Abstract
Enlarged perivascular spaces, ventricular volumes and the ageing brain
A Neelakantan*, N Mustafa†, S Salarirad†, T S Ahearn†, C J McNeil†, A D Murray†
*Aberdeen Royal Infirmary, NHS Grampian, Scotland, UK;
†University of Aberdeen, Aberdeen, Scotland, UK
E-mail:
Perivascular spaces (PVS) surround penetrating cerebral arteries. Although they are associated with other markers of small vessel disease,1-5 their precise pathogenesis is still unclear. Here we test the hypothesis that increased ventricular volume and enlarged perivascular spaces (EPVS) are both secondary to cerebrovascular disease, with the mechanism being increased pulsatility of the intracranial arteries; causing both expansion of perivascular spaces and, via transmitted choroid plexus pulsation to ventricular cerebrospinal fluid, increased ventricular volume. A total of 229 subjects from the Aberdeen 1936 birth cohort underwent brain magnetic resonance imaging. The number of EPVS in basal ganglia (BG) and centrum semiovale was manually assessed using previously proposed scale. White matter hyperintensities (WMH) on T2W images were assessed using the Scheltens’ scale. Three-dimensional lateral ventricular volumes were calculated using validated Freesurfer software on T1W images. Ventricular volume was not found to be associated with blood pressure (BP) but correlated with WMH (r = 0.25; P < 0.01). The number of BG EPVS was significantly associated with mean diastolic BP (r = 0.2; P < 0.01) and with total Scheltens’ score (r = 0.2; P < 0.01). While both increased ventricular volume and BG EPVS have a negative influence on the ageing brain; they probably have different pathophysiological bases. In addition to WMH, BG EPVS are a surrogate marker of cerebrovascular disease.
DOI: 10.1258/SMJ.2011.011163
‘New’ metastatic disease diagnosed on 18-fludeoxyglucose positron emission tomography/computed tomography: Should it have been identified on previous staging imaging?
A Simms and D Patel
Department of Radiology, Royal Infirmary of Edinburgh, Scotland, UK
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Our aim was to evaluate why ‘new’ metastatic disease diagnosed on 18-fludeoxyglucose positron emission tomography/computed tomography (18-FDG) PET/CT was not identified on previous staging CT scans. PET/CT reports from our institution were retrospectively reviewed, identifying cases showing newly diagnosed metastatic disease on the PET/CT. Two radiologists then reviewed the staging CT to identify why the ‘new’ metastases diagnosed on PET/CT had not been identified on the original staging CT scan. A total of 25 patients were included in the study. Ninety-three ‘new’ metastatic lesions were indentified on these patients PET/CT. In total, 41% (38) of ‘new’ metastatic lesions identified on PET/CT were visible on the staging CT, but were either missed or misinterpreted, 34% (32) of the lesions were not visible even retrospectively on the staging CT; and 25% of lesions were in areas not covered by the staging CT scan. In total, 41% of ‘new’ metastases identified on PET/CT were retrospectively visible on the staging CT. Fifteen percent of the total ‘new’ metastases were actually bone metastases that were visible on the staging scan. Careful interpretation and review of staging scans by experienced radiologists, with particular emphasis on the bones, would help reduce the number of unnecessary PET/CT examinations and decrease the waiting time to final staging and appropriate treatment.
DOI: 10.1258/SMJ.2011.011164
The current practice and safety of reporting out of hours emergency computed tomography scans by the on call radiology registrar in the West of Scotland
C J W Nicolson and P J G Garmany
Department of Radiology, Gartnavel General Hospital, Glasgow G12 0XH, Scotland, UK
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The aim was to assess the current practice and accuracy of radiology registrars’ provisional reporting of out of hours computed tomography (CT) scans. One hundred out of hours CT scans during a three-week period across all six Glasgow city hospitals were analysed, comparing the radiology registrars’ provisional reports to the final report verified by consultants. Discrepancies were classified into major and minor changes. Minor changes were those unlikely to affect management or outcome. Major changes were those that were thought clinically significant, and were subdivided into those that might affect immediate clinical management and those that would not. Forty percent of provisional reports were unchanged compared with the final consultant's report. Fifty-four percent of reports had minor changes. Seven percent of reports had major changes, with 7% having discrepancies that could change immediate management and clinical outcome. The majority of these were in CTs of the abdomen and pelvis. The current practice of reporting out of hours’ CT was deemed safe and acceptable. However, the highest percentage of major changes with potential immediate effect to the patient was seen in CTs of the abdomen and pelvis. It is therefore thought that radiology registrars should have a low threshold for obtaining consultant expertise in these scans.
