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Pitfalls and Pearls of Imaging Non-traumatic Thoracic Aortic Disease

Shmukler, Anna; Alis, Jonathan; Patel, Smita; Latson, Larry; Ko, Jane P
Imaging of the thoracic aorta is a common request in both the acute and outpatient settings, playing a crucial role in diagnosis and treatment planning of aortic disease. The findings of aortic pathology may be obvious or occult on imaging. Recognizing subtle changes is essential and may lead to early detection and prevention of serious morbidity and mortality. Knowledge of the anatomy and understanding the pathophysiology of aortic disease, as well as selecting the appropriate imaging modality and protocol will enable prompt diagnosis and early intervention of aortic pathology. Currently, computed tomography angiography and magnetic resonance angiography of the aorta are the most commonly used imaging modalities to evaluate the aorta. This review focuses on a spectrum of aortic pathology manifestations on computed tomography and magnetic resonance, including atherosclerosis and acute aortic syndromes, highlighting diagnostic challenges and approaches to aid in image interpretation.
PMID: 35688532
ISSN: 1558-5034
CID: 5248572

A Retrospective Multi-Site Academic Center Analysis of Pneumothorax and Associated Risk Factors after CT-Guided Percutaneous Lung Biopsy

Rong, Esther; Hirschl, David A; Zalta, Benjamin; Shmukler, Anna; Krausz, Steven; Levsky, Jeffrey M; Lin, Juan; Haramati, Linda B; Gohari, Arash
PURPOSE/OBJECTIVE:To assess the risk factors, incidence and significance of pneumothorax in patients undergoing CT-guided lung biopsy. METHODS:Patients who underwent a CT-guided lung biopsy between August 10, 2010 and September 19, 2016 were retrospectively identified. Imaging was assessed for immediate and delayed pneumothorax. Records were reviewed for presence of risk factors and the frequency of complications requiring chest tube placement. 604 patients were identified. Patients who underwent chest wall biopsy (39) or had incomplete data (9) were excluded. RESULTS:Of 556 patients (average age 66 years, 50.2% women) 26.3% (146/556) had an immediate pneumothorax and 2.7% (15/556) required chest tube placement. 297/410 patients without pneumothorax had a delayed chest X-ray. Pneumothorax developed in 1% (3/297); one patient required chest tube placement. Pneumothorax risk was associated with smaller lesion sizes (OR 0.998; 95% CI (0.997, 0.999); [p = 0.002]) and longer intrapulmonary needle traversal (OR 1.055; 95% CI (1.033, 1.077); [p < 0.001]). Previous ipsilateral lung surgery (OR 0.12; 95% CI (0.031, 0.468); [p = 0.002]) and longer needle traversal through subcutaneous tissue (OR 0.976; 95% CI (0.96, 0.992); [p = 0.0034]) were protective of pneumothorax. History of lung cancer, biopsy technique, and smoking history were not significantly associated with pneumothorax risk. CONCLUSION/CONCLUSIONS:Delayed pneumothorax after CT-guided lung biopsy is rare, developing in 1% of our cohort. Pneumothorax is associated with smaller lesion size and longer intrapulmonary needle traversal. Previous ipsilateral lung surgery and longer needle traversal through subcutaneous tissues are protective of pneumothorax. Stratifying patients based on pneumothorax risk may safely obviate standard post-biopsy delayed chest radiographs.
PMID: 33876295
ISSN: 1432-1750
CID: 4875772

Cracking the Opium Den: Cardiothoracic Manifestations of Drug Abuse

Blinick, Rachel; Chaya, Nathan; Zalta, Benjamin; Haramati, Linda B; Shmukler, Anna
Recreational drug use is increasing worldwide, with emergency room visits and total deaths from drug overdose rising in recent years. Complications from prescription and recreational drug use may result from the biochemical effects of the drugs themselves, impurities mixed with substances, or from causes related to the method of drug administration. The presentation of drug overdose may be complex due to multisubstance abuse, including cigarette smoking and alcoholism, and can impact any organ system. Patients may present without history, and radiologists may be the first clinicians to suggest the diagnosis. We aim to explore the cardiothoracic manifestations of drug abuse and their multimodality imaging manifestations.
PMID: 32102017
ISSN: 1536-0237
CID: 4368132

Utility of Apical Lung Assessment on Computed Tomography Angiography as a COVID-19 Screen in Acute Stroke

Esenwa, Charles; Lee, Ji-Ae; Nisar, Taha; Shmukler, Anna; Goldman, Inessa; Zampolin, Richard; Hsu, Kevin; Labovitz, Daniel; Altschul, David; Haramati, Linda B
BACKGROUND AND PURPOSE:Evaluation of the lung apices using computed tomography angiography of the head and neck during acute ischemic stroke (AIS) can provide the first objective opportunity to screen for coronavirus disease 2019 (COVID-19). METHODS:We performed an analysis assessing the utility of apical lung exam on computed tomography angiography for COVID-19-specific lung findings in 57 patients presenting with AIS. We measured the diagnostic accuracy of apical lung assessment alone and in combination with patient-reported symptoms and incorporate both to propose a COVID-19 era AIS algorithm. RESULTS:Apical lung assessment when used in isolation, yielded a sensitivity of 0.67, specificity of 0.93, positive predictive value of 0.19, negative predictive value of 0.99, and accuracy of 0.92 for the diagnosis of COVID-19, in patients presenting to the hospital for AIS. When combined with self-reported clinical symptoms of cough or shortness of breath, sensitivity of apical lung assessment improved to 0.83. CONCLUSIONS:Apical lung assessment on computed tomography angiography is an accurate screening tool for COVID-19 and can serve as part of a combined screening approach in AIS.
PMID: 33115325
ISSN: 1524-4628
CID: 5443192

