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Management of Cervical Artery Dissection: Key Points From the AHA Scientific Statement

21 Jan, 2025 | 11:05h | UTC

Introduction:
This document summarizes the American Heart Association (AHA) scientific statement on cervical artery dissection (CAD), an important cause of ischemic stroke, especially in younger and middle-aged adults. Cervical artery dissection often presents with nonspecific symptoms—such as headache, neck pain, or partial Horner syndrome—but can lead to serious neurological deficits. Early recognition, targeted imaging, appropriate acute treatment, and well-informed decisions on antithrombotic therapy are essential to optimize patient outcomes.

Key Recommendations:

  • Epidemiology and Risk Factors
    • CAD accounts for up to 25% of ischemic strokes in adults under 50 years of age, with a slightly higher incidence in men but lower peak age in women.
    • Risk factors include genetic predispositions (eg, connective tissue disorders), anatomic variants (elongated styloid process, vascular tortuosity), minor cervical trauma, and comorbidities such as hypertension or fibromuscular dysplasia.
  • Diagnosis and Imaging
    1. Clinical Suspicion
      • Suspect CAD in younger adults with new or worsening neck pain, headache, pulsatile tinnitus, partial Horner syndrome, or cranial nerve involvement, especially if there is a history of recent minor neck trauma or manipulation.
      • Up to 8%–12% of patients may have isolated neck or head pain with no initial ischemic signs.
    2. Imaging Modalities
      • Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA): High-resolution, fat-suppressed T1-weighted sequences are useful for detecting intramural hematoma.
      • Computed Tomography Angiography (CTA): Good sensitivity and specificity for luminal abnormalities and can detect intraluminal thrombus. Avoid false positives by distinguishing imaging artifacts from true double lumens or intimal flaps.
      • Conventional Digital Subtraction Angiography (DSA): Historically the gold standard but reserved for equivocal cases because of procedure-related risks (eg, iatrogenic dissection).
      • Ultrasound with Color Doppler: Operator-dependent but helpful for serial follow-up of vessel remodeling.
    3. Additional Diagnostic Testing
      • Connective Tissue Disorders: Consider genetic counseling if physical exam, family history, or recurrent dissections suggest a monogenic disorder (eg, vascular Ehlers-Danlos).
      • Screening for Fibromuscular Dysplasia (FMD): Patients with CAD, especially those with hypertension or evidence of FMD in other vascular beds, may warrant renal artery imaging.
      • Aortic and Intracranial Imaging: Aortic root dilation and cerebral aneurysms may be more prevalent in CAD; consider advanced imaging (eg, MRA) based on clinical judgment.
  • Hyperacute and Acute Stroke Management
    1. Intravenous Thrombolysis (IVT):
      • IVT (alteplase or tenecteplase) remains reasonable for otherwise eligible acute ischemic stroke patients, with no specific evidence of higher hemorrhagic risk in CAD. Caution is advised if there is intracranial extension of the dissection or other significant bleeding risk factors.
    2. Mechanical Thrombectomy:
      • Recommended for large-vessel occlusion in CAD patients who meet standard thrombectomy criteria. Tandem lesions (extracranial dissection and intracranial occlusion) can be addressed via retrograde (intracranial first) or antegrade (extracranial first) approach, with similar overall outcomes reported.
    3. Acute or Subacute Stenting:
      • May be considered in selected cases of severe flow-limiting stenosis leading to distal hypoperfusion or in persistent ischemia despite optimal medical therapy. Stenting in tandem occlusions can improve reperfusion but carries added risks (in-stent restenosis, stent thrombosis, or need for dual antiplatelet therapy).
  • Antithrombotic Therapy for Secondary Stroke Prevention
    1. Rationale for Early Treatment:
      • Artery-to-artery embolization underpins most CAD-related ischemic events. Early initiation of antithrombotics (ideally within the first 24–72 hours) reduces further embolic risk.
    2. Choice of Agent: Antiplatelet vs Anticoagulant
      • When to Prefer Anticoagulation:
        • Patients with high-risk imaging features: severe stenosis (>50%–70%), intraluminal thrombus, occlusion, multiple or early recurrent dissections.
        • Traditional option is heparin bridging to Vitamin K antagonist (target INR ≈2–3), but direct oral anticoagulants (DOACs) can be considered based on patient profile and preference.
      • When to Prefer Antiplatelet Therapy:
        • Patients with lower stroke risk (no significant stenosis, no intraluminal thrombus) or higher bleeding risk (large infarct, hemorrhagic transformation, intradural extension).
        • Aspirin monotherapy is typical; a short course of dual antiplatelet therapy (aspirin + clopidogrel) for 21–90 days can be considered if minor stroke/TIA criteria apply and bleeding risk is acceptable.
    3. Practical Start-Up and Monitoring:
      • Begin therapy as soon as deemed safe, ideally after hemorrhagic complications are excluded.
      • For VKA: bridge with heparin (IV unfractionated or low–molecular-weight) for at least 5 days until INR is therapeutic for ≥24 hours.
      • Regularly monitor clinical response and, if relevant, INR in anticoagulated patients.
    4. Duration of Therapy:
      • Minimum 3–6 months of antithrombotics, with vessel imaging at follow-up (eg, 3 or 6 months) to assess for healing or persistent dissection.
      • Decisions to extend antithrombotic therapy past the 6-month mark may be considered in the context of an individual’s overall vascular risk factor profile and in the context of neuroimaging features as remodeling occurs.
      • Consider extended or indefinite therapy (often antiplatelet) if persistent stenosis, high-risk anatomic factors, or recurrent dissections occur.
  • Risk of Recurrent Dissection and Lifestyle Precautions
    • Recurrence rates range from 1% to 2% per year but are higher in the first few months post-dissection. Fibromuscular dysplasia and younger age are associated with increased recurrence risk.
    • It is reasonable to advise patients to avoid high-risk neck activities (eg, contact sports, extreme neck manipulation) for 1–6 months or until imaging confirms vessel healing. In those with a known connective tissue disorder or recurrent dissection, lifelong caution is appropriate.
  • Follow-Up Imaging and Management of Dissecting Aneurysms
    • Recanalization most often occurs by 6–12 months; persistent occlusions or stenoses beyond 12 months rarely recanalize further.
    • Dissecting aneurysms form or enlarge in some cases but seldom rupture. Antithrombotic choice does not appear to affect aneurysm resolution rates.
    • Endovascular or surgical interventions are reserved for enlarging or symptomatic aneurysms causing compression or other complications.

