Effectiveness of Lymphatic Contrast Enhanced Ultrasound in the diagnosis of Cervical Lymph node metastasis from papillary thyroid carcinoma

Cervical lymph node metastasis (CLNM) is common in patients with papillary thyroid carcinoma (PTC), which is responsible for tumor staging and surgical strategy. The accurate preoperative identification of CLNM is essential. In this study, twenty consecutive patients with PTC received a parenchyma injection of Sonazoid followed by contrast enhanced ultrasound (CEUS) to identify CLNM. The specific lymphatic CEUS (LCEUS) signs for diagnosing CLNM were summarized, which were further compared with the resected specimens to get the pathological basis. After the injection of contrast agent, lymphatic vessel and lymph node (LN) could be exclusively displayed as hyperperfusion on LCEUS. The dynamic perfusion process of contrast agent in CLNM over time can be clearly visualized. Perfusion defect and interruption of bright ring were the two characteristic LCEUS signs in diagnosing CLNM. After comparing with pathology, perfusion defect was correlated to the metastatic foci in medulla and interruption of bright ring was correlated to the tumor seeding in marginal sinus (all p values < 0.001). The diagnostic efficacies of these two signs were high (perfusion defect vs. interruption of bright ring: AUC, 0.899, 95% CI 0.752–1.000 vs. 0.904, 0.803–1.000). LCEUS has advantages in identifying CLNM from PTC. The typical LCEUS signs of CLNM correlated with pathology.

Radiomic features of epicardial adipose tissue in coronary atherosclerosis

Aim. To investigate the association of the radiomic characteristics of epicardial adipose tissue (EAT) on contrast-free computed tomography (CT) of the heart with the severity of obstructive coronary lesion and myocardial ischemia.Methods. The study included 68 patients with coronary heart disease (mean age of 63.5±9.4, 45 men and 23 women), and 15 patients (mean age 30±4.8; 14 men and 1 woman) without cardiovascular disease as a control group. All the patients underwent multispiral computed coronary angiography, coronary calcium scores (CCS) determination and stress myocardial perfusion scintigraphy. Radiomic characteristics of EAT (texture analysis by gradations of gray color) were determined on non-contrast computer tomogram images of the heart using 3D-Sliser software and the SliserRadiomics module (version 4.10.2). The obtained indicators were compared between a control and under the study groups as well as between subgroups of patients divided according to the degree of obstruction of the coronary arteries, the size of the perfusion defect, and the value of the CCS.Results. The comparative analysis of radiomic indicators of EAT between patients with coronary artery disease and the control group showed the presence of statistically significant differences between them. At the same time, the correlation analysis in the study group did not reveal any correlations between the radiomic parameters and the size of the perfusion defect, CCS or degree of stenosis of the lumen of the coronary arteries.Conclusion. The textural characteristics of EAT in patients with coronary heart disease differ from those in individuals without cardiovascular pathology. At the same time, these indicators are not associated with the severity of obstructive lesions of the coronary arteries, the value of the CCS, and the size of the perfusion defect according to scintigraphy.

RELATIONSHIP BETWEEN FRONTAL QRS-T ANGLE AND MYOCARDIAL PERFUSION DEFECT (MPD) FROM SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT) IN PATIENTS WITH PRIOR MYOCARDIAL INFARCTION

Background: The frontal QRS-T angle is the angle between ventricular depolarization and repolarization. The QRS-T angle abnormalities will mirror the electrical instability, placing the patient in high risk of cardiac arrhythmia and sudden cardiac death. This study was conducted to analyzed as if the QRS-T angle will predict the myocardial perfusion defect in acute ST elevation myocardial infarction (STEMI). Methods: This is a cross sectional study which conducted in patients with previous history of STEMI in H. Adam Malik General Hospital Medan from June 2018 until March 2020. The patients will then be undergoing electrocardiography (ECG) and myocardial perfusion scintigraphy (SPECT) to acquire the frontal QRS-T angle and myocardial perfusion defect score. Results: Over 40 patients with prior STEMI we found the frontal QRS-T angle has a positive moderate correlation (r = 0,543; p < 0,001) with myocardial perfusion defect. The best cut-off value for frontal QRS-T angle to predict myocardial perfusion defect is > 70o with sensitivity and specificity of 70.6% and 82.6%, respectively. Conclusions: The frontal QRS-T angle is an independent predictor for myocardial perfusion defect in patient with previous history of STEMI. Keywords: STEMI; frontal QRS-T angle; myocardial perfusion defect.