DOI: 10.1258/SMJ.2011.011166
Splenic biopsy audit: a preliminary report
M Philippou and D Brown
Department of Radiology, Western General Hospital, Edinburgh, Scotland, UK
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Splenic biopsy is an established procedure with well documented results and complication rates. It has been performed in the unit for a number or years. Indications for the procedure include tissue sampling for the diagnosis of solid lesions, the investigation of lymphoma and as a trouble shooting technique in cases with indeterminate diagnosis from other modalities.1-3 This was done using data collection. The biopsy room log book was reviewed and patient details were retrieved and entered into a database. Twenty-three patients underwent the procedure between 2003 and 2010. Age range varied from 26 to 84 with a median age of 58. No significant male to female patient variation was observed. The procedure was performed by a consultant radiologist with interventional interest. Standard periprocedure investigations and observation was employed in accordance to the well established liver biopsy protocol. Prior informed consent was obtained along with recent laboratory FBC and coagulation studies (all within normal limits). All procedures were performed with local anaesthesia and conscious sedation when required. USS guidance was used. There was a median of two passes (range 1-4) with a 16 or 18 g needle. Five biopsies were targeted to specific lesions. In this subgroup, no complications were observed and the biopsy yielded a positive diagnostic answer. In the remaining 18 cases, the biopsy was performed to investigate splenomegaly and symptoms of possible lymphoma. In this subgroup, 11 patients underwent the procedure as the primary tissue sampling method. In the remaining seven, the procedure was performed to further clarify indeterminate lymph node or trephine biopsy results. A definitive diagnosis was made in 15 out of 18 cases, with two cases yielding indeterminate results and one returning normal tissue. Two patients experienced significant pain postprocedure; a splenic haematoma was diagnosed on further imaging in one of these patients and this was managed conservatively with no adverse effect. A third patient, however, suffered major bleeding that required emergency laparotomy and splenectomy, with good postoperative recovery. The observed diagnostic accuracy (86.7%) and complication rates are in line with the published data.,1-3 The results were presented in the regional haematology meeting in March 2010. Following discussion, the following changes were implemented:
Employ a coaxial biopsy technique and obtain three tissue samples (2 for pathology, 1 for chemistry);
Overnight stay for patients;
Where possible perform lymph node, trephine or solid lesion biopsy before considering splenic tissue sampling.
Data collection continues prospectively with the aim to repeat the audit cycle.
DOI: 10.1258/SMJ.2011.011167
Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction: a single centre experience over six years
S Vaidyanathan*, N Masson† and J Moss‡
*Specialty Registrar Radiology, UK;
†Interventional Fellow Radiology, UK;
‡Professor of Interventional Radiology, UK
Gastric outlet obstruction (GOO) secondary to malignancy is a debilitating preterminal event that severely impairs the individual's quality of life. Self-expanding metal enteral stenting is emerging as a safe and effective alternative to gastro-jejunostomy, but there is a paucity of data pertaining to early and late outcomes. Our objective was to assess the technical success rate and evaluate the early and late outcomes of stenting for GOO. This was carried out through retrospective secondary case analysis of patients who underwent gastroduodenal stenting with self-expanding metal stents for treatment of symptomatic malignant GOO in a tertiary referral centre in Glasgow, Scotland from June 2000 to March 2007. Outcomes evaluated included efficacy measure such as technical success, clinical success, and safety measures like secondary procedure rates, early and late complication rates, time to discharge, and mortality rate. Sixty-three adults with a mean age (range) of 69 (43-91) years underwent stenting between June 2000 and March 2007. Gastric carcinoma was the most frequent pathology encountered in 35 (56%), followed by pancreatic 14 (22%), duodenal 3 (5%), ovarian 3 (5%), cholangiocarcinoma 2 (3%), colon 2 (3%), gallbladder 1 (1%), lung 1 (1%) and unknown primary 1 (1%). Seventeen of the patients had multiple stent insertions. The procedure was technically successful in 59 patients (88%) and clinically successful in 57 (85%). Twenty-eight patients required further procedures, biliary stenting (13) and balloon dilation of the stent (15). There were three perforations, five stents migrated and nine stents were blocked due to tumour in-growth. Fifteen (23%) patients died within 30 days. The follow-up ranged from 15 days to six years. Survival curve analysis showed that technical success was associated with early discharge to the community and increased survival. Gastroduodenal stenting is safe and effective method of palliation in malignant GOO with a high technical and clinical success rate with a low need for re-intervention.
