Impact of a 4th generation iterative reconstruction technique on image quality in low-dose computed tomography of the chest in immunocompromised patients

PURPOSE To determine the image quality of an iterative reconstruction (IR) technique in low-dose MDCT (LDCT) of the chest of immunocompromised patients in an intraindividual comparison to filtered back projection (FBP) and to evaluate the dose reduction capability. MATERIALS AND METHODS 30 chest LDCT scans were performed in immunocompromised patients (Brilliance iCT; 20-40 mAs; mean CTDIvol: 1.7 mGy). The raw data were reconstructed using FBP and the IR technique (iDose4™, Philips, Best, The Netherlands) set to seven iteration levels. 30 routine-dose MDCT (RDCT) reconstructed with FBP served as controls (mean exposure: 116 mAs; mean CDTIvol: 7.6 mGy). Three blinded radiologists scored subjective image quality and lesion conspicuity. Quantitative parameters including CT attenuation and objective image noise (OIN) were determined. RESULTS In LDCT high iDose4™ levels lead to a significant decrease in OIN (FBP vs. iDose7: subscapular muscle 139.4 vs. 40.6 HU). The high iDose4™ levels provided significant improvements in image quality and artifact and noise reduction compared to LDCT FBP images. The conspicuity of subtle lesions was limited in LDCT FBP images. It significantly improved with high iDose4™ levels (> iDose4). LDCT with iDose4™ level 6 was determined to be of equivalent image quality as RDCT with FBP. CONCLUSION iDose4™ substantially improves image quality and lesion conspicuity and reduces noise in low-dose chest CT. Compared to RDCT, high iDose4™ levels provide equivalent image quality in LDCT, hence suggesting a potential dose reduction of almost 80%.

Added value of dual-energy computed tomography versus single-energy computed tomography in assessing ferromagnetic properties of ballistic projectiles: implications for magnetic resonance imaging of gunshot victims.

OBJECTIVE The objective of this study was to assess the discriminative power of dual-energy computed tomography (DECT) versus single-energy CT (SECT) to distinguish between ferromagnetic and non-ferromagnetic ballistic projectiles to improve safety regarding magnetic resonance (MR) imaging studies in patients with retained projectiles. MATERIALS AND METHODS Twenty-seven ballistic projectiles including 25 bullets (diameter, 3-15 mm) and 2 shotgun pellets (2 mm each) were examined in an anthropomorphic chest phantom using 128-section dual-source CT. Data acquisition was performed with tube voltages set at 80, 100, 120, and 140 kV(p). Two readers independently assessed CT numbers of the projectile's core on images reconstructed with an extended CT scale. Dual-energy indices (DEIs) were calculated from both 80-/140-kV(p) and 100-/140-kV(p) pairs; receiver operating characteristics curves were fitted to assess ferromagnetic properties by means of CT numbers and DEI. RESULTS Nine (33%) of the projectiles were ferromagnetic; 18 were nonferromagnetic (67%). Interreader and intrareader correlations of CT number measurements were excellent (intraclass correlation coefficients, >0.906; P<0.001). The DEI calculated from both 80/140 and 100/140 kV(p) were significantly (P<0.05) different between the ferromagnetic and non-ferromagnetic projectiles. The area under the curve (AUC) was 0.75 and 0.8 for the tube voltage pairs of 80/140 and 100/140 kV(p) (P<0.05; 95% confidence interval, 0.57-0.94 and 0.62-0.97, respectively) to differentiate between the ferromagnetic and non-ferromagnetic ballistic projectiles; which increased to 0.83 and 0.85 when shotgun pellets were excluded from the analysis. The AUC for SECT was 0.69 and 0.73 (80 and 100 kV[p], respectively). CONCLUSIONS Measurements of DECT combined with an extended CT scale allow for the discrimination of projectiles with non-ferromagnetic from those with ferromagnetic properties in an anthropomorphic chest phantom with a higher AUC compared with SECT. This study indicates that DECT may have the potential to contribute to MR safety and allow for MR imaging of patients with retained projectiles. However, further studies are necessary before this concept may be used to triage clinical patients before MR.

