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Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a complication of pulmonary embolism (PE). However, signs of CTEPH may exist in patients with a first symptomatic PE.Which radiologic findings on computed tomography pulmonary angiography (CTPA) at the time of acute PE could indicate the presence of a pre-existing CTEPH?We included unselected patients with acute PE who were prospectively followed for 2 years with a structured visit schedule. Two expert radiologists independently assessed patients' baseline CTPAs for pre-existing CTEPH; in case of disagreement, a decision was reached by 2:1 majority with a third expert. In addition, the radiologists checked for predefined individual parameters suggesting chronic PE and pulmonary hypertension. Signs of chronic PE or CTEPH at baseline were identified in 46 (15%) of 303 included patients. Intravascular webs, arterial narrowing or retraction, dilated bronchial arteries and right ventricular hypertrophy were the main drivers of the assessment. Five (1.7%) patients were diagnosed with CTEPH during follow-up. All four patients diagnosed with CTEPH early (83-108 days after acute PE) could be found in enriched subgroups based on the experts' overall assessment or fulfilling a minimum number of the predefined radiologic criteria at baseline. The specificity of pre-existing CTEPH diagnosis and the level of radiologists' agreement improved as the number of required criteria increased.Searching for predefined radiologic parameters suggesting pre-existing CTEPH at the time of acute PE diagnosis may allow for targeted follow-up strategies and risk-adapted CTEPH screening, thus facilitating earlier CTEPH diagnosis.

BACKGROUND: To evaluate whether volumetric iodine quantification of the lung allows for the automatic identification of patients with chronic thromboembolic pulmonary hypertension (CTEPH) and whether the extent of pulmonary malperfusion correlates with invasive hemodynamic parameters. METHODS: Retrospective data base search identified 30 consecutive patients with CTEPH who underwent CT pulmonary angiography (CTPA) on a spectral-detector CT scanner. Thirty consecutive patients who underwent an identical CT examination for evaluation of suspected acute pulmonary embolism and had no signs of pulmonary embolism or PH, served as control cohort. Lungs were automatically segmented for all patients and normal and malperfused volumes were segmented based on iodine density thresholds. Results were compared between groups. For correlation analysis between the extent of malperfused volume and mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) 3 patients were excluded because of a time span of more than 30 days between CTPA and right heart catheterization. RESULTS: Patients with CTEPH had a higher percentage of malperfused lung compared to controls (43.25%±24.72% vs. 21.82%±20.72%; P=0.001) and showed reduced mean iodine density in malperfused and normal-perfused lung areas, as well as in the vessel volume. Controls showed a left-tailed distribution of iodine density in malperfused lung areas while patients with CTEPH had a more symmetrical distribution (Skew: –0.382±0.435 vs. –0.010±0.396; P=0.004). Patients with CTEPH showed a significant correlation between the percentage of malperfused lung volume and the PVR (r=0.57, P=0.001). CONCLUSIONS: Volumetric iodine quantification helps to identify patients with CTEPH by showing increased areas of malperfusion. The extent of malperfusion might provide a measurement for disease severity in patients with CTEPH.

Introduction The occurrence of obstructive sleep apnea (OSA) is strongly associated with obesity. Behavioral, pharmacological, and surgical interventions that promote weight reduction can reduce OSA severity and improve other common obesity related complications and quality of life. While the relationship between weight reduction and apnea-hypopnea index (AHI) improvement has been documented, it does not seem to have been quantified adequately. The objective of this analysis was to quantify the association between percent change in body weight and percent change in AHI using results from the literature. Methods A literature search identified 13 studies with AHI and weight measurements before and after weight intervention in people living with obesity and OSA; 6 studies from bariatric surgery, 4 studies from diet and exercise intervention, and 3 studies from anti-obesity medications (including 2 placebo-controlled randomized clinical trials). A polynomial and a linear meta regression model as well as 95% prediction intervals were used to assess the relationship between % weight change from baseline and % change in AHI from baseline. Results Both the polynomial and linear models show, on average, weight reduction in patients living with obesity and OSA has a clinical benefit in reducing AHI. The linear meta-regression model that we developed suggests a mean AHI decrease of 2.6% per 1% weight reduction. As the prediction intervals are relatively wide, a precise relationship could not be established. For example, based on the linear model for a patient with 20% weight reduction we expect to see a mean 52.8% reduction in AHI with a 95% prediction interval (89.8%, 15.8%) AHI reduction. Conclusion Evidence shows that intentional weight reduction in people living with obesity and OSA results in improvements in OSA severity, and this was confirmed by our meta-analysis and modeling. The model shows that the degree of AHI improvement is dependent on the magnitude of weight reduction. However, establishing a precise relationship between percent change in AHI and percent weight reduction is challenging given the sparsity of data, variability in populations studied, and variability in AHI change following weight reduction. Support (if any) Eli Lilly and Company

