Massimiliano Sperandio

Evaluation with 64-slice CT of the prevalence of coronary artery variants and congenital anomalies: a retrospective study of 3,236 patients

PurposeThis study retrospectively evaluated the prevalence of anatomical coronary artery variants and congenital anomalies in 3,236 patients imaged with 64-slice computed tomography (CT).Materials and methodsOver a period of 4 years, 3,236 patients underwent CT coronary angiography performed with the standard protocol. We assessed coronary artery dominance, presence of the intermediate branch, presence and number of diagonal and marginal branches and coronary anomalies subdivided into anomalies of origin and course, intrinsic anomalies and termination anomalies.ResultsCoronary dominance was right-sided in 88.1% of patients; the intermediate branch was present in 21.3%, the number of diagonal and marginal branches was one to two in >90%, and the number of coronary anomalies was 224 (89 of origin and course, 129 intrinsic anomalies and six termination anomalies).ConclusionsSixty-four-slice CT coronary angiography provides accurate three-dimensional evaluation of the coronary artery tree with correct visualisation of any coronary anomalies, a relatively common finding that had a prevalence of 5.7% in our study population.RiassuntoObiettivo o]Scopo del nostro lavoro è stato valutare con uno studio retrospettivo la prevalenza di varianti anatomiche ed anomalie coronariche in una popolazione di 3236 pazientiMateriali e metodiUn totale di 3236 pazienti è stato sottoposto a tomografia computerizzata (TC)-64 strati delle coronarie in 4 anni, utilizzando il protocollo standard. È stata valutata: la dominanza coronarica, la presenza del ramo intermedio, la presenza e il numero di rami diagonali e marginali, le anomalie coronariche (AC) suddividendole in anomalie di origine e decorso, intrinseche e di terminazione.RisultatiÈ stata riscontrata una dominanza destra nel 88,1% dei casi, il ramo intermedio nel 21,3%, la presenza di 1–2 rami diagonali e marginali in più del 90%, 224 AC (89 di origine e decorso, 129 intrinseche e 6 di terminazione).ConclusioniLa TC volumetrica consente un’accurata valutazione tridimensionale del circolo coronarico con visualizzazione delle anomalie coronariche che rappresentano un reperto relativamente comune nella popolazione con prevalenza del 5,7%.

Diagnostic accuracy of 64-slice CT in evaluating coronary artery bypass grafts and of the native coronary arteries

PurposeOur aim was to evaluate the accuracy, sensitivity and specificity of 64-slice multidetector computed tomography (MDCT) in the assessment of occlusions and stenoses of arterial and venous bypass grafts and disease progression in the native vessels distal to the graft, and to compare the results with those of conventional coronary angiography.Materials and methodsWe enrolled 78 individuals (45 men, 33 women; mean age 59) and evaluated 213 bypass grafts using a 64-slice MDCT scanner. All patients underwent conventional coronary angiography with a mean time interval between the two examinations of 2 days.ResultsOne patient was excluded due to arrhythmia during the examination. The 212 bypass grafts in the remaining 77 patients (98.7%) consisted of 115 (54%) venous grafts and 97 (46%) arterial grafts. In the 115 venous grafts, MDCT showed a sensitivity, specificity and accuracy of 100% in evaluating occluded grafts and a sensitivity of 94.4%, specificity of 98.4% and accuracy of 96.9% in evaluating significant stenoses. In evaluating occluded arterial grafts, sensitivity was 83.3%, specificity 100% and accuracy 98.9%, whereas in evaluating stenoses of arterial grafts, sensitivity was 100%, specificity 97.7% and accuracy 98%.ConclusionsSensitivity, specificity and accuracy in evaluating native coronary vessels distal to the graft allow for a complete assessment of the surgical and native circulation. The examination appears therefore to be exhaustive in ruling out or confirming the presence of diseased vessels in the postoperative follow-up.RiassuntoObiettivoScopo dello studio è valutare l’accuratezza diagnostica, la sensibilità e la specificità della tomografia computerizzata (TC) a 64 strati nella valutazione delle occlusioni e delle stenosi di bypass arteriosi e venosi e dell’eventuale progressione di malattia a carico dei vasi nativi distali all’anastomosi chirurgica, rapportando i risultati ottenuti con i reperti della coronarografia convenzionale (CC).Materiali e metodiSono stati sottoposti a studio con TC 64 strati 78 pazienti (45 maschi, 33 femmine; età media 59 anni) per un totale di 213 bypass (115 innesti venosi e 98 arteriosi). Tutti i pazienti sono andati incontro a CC dopo una media di 2 giorni.RisultatiUn paziente (1,3%) è stato escluso per l’insorgenza di un episodio aritmico durante l’esame. I 212 bypass presi in esame dei rimanenti 77 soggetti (98,7%), erano costituiti da 115 (54%) innesti venosi e 97 (46%) innesti arteriosi. Nei 115 by-pass venosi, la TC ha mostrato una sensibilità, una specificità ed una accuratezza diagnostica del 100% nella valutazione dei bypass occlusi e una sensibilità del 94,4%, una specificità del 98,4% ed un’accuratezza diagnostica del 96,9% nella valutazione delle stenosi significative. Nei bypass arteriosi occlusi, la sensibilità è stata dell’83,3%, la specificità del 100% e l’accuratezza diagnostica del 98,9%, mentre nelle stenosi dei bypass arteriosi, la sensibilità è stata del 100%, la specificità del 97,7% e l’accuratezza diagnostica del 98%.ConclusioniCome dimostrato dai risultati ottenuti, la correttezza delle informazioni fornite dalla TC si avvicina a quelle della CC consentendo una completa valutazione del circolo chirurgico e nativo e risultando completamente esaustivo nell’escludere o confermare la presenza di patologia vasale nel follow-up post-operatorio.