DOI: 10.1258/SMJ.2011.011168
Endovascular management of bleeding pseudoaneurysms secondary to trauma
S N Reddy and S Ingram
Department of Clinical Radiology, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
Bleeding visceral pseudoaneurysms (PSA), while rare, have been associated with high mortality. Our aim was to review the incidence and management of bleeding PSA, as a result of trauma (penetrating, blunt or iatrogenic), within the adult inpatient population, referred to Lothian University Hospitals Division – Interventional Radiology Department. Patients treated with image-guided endovascular occlusion techniques, between August 2007 and June 2010 inclusive, were identified via the Radiological Information Systems and Audit databases. Retrospective analysis of the prospectively collected data was then performed. During the study period, 378 patients were referred for an embolization procedure, of which 21 patients (5.6%) were referred for the treatment of bleeding PSA. Within this cohort, 57% of patients underwent treatment as a result of blunt, penetrating and iatrogenic traumatic injuries; seven patients (33.3%) were treated for bleeding visceral PSA; and four patients (19%) required treatment for non-visceral bleeding PSA. Endovascular intervention was successful in all trauma patients with visceral bleeding PSA on the first attempt and coils were the embolization agent used in all cases. The median time period from diagnosis to successful treatment was four hours (range 2 hours to 1 day). There was no mortality in this subset with the median time to discharge 27 days (range 3-39 days). In the non-visceral bleeding PSA subset, a combination of coils and gelfoam was used as the embolization agent. The median time period from diagnosis to successful treatment was three hours (range 2 hours to 4 days). One patient required repeat intervention and two patients died as a result of their associated co-morbidity and not as a direct consequence of the intervention. Bleeding PSA are a serious and potentially fatal complication of trauma. Our study demonstrates that image-guided endovascular intervention is a viable treatment option for patients, with both visceral and non-visceral traumatic bleeding PSA. Endovascular occlusion is less invasive and allows treatment of arteries with difficult open surgical access. It should be the preferred treatment modality, where feasible, due to the reduced morbidity and mortality compared with surgical management, with no mortality demonstrated in the visceral patient subset in this study.
DOI: 10.1258/SMJ.2011.011169
What is the quickest way to find the needle in a haystack: An analysis of referral pattern and imaging pathways for patients with concerning soft tissue masses on ultrasound
M Szewczyk-Bieda, N Schembri and T B Oliver
Department of Clinical Radiology, Ninewells Hospital & Medical School, Dundee, Scotland, UK
Our aim was to assess the time from initial referral to completion of imaging for patients with concerning soft tissue masses on ultrasound (US) and determine ways by which this might be reduced. All patients in Tayside who had soft tissue US examination during a six-month period were identified. Following review of their request cards, those who had US for a suspected soft tissue mass were selected. From this group, patients who had a subsequent magnetic resonance imaging (MRI) scan to assess the soft tissue mass were identified using the local radiology information system. For each patient, the time intervals between initial US referral and subsequent steps in the imaging work-up to completion of MRI were documented, and the patient was assigned to one of several management pathways which were defined. A total of 1621 US examinations were performed within a six-month period. In total, 677 (42%) of these were requested to assess a suspected soft tissue mass. Out of 677, 54 suspected soft tissue masses had concerning US appearance, requiring further evaluation with MRI. Four management pathways were identified, on the basis of whether patients were referred for US directly from primary care or via secondary care and whether or not the reporting radiologist directly arranged MRI following the identification of concerning US features. Mean time from initial referral to completion of imaging for the different pathways ranged from 58.5 to 108 days, the most efficient being a two-step pathway; whereby general practitioners directly referred patients for US, bypassing secondary care, and the radiologist directly arranged MRI following US. Most patients with suspected soft tissue masses can be treated or discharged following US alone. For the minority who require further work-up, the time from initial referral to completion of imaging is, in the authors’ opinion, unacceptably long. Study of patient management pathways has suggested ways that this time could be reduced for most patients. The recently introduced national limit on imaging waiting times will partially address, but radiologists should also be proactive in arranging further imaging for patients with concerning US masses.
DOI: 10.1258/SMJ.2011.011170