Effectiveness of Lung-RADS in Reducing False-Positive Results in a Diverse, Underserved, Urban Lung Cancer Screening Cohort

Kaminetzky, Mark; Milch, Hannah S; Shmukler, Anna; Kessler, Abraham; Peng, Robert; Mardakhaev, Edward; Bellin, Eran Y; Levsky, Jeffrey M; Haramati, Linda B
PURPOSE/OBJECTIVE:) was created to standardize lung cancer screening CT reporting and recommendations but has not been well validated prospectively in clinical practice. The aim of this study was to determine the effectiveness of lung cancer screening using Lung-RADS in a diverse, underserved, academic clinical screening program, focusing on whether Lung-RADS would successfully reduce the 23.3% false-positive rate found in the National Lung Screening Trial. METHODS:Institutional review board approval was obtained to study the clinical lung cancer screening cohort. Low-dose CT results were prospectively assigned a Lung-RADS or equivalent score. The proportion of examinations in each Lung-RADS category and the corresponding lung cancer rate, subsequent imaging, interventions, mortality, and compliance were tracked. The National Death Index was queried for follow-up losses. RESULTS:The cohort comprised 1,181 patients with 2,270 person-years of follow-up from December 2012 to December 2016. The mean age was 64 ± 16.2 years, with 51% women, 63% nonwhite, 71% current smokers, 69% overweight and obese, and multiple comorbidities. The Lung-RADS false-positive rate was 10.4% (95% confidence interval, 8.8%-12.3%). Baseline CT results were negative in 87% (n = 1,031): for Lung-RADS 1, the lung cancer rate was 0.2%, and for Lung-RADS 2, the cancer rate was 0.5%. Positive baseline examinations were Lung-RADS 3 in 10% (n = 119), 4a in 1.2% (n = 14), and 4b in 1.5% (n = 18). Corresponding cancer rates were 3.4%, 43%, and 83%, respectively. Lung cancer prevalence was 2.1%. Mortality was 40% in patients with lung cancer versus 2.5% in the remaining cohort (P < .001). Fifty-four percent of patients were overdue for first annual examinations. Eighty-four percent of patients (n = 989) had follow-up verified via electronic records or personal contact, and the remainder had vital status ascertained via the National Death Index. CONCLUSIONS:Lung cancer screening using Lung-RADS was effective in reducing the false-positive rate compared with the National Lung Screening Trial in a diverse and underserved urban population.
PMID: 30146484
ISSN: 1558-349x
CID: 4368122

Ventricular Myocardial Fat: An Unexpected Biomarker for Long-term Survival?

Bader, Anna S; Levsky, Jeffrey M; Zalta, Benjamin A; Shmukler, Anna; Gohari, Arash; Jain, Vineet R; Chernyak, Victoria; Lovihayeem, Michael; Bellin, Eran Y; Haramati, Linda B
PURPOSE/OBJECTIVE:To examine the association between myocardial fat, a poorly understood finding frequently observed on non-contrast CT, and all-cause mortality in patients with and without a history of prior MI. MATERIALS AND METHODS/METHODS:A retrospective cohort from a diverse urban academic center was derived from chronic myocardial infarction (MI) patients (n = 265) and three age-matched patients without MI (n = 690) who underwent non-contrast chest CT between 1 January 2005-31 December 2008. CT images were reviewed for left and right ventricular fat. Electronic records identified clinical variables. Kaplan-Meier and Cox proportional hazard analyses assessed the association between myocardial fat and all-cause mortality. The net reclassification improvement assessed the utility of adding myocardial fat to traditional risk prediction models. RESULTS:Mortality was 40.1% for the no MI and 71.7% for the MI groups (median follow-up, 6.8 years; mean age, 73.7 ± 10.6 years). In the no MI group, 25.7% had LV and 49.9% RV fat. In the MI group, 32.8% had LV and 42.3% RV fat. LV and RV fat was highly associated (OR 5.3, p < 0.001). Ventricular fat was not associated with cardiovascular risk factors. Myocardial fat was associated with a reduction in the adjusted hazard of death for both the no MI (25%, p = 0.04) and the MI group (31%, p = 0.018). Myocardial fat resulted in the correct reclassification of 22% for the no MI group versus the Charlson score or calcium score (p = 0.004) and 47% for the MI group versus the Charlson score (p = 0.0006). CONCLUSIONS:Patients with myocardial fat have better survival, regardless of MI status, suggesting that myocardial fat is a beneficial biomarker and may improve risk stratification. KEY POINTS/CONCLUSIONS:• Myocardial fat is commonly found on chest CT, yet is poorly understood • Myocardial fat is associated with better survival in patients with and without prior MI and is not associated with traditional cardiovascular risk factors • This finding may provide clinically meaningful prognostic value in the risk stratification of patients.
PMID: 29948081
ISSN: 1432-1084
CID: 4368112

