a patient who had suffered left nephrectomy 8 years previously for RCC. The intense and early enhancement of the lesion suggested the possibility of a solitary colonic metastasis from RCC, a diagnosis which was pathologically confirmed.

Amyloidosis presenting as a perforated giant colonic diverticulum

Colonic amyloidosis is frequent, although rarely radiographically evident. The radiological findings are varied and unspecific. We report a case of perforated giant colonic diverticulum (GCD) diagnosed by helical CT in which amyloid deposition was pathologically demonstrated. The patient was a renal transplant recipient who previously had undergone hemodialysis for 10 years. A possible role of amyloidosis in the pathogenesis of this case is discussed. Giant colonic diverticulum must be included in the spectrum of gastrointestinal manifestations of amyloidosis.

Fibrosing mediastinitis: CT and MR findings

The aim of this study is to present the computed tomography (CT) and magnetic resonance (MR) findings in three cases of fibrosing mediastinitis, probably secondary to tuberculosis. Two patients had diffuse involvement of the mediastinum and one patient presented with a posterior mediastinal mass. On CT, the patients with diffuse involvement showed infiltrating soft-tissue masses with multiple foci of dense calcifications. One of these lesions enhanced mildly with contrast and one did not enhance. On MR examination, diffuse masses were of heterogeneous, intermediate and low signal on T1-weighted images (n = 2) and were of homogeneous low signal (n = 1) or heterogeneous (n = 1) signal intensity on T2-weighted images. After administration of Gd-DTPA, these mediastinal masses showed heterogeneous enhancement. The posterior mediastinal mass showed homogeneous pronounced enhancement on CT and was homogeneous with intermediate T1 signal intensity and hypointense T2 signal intensity. The CT findings of an infiltrative or well-defined mediastinal mass with scattered calcifications should suggest the diagnosis of fibrosing mediastinitis in the appropriate clinical setting. Although the appearance of calcification on MR are not specific, this technique provides further information than CT especially in those cases in which the lesions appear noncalcified, because MR imaging revealed areas of low signal intensity characteristic of fibrous tissue.

Pancreatic tuberculosis: CT findings

BACKGROUND

The purpose of this study was to describe the computed tomography (CT) findings in pancreatic tuberculosis (PT).

METHODS

We retrospectively reviewed the CT features in six patients with PT, three of whom had AIDS.

RESULTS

Pancreatic lesion masses were found in four patients, small (< 1 cm) low-attenuation pancreatic nodules in one, and diffuse enlargement of the pancreas in one. The pancreatic lesion masses were found in all the non-AIDS patients and in one patient with AIDS and were located in the head of the pancreas in two cases and involved the body, neck, and head of the gland in the other two. The masses showed low attenuation in two cases, soft-tissue attenuation in one, and appeared as an infiltrating inhomogeneous lesion with retropancreatic spread, encasing the celiac trunk and superior mesenteric artery in one. Low-attenuation peripancreatic and/or periportal adenopathies with peripheral rim enhancement were found in three cases, and slight bile duct dilatation was evident in four. Four patients had disseminated tuberculosis, whereas pancreatic and peripancreatic tuberculosis were the sole manifestation of tuberculosis in the other two.

CONCLUSION

The present data suggest that PT usually appears as a nonspecific focal lesion mass in HIV-seronegative patients, whereas there is a variable spectrum of CT findings including focal lesion mass, multiple small low-attenuation pancreatic nodules, or diffuse enlargement of the gland in AIDS patients. Low-attenuation peripancreatic and periportal adenopathies with peripheral rim enhancement and other data of disseminated tuberculosis are ancillary findings that should support a diagnosis of PT.

Elastofibroma dorsi: MR and CT findings

Elastofibroma dorsi is a benign, pseudotumoral soft tissue lesion of the periscapular area. The characteristical findings in magnetic resonance images and computed tomography usually allow the diagnosis and prevent radical surgery. We report the MR and CT findings of elastofibroma dorsi in four women presenting as an elongated soft tissue mass intermingled with fat, between the ribs and the serratus muscle, deep to the inferior angle of the scapula.

Bilateral renal lymphangiomatosis: US and CT findings

A case of bilateral renal lymphangiomatosis in an asymptomatic 50-year-old female is presented. Ultrasound and CT studies were performed. A finely septated fluid collection surrounding both kidneys and traversing the midline was found. Surgical biopsy was obtained and revealed findings compatible with lymphangiomatosis. A review of the literature of renal lymphangiomatosis is given.