Brachial Artery “Low-Flow Mediated Constriction” Is Associated with Myocardial Perfusion Defect Severity and Mediated by an Altered Flow Pattern during Occlusion

<b><i>Introduction:</i></b> The relationship between low flow-mediated constriction (LFMC), a new proposed measure of endothelial function, with cardiovascular disease severity and its hypothesized stimulus, that is, low flow, has not been comprehensively evaluated. The study evaluated association between change in brachial artery diameter during constriction with severity of myocardial perfusion defect (PD) and alterations in different components of flow profile. <b><i>Methods:</i></b> Brachial artery responses to occlusion were assessed in 91 patients and 30 healthy subjects. Change in anterograde and retrograde blood flow velocities (delta anterograde blood flow velocity and retrograde blood flow velocity), anterograde shear rate and retrograde shear rate (delta ASR and RSR, respectively), and oscillatory shear index (delta) during forearm occlusion at 50 mm Hg above systolic pressure, from baseline was calculated. Myocardial perfusion was evaluated in patients using exercise single positron emission computed tomography and % myocardial PD was calculated from summed stress score. <b><i>Results:</i></b> LFMC emerged as independent predictor of defect severity after correcting for age and gender (<i>p</i> = 0.014). Sixty-seven patients (73.6%) and 15 healthy subjects (50%) showed constriction during occlusion. In stepwise backward regression analysis, RSR contributed 35.5% and ASR contributed 20.1% of the total 63.9% variability in artery diameter during occlusion. <b><i>Conclusion:</i></b> The results suggest that LFMC is independently associated with myocardial perfusion severity and is “mediated” by an altered flow profile during occlusion.

“PERFUSION CT IN PREDICTING THE DEVELOPMENT OF PANCREATIC NECROSIS IN EARLY STAGE OF SEVERE ACUTE PANCREATITIS”

PURPOSE: To evaluate the role of perfusion CT (PCT) scan in predicting the development of pancreatic necrosis (PN) in early stage of severe acute pancreatitis (SAP). MATERIALS AND METHODS: A total of 20 adult patients with a clinical diagnosis of SAP presenting within 72 hours of onset of symptoms with a positive SIRS criteria were included in the study. All the patients underwent PCT on a 128 slice MDCT scannerusing 40 ml of non-ionic iodinated contrast followed by post processing using vendor provided CT perfusion software whereby perfusion parameters were calculated. Perfusion defect (PD) was dened as pancreatic BF and/or BV qualitatively less than hepatic BF and/or BV respectively on the color coded maps. A follow up CECT abdomen was done after 2 weeks as a 'gold standard' to assess whether PN developed in the corresponding region of PD. RESULTS: 8 out of 20 patients developed perfusion defect (PD) on the PCT, of which 6 patients developed PN on the follow up scan. Patients who did not show any PD on the PCT (12 out of 20) did not develop necrosis on the follow up CECT. The sensitivity, specicity, PPV, NPV and accuracy of PCT in predicting necrosis was 100%, 85.71%, 75%, 100% and 90% respectively. The cut off values of pancreatic BF and BV in predicting the development of PN were 34.87 ml/100ml/min and 11.70ml/100ml respectively based on the ROC curve. CONCLUSION: PCT is a useful technique that can predict development of PN in the early stage of SAP so that early aggressive management can be initiated.

Combining contrast-enhanced ultrasound and blood cell analysis to improve diagnostic accuracy of plasma cell mastitis

Plasma cell mastitis is a benign suppurative disease of the breast, lack of specific clinical manifestations, which is easy to be misdiagnosed and mistreated, often confused with mastitis, breast cancer (BC), and other diseases. Thus, we aimed to establish a combined model of promoting diagnostic accuracy of plasma cell mastitis by contrast-enhanced ultrasound (CEUS) patterns and routine blood cell analysis. Eighty-eight plasma cell mastitis, 91 breast cancer, and 152 other benign breast diseases’ patients grouped according to pathological diagnosis underwent CEUS and blood cell analysis examination; 100 healthy female donors were involved. All the plasma cell mastitis and breast cancer patients presented hyperenhancement of CEUS breast lesions compared with others. The majority of plasma cell mastitis (65/88) showed perfusion defect of CEUS patterns with smooth edge (56/65) and multiple lesions (49/65); in contrast, fewer breast cancer patients (30/91) displayed perfusion defect. White blood cell count (WBC), neutrophils, and neutrophils/lymphocytes ratio of blood cell analysis in plasma cell mastitis patients increased significantly compared with other patients ( P < 0.0001). Combining perfusion defect of CEUS patterns and WBC yielded an area under the receiver operating characteristic curve of 0.831, higher than single 0.720 and 0.774, respectively. The cut-off value of WBC (7.28 × 109/L) helped remaining 65.2% (15/23) atypical cases to be correctly diagnosed as plasma cell mastitis, not misdiagnosed as breast cancer. In conclusion, CEUS presented a clear perfusion defect pattern of plasma cell mastitis lesion for the first time. A precise WBC by routine blood cell analysis test can assist CEUS examination in the differential diagnosis of plasma cell mastitis and breast cancer. It is a promised combination for laboratory diagnostic of PCM.

