Journal Effects of Dual-Energy Technique on Radiation Exposure and Image Quality in Pediatric Body CT.

Effects of Dual-Energy Technique on Radiation Exposure and Image Quality in Pediatric Body CT.

AJR Am J Roentgenol. 2016 Aug 4:1-10. [Epub ahead of print]
Siegel MJ1, Curtis WA1, Ramirez-Giraldo JC2.
Abstract

OBJECTIVE: The purpose of this study was to assess the effects of dual-energy CT (DECT) on radiation exposure and image quality in pediatric body CT.

MATERIALS AND METHODS: This retrospective study included 79 children (median age, 10.1 years; range, 12 days-18 years) who underwent thoracic or abdominal-pelvic CT or CT angiography with dual-energy technique between October 2014 and March 2015. The delivered volume CT dose index (CTDIvol) from DECT was recorded and compared with the estimated CTDIvol had the patient undergone scanning with a standard single-energy CT (SECT) protocol. Size-specific dose estimates were calculated for both DECT and SECT. Image quality was subjectively scored (scale, 1-4). For 16 of 79 patients who underwent both DECT and SECT, image contrast and noise were measured and contrast-to-noise ratio calculated. Parametric and nonparametric testing of independent and paired samples was performed.

RESULTS: For all 79 studies, actual median CTDIvol and size-specific dose estimate were 3.7 and 5.9 mGy for DECT versus prescanning estimates of 4.4 and 7.7 mGy for SECT, resulting in 12.5% and 11.2% radiation exposure reduction (p < 0.01). Diagnostic image quality was achieved in all patients. In the 16-patient subset, the median CTDIvol values of DECT and SECT were 3.1 and 3.4 mGy (p < 0.05). Median noise was greater with DECT than with SECT (p < 0.01), but the mean contrast-to-noise ratios for the liver and portal vein were similar (liver, p = 0.32; portal vein, p = 0.21).

CONCLUSION: In pediatric body CT, the use of DECT results in radiation exposures comparable to or less than those of SECT while maintaining contrast and contrast-to-noise ratio.

Journal Criteria Low Back Pain

ACR Appropriateness Criteria Low Back Pain.

J Am Coll Radiol. 2016 Sep;13(9):1069-78. doi: 10.1016/j.jacr.2016.06.008. Epub 2016 Aug 3.
Patel ND1, Broderick DF2, Burns J3, Deshmukh TK4, Fries IB5, Harvey HB6, Holly L7, Hunt CH8, Jagadeesan BD9, Kennedy TA10, O'Toole JE11, Perlmutter JS12, Policeni B13, Rosenow JM14, Schroeder JW15, Whitehead MT16, Cornelius RS17, Corey AS18.
Abstract

Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI.

The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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CT Cancer Pediatric

CT Cancer Pediatric

Clinical history of CT Canser pediatric

This 17 year-old cancer patient was referred to Phoenix Children's Hospital for a follow-up CT abdominal scan on the iCT system. The technologist used IMR knowledge-based reconstruction to perform the exam.

with parameters, Image scan parameters

  • 120 kVp
  • 52 mAs/slice
  • 26.4 cms
  • 2.6 second scan time
  • 4.2 mGy CTDIvol
  • 188 mGy x cm DLP
    Left image: iDose<sup>4</sup> reconstruction; Right image: IMR <br />

    Left image: iDose<sup>4</sup> reconstruction; Right image: IMR <br />

    Left image: iDose<sup>4</sup> reconstruction; Right image: IMR

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    Acute stroke , Subdural haematoma (SDH) , Extradural haematoma , Subarachnoid haemorrhage , Cerebral venous sinus thrombosis , Contusions , Skull fractures , Meningitis , Raised intracranial pressure , Hydrocephalus , Abscesses , Arteriovenous malformation , Solitary lesions , Multiple lesions , Self-assessment section , Self Assessment – Answers 
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    abnormal mri brain in meningitis case

    This abnormal mri brain in meningitis case, infection of the meninges, may be suppurative or granulomatous.

    Untitled

    abnormal mri brain images of meningitis with mri, visible in arrow.

