B.M. Fox

Computed tomography of the brain in acute carbon monoxide poisoning

Of 107 patients admitted to the South Western Hyperbaric Medical Centre with acute carbon monoxide poisoning for hyperbaric oxygen therapy 19 had cerebral imaging performed: 17 patients had CT, one patient had MRI and CT and one patient MRI alone. The role of brain CT is established in determining the prognosis from acute carbon monoxide poisoning. Brain imaging was indicated because of unconsciousness on admission and failure or delayed improvement in neurological status after initiation of hyperbaric oxygen therapy. Of the 18 patients who underwent brain CT, seven were found to have the characteristic changes of bilateral low attenuation areas within the globus pallidus and six had low attenuation changes within cerebral white matter. In two patients there were both globus pallidus and cerebral white matter changes. Out of the total of the 19 patients who were studied, four patients died, 10 recovered fully and five had variable disabilities ranging from short term memory loss to more severe cognitive impairment and physical disability. The role of CT and the practicalities of hyperbaric oxygen therapy for acute carbon monoxide poisoning are discussed in the light of the experience from a regional dedicated medical diving centre.

Imaging features of ductal plate malformations in adults

Ductal plate malformations, also known as fibrocystic liver diseases, are a group of congenital disorders resulting from abnormal embryogenesis of the biliary ductal system. The abnormalities include choledochal cyst, Carolis disease and Carolis syndrome, adult autosomal dominant polycystic liver disease, and biliary hamartoma. The hepatic lesions can be associated with renal anomalies such as autosomal recessive polycystic kidney disease (ARPKD), medullary sponge kidney, and nephronophthisis. A clear knowledge of the embryology and pathogenesis of the ductal plate is central to the understanding of the characteristic imaging appearances of these complex disorders. Accurate diagnosis of ductal plate malformations is important to direct appropriate clinical management and prevent misdiagnosis.

Azygos reflux : a CT sign of cardiac tamponade

Three patients who were investigated with dynamic contrast medium enhanced computed tomography (CT) of the thorax were noted to have pericardial effusions with reflux of contrast medium back along the azygos vein. The diagnosis of cardiac tamponade was not made clinically, but in each case was suggested from the CT findings. Confirmation of the diagnosis was made in all three cases, two patients with echocardiography and one at post mortem. One patient made a rapid recovery following the insertion of a pericardial drain, another made a temporary recovery after pericardiocentesis but the third died. Thirty CT scans performed with similar protocol were reviewed and none of these demonstrated reflux along the azygos vein. The presence of contrast medium refluxing into the azygos vein implies significant haemodynamic disturbance, and in the presence of a pericardial effusion suggests the diagnosis of cardiac tamponade.

PET/CT in anal cancer — is it worth doing?

AIM To evaluate the role of 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/ computed tomography (CT) in the current multidisciplinary management of anal cancer, both in initial staging and in follow-up post-treatment. MATERIALS AND METHODS All patients referred to the region-wide multidisciplinary meeting for anal cancer during the study period received PET/CT imaging in addition to conventional imaging [CT and magnetic resonance imaging (MRI)]. Whether PET/CT altered the stage of the tumour from that suggested by conventional imaging was retrospectively assessed. The effect on management was evaluated. RESULTS Fifty PET/CT examinations were performed on 44 patients with anal cancer. Thirty were part of initial staging, and 20 were post-chemo/radiotherapy or surgery. Two PET/CTs produced inadequate contemporaneous conventional imaging to allow comparison. Overall PET/CT increased the stage of the anal cancer in 17% of cases (8/48), decreased the stage in 19% (9/48), and did not alter the stage in 65% (31/48). The tumour stage was altered more frequently in initial staging than in follow up imaging. The PET/CT findings altered patient management in 29% (14/48) of cases. The majority (11) of these were cases in which PET/CT was used as part of initial staging. CONCLUSION PET/CT alters the initial staging sufficiently frequently that it should be used routinely in anal cancer, where it is available. The role of PET/CT in the follow-up of anal cancer is not as clear. Routine follow-up with PET/CT may not be justified, but selected use is of definite benefit in problem solving or if salvage surgery is planned, after multidisciplinary discussion.