Introduction Weight reduction is a standard recommended component of OSA treatment in people with obesity or overweight; however, the challenge to achieve and maintain weight reduction has limited its clinical application outside of the benefit established after bariatric surgery. Currently no FDA-approved anti-obesity medication (AOM) has demonstrated clinically meaningful improvement in OSA severity and symptomology. Methods Tirzepatide is a single molecule GIP and GLP-1 receptor agonist. In SURMOUNT-1, a 72-week phase 3 clinical trial in participants with obesity or overweight, tirzepatide 15mg provided average reductions in body weight of 22.5% which occurred with beneficial effects on blood pressure, lipids, and physical functioning. In a linear meta regression model, we estimated that tirzepatide treatment would provide clinically meaningful apnea-hypopnea index decrease compared to placebo-treated participants with obesity and OSA. SURMOUNT-OSA, a placebo controlled 52-week, phase 3 trial, will investigate efficacy and safety of tirzepatide for the treatment of moderate to severe OSA (defined as AHI ≥15) in participants with obesity. SURMOUNT-OSA utilizes an umbrella master protocol and 2 Intervention-Specific Appendices (ISAs): ISA 1 includes participants with no current OSA treatment and ISA 2 includes participants using positive airway pressure therapy. Approximately 412 participants will be randomly assigned to placebo or tirzepatide across the entire master protocol, with approximately 206 participants in each ISA. While participants will receive tirzepatide or placebo based on a 1:1 randomization ratio, all participants will receive background lifestyle intervention for weight reduction. Results The primary endpoint for the individual ISAs is the difference in AHI response measured by polysomnography between tirzepatide and placebo arms at week 52. Secondary endpoints include hypoxic burden, functional outcomes and cardiometabolic biomarkers. The trial is utilizing a unique hierarchical functional outcomes endpoint based on Functional Outcomes of Sleep Questionnaire methodology. The trial employs wearables, such as home sleep testing and accelerometry to capture time to improvement as exploratory outcomes. Conclusion SURMOUNT-OSA aims to explore whether tirzepatide provides clinically meaningful improvement in obesity-related OSA by targeting an underlying etiology. Support (if any) Eli Lilly

Dilated cardiomyopathy (DCM), an incurable disease of the cardiomyocyte terminating in systolic heart failure (HFrEF), is prevalent, causes hospitalization and is associated with increased mortality. Despite evidence of immune activation in DCM, anti-inflammatory interventions so far did not prove to alter the course of this disease. Here we show that myeloperoxidase (MPO), the principal heme peroxidase expressed by polymorphonuclear neutrophils (PMN) and monocytes, critically contributes to HFrEF in DCM.Muscle LIM protein (MLP) deficient mice, which spontaneously develop DCM, display increased circulating PMN counts and augmented levels of vessel-immobilized MPO. Genetic ablation and pharmacological inhibition of MPO resulted in enhanced nitric oxide (NO) bioavailability of systemic conductance and resistance vessels, and subsequently restoration of systolic left ventricular (LV) function, whereas infusion of MPO worsened systolic LV function. When patients diagnosed for DCM were treated with an orally available MPO inhibitor, systolic LV function increased, natriuretic peptides declined, and functional status improved.Impairment of endothelial NO bioavailability by release of leukocyte-derived MPO evolves as a disease-aggravating mechanism in DCM. MPO inhibition profoundly improved ventricular function by lowering systemic vascular resistance and thus holds promise as a novel and complementary treatment strategy for patients with DCM.

Background/Introduction Chronic thromboembolic pulmonary hypertension (CTEPH) is considered to be a late complication of acute pulmonary embolism (PE). However, up to one third of CTEPH patients do not report prior symptomatic venous thromboembolism (VTE). Furthermore, a substantial proportion of patients presenting with an acute PE event may exhibit radiological signs of chronicity at baseline computed tomography pulmonary angiography (CTPA). Purpose To determine the prevalence of baseline radiological parameters indicating chronic thrombosis or pulmonary hypertension, and ultimately pre-existing CTEPH, among patients with acute PE enrolled in the prospective multicentre Follow-Up after Acute Pulmonary Embolism (FOCUS) cohort study. Methods Patients with acute symptomatic PE and absence of a known history of CTEPH, enrolled at two large FOCUS centres, were included. The assessment of index CTPA scans was conducted by two independent expert radiologists who were unaware of the clinical characteristics and the follow-up data of the patients. CTPA parameters indicating chronicity were prespecified on the basis of recently proposed criteria in the literature. A third independent expert radiologist provided an assessment in case of disagreement between the first two. Baseline radiological data were prospectively validated with the aid of two-year prospective clinical follow-up data focusing on CTEPH and the post-PE syndrome (co-primary outcomes of the FOCUS study). Results A total of 303 patients (median age: 63 years, 44.6% women) were included. In >95% of the patients, the expert radiologists could confirm signs of acute PE at baseline CTPA. Radiological signs of chronic thrombi or pulmonary hypertension at baseline were detected in 46 (15.2%) patients. In 8 patients, the expert radiologists agreed on the presence of pre-existing CTEPH based on their interpretation of the overall radiological pattern. During follow-up, five (1.7%; 95% CI 0.7–3.8%) of 303 patients were diagnosed with CTEPH, over a median time of 95 days after baseline. Four of them were among the 8 patients in whom the radiological experts suspected pre-existing CTEPH at baseline, and among the 46 patients in whom CTPA findings suggesting chronic thrombi or chronic pulmonary hypertension were present at baseline. The use of the predefined individual parameters of chronicity from the literature also helped identifying patients with chronic disease, and could be used as a tool for screening acute PE patients for pre-existing CTEPH. Conclusion A substantial proportion of patients who are diagnosed with CTEPH during follow-up after acute PE may already have pre-existing CTEPH at the time of the index event. An intensified follow-up programme and focussed screening for CTEPH should be considered in patients with signs of chronicity at baseline CTPA. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Bayer Health Care

Clinical use of augmented reality, mixed reality, three-dimensional-navigation and artificial intelligence in liver surgery

Obesity is a growing global concern compounded by limited availability of effective treatment options. The SURMOUNT development program aims to evaluate the efficacy and safety of tirzepatide as an adjunct to lifestyle intervention compared with placebo on chronic weight management in adults with BMI ≥ 27 kg/mThe SURMOUNT program includes four global phase 3 trials NCT04184622 (SURMOUNT-1), NCT04657003 (SURMOUNT-2), NCT04657016 (SURMOUNT-3), and NCT04660643 (SURMOUNT-4). Participants are randomized to once-weekly subcutaneous tirzepatide versus placebo in a double-blind manner. The primary end point in all trials is the percentage change in body weight from randomization to end of treatment. Results for the primary end point for SURMOUNT-1 were published recently and results for the other trials are expected in 2023.Across trials, participants have a mean age of 44.9 to 54.2 years, are mostly female (50.7% to 69.7%), and have a mean BMI of 36.1 to 38.9.The extensive assessment of once-weekly tirzepatide in the global SURMOUNT program will detail the clinical effects of this first-in-class glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist in chronic weight management.