    Aseptic Meningitis :

    —All non-bacterial causes of meningitis, Typically less ill appearing than bacterial meningitis, Most common cause is viral, HSV,  type II, Enterovirus (coxsackie, echovirus), Affects all ages, Generally self-limited illness, Other Viral, HIV, Lymphocytic choriomeningitis virus, Arbovirus, Mumps, CMV, EBV, VZV, Adenovirus, Measles, Rubella, Rotavirus, Influenza and parainfluenza, Other infectious, Borrelia burgdorferi, Mycobacterium tuberculosis, Treponema pallidum, Mycoplasma pneumoniae, Rickettsia, erlichia, brucella, Chlamydia, Fungal, Cryptococcus, Coccidiodes, Histoplasmosis, Parasitic, Angiostrongylus, Toxoplamosis,  Medication, NSAID’s , Bactrim, Pyridium, Malignancy, Lymphoma and leukemia, Malignancy, Lymphoma and leukemia, Metastatic carcinoma, Autoimmune, Sarcoid, Behcet’s, SLE

    abnormal mri brain meningitis

    abnormal mri brain meningitis 2

    abnormal mri brain in meningitis case.

    abnormal mri brain

    abnormal mri brain Neonatal meningitis

    —Leading cause of newborn meningitis in developed countries

    —Best diagnostic clue: Meningoencephalitis in anewborn

    abnormal mri brain meningitis 2

    the images of abnormal mri brain.

    abnormal mri brain neonatal.

    abnormal mri brain meningitis 2

    abnormal mri brain meningitis 2

    abnormal mri brain IN MENINGITIS CASE.

    abnormal mri brain Intracranial Empyema

    Abnormal mri brain Subdural empyema l

    Ø collection of pus between dura and leptomeninges

    Øas a complication of meningitis, paranasal sinusitis, otitis media, osteomyelitis, or a penetrating wound of the skull

    Ø Frontal sinusitis is the most common cause

    Ø Route: retrograde fashion through a dural sinus or through bridging veins

    Ø even when small, usually cause focal neurologic deficits

    Ø considered a neuro-surgical emergency because of its progressive clinical course.

    ØDespite recent improvement in surgical technique and antibiotics, mortality remains high (25% to 40%).

    ØComplications :venous thrombosis and infarction

    abnormal mri brain meningitis 2

    hypodense or isodense crescentic or lenticular area adjacent to the inner table of the skull CECT and enhancement of the medial rim may be seen

    abnormal mri brain meningitis 2

    abnormal mri brain, Enhancement of the margin of the empyema is characteristic better visualized with MRI than with CT

    Abnormal mri brain of the empyema

    abnormal mri brain Herpes encephalitis

    Herpes simplex encephalitis

    —most common endemic encephalitis in the USA (2 per million) and causes 10-20% of all viral encephalitis.

    —Early diagnosis is important because AV therapy can decrease mortality and morbidity.

    —HSV1 causes 95% of HSE. Most commonly occurs due to virus reactivation. HSV2 causes 80-90% of neonatal encephalitis

    Source: Panagaria A. Neurol In. 49:360; 2001.

    §Definitive diagnosis: PCR, intrathecal antibodies, brain biopsy – take time and may be false negative in early disease [1].

    §Imaging helps in establishing an early diagnosis.

    source > Akyldz BN Paeditr Emerg Care 24;377 :2008.

    — Usually bilateral

    — Hemorrhage and enhancement seen

    — Basal ganglia tend to be spared or involved in contiguity with the TL.

    — Pons may be involved [Tien AJR:161,1993]

    MR is more sensitive and shows lesions earlier than CT or SPECT,

    abnormal mri brain

    abnormal mri brain

    abnormal mri brain

    Abnormal mri brain Of Herphes

    abnormal mri brain

    abnormal mri brain Epidural Empyema

    —collection of pus between the dura and calvaria,

    — complication of otitis media, mastoiditis, sinusitis, or osteomyelitis of the skull.

    — not as toxic as that with subdural empyema.

    —Displacement of the falx and dural sinuses away from the inner table of the skull, an important and useful sign indicating the epidural location of a collection

    image

    > T2-weighted MR images , A hypointense rim, representing inflamed dura, in an epidural, but not a subdural, empyema

    >, epidural empyema may extend into the subgaleal space through emissary veins or adjacent

    > Epidural empyema, like epidural hematoma, can across the midline but is limited by the sutures

    >  In contrast, a subdural collection of any kind cannot cross the midline but is not limited by the sutures

    abnormal mri brain

    abnormal mri brain EPIDURAL EMPYEMA

    abnormal mri brain HSV

    — Both HSV1 and 2 are commonly prevalent in Indian population. (Mixed=83%, HSV1=10%, HSV2=1%) [1]

    — HSV2 along with TORCH agents are major causes of neonatal encephalitis.

    — Infections result from maternal birth canal or transplacental spread

    — Unlike HSV1, HSV2 infection in neonates is diffuse.

    HSV 2:

    — Imaging findings are nonspecific.

    — CT scans in early disease may be negative or show subtle areas of low density

    — Conventional MR and DWI show lesions better.

    — Lesions may be multifocal involving almost any area of brain or limited to temporal lobes brainstem and cerebellum.