A case of coronary artery fistula visualized by 64-slice multidetector CT.

Background A 27-year-old woman was admitted to hospital with a 1-year history of mild dyspnea.Investigations Physical examination, chest radiography, electrocardiography, transthoracic echocardiography, 64-slice multidetector CT and coronary angiography.Diagnosis Fistula originating from the left anterior coronary artery and draining into the right ventricle, in conjunction with an aneurysm of the left anterior descending artery.Management Surgical closure of the fistula using normothermic cardiopulmonary bypass.

Role of 64-slice cardiac computed tomography in the evaluation of patients with non-ST-elevation acute coronary syndrome

PurposeThis study was done to evaluate the feasibility, sensitivity and specificity of 64-slice computed tomography (CT) in identifying haemodynamically significant (>50%) coronary artery stenoses in patients with suspected acute coronary syndrome (ACS) by correlating the CT findings with the clinical event and data provided by conventional coronary angiography (CCA).Materials and methodsSixty-four patients (38 men and 26 women; mean age 65 years; range±10 years) presenting to our hospital’s emergency department with a clinical suspicion of ACS were studied with 64-slice CT followed by CCA within 24 h of arrival.ResultsTwo patients (3.1%) were excluded from the analysis due to artefacts. Per-patient analysis in the remaining 62 patients identified 24 cases (38.7%) of negative CT findings (no stenoses or stenoses <50%), 35 cases of positive CT findings (56.4%) with identification of the culprit lesion, two cases in which the culprit lesion was not identified and one patient with unconfirmed stenosis. Sensitivity and specificity were 94.6% and 96%, respectively. Per-vessel analysis (186 vessels) revealed 17 non-evaluable vessels (9.1%) due to motion artefacts, 61 vessels (32.8%) with stenosis >50%, seven overestimated vessels (3.7%) due to extensive calcifications, three vessels (1.6%) with underestimated stenosis and 98 vessels (52.6%) without stenosis. Sensitivity and specificity were 95.3% and 93.3%, respectively.ConclusionsIn this type of emergency, coronary CT angiography could lead to considerably lower healthcare costs by identifying patients without coronary disease and allowing immediate discharge without any need for further diagnostic procedures.RiassuntoObiettivoScopo di questo lavoro è stato valutare fattibilità, sensibilità e specificità della tomografia computerizzata (TC)-volumetrica a 64 strati nell’identificazione di stenosi emodinamicamente significative (>50%) delle arterie coronarie in soggetti con sospetta sindrome coronarica acuta (SCA), correlando il reperto TC con l’evento clinico del paziente e confrontando successivamente i dati ottenuti con quelli della coronarografia convenzionale (CC).Materiali e metodiSessantaquattro pazienti (38 maschi e 26 femmine, età 65±10 anni) pervenuti presso il Pronto Soccorso (PS) del nostro policlinico universitario con sospetta SCA sono stati sottoposti a TC-volumetrica a 64strati e a successiva CC entro 24 ore dalla presentazione in PS.RisultatiDue pazienti (3,1%) sono stati totalmente esclusi per artefatti. L’analisi per paziente dei rimanenti 62 ha visto 24 pazienti (38,7%) negativi allo studio TC (stenosi assenti o <50%), 35 pazienti (56,4%) positivi, con identificazione della lesione culprit, 2 pazienti dove non è stato possibile identificare la lesione culprit ed 1 paziente con stenosi non confermata; sensibilità e specificità sono risultate del 94,6% e del 96%. L’analisi globale per coronaria (186 vasi) ha evidenziato 17 vasi (9,1% non valutabili per artefatti da movimento, 61 vasi (32,8%) con stenosi>50%, 7 vasi (3,7%) sovrastimati per presenza di estese calcificazioni, 3 vasi (1,6%) sottostimati circa la significatività della stenosi e 98 vasi (52,6%) privi di stenosi. I valori della sensibilità e della specificità sono risultati del 95,3% e del 93,3%.ConclusioniL’utilizzo della coronaro-TC nella pratica clinica, in questo tipo di emergenze, potrebbe incidere in maniera ragguardevole sui costi del Sistema Sanitario, stratificando i pazienti privi di patologia coronarica o di altra patologia e consentendone la dimissione in tempi immediati, senza necessità di ulteriori indagini diagnostiche.