Background Phase contrast magnetic resonance imaging, PC MRI, is a valuable tool allowing for non-invasive quantification of CSF dynamics, but has lacked adoption in clinical practice for Chiari malformation diagnostics. To improve these diagnostic practices, a better understanding of PC MRI based measurement agreement, repeatability, and reproducibility of CSF dynamics is needed. Methods An anatomically realistic in vitro subject specific model of a Chiari malformation patient was scanned three times at five different scanning centers using 2D PC MRI and 4D Flow techniques to quantify intra-scanner repeatability, inter-scanner reproducibility, and agreement between imaging modalities. Peak systolic CSF velocities were measured at nine axial planes using 2D PC MRI, which were then compared to 4D Flow peak systolic velocity measurements extracted at those exact axial positions along the model. Results Comparison of measurement results showed good overall agreement of CSF velocity detection between 2D PC MRI and 4D Flow (p = 0.86), fair intra-scanner repeatability (confidence intervals ± 1.5 cm/s), and poor inter-scanner reproducibility. On average, 4D Flow measurements had a larger variability than 2D PC MRI measurements (standard deviations 1.83 and 1.04 cm/s, respectively). Conclusion Agreement, repeatability, and reproducibility of 2D PC MRI and 4D Flow detection of peak CSF velocities was quantified using a patient-specific in vitro model of Chiari malformation. In combination, the greatest factor leading to measurement inconsistency was determined to be a lack of reproducibility between different MRI centers. Overall, these findings may help lead to better understanding for application of 2D PC MRI and 4D Flow techniques as diagnostic tools for CSF dynamics quantification in Chiari malformation and related diseases.

The aim of this study was to report outcomes following percutaneous microwave and cryoablation of lung metastases from adenoid cystic carcinoma (ACC) of the head and neck. This bi-institutional retrospective cohort study included 10 patients (6 females, median age 59 years [range 28–81]) who underwent 32 percutaneous ablation sessions (21 cryoablation, 11 microwave) of 60 lung metastases (median 3.5 tumors per patient [range 1–16]) from 2007 to 2019. Median tumor diameter was 16 mm [range 7–40], significantly larger for cryoablation (22 mm, p = 0.002). A median of two tumors were treated per session [range 1–7]. Technical success, local control, complications, and overall survival were assessed. Primary technical success was achieved for 55/60 tumors (91.7%). Median follow-up was 40.6 months (clinical) and 32.5 months (imaging, per tumor). Local control at 1, 2, and 3 years was 94.7%, 80.8%, and 76.4%, respectively, and did not differ between ablation modalities. Five of fifteen recurrent tumors underwent repeat ablation, and secondary technical success was achieved in four (80%). Assisted local tumor control at 1, 2, and 3 years was 96.2%, 89.8%, and 84.9%, respectively. Complications occurred following 24/32 sessions (75.0%) and 57.2% Common Terminology Criteria for Adverse Events (CTCAE) lower than grade 3. Of 13 pneumothoraces, 7 required chest tube placements. Hemoptysis occurred after 7/21 cryoablation sessions, and bronchopleural fistula developed more frequently with microwave (p = 0.037). Median length of hospital stay was 1 day [range 0–10], and median overall survival was 81.5 months (IQR 40.4–93.1). Percutaneous computed tomography-guided microwave and cryoablation can treat lung metastases from ACC of the head and neck. Complications are common but manageable, with full recovery expected.

Objective: Obesity and prediabetes are widespread in the U.S., with an estimated 42% of adults living with obesity and 35% living with prediabetes. This research examines the prevalence of comorbidities among people with obesity with or without prediabetes over a 5-year period. Methods: This observational study uses Optum® Market Clarity deidentified data from 2007-2020. For adults with obesity and prediabetes, the index date was defined as the first date where the person was identified with both obesity (BMI ≥ 30 kg/m2) and prediabetes (5.7% ≤ A1c < 6.5%) while for adults with obesity without prediabetes (obesity only) , the index date was defined as the first date with BMI ≥ 30 kg/m2. All patients were required to be continuously insured from 1 year prior through 5 years post index date. For both cohorts, patients were excluded if there was any prior evidence of diabetes and in the obesity only cohort individuals were excluded if identified with prediabetes in the pre-period. Prevalence rates and 95% CIs were calculated for comorbidities for each 365-day period post index date and over the entire 5-year post-period. Results: There were 22,423 individuals with obesity and prediabetes (mean age = 58.5 years; 42.2% male) and 902,975 individuals with obesity only (mean age = 51.7 years; 46.1% male) . The mortality rate after 5 years was 16.7% for adults with obesity and prediabetes and 9.9% for adults with obesity only (p Conclusion: Findings indicate that the presence of prediabetes contributes to the development of additional morbidity and mortality in adults with obesity over time. Disclosure J.Ford: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. M.J.Lage: Consultant; Eli Lilly and Company. K.Boye: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. J.P.Bae: None. K.A.Terrell: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. M.C.Bunck: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company.

