Associated projectile inferior vena cava wound with subsequent pulmonary artery missile embolization: a case report and literature review

A rare and unpredictable complication of firearm and missile injuries is projectile embolism. With only a few cases described in the literature, bullet embolism may become a diagnostic challenge for emergency physicians and military surgeons. Bullet embolization is a rare phenomenon, but the complications can be devastating. Case presentation. A 34‑year‑old man sustained a severe complex abdominoskeletal mine‑blast injury with damage to the hollow organs (duodenum and transverse colon), inferior vena cava and both low extremities. The internal hemorrhage was stopped by phleborrhaphy. The wounds of the duodenum and large intestine were sutured, and gunshot fractures of both anticnemions were stabilized by extrafocal osteosynthesis. The whole‑body CT showed that there was a projectile embolus into the branch of the right mid‑lobe pulmonary artery. No clinical manifestations of pulmonary artery embolism were observed in the patient. After surgery, he developed multiple necrosis and transverse colon perforations that resulted in fecal peritonitis. The suture line leakage that caused the formation of a duodenal fistula and postoperative wound infection were also detected. The complications were managed by multiple reoperations. The attempts of endovascular bullet extraction weren’t undertaken due to severe concomitant injuries, complications and asymptomatic clinical course of pulmonary artery projectile embolism. Open surgery retrieval of the embolus was successfully performed on the 80th day after injury. The patient was discharged from the hospital in good condition on the 168th day after the missile wound. Conclusions. Patients with missile wounds and no exit gunshot perforation should be examined using the whole‑body CT for determining possible migration of a projectile with the blood flow. Patients with asymptomatic pulmonary artery embolism should be managed nonoperatively. In case of symptomatic pulmonary artery projectile embolism, it is reasonable to consider the possibility of open thoracic surgery.

Breast Implants on Computed Tomography—A Pictorial Review of Normal and Pathologic Findings

Breast augmentation with implants is frequently performed. Therefore breast implants can be seen quite frequently on computed tomography (CT) of the body. This offers the possibility to detect incidental pathology and help to improve patient outcome. Basic knowledge about imaging findings of breast implants on CT is therefore needed for radiologists reporting body CT. CT may also be used for further workup of breast implants if magnetic resonance imaging (MRI) is contraindicated or not available. The purpose of this pictorial review is to give a brief overview of normal and pathologic findings of breast implants on CT.

Image quality assessment of pediatric chest and abdomen CT by deep learning reconstruction

Background Efforts to reduce the radiation dose have continued steadily, with new reconstruction techniques. Recently, image denoising algorithms using artificial neural networks, termed deep learning reconstruction (DLR), have been applied to CT image reconstruction to overcome the drawbacks of iterative reconstruction (IR). The purpose of our study was to compare the objective and subjective image quality of DLR and IR on pediatric abdomen and chest CT images. Methods This retrospective study included pediatric body CT images from February 2020 to October 2020, performed on 51 patients (34 boys and 17 girls; age 1–18 years). Non-contrast chest CT (n = 16), contrast-enhanced chest CT (n = 12), and contrast-enhanced abdomen CT (n = 23) images were included. Standard 50% adaptive statistical iterative reconstruction V (ASIR-V) images were compared to images with 100% ASIR-V and DLR at medium and high strengths. Attenuation, noise, contrast to noise ratio (CNR), and signal to noise (SNR) measurements were performed. Overall image quality, artifacts, and noise were subjectively assessed by two radiologists using a four-point scale (superior, average, suboptimal, and unacceptable). A phantom scan was performed including the dose range of the clinical images used in our study, and the noise power spectrum (NPS) was calculated. Quantitative and qualitative parameters were compared using repeated-measures analysis of variance (ANOVA) with Bonferroni correction and Wilcoxon signed-rank tests. Results DLR had better CNR and SNR than 50% ASIR-V in both pediatric chest and abdomen CT images. When compared with 50% ASIR-V, high strength DLR was associated with noise reduction in non-contrast chest CT (33.0%), contrast-enhanced chest CT (39.6%), and contrast-enhanced abdomen CT (38.7%) with increases in CNR at 149.1%, 105.8%, and 53.1% respectively. The subjective assessment of overall image quality and the noise was also better on DLR images (p < 0.001). However, there was no significant difference in artifacts between reconstruction methods. From NPS analysis, DLR methods showed a pattern of reducing the magnitude of noise while maintaining the texture. Conclusion Compared with 50% ASIR-V, DLR improved pediatric body CT images with significant noise reduction. However, artifacts were not improved by DLR, regardless of strength.

Body CT and PET/CT Detection of Extracranial Lymphoma in Patients with Newly Diagnosed Central Nervous System Lymphoma

Background We aimed to investigate the detection rate of body CT or PET/CT for sites of extracranial disease in patients with a new pathological diagnosis of CNS DLBCL and to identify factors associated with sites of extracranial disease. Methods An international multicenter cohort study of consecutive immunocompetent patients with a new diagnosis of CNS DLBCL confirmed by brain biopsy who underwent CT and/or PET/CT to evaluate for sites of extracranial disease between 1998 and 2019. The primary outcome was the detection rate of extracranial lymphoma by CT or PET/CT. Subgroup analyses according to age and EBV status were also performed. Logistic regression analyses were performed to determine factors related to sites of extracranial disease. Detection rates of CT and PET/CT were compared. Results 1043 patients were included. The overall detection rate of CT or PET/CT was 2.6% (27/1043). The treatment approach was adjusted in 74% of these patients. Multivariable analysis demonstrated that age&gt;61-years (OR, 3.10; P=.016) and EBV positivity (OR, 3.78; P=.045) were associated with greater odds of extracranial lymphoma. There was no statistically significant difference in detection rate between CT and PET/CT (P=.802). In patients≤61 years old, the false-referral rates were significantly higher than the detection rates (P&lt;.001). Conclusion Our results showed increased odds of extracranial lymphoma in patients with older age or EBV-positive lymphoma. Treatment was adjusted in a majority of patients diagnosed with extracranial lymphoma, thereby supporting the current guidelines for the use contrast-enhanced body CT or PET/CT in patients with newly diagnosed CNS DLBCL.

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment

Background We examined the visibility of fractures of hand and forearm in whole-body CT and its influence on delayed diagnosis. This study is based on a prior study on delayed diagnosis of fractures of hand and forearm in patients with suspected polytrauma. Methods Two blinded radiologists examined CT-scans of patients with fractures of hand or forearm that were diagnosed later than 24 h after admission and control cases with unremarkable imaging of those areas. They were provided with clinical information that was documented in the admission report and were asked to examine forearm and hands. After unblinding, the visibility of fractures was determined. We examined if time of admission or slice thickness was a factor for late or missed diagnoses. Results We included 72 known fractures in 36 cases. Of those 65 were visible. Sixteen visible fractures were diagnosed late during hospital stay. Eight more fractures were detected on revision by the radiologists. Both radiologists missed known fractures and found new fractures that were not reported by the other. Missed and late diagnoses of fractures occurred more often around 5 pm and 1 am. Slice thickness was not significantly different between fractures and cases with fractures found within 24 h and those found later. Conclusions The number of late diagnosis or completely missed fractures of the hand and forearm may be reduced by a repeated survey of WBCT with focus on the extremities in patients with suspected polytrauma who are not conscious. Level of evidence III