Conclusion: Cervical artery dissection warrants vigilant clinical recognition, prompt imaging, and individualized treatment strategies. Early antithrombotic therapy—whether anticoagulation or antiplatelet—plays a critical role in preventing stroke. Decisions should reflect both the patient’s hemorrhagic risk and the presence of imaging features predictive of stroke. Mechanical thrombectomy and, in selected cases, stenting are viable acute interventions for high-risk presentations. Although recurrences are uncommon, thoughtful follow-up imaging, patient education, and avoidance of high-risk neck activities are central to minimizing future dissections and optimizing outcomes.

Reference: Yaghi S, Engelter S, Del Brutto VJ, Field TS, Jadhav AP, Kicielinski K, Madsen TE, Mistry EA, Salehi Omran S, Pandey A, Raz E, on behalf of the American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Peripheral Vascular Disease. Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. Stroke. 2024;55(3). DOI: https://doi.org/10.1161/STR.0000000000000457

 

AGA Clinical Practice Update on Managing Portal Vein Thrombosis in Cirrhotic Patients: Expert Review

3 Jan, 2025 | 10:00h | UTC

Introduction: This summary highlights key recommendations from an AGA expert review on portal vein thrombosis (PVT) in cirrhotic patients. PVT is common in cirrhosis, with an estimated five-year incidence of around 11%, and may worsen portal hypertension and elevate mortality. Management is challenging because of limited evidence, the potential complications of both PVT and anticoagulation, and significant heterogeneity regarding clot characteristics, host factors, and cirrhosis severity. This review presents the latest guidance on identifying clinically relevant PVT, selecting anticoagulation, and considering endovascular interventions, including TIPS (transjugular intrahepatic portosystemic shunt).