CT-guided core-needle biopsy in omental pathology

PURPOSE

To assess the accuracy and clinical usefulness of CT-guided core-needle biopsy in the diagnosis of omental pathology.

MATERIAL AND METHODS

We retrospectively reviewed the results of CT-guided percutaneous core biopsies in 25 patients with focal (n = 2) or diffuse (n = 23) omental pathology. These results were compared to the final diagnoses as determined by laparotomy (n = 15), laparoscopic biopsy (n = 3), endoscopic biopsy (n = 1), or by the results of percutaneous biopsy and clinical-radiological and bacteriological modalities (n = 6). The final diagnoses showed 4 patients with isolated omental pathology and 21 with widespread peritoneal involvement. The CT-guided biopsies were performed with 1.0-1.8-mm Surecut core-needles.

RESULTS

In 16 patients, the final diagnosis was metastatic adenocarcinoma--with the primary tumor sites in the ovary (n = 3), stomach (n = 1), appendix (n = 2), and unknown (n = 10). In the remaining 9 patients, the final diagnosis was hepatocellular carcinoma, lymphoma, and mesothelioma in 1 patient each; tuberculosis in 5; and actinomycosis in 1. Sufficient histological (n = 16) or cytological (n = 8) material was obtained by CT biopsy in 24/25 (96%) cases; the specimen was insufficient for diagnosis in 1 case. In differentiating benign from malignant disease, CT-guided biopsy showed a sensitivity, specificity and accuracy of respectively 89.5%, 100% and 92%. It gave a specific diagnosis in 78.9% (15/19) of patients with malignant conditions and in 50% (3/6) of patients with benign disorders. There were no biopsy-related complications.

CONCLUSION

CT-guided percutaneous core-needle biopsy of the omentum is a safe, useful and highly accurate procedure for diagnosing malignant omental pathology.

Cervical lymph node metastases of medullary thyroid carcinoma: CT findings

Medullary thyroid carcinoma (MTC) is a rare malignancy which spreads frequently to cervical lymph nodes. We report the CT findings of MTC metastatic cervical adenopathies in two patients with previously resected MTC. The CT scans showed calcifications (one patient) and massive homogeneous postcontrast nodal enhancement. Medullary thyroid carcinoma should be included in the differential diagnosis of entities showing calcifications and intense homogeneous adenopathic enhancement on CT studies.

Peritoneal tuberculosis versus peritoneal carcinomatosis: distinction based on CT findings

OBJECTIVE

The purpose of this study was to determine the utility of CT in distinguishing peritoneal tuberculosis (PT) from peritoneal carcinomatosis (PC).

MATERIALS AND METHODS

CT scans were retrospectively reviewed in 19 patients known to have PT and compared with scans in 19 patients known to have PC. CT images were evaluated for thickening (smooth versus irregular), enhancement, presence of nodules, and site of involvement on the parietal peritoneum. The existence of omental caking, nodules, and smudged patterns in the omentum, mesentery, and gastrocolic ligament was noted. The presence, distribution, and loculation of ascites were also evaluated.

RESULTS

Ascites was present in all cases of PT and PC, loculated in 10 cases (PT = 4, PC = 6), and located in the greater peritoneal sac (PT = 15, PC = 10) or in the greater and lesser sacs (PT = 4, PC = 9). Slight smooth thickening and pronounced enhancement of the parietal peritoneum were seen in 15 of 19 PT patients and in 5 of 19 PC patients (p<0.001), whereas irregular thickening was found in only 9 of 19 PC patients (p <0.001). Peritoneal nodules were present exclusively in PC (7/19) (p <0.01). The sites of the parietal peritoneum involvement were the pelvic (PT = 9, PC = 3) (p <0.05), paracolic gutters (PT = 5, PC = 6), juxtadiaphragmatic (PT = 0, PC = 9) (p <0.001), and perihepatic (PT = 6, PC = 8) regions. Omental cakes were found in 4 of 19 PT and in 7 of 19 PC patients. The smudged pattern was the most common abnormality in the omentum (PT = 9/19, PC = 11/19), gastrocolic ligament (PT = 5/19, PC = 11/19) (p <0.01), and mesentery (PT = 7/19, PC = 11/19). Isolated and discrete well defined nodules were exclusively found in the mesentery (PT = 5/19, PC = 3/19).