Coronary-to-bronchial artery fistula in a patient with multivessel coronary disease treated by percutaneous coronary intervention.

We describe the case of a 78-year-old patient, admitted to our hospital with an acute coronary syndrome. Coronary angiography showed multivessel coronary artery disease and an anomalous coronary vessel branching from the right coronary artery. After successful percutaneous revascularization and discharge, the anomalous vessel was diagnosed by contrast enhanced 64-multidetector computed tomography as a coronary-to-bronchial fistula. Since the patient was asymptomatic, conservative treatment was selected.

Malignant Peripheral Nerve Sheath Tumour: CT and MRI Findings

Malignant peripheral nerve sheath tumour (MPNST) is extremely rare malignancy in the general population, occurring more frequently in patients with Neurofibromatosis type 1 (NF1). In the literature five cases of MPNST arising from the parapharyngeal space (PPS) in patients without neurofibromatosis have been reported. We report imaging techniques in a patient with MPNST in the PPS, who had neither a family history nor sign of NF1. Computed tomography (CT) scan and magnetic resonance imaging (MRI) were performed for a correct therapeutic planning. CT and MRI findings were correlated with hystopathological diagnosis.

Evaluation of coronary in-stent restenosis by 64-slice computed tomography in patients with optimal heart rate control by systematic administration of beta-blocker drugs.

Background Imaging artifacts due to metallic stent struts can reduce the diagnostic accuracy of multislice computed tomography (MSCT) in the evaluation of in-stent restenosis (ISR). Our aim was to determine the accuracy of binary ISR exclusion using a 64-slice MSCT scanner and a systematic administration of beta-blockers having an aggressive heart rate (HR) control. Methods We performed 64-slice MSCT in 218 consecutive patients revascularized by stenting. All patients were treated with oral/intravenous beta-blocker drugs in order to obtain a HR less than 65 beats/min in the prescan phase. Coronary stents were evaluated by two experienced observers in order to rule out the presence of significant (>50%) ISR. Quantitative conventional coronary angiography (CCA) served as a standard for reference. Results Five patients (2.3%) were excluded from the analysis; mean HR was 59 ± 3 beats/min in the prescan phase and 62 ± 5 beats/min during acquisition. In the 321 stented coronary segments, CCA found 27 significant ISRs. MSCT correctly diagnosed 26 significant ISRs, with two false-positive and one false-negative case. In a per-segment analysis, the sensitivity was 96%, specificity 99%, positive predictive value (PPV) 92.8%, and negative predictive value (NPV) 99%. In a per-patient analysis, the sensitivity was 100%, specificity 98.9%, PPV 92.8%, and NPV 100%. Conclusion : In our study, the evaluation of significant ISR by MSCT showed an excellent diagnostic accuracy with a PPV of 92.8% and a NPV of 99%. Selection criteria and radiation exposure can be considered a limitation of the method.