Key Recommendations:

  1. No Routine Screening: Asymptomatic patients with compensated cirrhosis do not require regular screening for PVT in the absence of suggestive clinical changes.
  2. Imaging Confirmation: When Doppler ultrasound reveals suspected PVT, contrast-enhanced CT or MRI is recommended to confirm the diagnosis, exclude malignancy, and characterize clot extent and occlusion.
  3. Hypercoagulability Testing: Extensive thrombophilia workup is not indicated unless there is family or personal history of thrombotic events, or associated laboratory abnormalities.
  4. Intestinal Ischemia Management: Patients who develop PVT with evidence of intestinal ischemia should receive prompt anticoagulation and, ideally, multidisciplinary team care involving gastroenterology, hepatology, interventional radiology, hematology, and surgery.
  5. Observation of Minor or Recent Thrombi: In cirrhotic patients without ischemia, with recent (<6 months) thrombi that are <50% occlusive, close imaging follow-up every three months is a reasonable option to track potential spontaneous clot regression.
  6. Anticoagulation for Significant PVT: Consider anticoagulation for more extensive or obstructive (>50%) recent PVT, especially if the main portal vein or mesenteric vessels are involved. Candidates for liver transplantation and those with inherited thrombophilia may derive additional benefit.
  7. Chronic Cavernous PVT: Anticoagulation is generally not advised in patients with long-standing (>6 months) complete occlusion and well-formed collateral channels.
  8. Variceal Screening: Perform endoscopic screening or ensure prophylaxis for varices. Avoid delays in initiating anticoagulation, as timeliness is essential for better recanalization outcomes.
  9. Choice of Anticoagulant: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants (DOACs) are all viable options in cirrhosis. DOACs may be appropriate in well-compensated (Child-Turcotte-Pugh class A or certain class B) cirrhosis but should be avoided in class C. Treatment selection should consider patient preferences, monitoring feasibility, and risk of bleeding.
  10. Duration of Therapy: Reassess clot status with cross-sectional imaging every three months. Continue anticoagulation for transplant-eligible individuals who show partial or complete recanalization, and consider discontinuation in nonresponders after six months if futility is evident.
  11. TIPS Revascularization: Portal vein revascularization using TIPS may be pursued in patients who have other TIPS indications (like refractory ascites or variceal bleeding) or to improve transplant feasibility by recanalizing portal flow.

Conclusion: PVT in cirrhosis remains a complex clinical issue requiring careful evaluation of clot extent, timing, and the potential need for transplantation. The recommendations presented here underscore prompt imaging, timely anticoagulation for high-risk thrombi, and individualized therapy based on Child-Turcotte-Pugh classification and bleeding risk. When necessary, multidisciplinary collaboration is key to achieving optimal patient outcomes. Prospective randomized trials and standardized classifications of PVT will be instrumental in refining future guidelines.

Reference:
Davis JPE, Lim JK, Francis FF, Ahn J. AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review. Gastroenterology. 2024. DOI: http://doi.org/10.1053/j.gastro.2024.10.038

 

Large Language Models for Structured Reporting in Radiology: Past, Present, and Future

21 Dec, 2024 | 14:12h | UTC

Introduction/Context: Structured reporting (SR) has been a topic of discussion for decades as a way to standardize and improve the quality of radiology reports. Although there is evidence that SR can reduce errors and enhance guideline adherence, widespread adoption remains limited. Large language models (LLMs), transformer-based and trained on large volumes of text, have emerged as a promising solution to automate and facilitate structured radiology reporting. This narrative review provides an overview of LLM-based SR, while also discussing limitations, regulatory challenges, and future applications.

Key Points/Findings/Recommendations:

  1. Application of LLMs in Structured Reporting: Studies focus on models such as GPT-3.5 and GPT-4, showing promising results in converting free-text radiology reports into structured formats, including multilingual capabilities.
  2. Main Advantages:
    • Consistency and improved standardization of reports.
    • Potential to reduce errors and enhance comprehensiveness.
    • Streamlining the use of predefined templates and formats.
  3. Multilingual and Translational Capabilities: Research shows that several LLMs can process reports in different languages, promoting broader global collaboration.
  4. Technical Limitations: Hallucination (fabricated content), terminology inconsistencies, and misinterpretations remain hurdles to large-scale adoption.
  5. Regulatory and Privacy Challenges: Proprietary model opacity and a lack of regulated pathways pose difficulties for safely integrating these systems into clinical practice.

Implications for Practice:

  • Automation and Efficiency: LLMs can streamline the reporting process, reduce typing effort, and facilitate standardized descriptions, offering efficiency gains.
  • System Integration: Incorporation of LLMs into radiology systems (PACS, RIS) could help with documentation and report formatting, improving communication across teams.
  • Broader Clinical Perspective: Standardized reports may enhance information sharing and potentially patient safety, especially in multidisciplinary settings.