Comparison of the critical shoulder angle in radiographs and computed tomography.

OBJECTIVE The critical shoulder angle (CSA) is an indicator of degenerative shoulder pathologies. CSAs above 35° are associated with degenerative rotator cuff disease, whereas values below 30° are common in osteoarthritis of the glenohumeral joint. Measurements are usually performed on radiographs; however, no data have been reported regarding the reliability of CT scan measurements between different readers or the reproducibility of measurements from radiographs to CT scans. The purpose of our study was to clarify whether CSA measurements on radiographs and CT scans of the same patients show similar values. MATERIALS AND METHODS CSA measurements of 60 shoulders (59 patients) were performed on radiographs and multiplanar reconstructions of corresponding CT scans. Inter-reader reliability and inter-method correlation were calculated. RESULTS The mean discrepancy between readers was only 0.2° (SD ±1.0°) on radiographs. CT scan measurements showed a mean discrepancy of 0.3° (SD ±1.2°). The inter-reader reliability was 0.993 for radiographs and 0.989 for CT scans. There was a very strong inter-method correlation between the CSA measured on radiographs and CT scans (Spearman's rho = 0.974). The mean differences between angles on radiographs and CT measurements were -0.05° (SD ±1.2°) and 0.1° (SD ±1.2°), respectively. CONCLUSION Measurements of the CSA on anterior-posterior radiographs and CT scans are highly correlated, and inter-modality differences are negligible.

Post-mortem whole body computed tomography of opioid (heroin and methadone) fatalities: frequent findings and comparison to autopsy

OBJECTIVE To investigate frequent findings in cases of fatal opioid intoxication in whole-body post-mortem computed tomography (PMCT). METHODS PMCT of 55 cases in which heroin and/or methadone had been found responsible for death were retrospectively evaluated (study group), and were compared with PMCT images of an age- and sex-matched control group. Imaging results were compared with conventional autopsy. RESULTS The most common findings in the study group were: pulmonary oedema (95 %), aspiration (66 %), distended urinary bladder (42 %), cerebral oedema (49 %), pulmonary emphysema (38 %) and fatty liver disease (36 %). These PMCT findings occurred significantly more often in the study group than in the control group (p < 0.05). The combination of lung oedema, brain oedema and distended urinary bladder was seen in 26 % of the cases in the study group but never in the control group (0 %). This triad, as indicator of opioid-related deaths, had a specificity of 100 %, as confirmed by autopsy and toxicological analysis. CONCLUSIONS Frequent findings in cases of fatal opioid intoxication were demonstrated. The triad of brain oedema, lung oedema and a distended urinary bladder on PMCT was highly specific for drug-associated cases of death. KEY POINTS Frequent findings in cases of fatal opioid intoxication were investigated. Lung oedema, brain oedema and full urinary bladder represent a highly specific constellation. This combination of findings in post-mortem CT should raise suspicion of intoxication.

Accuracy of computed tomography angiography in the detection of pulmonary embolism in patients with high body weight

BACKGROUND The accuracy of CT pulmonary angiography (CTPA) in detecting or excluding pulmonary embolism has not yet been assessed in patients with high body weight (BW). METHODS This retrospective study involved CTPAs of 114 patients weighing 75-99 kg and those of 123 consecutive patients weighing 100-150 kg. Three independent blinded radiologists analyzed all examinations in randomized order. Readers' data on pulmonary emboli were compared with a composite reference standard, comprising clinical probability, reference CTPA result, additional imaging when performed and 90-day follow-up. Results in both BW groups and in two body mass index (BMI) groups (BMI <30 kg/m(2) and BMI ≥ 30 kg/m(2), i.e., non-obese and obese patients) were compared. RESULTS The prevalence of pulmonary embolism was not significantly different in the BW groups (P=1.0). The reference CTPA result was positive in 23 of 114 patients in the 75-99 kg group and in 25 of 123 patients in the ≥ 100 kg group, respectively (odds ratio, 0.991; 95% confidence interval, 0.501 to 1.957; P=1.0). No pulmonary embolism-related death or venous thromboembolism occurred during follow-up. The mean accuracy of three readers was 91.5% in the 75-99 kg group and 89.9% in the ≥ 100 kg group (odds ratio, 1.207; 95% confidence interval, 0.451 to 3.255; P=0.495), and 89.9% in non-obese patients and 91.2% in obese patients (odds ratio, 0.853; 95% confidence interval, 0.317 to 2.319; P=0.816). CONCLUSION The diagnostic accuracy of CTPA in patients weighing 75-99 kg or 100-150 kg proved not to be significantly different.

