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PubMedDate not supplied

Helical CT for the evaluation of suspected acute pulmonary embolism: diagnostic pitfalls.

Helical CT is being increasingly utilized for the evaluation of suspected pulmonary embolism (PE). Proper scan interpretation depends on the awareness of several diagnostic pitfalls that may simulate PE, including normal bronchovascular structures such as pulmonary veins, bronchi, and lymph nodes, technical considerations such as improper bolus timing and streak artifacts, and patient-related factors such as motion artifacts, pulmonary arterial catheters, and vascular shunts. An understanding of these pitfalls facilitates accurate diagnosis.

Acute Disease↗
PubMed1978

Detection of myocardial scar tissue by M-mode echocardiography.

Wall thicknesses were measured and echo densities were evaluated from the left ventricular echograms of 182 patients. The echogram was considered to reflect scar tissue when 1) either the interventricular septum, the posterior left ventricular wall or the anterior left ventricular wall was less than 7 mm thick in mid-diastole and was more echo-producing than its opposing wall or another area of the same wall in a sector scan, or 2) an area of myocardium was 30% less thick than an adjacent area within a sector scan. Myocardial scarring was diagnosed by echocardiography in 52 of the 182 patients. The echocardiographic presence or absence of scarring was confirmed in 95% (173 of 182) of cases, 34 cases by microscopic examination and 139 by surgical appearance. This study shows that M-mode echocardiography is both a sensitive and specfic method for detecting myocardial scar tissue.

Coronary Angiography↗
PubMed2002

Optimizing the technique of contrast transcranial Doppler ultrasound in the detection of right-to-left shunts.

BACKGROUND AND PURPOSE: A cardiac right-to-left shunt (RLS) can be identified by transesophageal echocardiography and transcranial Doppler ultrasound (TCD) with contrast agents and a Valsalva maneuver (VM) as a provocation procedure. This article applies the modalities of these tests detailed in previous studies to a large patient cohort and compares 2 contrast agents (saline and Echovist-300). METHODS: Eighty-one patients were investigated by both transesophageal echocardiography and bilateral TCD of the middle cerebral arteries. The following protocol with injections of 10 mL agitated saline was applied in a randomized way: (1) no VM, (2) VM for 5 seconds starting 5 seconds after the beginning of contrast injection, and (3) repetition of the test with VM if the first test with VM was negative. The VM was performed for 5 seconds starting exactly 5 seconds after the beginning of saline injection. Thereafter, the same protocol was repeated with 10 mL Echovist-300 instead of saline. RESULTS: Thirty-one patients had a cardiac RLS. The Echovist-300 investigation disclosed all these 31 shunts, but saline disclosed only 29 of them. Twenty-two had an RLS only in at least 1 of the above TCD tests, some of them even with a considerable shunt volume. CONCLUSIONS: Contrast TCD performed with Echovist-300 but not with saline yields a 100% sensitivity to identify transesophageal echocardiography-proven cardiac RLSs. The TCD test should be repeated if negative the first time. This article gives detailed information for the optimization of the contrast TCD technique. Extracardiac shunts detected only during contrast TCD can have a considerable shunt volume and may allow for paradoxical embolism.

Adult↗
PubMed1999

Methodological parameters influence the detection of right-to-left shunts by contrast transcranial Doppler ultrasonography.