Coronary collaterals not visible by invasive angiography can provide more than half of normal resting perfusion in patients with coronary artery disease

Background: There is sufficient collateral flow to prevent myocardial ischemia during balloon occlusion in approximately one in five patients. However, the magnitude of myocardial perfusion provided by the coronary collateral circulation during occlusion is unknown. Therefore, the aim of this study was to quantify collateral myocardial perfusion during balloon occlusion in patients with coronary artery disease (CAD). Methods: Patients without angiographically visible collaterals undergoing elective percutaneous transluminal coronary angioplasty (PTCA) to a single epicardial vessel underwent two scans with 99mTc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT). All subjects underwent at least three minutes of angiographically verified complete balloon occlusion, at which time an intravenous injection of the radiotracer was administered, followed by SPECT imaging. A second radiotracer injection followed by SPECT imaging was performed 24 hours after PTCA. Results: The study included 21 patients (median [interquartile range] age 70 [56-74] years, 48% female). The diameter stenosis ranged from 60-99%, with successful PTCA performed with a mean 5-minute balloon occlusion. The perfusion defect extent was 16 [8-30]% of the LV. The collateral perfusion at rest was 64 [58-68]% of normal perfusion. Collateral perfusion was negatively correlated with perfusion defect size (R2=0.85, p<0.001), and did not differ by sex (p=0.27) or age (p=0.58). Conclusions: This is the first study to describe the magnitude of coronary microvascular collateral perfusion in patients with CAD. On average, despite coronary occlusion and an absence of angiographically visible collateral vessels, collaterals provide approximately 60% of the perfusion that reaches the jeopardized myocardium during coronary occlusion.

Quantification of myocardial ischemia and subtended myocardial mass at adenosine stress cardiac computed tomography. A feasibility study

Introduction Combination of computed tomography angiography (CTA) and adenosine stress CT myocardial perfusion (CTP) allows for coronary artery lesion assessment as well as myocardial ischemia. Nowadays, ischemia on CTP is assessed semi-quantitatively by visual analysis. The aim of this study was to fully quantify myocardial ischemia and the subtended myocardial mass on CTP. Methods We included 33 patients referred for a combined CTA and adenosine stress CTP with good or excellent imaging quality on CTP. Firstly, the coronary artery tree was automatically extracted from CTA and the relevant coronary artery lesions (≥50%) were manually defined (Fig. 1A). Secondly, epi- and endocardial contours along with CTP deficits were manually defined in short-axis images (Fig. 1D, 1E). Thirdly, a Voronoi-based algorithm was used to quantify the subtended myocardial mass (Fig. 1B). Fourthly, the perfusion defect and subtended myocardial mass were spatially registered to the CTA and measured in grams (Fig. 1F, 1C). Finally, this can be used to quantitatively correlate the perfusion defect to the subtended myocardial mass. Results Voronoi-based segmentation was successful in all cases. We assessed a total of 64 relevant coronary artery lesions. Average values for left ventricular mass, total subtended mass and perfusion defect mass were 118, 69 and 7 grams respectively. In 19/33 patients (58%) the total perfusion defect mass could be distributed over the relevant coronary artery lesion(s). Conclusions Quantification of myocardial ischemia and subtended myocardial mass using a Voronoi-based segmentation algorithm seem feasible at adenosine stress CTP and allows for quantitative correlation of coronary artery lesions to corresponding areas of myocardial hypoperfusion. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

Diagnostic Accuracy of Coronary Artery Occlusion and Myocardial Perfusion Defect on Non-Gated Enhanced Chest CT in Predicting Acute Myocardial Infarction

The purpose of this study was to evaluate the diagnostic accuracy of coronary artery occlusion (CAO) and myocardial perfusion defect (MPD) identified on non-gated enhanced chest CT in patients with acute myocardial infarction (AMI). We retrospectively assessed 99 patients with AMI (group 1, n = 33) and without AMI (group 2, n = 66) who underwent non-gated chest CT. We analyzed the presence of MPD and CAO on non-gated chest CT. MPD on the CT was categorized using a three-point scale (0 = no definite MPD; 1 = probable artifact or questionable MPD; 2 = probable MPD). Presence of CAO was defined as an abrupt change of contrast enhancement in a coronary artery segment with no or minimal coronary motion on the CT. There were 42.4% and 12.1% patients with probable MPD (p = 0.002), and 18.2% and 0% patients with CAO (p = 0.001) in groups 1 and 2, respectively. Probable MPD alone and simultaneous presence of CAO and probable MPD to predict AMI resulted in sensitivity, specificity, negative predictive value, and positive predictive valve of 42.4%, 87.9%, 75.3%, and 63.6%, respectively, and 12.1%, 100%, 69.5%, and 100%, respectively. In conclusion, probable MPD alone on non-gated chest CT demonstrated a relatively low sensitivity, high specificity, and modest positive predictive value for the prediction of AMI on non-gated enhanced chest CT. Although it is rare, simultaneous presence of CAO and probable MPD had a high positive predictive value to predict AMI on non-gated enhanced chest CT.