Body Height Estimation from Femur Measurements in Postmortem Computed Tomography

After attending this presentation, attendees will: (1) understand how body height from computed tomography data can be estimated; and, (2) gain knowledge about the accuracy of estimated body height and limitations. The presentation will impact the forensic science community by providing knowledge and competence which will enable attendees to develop formulas for single bones to reconstruct body height using postmortem Computer Tomography (p-CT) data. The estimation of Body Height (BH) is an important component of the identification of corpses and skeletal remains. Stature can be estimated with relative accuracy via the measurement of long bones, such as the femora. Compared to time-consuming maceration procedures, p-CT allows fast and simple measurements of bones. This study undertook four objectives concerning the accuracy of BH estimation via p-CT: (1) accuracy between measurements on native bone and p-CT imaged bone (F1 according to Martin 1914); (2) intra-observer p-CT measurement precision; (3) accuracy between formula-based estimation of the BH and conventional body length measurement during autopsy; and, (4) accuracy of different estimation formulas available.1 In the first step, the accuracy of measurements in the CT compared to those obtained using an osteometric board was evaluated on the basis of eight defleshed femora. Then the femora of 83 female and 144 male corpses of a Swiss population for which p-CTs had been performed, were measured at the Institute of Forensic Medicine in Bern. After two months, 20 individuals were measured again in order to assess the intraobserver error. The mean age of the men was 53±17 years and that of the women was 61±20 years. Additionally, the body length of the corpses was measured conventionally. The mean body length was 176.6±7.2cm for men and 163.6±7.8cm for women. The images that were obtained using a six-slice CT were reconstructed with a slice thickness of 1.25mm. Analysis and measurements of CT images were performed on a multipurpose workstation. As a forensic standard procedure, stature was estimated by means of the regression equations by Penning & Riepert developed on a Southern German population and for comparison, also those referenced by Trotter & Gleser “American White.”2,3 All statistical tests were performed with a statistical software. No significant differences were found between the CT and osteometric board measurements. The double p-CT measurement of 20 individuals resulted in an absolute intra-observer difference of 0.4±0.3mm. For both sexes, the correlation between the body length and the estimated BH using the F1 measurements was highly significant. The correlation coefficient was slightly higher for women. The differences in accuracy of the different formulas were small. While the errors of BH estimation were generally ±4.5–5.0cm, the consideration of age led to an increase in accuracy of a few millimetres to about 1cm. BH estimations according to Penning & Riepert and Trotter & Gleser were slightly more accurate when age-at-death was taken into account.2,3 That way, stature estimations in the group of individuals older than 60 years were improved by about 2.4cm and 3.1cm.2,3 The error of estimation is therefore about a third of the common ±4.7cm error range. Femur measurements in p-CT allow very accurate BH estimations. Estimations according to Penning led to good results that (barely) come closer to the true value than the frequently used formulas by Trotter & Gleser “American White.”2,3 Therefore, the formulas by Penning & Riepert are also validated for this substantial recent Swiss population.