Anatomical and functional evaluation of the myocardium in patients with acute coronary syndrome (NSTEMI) using MR imaging

PurposeThe aim of our study was to evaluate the role of magnetic resonance (MR) imaging in identifying the location and extent of acute ischaemic injury to predict reversibility and distinguish areas of acute from chronic ischaemia in patients with acute coronary syndrome non- ST-elevation myocardial infarction (NSTEMI).Materials and methodsWe evaluated 22 patients with NSTEMI acute coronary syndrome confirmed by coronary angiography (CA). We studied ventricular function indices and segmental changes in wall thickness and kinetics by cine-MR imaging sequences. Subsequently, we evaluated myocardial wall oedema with T2-weighted black-blood short-tau inversion recovery turbo spin echo (T2 BB-STIRTSE) sequences and identified areas of myocardial necrosis using T1-weighted turbo field-echo inversion recovery (T1 TFE-IR) sequences after contrast material administration.ResultsThe results obtained with the single sequences were as follows: T2 BB-STIR-TSE: 96.8% sensitivity, 100% specificity, 99.7% negative predictive value, 99.7% positive predictive value; T1 TFE-IR: 45.8% sensitivity, 96.9% specificity, 92.3% negative predictive value, 90.3% positive predictive value; systolic wall thickening: 87.5% sensitivity, 91.8% specificity, 98.7% negative predictive value, 50% positive predictive value, 91.4% accuracy.ConclusionsOur study suggests that the sequences used for evaluating oedema and assessing viability allow for precise localisation and differentiation of areas of acute and chronic ischaemia by quantifying the possible mismatch between ischaemia and necrosis.RiassuntoObiettivoL’obiettivo del nostro studio è di valutare la capacità della risonanza magnetica (RM) nell’identificare localizzazione ed estensione del danno ischemico acuto, nel predire la reversibilità del danno e nel distinguere fra aree ischemiche acute e croniche nei pazienti con ischemia miocardica senza elevazione del tratto ST (NSTEMI).Materiali e metodiSono stati sottoposti ad esame cardio-RM 22 soggetti con sindrome coronarica acuta riconducibile ad un quadro di infarto NSTEMI, confermato all’esame coronarografico. Abbiamo studiato l’indice della funzione ventricolare e le alterazioni segmentarie dello spessore e della cinetica parietale ventricolare attraverso sequenze cine-RM. Abbiamo successivamente valutato edema parietale attraverso sequenze black-blood (BB) turbo spin echo (TSE) T2 (short tau inversion recovery [STIR]) ed aree miocardiche necrotiche mediante scansioni inversion recovery (IR) 3D turbo field echo (TFE) T1 pesate dopo iniezione di mezzo di contrasto (MdC).RisultatiI risultati che abbiamo ottenuto sono stati: BB TSE T2w (STIR): sensibilità 96,8%, specificità 100%, valore predittivo negativo (VPN) 99,7%, valore predittico positivo (VPP) 99,7%; IR TFE T1w: sensibilità 45,8%, specificità 96,9%, VPN 92,3%, VPP 90,3%; ispessimento parietale sistolico: sensibilità 87,5%, specificità 91,8%, VPN 98,7%, VPP 50%, accuratezza 91,4%.ConclusioniIl nostro studio ha dimostrato che le sequenze per la valutazione della vitalità miocardica e quelle per l’identificazione dell’edema consentono una precisa localizzazione e differenziazione delle aree ischemiche acute dalle croniche, quantificando il mismatch ischemia/necro.

Reduction of left ventricular hypertrophy detected by cardiac magnetic resonance in a patient after renal denervation

The pathophysiology of LVH is complex: the renin– angiotensin–aldosterone system plays an important role in mediating LVH. By stimulating the angiotensin receptor, angiotensin II induces hypertrophy and hyperplasia in myocytes and smooth muscle cells, and may regulate collagen synthesis by myofibroblasts. Angiotensin II may also promote interstitial collagen deposition by inhibiting collagenase activity. Aldosterone, therefore, contributes to extracellular collagen deposition and myocardial fibrosis.

Multimodality imaging evaluation of a primary cardiac lymphoma

Primary cardiac lymphoma is a rare form of non-Hodgkin lymphoma that involves the heart with extension to pericardium and great vessels. Prognosis is poor in the absence of a prompt diagnosis and adequate therapy. Differential diagnosis includes malignant neoplasms such as angiosarcoma or metastatic carcinoma and melanoma. Clinical manifestations may be heterogeneous. Multimodality imaging work-up represents the best method for tumor detection and evaluation of its size and extension: echocardiography, computed tomography, magnetic resonance imaging, and nuclear imaging are the best imaging tools. Definitive diagnosis is achieved with cytological and histological evaluation. We report the case of a 76-year-old woman admitted to our emergency department with symptoms of congestive heart failure. Multimodality imaging work-up showed a mediastinal bulky tumor involving heart and pericardium. Pathology revealed a large B-cell primary cardiac lymphoma.