    — Watershed infarcts may be seen

    —  In-utero infections can result in microcephaly, encephalomalacia or calcification.

    sOURCE )Vossough.2008. Neuroradiol 50:355

    abnormal mri brain

    Axial T1WI MR shows diffuse cystic encephalomalacia and prominent CSF-containing spaces

     

    abnormal mri brain

    Axial T2WI MR shows areas of high signal in frontal lobes WM due to acute H5V-2

    abnormal mri brain

    abnormal mri brain HSV 1 AND HSV2

    abnormal mri brain HIV Encephalitis

    1. —Syndrome of cognitive, behavioral, and motor abnormalities attributed to direct HIV effect on brain, in the absence of opportunistic brain infections.
    2. —Location: Bilateral periventricular and centrum semiovale WM, basal ganglia, cerebellum, brainstem

      Best diagnostic clue: Combination of atrophy and symmetric, periventricular or diffuse white matter (WM) disease suggests HIVE)

      abnormal mri brain

      abnormal mri brain

      Abnormal mri brain, HIV

    abnormal mri brain Japanese encephalitis

    1. — mosquito borne Flaviviral encephalitis.
    2. —  Pigs and heron like birds are main amplifiers.
    3. — leading cause of acute meningoencephalitis affecting children and adults in the world.
    4. — JE is endemic to Indian subcontinent, particularly in the NE state of Assam
    5. — Epidemics occur in the summer rainy season which favor breeding of mosquitoes.
    6. — First recognized in India in 1955, Epidemics occur every year in several Indian states since the first in WB(1973).
    7. — Lesions of JE are most commonly seen in the thalami and substantia nigra,
    8. — Basal ganglia, cerebral cortex, hippocampi, midbrain, pons, medulla and cerebellum lesions are also seen.
    9. — Lesions hyperintense on T2 and FL and iso to hypo on T1 with local or generalized brain swelling.
    10. — No enhancement.
    11. — Hemorrhagic change has been reported from India.
    12. — MRI is the investigation of choice with reported sensitivity of 89-100% compared to CT (38-55%) .
    13. — DWI has been reported to help in early diagnosis and in assessing temporal evolution of lesions
    14. —  Was helpful in making an early diagnosis in JE showing additional lesions
    15. abnormal mri brainabnormal mri brain

    abnormal mri brain Japanese encephalitis.

    abnormal mri brain Dengue

    1. —Dengue is caused by a mosquito borne flavivirus like JE. Neurologic manifestations in dengue fever, hemorrhagic fever and Shock syndrome have been thought to be due to encephalopathy
    2. —Recent reports have shown that dengue virus can cause neuroinvasion and encephalitis
    3. Lum. Am J Trop Med Hyg. 1996;54:256 (2) Muzaffar. Sing Med J 2006;47:975abnormal mri brain

    Abnormal mri brain DENGUE

    abnormal mri brain Rabies encephalitis

    1. —Transmitted by bites of infected animals or by transplants. 100% fatal.
    2. —In India rabies occurs in all parts of the country except in Lakshadweep, Andaman and Nicobar islands.
    3. abnormal mri brain

    abnormal mri brain Rabies encephalitis

    abnormal mri brain “Nipah virus encephalitis”

    1. —MR shows fairly characteristic findings with small T2 hyperintense white or gray matter lesions with transient T1 hyperintense punctate cortical lesions in subacute phase.
    2. Source (1) Lim. Radiol 2002;222:219abnormal mri brain
    3. —paramyxovirus spread to man from fruit-bats or pigs infected by fruit-bats.
    4. — Subsequent spread from man to man occurs.
    5. —First identified in Malaysia and Singapore in 1988-89, outbreaks have occurred in Bangladesh (2001-4,5)and Siliguri (2001). Case fatality in India and Bangladesh was 75%.
    6. Source :(1) Halder. Ann Ind Acad Neurol 2006;9:137Abnormal mri brain Emerging viruses.

    abnormal mri brain Progressive Multifocal Leukoencephalopathy

    • —CT scans low-density lesions in white matter.
    • — Early involvement -asymmetrical pattern,
    • —later disease -symmetrical and diffusely confluent.
    • —Contrast enhancement is usually absent but may occur.[155.
    • —MRI shows a focal region of hypointensity in the white matter on T1-weighted images and hyperintensity on T2-weighted images
    • —. Involvement of the subcortical U-fiber is characteristic for PML, as opposed to other HIV- related encephalopathy.
    • . MRI is more sensitive than CT in detecting abnormalities.
    • abnormal mri brain
    • abnormal mri brain Progressive Multifocal

    abnormal mri brain Cytomegalovirus Encephalitis

    • —affect the immunocompetent as well as immunocompromised patients
    • —cause meningoencephalitis or subacute encephalitis.
    • —CMV can produce demyelination and necrosis within the white matter.
    • —CMV is the most frequent cause of fetal and neonatal viral infection.
    • —calcifications are usually in the subependymal region, whereas in infants with toxoplasmosis, calcifications are seen everywhere, including the periventricular region.
    • — CT scans show low density in the white matter, which may or may not enhance with contrast agents
    • —. MRI shows high signal intensity in the white matter on T2-weighted and FLAIR images and is more sensitive than CT in detecting leukoencephalitis
    • abnormal mri brain