Venous occlusion that affects the subclavian or innominate vein is a common problem in cardiac implantable electronic device (CIED) patients, with a reported range between 3% and 5%.1 In contrast, occlusion of the superior vena cava (SVC) not associated with malignancy (thus termed “benign”) is a rare condition (incidence 0.03%–0.15%) that causes a clinical syndrome of upper extremity and face swelling, pleural effusions, orthostatic hypotension, and collateral circulation and might even give rise to life-threatening complications if undetected, as illustrated by this case report.2,3

Radiological reports of pancreatic lesions are currently widely formulated as free texts. However, for optimal characterization, staging and operation planning, a wide range of information is required but is sometimes not captured comprehensively. Structured reporting offers the potential for improvement in terms of completeness, reproducibility and clarity of interdisciplinary communication. Interdisciplinary consensus finding of structured report templates for solid and cystic pancreatic tumors in computed tomography (CT) and magnetic resonance imaging (MRI) with representatives of the German Society of Radiology (DRG), German Society for General and Visceral Surgery (DGAV), working group Oncological Imaging (ABO) of the German Cancer Society (DKG) and other radiologists, oncologists and surgeons. Among experts in the field of pancreatic imaging, oncology and pancreatic surgery, as well as in a public online survey, structured report templates were developed by consensus. These templates are available on the DRG homepage under www.befundung.drg.de and will be regularly revised to the current state of scientific knowledge by the participating specialist societies and responsible working groups. This article presents structured report templates for solid and cystic pancreatic tumors to improve clinical staging (cTNM, ycTNM) in everyday radiology. · Structured report templates offer the potential of optimized radiological reporting with regard to completeness, reproducibility and differential diagnosis.. · This article presents consensus-based, structured reports for solid and cystic pancreatic lesions in CT and MRI.. · These structured reports are available open source on the homepage of the German Society of Radiology (DRG) under www.befundung.drg.de..· Persigehl T, Baumhauer M, Baeßler B et al. Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG). Fortschr Röntgenstr 2020; 192: 641 - 655. In der klinischen Radiologie werden aktuell radiologische Befundberichte bei Pankreasläsionen weitverbreitet als Freitexte formuliert. Für die optimale klinische Versorgung, das Staging und die Operationsplanung sind mannigfaltige Informationen erforderlich, die mitunter nicht umfänglich erfasst werden. Die strukturierte Befundung bietet hier das Potenzial einer Verbesserung in Bezug auf Vollständigkeit, Reproduzierbarkeit sowie Klarheit der interdisziplinären Kommunikation. Interdisziplinäre Erstellung von strukturierten Befundvorlagen für solide und zystische Pankreastumoren in der Computertomografie (CT) und in der Magnetresonanztomografie (MRT) mit Vertretern der Deutschen Röntgengesellschaft (DRG), der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), der Arbeitsgemeinschaft Onkologische Bildgebung (ABO) der Deutschen Krebsgesellschaft (DKG) sowie weiteren Radiologen, Onkologen und Chirurgen. Unter Experten auf dem Gebiet der Pankreasbildgebung, onkologischen Versorgung und Pankreaschirurgie sowie in einer öffentlichen Online-Umfrage wurden strukturierte Befundvorlagen im Konsensus-Verfahren entwickelt, die im weiteren Verlauf regelmäßig durch die beteiligten Fachgesellschaften und verantwortlichen Arbeitsgemeinschaften auf den aktuellen Stand der wissenschaftlichen Erkenntnis angepasst werden sollen. Dieser Artikel stellt strukturierte Befundvorlagen für solide und zystische Pankreastumoren vor, die im radiologischen Alltag helfen sollen, das klinische Staging (cTNM, ycTNM) zu verbessern. · Strukturierte Befundvorlagen bieten das Potenzial einer optimierten radiologischen Befundung in Bezug auf Vollständigkeit, Reproduzierbarkeit und Differenzialdiagnose.. · Dieser Artikel stellt Konsensus-basierte, strukturierte Befundvorlagen für solide und zystische Pankreasläsionen im CT und MRT vor.. · Die von der Deutsche Röntgengesellschaft entwickelten Befundvorlagen werden unter www.befundung.drg.de zur Verfügung gestellt..· Persigehl T, Baumhauer M, Baeßler B et al. Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG). Fortschr Röntgenstr 2020; 192: 641 – 656.

ObjectivesTo evaluate the usefulness of spectral detector CT (SDCT)-derived pulmonary perfusion maps and pulmonary parenchyma characteristics for the semiautomated classification of pulmonary hypertension (PH).MethodsA total of 162 consecutive patients with right heart catheter (RHC)-proven PH of different aetiologies as defined by the current ESC/ERS guidelines who underwent CT pulmonary angiography (CTPA) on SDCT and 20 patients with an invasive rule-out of PH were included in this retrospective study. Semiautomatic lung segmentation into normal and malperfused areas based on iodine density (ID) as well as automatic, virtual non-contrast-based emphysema quantification were performed. Corresponding volumes, histogram features and the ID SkewnessPerfDef-Emphysema-Index (δ-index) accounting for the ratio of ID distribution in malperfused lung areas and the proportion of emphysematous lung parenchyma were computed and compared between groups.ResultsPatients with PH showed a significantly greater extent of malperfused lung areas as well as stronger and more homogenous perfusion defects. In group 3 and 4 patients, ID skewness revealed a significantly more homogenous ID distribution in perfusion defects than in all other subgroups. The δ-index allowed for further subclassification of subgroups 3 and 4 (p < 0.001), identifying patients with chronic thromboembolic PH (CTEPH, subgroup 4) with high accuracy (AUC: 0.92, 95%-CI, 0.85–0.99).ConclusionAbnormal pulmonary perfusion in PH can be detected and quantified by semiautomated SDCT-based pulmonary perfusion maps. ID skewness in malperfused lung areas, and the δ-index allow for a classification of PH subgroups, identifying groups 3 and 4 patients with high accuracy, independent of reader expertise.