Limitations/Considerations:

  • Hallucination: Even advanced models may generate inaccurate or fictitious content unrelated to the evidence.
  • Lack of Transparency: Proprietary models often do not disclose their training data or algorithms, hindering external validation.
  • Evolving Regulations: The European Union and other countries are developing AI-specific legal frameworks. Meeting safety, reliability, and transparency requirements is critical for clinical use.
  • Availability of Open-Source Models: While open-source models offer more regulatory flexibility, they still require significant validation and refinement for clinical application.

Conclusion: LLMs have significant potential to transform structured radiology reporting, offering increased efficiency and accuracy. However, regulatory issues, model opacity, and current technical limitations must be addressed before these tools can be safely and effectively integrated into clinical practice. Future research should explore clinical acceptance of LLM-generated reports, compare them to radiologist-produced reports, and investigate how these models can be best integrated into existing systems.

Sources and Links:

 

RCT: Adjunctive Middle Meningeal Artery Embolization Reduces Reoperation in Subdural Hematoma

24 Nov, 2024 | 13:53h | UTC

Background: Subacute and chronic subdural hematomas are common neurosurgical conditions with a high recurrence rate after surgical evacuation, affecting 8% to 20% of patients. Middle meningeal artery embolization (MMAE) is a minimally invasive procedure targeting the blood supply to these membranes. Preliminary studies suggest that adjunctive MMAE may reduce hematoma recurrence, but its impact on reoperation risk remains unclear.

Objective: To determine whether adjunctive MMAE reduces the risk of hematoma recurrence or progression leading to repeat surgery within 90 days compared to surgery alone in patients with symptomatic subacute or chronic subdural hematoma.

Methods: In this prospective, multicenter, randomized controlled trial, 400 patients aged 18 to 90 years with symptomatic subacute or chronic subdural hematoma requiring surgical evacuation were randomly assigned to receive either MMAE plus surgery (n=197) or surgery alone (n=203). The primary endpoint was hematoma recurrence or progression leading to repeat surgery within 90 days after the index treatment. The secondary endpoint was deterioration of neurologic function at 90 days, assessed using the modified Rankin Scale.

Results: Hematoma recurrence or progression requiring repeat surgery occurred in 8 patients (4.1%) in the MMAE plus surgery group versus 23 patients (11.3%) in the surgery-alone group (relative risk, 0.36; 95% CI, 0.11 to 0.80; P=0.008). Functional deterioration at 90 days was similar between groups (11.9% vs. 9.8%; risk difference, 2.1 percentage points; 95% CI, −4.8 to 8.9). Mortality at 90 days was 5.1% in the MMAE group and 3.0% in the control group. Serious adverse events related to the embolization occurred in 4 patients (2.0%), including disabling stroke in 2 patients.

Conclusions: Adjunctive MMAE combined with surgery significantly reduced the risk of hematoma recurrence or progression requiring reoperation within 90 days compared to surgery alone. However, there was no significant difference in neurologic functional deterioration, and the procedure was associated with procedural risks.

Implications for Practice: MMAE may be considered as an adjunct to surgical evacuation in patients with subacute or chronic subdural hematoma to reduce reoperation risk. Clinicians should carefully weigh the potential benefits against the risks of procedural complications, including stroke.

Study Strengths and Limitations: Strengths include the randomized controlled design and multicenter approach, enhancing generalizability. Limitations involve the open-label design, introducing potential bias since the primary endpoint was based on surgeon judgment. A substantial loss to follow-up (13.2%) could affect results, and the study was not powered to detect differences in mortality or serious adverse events.

Future Research: Further studies with larger sample sizes are needed to fully evaluate the safety and efficacy of MMAE, including long-term outcomes. Research should focus on optimizing patient selection and assessing the procedure’s impact on mortality and serious adverse events.

Reference: Davies JM, et al. Adjunctive Middle Meningeal Artery Embolization for Subdural Hematoma. New England Journal of Medicine. 2024; DOI: http://doi.org/10.1056/NEJMoa2313472

 

Review: Endovascular Management of Acute Stroke

20 Oct, 2024 | 14:43h | UTC

Introduction: Stroke due to large vessel occlusion (LVO) remains a leading cause of disability and mortality worldwide. Endovascular therapy has revolutionized acute ischemic stroke management by enhancing recanalization rates and improving patient outcomes. This review outlines the evolution of endovascular treatments, expansion of therapeutic indications, current best practices, and ongoing research in the endovascular management of acute stroke.