      Nonenhanced CT scans in a newborn show periventricular calcification and ventricular dilatation

      abnormal mri brain, Cytomegalovirus

    abnormal mri brain stages in the evolution of cerebral abscess

    • —Early abscess (at 10 to 14 days). Formation of a collagenous capsule by fibroblasts is seen. The central necrotic area is liquefied. Surrounding edema persists.
      Mature abscess (after 14 days). A decrease in surrounding edema
    • —gliotic reaction at outer margin of the abscess capsule.
    • abnormal mri brain

    abnormal mri brain of abscess >> The wall of the mature abscess consists of three layers: (1) an inner inflammatory layer of granulation tissue containing macrophages, (2) a middle collagenous layer, and (3) an outer gliotic layer

    abnormal mri brain Cerebritis and Abscess

    • —most brain abscesses are bacterial
    • — streptococci accounting for the majority
    • —haematogenous dissemination, penetrating trauma or direct spread
    • — Blood-borne infection can occur anywhere in the brain, but has a predilection for the territory of the middle cerebral arteries
    • —fever ,headache and focal neurological deficits. Brain abscesses are multiple in 10–50 per
    • stages in the evolution of cerebral abscess.
    • —there are four stages
    • —1. Acute cerebritis (the first 4 to 5 days).
    • In early cerebritis, mild central nodular enhancement may be seen on contrast-enhanced CT or MRI scans
    • abnormal mri brain
    • abnormal mri brain

    2. Late cerebritis (at 7 to 10 days). In the late cerebritis stage brain enhancement on CT scans

    abnormal mri brain

    abnormal mri brain Late cerebritis. A, Gadolinium-enhanced MRI study shows thick, smooth, ringlike enhancement with surrounding edema. B, Gadolinium-enhanced MRI study (coronal view) shows a second small, adjacent ringlike enhancement.

    stages in the evolution of cerebral abscess

    —3. Early abscess (at 10 to 14 days). Formation of a collagenous capsule by fibroblasts is seen. The central necrotic area is liquefied. Surrounding edema persists.
    4. Mature abscess (after 14 days). A decrease in surrounding edema

    —gliotic reaction at outer margin of the abscess capsule.

    abnormal mri brain

    abnormal mri brain

    Abscess treated conservatively with antibiotics

    abnormal mri brain

    • Abscess caused by gas-forming organism
    • —The most distinctive feature of abscess on imaging is the presence of a smooth, thin capsule with a moderate amount of cerebral edema.
    • — It is located at the corticomedullary junction and usually extends into the white matter.
    • —Nonenhanced CT scans show a low-density area with mass effect and compression of the ventricular system.
    • — rupture of the abscess into an adjacent ventricle {medially into the ventricular system because the medial wall is thinner than the lateral wall

    Abnormal mri brain Abscess

    abnormal mri brain “Differential diagnosis”

    — necrotic primary brain tumor, cystic metastatic tumor, infarction, resolving hematoma, cysticercosis, and thrombosed aneurysm.

    image

    • Infarcts often show gyral enhancement, occasionally mimicking ring enhancementThe MRI differential diagnosis of abscess is similar to the CT diagnosis except for hematomas,
    • which can be recognized by their characteristic MRI signal intensity patterns, depending on the age of the hematomas

    abnormal mri brain Ependymitis

    • —Ventriculitis, or ependymitis, is an inflammation of the ependymal lining of the ventricular system
    • —\rupture of periventricular abscess or from retrograde spread of infection from the basal cisterns by way of the fourth ventricle
    • —Hydrocephalus may result from intraventricular adhesions and septation caused by organization of intraventricular exudate and debris, resulting in blockage of the interventricular foramina.
    • — A trapped fourth ventricle may result from obstruction of its outlets and the aqueduct because of ependymitis

    abnormal mri brain

    abnormal mri brain

    Gadolinium-enhanced MRI studies show thin, smooth ependymal enhancement in an AIDS patient with cytomegalovirus ependymitis

    —The differential diagnosis on CT and MRI studies includes ependymal seeding of intracranial neoplasm. The ependymal enhancement may be irregular or nodular if it is secondary to seeding of neoplasm, the clinical history may be helpful in arriving at the correct diagnosis. see below images.

    abnormal mri brain

    RADIOLOGY-INFORMATION.BLOGSPOT.COM > Abnormal mri brain Ependymitis

    Chest X Ray Imaging