Purpose: The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period. Materials and Methods: Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints. Results: In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (pConclusions: Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling. Clinical Impact In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p

ObjectiveLiver cancer is one of the most commonly diagnosed cancer, and energy-based tumor ablation is a widely accepted treatment. Automatic and robust segmentation of liver tumors and ablation zones would facilitate the evaluation of treatment success. The purpose of this study was to develop and evaluate an automatic deep learning based method for (1) segmentation of liver and liver tumors in both arterial and portal venous phase for pre-treatment CT, and (2) segmentation of liver and ablation zones in both arterial and portal venous phase for after ablation treatment.Materials and Methods252 CT images from 63 patients undergoing liver tumor ablation at a large University Hospital were retrospectively included; each patient had pre-treatment and post-treatment multi-phase CT images. 3D voxel-wise manual segmentation of the liver, tumors and ablation region by the radiologist provided reference standard. Deep learning models for liver and lesion segmentation were initially trained on the public Liver Tumor Segmentation Challenge (LiTS) dataset to obtain base models. Then, transfer learning was applied to adapt the base models on the clinical training-set, to obtain tumor and ablation segmentation models both for arterial and portal venous phase images. For modeling, 2D residual-attention Unet (RA-Unet) was employed for liver segmentation and a multi-scale patch-based 3D RA-Unet for tumor and ablation segmentation.ResultsOn the independent test-set, the proposed method achieved a dice similarity coefficient (DSC) of 0.96 and 0.95 for liver segmentation on arterial and portal venous phase, respectively. For liver tumors, the model on arterial phase achieved detection sensitivity of 71%, DSC of 0.64, and on portal venous phase sensitivity of 82%, DSC of 0.73. For liver tumors >0.5cm3 performance improved to sensitivity 79%, DSC 0.65 on arterial phase and, sensitivity 86%, DSC 0.72 on portal venous phase. For ablation zone, the model on arterial phase achieved detection sensitivity of 90%, DSC of 0.83, and on portal venous phase sensitivity of 90%, DSC of 0.89.ConclusionThe proposed deep learning approach can provide automated segmentation of liver tumors and ablation zones on multi-phase (arterial and portal venous) and multi-time-point (before and after treatment) CT enabling quantitative evaluation of treatment success.

Background and purpose For the assessment of cardiovascular blood flow, 2D flow (2D) and 4D flow with a single venc (4D Mono) are established techniques. The objective of this study was to validate a multi-venc 4D flow (4D Multi) sequence for the improved simultaneous assessment of arterial and venous flow in high and low flow conditions and to investigate the scan-rescan reproducibility and inter-observer variability of the novel sequence. Methods Eleven volunteers with no known heart condition (female: 6, mean age: 25.8 ± 9.1 years) and two patients with a Fontan circulation were examined using phase-contrast 2D and 4D flow MRI. Stroke volumes, maximum velocities, net flow curves and internal consistency were measured and compared between 2D, 4D Mono and 4D Multi. Additionally, scan-rescan and inter-observer variabilities were analyzed. Finally, qualitative visualization comparisons were performed. Results Bland-Altman analysis show a higher agreement in stroke volumes between 4D Multi and 2D (7 ± 11%) than 4D Mono and 2D (11 ± 24%). 4D Multi is more accurate than 4D Mono in measuring time-resolved net flow throughout the cardiac cycle and qualitative blood flow visualization of 4D Multi is more accurate in visualizing flow patterns revealing more details and less artifacts than 4D Mono. Scan-rescan reproducibility is higher in 4D Multi (−0.04 ± 4.5 ml) than 2D (2.1 ± 7.3 ml) and inter-observer variability is low in both techniques (2D: −0.4 ± 3.4 ml and 4D Multi: 0.4 ± 3.5 ml). Internal consistency was improved in volunteers and patients when using 4D Multi as compared to 4D Mono. Conclusion 4D Multi offers a comprehensive way to accurately quantify flow in arteries and veins both in high and low flow situations and to visualize detailed flow patterns. This technique is readily applicable in the clinical setting and has the potential to be beneficial in the clinical assessment of valvular and congenital heart diseases.