CONCLUSION

The most useful CT findings for distinguishing PT from PC were observed in the parietal peritoneum. The presence of a smooth peritoneum with minimal thickening and pronounced enhancement suggests PT, whereas nodular implants and irregular peritoneal thickening suggest PC.

[Alveolar lipoproteinosis treated by bronchopulmonary lavage]

Alveolar lipoproteinosis is a rare disease, a review of the Spanish Medical Index for 1971 to June 1994 showing only 9 reported cases. The intra-alveolar deposit of lipoprotein-type matter produces severe hypoxemia and favors infection by opportunistic germs. Treatment with massive bronchial lavage (MBL) removes the matter from the alveolar space, improves gas exchange and decreases the risk of infection. We report a case of primary alveolar lipoproteinosis treated with MBL in which the patient developed infections by Aspergillus fumigatus before lavage and after starting steroid treatment. The procedure was performed without complications, with significant clinical and gasometric improvement. The natural evolution of this disease is poorly understood. Spontaneous remissions have been observed, and as MBL is not a risk-free procedures, its use in treatment is controversial. We believe that when severe hypoxemia is present, MBL should be used early, when the risk is slight; MBL improves gas exchange and probably reduces the risk of opportunistic infection.

Tuberculosis of the nasal fossa manifested by a polypoid mass

Since the introduction of effective antituberculous chemotherapy, upper respiratory tract tuberculosis is infrequent; nasal involvement is a very rare form of this disease. In this localization, tuberculosis is usually unilateral and typically discloses a definite granular mass or an ulcer. We report a case manifested by an intranasal mass on computerized tomography scans that evolved as chronic rhinitis.

MRI of pseudocoarctation of the aorta: morphological and cine-MRI findings

We report a case of pseudocoarctation of the thoracic aorta diagnosed by magnetic resonance imaging. Morphological spin-echo findings and cine-MRI performed by gradient-echo multiphase images are reported. No other more invasive examinations were needed to establish the diagnosis of pseudocoarctation and to differentiate from other aortic abnormalities.

MR findings in hereditary spherocytosis

The magnetic resonance findings of intrathoracic extramedullary hematopoiesis associated with bone marrow reconversion, and reticuloendothelial hemosiderosis in a 50-years-old are reported. Radiologic finding of extramedullary hematopoiesis was the first step to the diagnosis of previously unknown hereditary spherocytosis.

Aortic calcification and renal cysts demonstrated by CT in a teenager with Alagille syndrome

Alagille syndrome, or arteriohepatic dysplasia, is a disorder characterized by paucity of intrahepatic bile ducts, peculiar facies and skeletal anomalies. We report a typical case of this syndrome in an 18-year-old girl, in whom abdominal CT showed bilateral renal cysts and aortic wall calcification, findings unreported in the radiological literature.

[Malignant pancreatic oncocytoma]

A pancreatic oncocytoma in a 77 year old man is described. A CT scan showed liver metastases three years earlier. The patient died from complications after surgery for a perforated duodenal ulcer, and at autopsy a primary tumor in the tail of the pancreas and several liver metastases were found. The morphologic and biologic features of this unusual tumor are discussed.

CT attenuation values and enhancing characteristics of thoracoabdominal lymphomatous adenopathies

OBJECTIVE

Thoracoabdominal lymphomatous adenopathies have been described as homogeneous and typically showing little enhancement on postcontrast CT. After observing pronounced adenopathic contrast enhancement in one patient with lymphoma, we prospectively investigated the CT enhancing characteristics and attenuation values of pathologic thoracic and abdominal lymph nodes in 25 patients with lymphoma.

MATERIALS AND METHODS

Unenhanced CT of the chest, abdomen and pelvis was performed in all cases. The enhancing characteristics and attenuation values of the largest node or group of nodes were evaluated at 1, 2, 5, and 10 min after a 100 ml intravenous bolus injection of contrast medium.

RESULTS

On unenhanced CT the nodes were of soft-tissue attenuation (42 +/- 5 HU) in 23 cases and of low attenuation (31 and 28 HU) in 2 cases. The maximum enhancement was achieved at 1 or 2 min postinjection and was low (16 +/- 6 HU) or moderate (31 +/- 6 HU) in 21 cases and pronounced (61 +/- 5 HU) in 4. The patterns of enhancement were classified as homogeneous (no. = 23) inhomogeneous (no. = 1), and peripheral (no. = 1).