Imaging features of therapeutic drug-induced musculoskeletal abnormalities.

Increasing use of a wide variety of therapeutic drugs with known musculoskeletal side-effect profiles necessitates a rigorous understanding and approach when evaluating imaging features suggestive of drug-induced musculoskeletal abnormalities. The etiology of such abnormalities is diverse, and the clinical and imaging manifestations may be nonspecific. The recognition of adverse effects depends, first, on the physicians vigilant review of clinical information for relevant drug history and indicative signs, and second, on the radiologists ability to detect musculoskeletal changes consistent with known potential effects of specific drugs. Musculoskeletal abnormalities induced by therapeutic drugs may be broadly categorized as embryopathic, juvenile, or postmaturation. Embryopathic skeletal abnormalities result from the teratogenic effects of drugs administered to pregnant women (eg, thalidomide, anticonvulsants). Other therapeutic agents characteristically lead to abnormalities during postnatal skeletal maturation (eg, high-dose vitamins or prostaglandin) either because they are used exclusively in children or because they have idiosyncratic effects on immature musculoskeletal structures. Many drugs (eg, statins) may have musculoskeletal side effects that, although independent of the stage of skeletal maturation, are most often seen in adults or elderly people because they are commonly prescribed for people in these age groups. Drug-induced musculoskeletal abnormalities may be further characterized according to the predominant skeletal manifestations as osteomalacic, proliferative, or osteoporotic and according to the involvement of soft tissues as musculotendinous or chondral.

The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease

Pancreatic and biliary disease continues to have a significant impact on the workload of the National Health Service (NHS), for which there exists a multimodality approach to investigation and diagnosis. Endoscopic ultrasound (EUS) is fast becoming a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but also because of its valuable role as a problem-solving tool and ever-improving ability in an interventional capacity. We provide a comprehensive review of the benefits of EUS in everyday clinical practice.

Pictorial review: computed tomography features of cardiovascular emergencies and associated imminent decompensation

Multi-detector computed tomography (MDCT) scanner is available in most hospitals and is increasingly being used as the first line imaging in trauma and suspected cardiovascular emergencies, such as acute coronary syndrome, pulmonary artery thrombo-embolism, abdominal aortic aneurysm and acute haemorrhage (Ryan et al. Clin Radiol 60:599–607, 2005). A significant number of these patients are haemodynamically unstable and can rapidly progress into shock and death. Recognition of computed tomography (CT) signs of imminent cardiovascular decompensation will alert the clinical radiologist to the presence of shock. In this review, the imaging findings of cardiovascular emergencies in both acute traumatic and non-traumatic settings with associated signs of imminent decompensation will be described and illustrated.

Value of trainees in a radiology department. A retrospective semi-quantitative analysis.

AIM To examine the productivity (both economic and otherwise) of trainees within a radiology department at our institution. MATERIALS AND METHODS Productivity was measured in three ways: (1) independent workload contribution, (2) impact on on-call services, and (3) impact on day-to-day practice as perceived by consultant radiologists. Data were collected using retrospective searches on computerized radiology information system (CRIS), analysis of trainees and consultant rotas, and a questionnaire to consultants and trainees. Where possible, productivity was quantified in terms of number of programmed activities (PAs). RESULTS The contribution of independent work by trainees in a single week was 52.75 PAs (or 1.45 PAs per trainee per week). In addition, the on-call contribution was 23.1 PAs per week (or 0.93 PAs per trainee per week). When both trainees and consultants report independently, productivity in a single list in most cases increased and can be as much as 197%. On calculating the economic impact, this amounts to significant savings of around £1.2million per year at our institution. CONCLUSION Based upon objectively measurable areas of service provision, the employment of trainees yields considerable economic benefit. Furthermore, based upon qualitative methods we have shown that trainees contribute positively in those areas, which are much harder to quantifiably evaluate. These are benefits in addition to fundamental requirement to train future competent radiologists.