In multiple sclerosis (MS), the heterogeneous and numerous appearances of lesions may impair diagnostic accuracy. This study investigates if a combined automated co-registration and lesion color-coding method (AC) improves assessment of MS follow-up MRI compared with conventional reading (CR). We retrospectively assessed 70 follow-up MRI of 53 patients. Heterogeneous datasets of diverse scanners and institutions were used. Two readers determined presence of (a) progression, (b) regression, (c) mixed change, or (d) stable disease between the two examinations using corresponding FLAIR sequences in CR and AC-assisted reading. Consensus reference reading was provided by two blinded radiologists. Kappa statistics tested interrater agreement, McNemar’s test dichotomous variables, and Wilcoxon’s test continuous variables (statistical significance p ≤ 0.05). The cohort comprised 41 female and 12 male patients with a mean age of 40 (± 14) years. Average rating time was reduced from 78 (± 36) to 44 (±22) s with the AC approach (p

To evaluate the value of spectral-detector CT (SDCT) in the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), its differentiation against other etiologies of pulmonary hypertension (PH) and in the prediction of disease severity.60 patients with suspected PH underwent SDCT. Additional diagnostic tests in accordance with the ESC guidelines including right heart catherization and VQ-SPECT were performed. After full diagnostic work-up patients were classified as: 21 precapillary PH, 5 postcapillary PH, 6 combined pre- and postcapillary PH, 19 CTEPH, 9 no PH. SDCT examinations were analyzed by two blinded readers deciding on the diagnosis of CTEPH and scoring the extent of perfusion abnormalities on iodine density images. An additional reading was performed using conventional CTPA images only.With access to SDCT data, both readers reached a sensitivity of 100% for the diagnosis of CTEPH with a specificity of 95.1% and 87.8%. On analysis of conventional CTPA images alone, specificity and diagnostic confidence decreased for both readers (Specificity 90.2 and 85.3%) while sensitivity dropped for the less experienced reader only (Sensitivity 78.9%). Patients with PH showed significantly more perfusion abnormalities than patients without PH (16.6 ± 8.4 vs. 9.5 ± 8.9 p 0.001) and the extent of perfusion abnormalities correlated with the mean pulmonary artery pressure (r = 0.37 p = 0.008).SDCT offers confident identification of patients with CTEPH and enables a comprehensive analysis of pulmonary vasculature, pulmonary perfusion and the lung parenchyma in a single examination for patients with suspected PH.

Background Endovascular treatment can be a fast and safe option in the case of acute, internal bleeding – but it requires special knowledge and technical skills. Interventionalists must consider the anatomy and potential complications. As in this case report, the anterior spinal artery, for example, can be a crucial vessel that must always be considered when embolizing intercostal or lumbar arteries. The risk of spinal ischemia has to be taken into account and should be minimized by choosing the appropriate treatment option. Case presentation We report about a 77 year old, male patient with upper gastrointestinal bleeding after esophagectomy and gastric conduit reconstruction. A CT scan identified a pseudoaneurysm of an intercostal artery penetrating the gastric conduit as the bleeding source. In the DSA, a direct connection between the intercostal artery and the anterior spinal artery appeared to be likely. Due to the associated risk of spinal ischemia, an embolization of the intercostal artery was not an option. We decided to implant a stentgraft that would stop the perfusion of the pseudoaneurysm, but preserve the perfusion of the intercostal artery. Due to the small diameter of the vessel, we could not implant our commonly used stentgrafts in this case. Therefore, we chose an uncommon solution and used a stentgraft that is designed primarily for coronary arteries. Conclusions Whenever intercostal or lumbar arteries need to be embolized, a possible connection to the anterior spinal artery must be considered and interventionalists have to be aware of possible ischemic complications. In this case, a stentgraft designed primarily for coronary arteries offered a good endovascular treatment option for the pseudoaneurysm of an intercostal artery. The risk of spinal ischemia could be minimized by using this stentgraft.

Background: Phase contrast magnetic resonance imaging, PC MRI, is a valuable tool allowing for non-invasive quantification of CSF dynamics, but has lacked adoption in clinical practice for Chiari malformation diagnostics. To improve these diagnostic practices, a better understanding of PC MRI based measurement agreement, repeatability, and reproducibility of CSF dynamics is needed.Methods: An anatomically realistic in vitro subject specific model of a Chiari malformation patient was scanned three times at five different scanning centers using 2D PC MRI and 4D Flow techniques to quantify intra-scanner repeatability, inter-scanner reproducibility, and agreement between imaging modalities. Peak systolic CSF velocities were measured at nine axial planes using 2D PC MRI, which were then compared to 4D Flow peak systolic velocity measurements extracted at those exact axial positions along the model. Results: Comparison of measurement results showed good overall agreement of CSF velocity detection between 2D PC MRI and 4D Flow (p = 0.86), fair intra-scanner repeatability (confidence intervals ±1.5 cm/s), and poor inter-scanner reproducibility. On average, 4D Flow measurements had a larger variability than 2D PC MRI measurements (standard deviations 1.83 and 1.04 cm/s, respectively). Conclusion: Agreement, repeatability, and reproducibility of 2D PC MRI and 4D Flow detection of peak CSF velocities was quantified using a patient-specific in vitro model of Chiari malformation. In combination, the greatest factor leading to measurement inconsistency was determined to be a lack of reproducibility between different MRI centers. Overall, these findings may help lead to better understanding for application of 2D PC MRI and 4D Flow techniques as diagnostic tools for CSF dynamics quantification in Chiari malformation and related diseases.

Background Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) represents the gold standard for assessment of myocardial viability. The purpose of this study was to investigate the clinical potential of Compressed SENSE (factor 5) accelerated free-breathing three-dimensional (3D) whole heart LGE with high isotropic spatial resolution (1.4 mm3 acquired voxel size) compared to standard breath-hold LGE imaging. Methods This was a retrospective, single-center study of 70 consecutive patients (45.8 ± 18.1 years, 27 females; February–November 2019), who were referred for assessment of left ventricular myocardial viability and received free-breathing and breath-hold LGE sequences at 1.5 T in clinical routine. Two radiologists independently evaluated global and segmental LGE in terms of localization and transmural extent. Readers scored scans regarding image quality (IQ), artifacts, and diagnostic confidence (DC) using 5-point scales (1 non-diagnostic—5 excellent/none). Effects of heart rate and body mass index (BMI) on IQ, artifacts, and DC were evaluated with ordinal logistic regression analysis. Results Global LGE (n = 33) was identical for both techniques. Using free-breathing LGE (average scan time: 04:33 ± 01:17 min), readers detected more hyperenhanced lesions (28.2% vs. 23.5%, P Conclusions In a clinical setting, free-breathing Compressed SENSE accelerated 3D high isotropic spatial resolution whole heart LGE provides good to excellent image quality in 80% of scans independent of heart rate while enabling improved depiction of small and particularly non-ischemic hyperenhanced lesions in a shorter scan time than standard breath-hold LGE.