CONCLUSION

Thoracic and abdominal lymphomatous adenopathies are usually of soft-tissue attenuation on unenhanced CT and can show slight, moderate, or even pronounced enhancement on postcontrast CT.

Percutaneous catheter drainage of tuberculous psoas abscesses

Six patients with 7 tuberculous psoas or ilio-psoas abscesses were treated by CT-guided catheter drainage and chemotherapy. The abscesses (5 unilateral and 1 bilateral) were completely drained using a posterior or lateral approach. The abscess volume was 70 to 700 ml (mean 300 ml) and the duration of drainage 5 to 11 days (mean 7 days). Immediate local symptomatic improvement was achieved in all patients, and there were no procedural complications. CT follow-up at 3 to 9 months showed normalization in 5 patients, 2 of whom are still on medical therapy. One patient, who did not take the medication regularly, had a recurrent abscess requiring new catheter drainage after which the fluid collection disappeared. Percutaneous drainage represents an efficient and attractive alternative to surgical drainage as a supplement to medical therapy in the management of patients with large tuberculous psoas abscesses.

Multicystic fibrolamellar hepatocellular carcinoma. CT appearance

An unusual case of fibrolamellar hepatocellular carcinoma (FLHCC) presenting as multiple intrahepatic lesions of cystic appearance on the computed tomography (CT) study is described.

Chylous ascites associated with acute pancreatitis in a patient undergoing continuous ambulatory peritoneal dialysis

We report on a case of chylous ascites associated with acute pancreatitis secondary to gallbladder stone disease, in a patient undergoing continuous ambulatory peritoneal dialysis. The initial clinical presentation was one of bacterial peritonitis, with later appearance of chylous peritoneal drainage. Diagnosis was suggested by abdominal computed tomography and confirmed by surgical exploration. We discuss the main diagnostic keys of peritoneal dialysis-associated pancreatitis and the possible etiologic role of this entity in chylous ascites of these patients.

Patterns of contrast enhancement of tuberculous lymph nodes demonstrated by computed tomography

The purpose of this study was to evaluate the contrast-enhanced CT characteristics of pathologic thoraco-abdominal lymph nodes in 38 patients infected with Mycobacterium tuberculosis (30 without AIDS and eight with AIDS). Unenhanced scans of chest, abdomen and pelvis were also done in all cases. The CT attenuation values and the enhancement characteristics of the largest node or group of lymph nodes were evaluated in a dynamic sequence over a period of 10 min. On unenhanced CT the nodes were of low attenuation (less than 30 HU) in 18 cases and of soft tissue attenuation (greater than 35 HU) in 20 cases. Four post-contrast patterns of enhancement were found: (i) peripheral rim enhancement (n = 22); (ii) inhomogeneous enhancement (n = 8); (iii) homogeneous enhancement (n = 6); and (iv) homogeneous nonenhancing nodes (n = 2). Increase of attenuation and obliteration of perinodal fat was found in 13 cases, most of them with the peripheral rim enhancement pattern. Seven cases had a combination of enhancing patterns in the same nodal group. The central enhancement was usually moderate (mean, 30 HU) but was marked (greater than 60 HU) in three patients with the homogeneous enhancement pattern. Neither the nodal attenuation values nor the patterns of enhancement are characteristic of tuberculosis, however adenopathy showing peripheral rim-enhancement with relative low attenuation centres can suggest a diagnosis of tuberculosis in the appropriate clinical setting.

[Bilateral adrenal hemorrhage secondary to heparin treatment: a case report]

Bilateral suprarenal haemorrhage (BSH) has not been often described as a cause of chronic suprarenal insufficiency. The diagnosis before death is difficult and it was rare until the CAT scan became a routine diagnostic tool. Of 25 cases reported since 1981, 23 were diagnosed by CAT scan. We report a case of a patient that developed bilateral suprarenal haemorrhage (BSH) during heparin therapy for pulmonary embolism. The early clinical picture resembled a septic shock, and the diagnosis of Addison disease was made later. We reviewed the medical literature and we emphasized the clinical problems in which we should suspect the diagnosis of BSH, where early therapy with steroids may be critical to save the patient's life.

Aortic dissection presenting as acute pancreatitis: CT diagnosis

A 42-year-old male developed epigastric pain and elevation of serum amylase of 2045 U/L. A contrast-enhanced abdominal CT disclosed inflammatory changes involving the pancreas and peripancreatic tissues and findings indicative of aortic dissection. The possibility of aortic dissection should be considered in the management of patients with acute pancreatitis.