BACKGROUND AND PURPOSE: Contrast transcranial Doppler ultrasonography is a new method to detect intracardiac right-to-left shunts, such as the patent foramen ovale. However, the methodology of the procedure varies considerably among investigators. This study was undertaken to assess the influence of methodological parameters on the results of the contrast transcranial Doppler examination in the detection of right-to-left shunts. METHODS: A total of 72 patients (mean age, 58.2+/-14.7 years) had a contrast transcranial Doppler ultrasonography examination. To study the influence of methodological factors, patients with evidence of a right-to-left shunt underwent repeated examinations with modified procedures. Parameters under investigation were the timing of the Valsalva maneuver, the dose of the contrast medium, and the patient's posture during the examination. RESULTS: The median contrast signal count was 58.5 and 48.0 (P<0.001) and the median latency of the first intracranially detected contrast signal was 12.5 and 8.5 seconds (P=0.05) when the Valsalva maneuver was performed 5 and 0 seconds after the start of the injection, respectively. Reducing the contrast medium dose from 10 to 5, 2.5, and 1.2 mL resulted in a decline of the median signal count from 54.5 to 28.5, 20.5, and 12.0 (P<0.01), respectively, while the latency of the first contrast signal increased from 13.3 to 14.0, 14.6, and 15.0 seconds (P<0.05). The sitting position also produced a lower signal count than the supine position (P<0.02). CONCLUSIONS: This study demonstrates that several essential methodological parameters influence the results of the contrast transcranial Doppler ultrasonography examination. Therefore, it is necessary to standardize the procedure to permit comparable quantitative assessments of the shunt volume. The findings of the present study suggest that 10 mL of contrast medium be injected with the patient in the supine position and that the Valsalva maneuver be performed 5 seconds after the start of the injection.

Adult↗
PubMed2003

Contrast M-mode power Doppler ultrasound in the detection of right-to-left shunts: utility of submandibular internal carotid artery recording.

Cardiac right-to-left shunts (RLSs) can be detected by echocardiography and transcranial Doppler ultrasound (TCD). In patients without adequate transtemporal bone windows, results may be obtained by insonating extracranial arteries; however, the sensitivity and practicality of this approach is unknown. In 34 patients evaluated with echocardiography for RLSs, 73 studies were performed with unilateral, simultaneous contrast TCD (cTCD) of the middle cerebral artery (MCA) and anterior cerebral artery (ACA) and submandibular power M-mode Doppler (PMD) ultrasound of the extracranial internal carotid artery (ecICA). The number of microbubble (MB) signals and their times of first appearance were determined. RLS volume was graded on 6 levels (I = trace, II = small, III = medium, IVa = large, IVb = shower, IVc = curtain) and compared between MCA and ecICA recordings. In 2 of 24 cTCD studies in 15 patients without evidence of RLSs on single-gated MCA monitoring, low-volume RLSs (grades I and II) were detected via ecICA insonation; in both, MB signatures were tracked in the ecICA, passing into the ipsilateral ACA. In 40 of 49 studies (26 patients) in which RLSs were demonstrated with single-gated MCA monitoring, more MBs were detected in the ecICA than the MCA, with either single-gated or M-mode images, with increases of 76.9% and 66.1%, respectively (P = .027). Compared to single-gated studies, M-mode technology detected nonsignificant increases in MB number in both the MCA and the ecICA (by 20.2% and 14.0%, respectively). Contrast PMD with cervical ICA recording is at least as sensitive and specific as the traditional MCA method in detecting RLSs; furthermore, this method seems to be more sensitive for low-volume RLSs (grades I-III) because of air MB decay (9.2%) and entry into the ipsilateral ACA (34.2%). This is in concordance with the increase of detected RLS grades observed in 32.7% of patients with echocardiography-documented RLSs. The authors therefore suggest the incorporation of ecICA PMD not only in patients with poor ultrasonic bone windows but also in every patient being evaluated for suspected RLSs.

Carotid Artery, Internal↗
PubMed1979

Pulmonary artery banding in infants with complete atrioventricular canal.

Management of symptomatic atrioventricular canal (AVC) in infancy may be difficult. Between July, 1969, and September, 1977, 31 infants with complete AVC presented in congestive heart failure (CHF) to the University of Minnesota Hospitals. Fifteen of these patients have responded to medical management and have been followed as outpatients. The other 16 patients remained in CHF. Six of them died of persistent heart failure within 4 months. The other 10 infants, aged 3 weeks to 1 year (mean 4 months), underwent pulmonary artery banding and seven survived operation. One of the survivors died with apparent pneumonia 1 month postoperatively. Each of the remaining six patients, who have been followed for 9 months to 9 years, had minimal mitral insufficiency and a large ventricular shunt. The three patients dying after banding had significant mitral insufficiency. We believe that pulmonary artery banding is an effective palliative procedure for infants with complete AVC and CHF who have large ventricular shunts and minimal mitral insufficiency.

Angiocardiography↗