To evaluate the feasibility of a k-t accelerated multi-VENC 4D phase contrast flow MRI acquisition of the main heart-surrounding vessels, its benefits over a traditional single-VENC acquisition and to present reference flow and velocity values in a large cohort of volunteers.44 healthy volunteers were examined on a 3 T MRI scanner (Ingenia, Philips, Best, The Netherlands). 4D flow measurements were obtained with a FOV including the aorta and the pulmonary arteries. VENC values were set to 40, 100 and 200 cm/s and unfolded based on an MRI signal model. Unfolded multi-VENC data was compared to the single-VENC with VENC 200 cm/s. Flow and velocity quantification was performed in several regions of interest (ROI) placed in the ascending aorta and in the main pulmonary artery. Conservation of mass analysis was performed for single- and multi-VENC datasets. Values for mean and maximal flow velocity and stroke volume were calculated and compared to the literature.Mean scan time was 13.8 ± 4 min. Differences between stroke volumes between the ascending aorta and the main pulmonary artery were significantly lower in multi-VENC datasets compared to single-VENC datasets (9.6 ± 7.8 mL vs. 25.4 ± 26.4 mL, p0.001). This was also true for differences in stroke volume between up- and downstream ROIs in the ascending aorta and pulmonary artery. Values for mean and maximal velocities and stroke volume were in-line with previous studies. To highlight potential clinical applications two exemplary 4D flow measurements in patients with different pathologies are shown and compared to single-VENC datasets.k-t accelerated multi-VENC 4D phase contrast flow MRI acquisition of the great vessels is feasible in a clinically acceptable scan duration. It offers improvements over traditional single-VENC 4D flow, expectedly being valuable when vessels with different flow velocities or complex flow phenomena are evaluated.

Background In order to efficiently perform laparoscopic microwave ablation of liver tumours precise positioning of the ablation probe is mandatory. This study evaluates the precision and ablation accuracy using the innovative laparoscopic stereotactic navigation system CAS-One-SPOT in comparison to 2d ultrasound guided laparoscopic ablation procedures. Methods In a pig liver ablation model four surgeons, experienced (n = 2) and inexperienced (n = 2) in laparoscopic ablation procedures, were randomized for 2d ultrasound guided laparoscopic or stereotactic navigated laparoscopic ablation procedures. Each surgeon performed a total of 20 ablations. Total attempts of needle placements, time from tumor localization till beginning of ablation and ablation accuracy were analyzed. Results The use of the laparoscopic stereotactic navigation system led to a significant reduction in total attempts of needle placement. The experienced group of surgeons reduced the mean number of attempts from 2.75 ± 2.291 in the 2d ultrasound guided ablation group to 1.45 ± 1.191 (p = 0.0302) attempts in the stereotactic navigation group. Comparable results could be observed in the inexperienced group with a reduction of 2.5 ± 1.50 to 1.15 ± 0.489 (p = 0.0005). This was accompanied by a significant time saving from 101.3 ± 112.1 s to 48.75 ± 27.76 s (p = 0.0491) in the experienced and 165.5 ± 98.9 s to 66.75 ± 21.96 s (p Conclusion The use of a stereotactic navigation system for laparoscopic microwave ablation procedures of liver tumors significantly reduces the attempts and time of predicted correct needle placement for novices and experienced surgeons without impairing the accuracy of the ablation procedure.

To compare a novel Compressed SENSE accelerated ECG- and respiratory-triggered flow-independent 3D isotropic Relaxation-Enhanced Angiography without Contrast and Triggering (modified REACT) with standard non-ECG-triggered 3D contrast-enhanced magnetic resonance angiography (CE-MRA) for imaging of the thoracic aorta in patients with connective tissue diseases (CTD) or other aortic diseases using manual and semiautomatic measurement approaches. This retrospective, single-center analysis of 30 patients (June–December 2018) was conducted by two radiologists, who independently measured aortic diameters on modified REACT and CE-MRA using manual (Multiplanar-Reconstruction) and semiautomatic (Advanced Vessel Analysis) measurement tools on seven levels (inner edge): Aortic annulus and sinus, sinotubular junction, mid- and high-ascending aorta, aortic isthmus, and descending aorta. Bland–Altman analysis was conducted to evaluate differences between the mean values of aortic width and ICCs were calculated to assess interobserver agreement. For each level, image quality was evaluated on a four-point scale in consensus with Wilcoxon matched-pair test used to evaluate for differences between both MRA techniques. Additionally, evaluation time for each measurement technique was noted, which was compared applying one-way ANOVA. When comparing both imaging and measurement methods, CE-MRA (mean difference 0.24 ± 0.27 mm) and the AVA-tool (− 0.21 ± 0.15 mm) yielded higher differences compared to modified REACT (− 0.11 ± 0.11 mm) and the MPR-tool (0.07 ± 0.21 mm) for all measurement levels combined without yielding clinical significance. There was an excellent interobserver agreement between modified REACT and CE-MRA using both tools of measurement (ICC > 0.9). Modified REACT (average acquisition time 06:34 ± 01:36 min) provided better image quality from aortic annulus to mid-ascending aorta (p