SADMFR Guidelines for the Use of Cone-Beam Computed Tomography/Digital Volume Tomography

In 2011, the first consensus conference on guidelines for the use of cone-beam computed tomography (CBCT) was convened by the Swiss Society of Dentomaxillofacial Radiology (SGDMFR). This conference covered topics of oral and maxillofacial surgery, temporomandibular joint dysfunctions and disorders, and orthodontics. In 2014, a second consensus conference was convened on guidelines for the use of CBCT in endodontics, periodontology, reconstructive dentistry and pediatric dentistry. The guidelines are intended for all dentists in order to facilitate the decision as to when the use of CBCT is justified. As a rule, the use of CBCT is considered restrictive, since radiation protection reasons do not allow its routine use. CBCT should therefore be reserved for complex cases where its application can be expected to provide further information that is relevant to the choice of therapy. In periodontology, sufficient information is usually available from clinical examination and periapical radiographs; in endodontics alternative methods can often be used instead of CBCT; and for implant patients undergoing reconstructive dentistry, CT is of interest for the workflow from implant planning to the superstructure. For pediatric dentistry no application of CBCT is seen for caries diagnosis.

Diagnostic Accuracy of Full-Body Linear X-Ray Scanning in Multiple Trauma Patients in Comparison to Computed Tomography

Purpose: The purpose of this study was to evaluate the diagnostic accuracy of full-body linear X-ray scanning (LS) in multiple trauma patients in comparison to 128-multislice computed tomography (MSCT). Materials and Methods: 106 multiple trauma patients (female: 33; male: 73) were retrospectively included in this study. All patients underwent LS of the whole body, including extremities, and MSCT covering the neck, thorax, abdomen, and pelvis. The diagnostic accuracy of LS for the detection of fractures of the truncal skeleton and pneumothoraces was evaluated in comparison to MSCT by two observers in consensus. Extremity fractures detected by LS were documented. Results: The overall sensitivity of LS was 49.2 %, the specificity was 93.3 %, the positive predictive value was 91 %, and the negative predictive value was 57.5 %. The overall sensitivity for vertebral fractures was 16.7 %, and the specificity was 100 %. The sensitivity was 48.7 % and the specificity 98.2 % for all other fractures. Pneumothoraces were detected in 12 patients by CT, but not by LS. 40 extremity fractures were detected by LS, of which 4 fractures were dislocated, and 2 were fully covered by MSCT. Conclusion: The diagnostic accuracy of LS is limited in the evaluation of acute trauma of the truncal skeleton. LS allows fast whole-body X-ray imaging, and may be valuable for detecting extremity fractures in trauma patients in addition to MSCT. Key Points: • The overall sensitivity of LS for truncal skeleton injuries in multiple-trauma patients was < 50 %.• The diagnostic reference standard MSCT is the preferred and reliable imaging modality.• LS may be valuable for quick detection of extremity fractures. Citation Format: • Jöres APW., Heverhagen JT, Bonél H et al. Diagnostic Accuracy of Full-Body Linear X-Ray Scanning in Multiple Trauma Patients in Comparison to Computed Tomography. Fortschr Röntgenstr 2016; 188: 163 - 171.

Radiopaque stomach contents in postmortem CT in suicidal oral medication intoxication: report of three cases

In clinical medicine, plane radiography is used for detecting the remains of medications in the stomach in oral medication intoxication cases. Since postmortem computed tomography (CT), performed prior to autopsy, is currently intensively entering the forensic routine, the technique was applied to three fatal cases of oral medication intoxication. Here we report CT and autopsy findings for these cases. In all three cases, hyperdense areas within the stomach content were documented. The measurement of Hounsfield Units (HU) beyond 74HU showed mean values of 338, 88 and 98HU. Postmortem CT also showed brain edema and pulmonary aspiration in one case. At autopsy, tablet remains in the stomach were detected microscopically in all three cases. The ex vivo CT scans of the ingested medicaments showed similar HU values. Despite the fact that further case studies are necessary beyond this one, and in spite of its limitations, postmortem CT was found to be a useful screening and documentation method for stomach contents in oral medication intoxication.