Navigating the Pulmonary Perfusion Map: Dual-Energy Computed Tomography in Acute Pulmonary Embolism

Alis, Jonathan; Latson, Larry A; Haramati, Linda B; Shmukler, Anna
Pulmonary embolism is the third most common acute cardiovascular disease. Dual-energy computed tomography perfusion imaging is a promising adjunct in the detection of acute PE providing simultaneous functional assessment of pulmonary perfusion alongside the high-resolution morphological information from computed tomography pulmonary angiography. We review the evidence to date and common causes of perfusion defects including artifacts, parenchymal, and vascular causes, and discuss its potential in furthering our understanding of physiology and pathophysiology in acute pulmonary embolism.
PMID: 30371612
ISSN: 1532-3145
CID: 3401022

Patent foramen ovale in patients with pulmonary embolism: A prognostic factor on CT pulmonary angiography?

Zhang, Meng; Tan, Stephanie; Patel, Vishal; Zalta, Benjamin A; Shmukler, Anna; Levsky, Jeffrey M; Jain, Vineet R; Shaban, Nada M; Haramati, Linda B
BACKGROUND:Patent foramen ovale (PFO) in patients with acute pulmonary embolism (PE) represents a risk factor for mortality, but this has not been evaluated for CT pulmonary angiography (CTPA). The purpose of the present study was to assess the relationship between PFO and mortality in patients with acute PE diagnosed on CTPA. MATERIALS AND METHODS/METHODS:This retrospective study included 268 adults [173 women, mean age 61 (range 22-98) years] diagnosed with acute PE on non-ECG-gated 64-slice CTPA in 2012 at our medical center. The images were reviewed for PFO by a panel of cardiothoracic radiologists with an average of 11 years of experience (range 1-25 years). CT signs of right heart strain and PE level were noted. Transthoracic echocardiograms (TTE), when available (n = 207), were reviewed for PFO by a cardiologist with subspecialty training in advanced imaging and with 3 years of experience. The main outcome was 30-day mortality. Fischer's exact test was utilized to compare mortality. RESULTS:PFO prevalence on CTPA was 22% (58/268) and 4% (9/207) on TTE. Overall 30-day mortality was 6% (16/268), 9% (5/58) for patients with PFO and 5% (11/210) for those without (p = 0.35). CT signs of right heart strain trended with higher mortality, but statistically significant only for hepatic vein contrast reflux [14% (6/44) vs 4% (10/224), p = 0.03]; right ventricular (RV) to left ventricular (LV) diameter ratio >1 [8% (13/156) vs RV:LV ≤ 1 3% (3/112), p = 0.07], septal bowing [10% (4/42) vs without 5% (12/226), p = 0.30]. CONCLUSION/CONCLUSIONS:PFO was demonstrated on CTPA in a proportion similar to the known population prevalence, while routine TTE was less sensitive. Mortality was non-significantly higher in patients with acute PE and PFO in this moderate-sized study. A larger study to answer this clinically important question is worthwhile.
PMID: 29217343
ISSN: 1876-861x
CID: 4368102

False-Positive Ventilation-Perfusion Studies Due to Nonembolic Pulmonary Artery Compromise [Case Report]

Alis, Jonathan; Hulkower, Miriam; Shmukler, Anna; Chun, Kwang J; Freeman, Leonard M
Ventilation/perfusion (V/Q) scans are highly sensitive in detecting clinically significant pulmonary embolisms; however, V/Q mismatches are not specific to pulmonary embolism alone, and other etiologies can cause false-positive results. We present 3 cases where the pulmonary vasculature was compromised, from either intraluminal narrowing or external compression, with resultant mismatches. This raises the importance of interpreting V/Q scan results in conjunction with a thorough medical/surgical history and careful analysis of the chest radiograph.
PMID: 28825949
ISSN: 1536-0229
CID: 4368092

Rosai-Dorfman disease of the lung with features of obliterative arteritis

Mantilla, Jose G.; Shmukler, Anna; Wang, Yanhua
Sinus histiocytosis with massive lymphadenopathy, also known as Rosai-Dorfman disease (RDD), is a rare benign non-Langerhans cell histiocytosis. Twenty-five to forty percent of the cases are extranodal and have been reported in virtually all anatomic locations. In this article, we report a highly unusual case of RDD which presented as multiple pulmonary nodules and associated hilar lymphadenopathy. On resection, extensive obliterative arteritis was noticed. This pathologic presentation of RDD has not been reported before in the English literature. Accurate recognition of this entity is crucial to prevent unnecessary aggressive treatment.
ISSN: 1865-5785
CID: 5486742