Background Non-invasive coronary imaging after stent placement remains challenging. Favorable results for dual-energy computed tomography (DECT) derived monoenergetic (MonoE) images have been reported for this purpose. Nowadays, there are different dual-energy techniques available, each with specific advantages and disadvantages. However, for the evaluation of coronaries after stent implantation there is no systematic comparison between different dual-energy techniques. Therefore, the aim of our study was to compare two widely used DECT systems using an in-stent restenosis (ISR) phantom setup. Methods Soft-plaque-like stenoses (~50% of lumen) were inserted into ten coronary stents embedded in contrast-filled vessel phantoms. A dual-source CT (DSCT) and a dual-layer CT (DLCT) with comparable acquisition and reconstruction parameters were used. Conventional polyenergetic (PolyE) and MonoE images with 9 different levels (40-120 keV) were calculated. ISR assessability was evaluated by subjective scoring using a 5-point scale and by the following quantitative parameters: image noise, visible lumen diameter (VLD) and ISR contrast-to-noise ratio (CNR). Results A non-significant trend towards larger VLD in DLCT images was observed. Highest noise was found in low-keV MonoE with significantly higher values for DSCT than for DLCT. Conversely, noise was significantly lower for DSCT at higher-keV MonoE. Peak ISR CNR values were found at low-keV MonoE with no significant difference between both systems. However, for PolyE and mid-energy MonoE, CNRs were significantly higher for DSCT. Subjective image quality was significantly better for PolyE and low-keV MonoE than for high-keV MonoE, also without significant difference between both systems. Conclusions Conspicuity of ISR benefits from DECT. Peak CNRs were comparable for both DECT systems and low-keV MonoE offered the highest CNR values and best subjective image quality. In contrast, high-keV MonoE cannot be recommended for stent evaluation due to poor CNR values and therefore significantly limited visualization of stenoses.

Purpose To evaluate the correlation between left atrial diverticula (LAD) and left-sided septal pouches (LSSP) with ischemic brain alterations in MRI. Methods A retrospective analysis of 174 patients who received both, a dedicated cardiac CT angiography (CCTA) and a brain MRI examination was performed. Two radiologists independently reviewed all examinations for the presence of LAD and LSSP as well as ischemic alterations of the brain. Subsequently, the correlation between these cardiac and cerebral findings as well as to other potentially related risk factors was assessed. Results 71 LAD (total prevalence 41%) and 65 LSSP (total prevalence 37%) were identified in 174 patients. Combined prevalence was 10%. Ischemic brain alterations were found in patients with a LAD in 42.3% (30/71) and with a LSSP in 64.6% (42/65). Patients without any anatomical variant in the left atrium showed ischemic brain alterations in 39.4% (26/66). The presence of a LSSP was associated with an increased risk for ischemic brain alterations in multivariate logistic regression analysis after adjusting for other risk factors (OR = 3.57, 95% CI = 0.51–2.09, p Conclusion In our study cohort LAD and LSSP are highly prevalent anatomical structures within the left atrium. Patients with LSSP showed an approximated 3.5-fold higher probability for ischemic brain alterations. Therefore, LSSP should be considered as a potential risk factor for cardioembolic strokes and its presence should be stated in cardiac CT reports.

Patients with Congenital heart disease (CHD) require repetitive imaging of the pulmonary vasculature throughout their life. In this study, we compared a novel Compressed SENSE accelerated (factor 9) electrocardiogram (ECG)- and respiratory-triggered 3D modified Relaxation-Enhanced Angiography without Contrast and Triggering (modified REACT-non-contrast-enhanced magnetic resonance angiography (modified REACT-non-CE-MRA)) with standard non-ECG-triggered time-resolved 4D CE-MRA for imaging of the pulmonary arteries and veins in patients with CHD.This retrospective analysis of 25 patients (June 2018-April 2019) with known or suspected CHD was independently conducted by two radiologists executing measurements on modified REACT-non-CE-MRA and 4D CE-MRA on seven dedicated points (inner edge): Main pulmonary artery (MPA), right and left pulmonary artery, right superior and inferior pulmonary vein, left superior (LSPV) and inferior pulmonary vein. Image quality for arteries and veins was evaluated on a four-point scale in consensus.Twenty-three of the 25 included patients presented a CHD. There was a high interobserver agreement for both methods of imaging at the pulmonary arteries (ICC ≥ 0.96); at the pulmonary veins, modified REACT-non-CE-MRA showed a slightly higher agreement, pronounced at LSPV (ICC 0.946 vs. 0.895). Measurements in 4D CE-MRA showed higher diameter values compared to modified REACT-non-CE-MRA, at the pulmonary arteries reaching significant difference (e.g. MPA: mean 0.408 mm, p = 0.002). Modified REACT-non-CE-MRA (average acquisition time 07:01 ± 02:44 min) showed significant better image quality than 4D CE-MRA at the pulmonary arteries (3.84 vs. 3.32, p 0.001) and veins (3.32 vs. 2.72, p = 0.015).Compressed SENSE accelerated (factor 9) ECG- and respiratory-triggered 3D modified REACT-non-CE-MRA allows for reliable and fast imaging of the pulmonary arteries and veins with higher image quality and slightly higher interobserver agreement than 4D CE-MRA without contrast agent and associated disadvantages. Therefore, it represents a clinically suitable technique for patients requiring repetitive imaging of the pulmonary vasculature, e.g. patients with CHD.