Postmortem whole-body computed tomography angiography visualizing vascular rupture in a case of fatal car crash

In addition to the increasingly significant role of multislice computed tomography in forensic pathology, the performance of whole-body computed tomography angiography provides outstanding results. In this case, we were able to detect multiple injuries of the parenchymal organs in the upper abdomen as well as lesions of the brain parenchyma and vasculature of the neck. The radiologic findings showed complete concordance with the autopsy and even supplemented the autopsy findings in areas that are difficult to access via a manual dissection (such as the vasculature of the neck). This case shows how minimally invasive computed tomography angiography can serve as an invaluable adjunct to the classic autopsy procedure.

Optimal sites for orthodontic mini-implant placement assessed by cone beam computed tomography

OBJECTIVES: To determine (1) the optimal sites for mini-implant placement in the maxilla and the mandible based on dimensional mapping of the interradicular spaces and cortical bone thickness and (2) The effect of age and sex on the studied anatomic measurements. MATERIAL AND METHODS: The cone beam computed tomography images of 100 patients (46 males, 54 females) divided into two age groups (13-18 years), and (19-27 years) were used. The following interradicular measurements were performed: (1) Buccolingual bone thickness; (2) Mesiodistal spaces both buccally and palatally/lingually; and (3) Buccal and palatal/lingual cortical thicknesses. RESULTS: In the maxilla, the highest buccolingual thickness existed between first and second molars; the highest mesiodistal buccal/palatal distances were between the second premolar and the first molar. The highest buccal cortical thickness was between the first and second premolars. The highest palatal cortical thickness was between central and lateral incisors. In the mandible, the highest buccolingual and buccal cortical thicknesses were between the first and second molars. The highest mesiodistal buccal distance was between the second premolar and the first molar. The highest mesiodistal lingual distance was between the first and second premolars. The highest lingual cortical thickness was between the canine and the first premolar. The males and the older age group had significantly higher buccolingual, buccal, and palatal cortical thicknesses at specific sites and levels in the maxilla and the mandible. CONCLUSIONS: A clinical guideline for optimal sites for mini-implant placement is suggested. Sex and age affected the anatomic measurements in certain areas in the maxilla and the mandible.

Morphology of the nasopalatine canal and dental implant surgery: a radiographic analysis of 100 consecutive patients using limited cone-beam computed tomography

To analyze the dimensions and anatomic characteristics of the nasopalatine canal and the corresponding buccal bone plate of the alveolar process, using limited cone-beam computed tomography (CBCT) imaging.

Pros and cons of post-mortem CT imaging on aspiration diagnosis

Recently, the field of forensics has experienced a rapid increase in the use of modern cross-sectional imaging in forensic investigations. We examined the value of post-mortem computed tomography (CT) imaging relative to autopsy for distinguishing aspiration into the lungs from airways, from lung alterations due to other causes, and for identifying the aspirated material. We selected 54 bodies submitted to whole-body CT scanning prior to autopsy. All cases had autopsy findings of blood (31 cases), fresh water (12 cases), or gastric content (11 cases) aspiration. The radiological images were retrospectively analyzed for airway and lung aspiration. In all cases, CT imaging detected pulmonary abnormalities suggestive of aspiration. Nevertheless, analysis of the CT images alone was not able to identify the aspirated material or to distinguish pulmonary findings of aspiration from lung changes due to other causes, except for a few cases of hemo-aspiration. However, due to its ability to visualize the entire parenchyma, CT imaging was superior to autopsy in providing additional data about the distribution and severity of the aspiration as well as in detecting small abnormalities. Post-mortem CT imaging should be considered as a superior tool for forensic investigations of aspiration due to its ability to document diagnostic conclusions and to guide the forensic pathologist during lung tissue examination.

Suicidal knife wound to the heart: challenges in reconstructing wound channels with post mortem CT and CT-angiography

We present a case of an individual who stabbed himself through the heart with a large knife. Post mortem computed tomography (CT) and CT-angiography were used to assess the stab channel and to reconstruct the sequence of events. After penetrating injuries to the chest, both the intra-thoracic organs and the injury causing instrument may shift (e.g. from pnemothorax) and render forensic reconstructions more challenging. This case report illustrates the potentials and the pitfalls of CT for the reconstruction of penetrating injures to the chest.