Key Recommendations:

  1. Early Time Window Therapy (0–6 Hours): Robust evidence from randomized controlled trials demonstrates that mechanical thrombectomy significantly improves functional outcomes in patients with anterior circulation LVO presenting within 6 hours of symptom onset. Patients are selected based on moderate-to-severe neurological deficits and small infarct cores identified via imaging.
  2. Extended Time Window Therapy (6–24 Hours): Trials such as DAWN and DEFUSE3 have extended thrombectomy benefits to patients up to 24 hours after symptom onset. Advanced imaging techniques, like CT perfusion and MRI, identify patients with substantial penumbral tissue, indicating potential for recovery.
  3. Large Ischemic Core Infarcts: Recent studies (e.g., SELECT2, ANGEL-ASPECT) suggest that patients with large core infarcts can benefit from endovascular therapy, challenging previous contraindications. Individualized patient selection is crucial to balance risks and benefits.
  4. Basilar Artery Occlusion: New evidence supports thrombectomy for basilar artery occlusions, especially in patients with moderate-to-severe symptoms. This intervention improves outcomes in a condition historically associated with high morbidity and mortality.
  5. Bridging Thrombolysis: The necessity of intravenous thrombolysis before thrombectomy in patients directly admitted to endovascular centers is under debate. Meta-analyses indicate that omitting thrombolysis may not adversely affect outcomes, although it remains standard for patients at non-thrombectomy centers.
  6. Simplified Imaging for Patient Selection: The use of non-contrast CT and CT angiography alone has proven effective for patient selection, reducing treatment delays and expanding access to thrombectomy, particularly in resource-limited settings.

Conclusion: Advancements in endovascular therapy have markedly improved outcomes for patients with acute ischemic stroke due to LVO. Expanded treatment indications and simplified imaging protocols have broadened patient eligibility for thrombectomy. Ongoing research into adjunctive therapies and optimization of management strategies holds promise for further reducing stroke-related disability and mortality.

Reference: Nguyen TN, et al. (2024) Endovascular management of acute stroke. Lancet. DOI: http://doi.org/10.1016/S0140-6736(24)01410-7

 

RCT: MRI-Guided Biopsy Reduces Overdiagnosis of Clinically Insignificant Prostate Cancer

26 Sep, 2024 | 12:22h | UTC

Background: Overdiagnosis of clinically insignificant prostate cancer is a significant issue in population-based screening programs, primarily when prostate-specific antigen (PSA) testing is followed by systematic biopsy. Magnetic resonance imaging (MRI)-guided biopsies, which avoid systematic biopsies in men with negative MRI results, have shown potential in reducing unnecessary cancer diagnoses. However, long-term data are needed to confirm the safety and efficacy of this approach.

Objective: To evaluate whether MRI-targeted biopsies, when combined with PSA screening, can reduce the detection of clinically insignificant prostate cancer without compromising the identification of clinically significant or advanced disease.

Methods: This population-based, randomized trial in Sweden (GÖTEBORG-2) enrolled 13,153 men aged 50-60 years who underwent PSA screening. Men with PSA levels ≥3 ng/mL were randomized into two groups: (1) MRI-targeted biopsy only in cases with suspicious lesions, or (2) systematic biopsy in all cases with PSA elevation. Screening occurred every 2, 4, or 8 years depending on PSA levels, with follow-up for up to four years. The primary outcome was the detection of clinically insignificant prostate cancer, and secondary outcomes included clinically significant and advanced or high-risk prostate cancer.

Results: After a median follow-up of 3.9 years, the detection of clinically insignificant prostate cancer was significantly lower in the MRI-targeted biopsy group (2.8%) compared to the systematic biopsy group (4.5%), with a relative risk (RR) of 0.43 (95% CI, 0.32-0.57; P < 0.001). The relative risk of detecting clinically significant cancer was 0.84 (95% CI, 0.66-1.07), indicating no significant difference between the two groups. Advanced or high-risk cancers were detected in 15 men in the MRI group and 23 men in the systematic group (RR, 0.65; 95% CI, 0.34-1.24). Severe adverse events occurred in five patients (three in the systematic biopsy group, two in the MRI-targeted biopsy group).

Conclusions: Omitting biopsies in men with negative MRI results substantially reduced the diagnosis of clinically insignificant prostate cancer without increasing the risk of missing clinically significant or advanced cancers. MRI-targeted biopsy strategies can effectively limit overdiagnosis while maintaining safety in screening programs.

Implications for Practice: MRI-targeted biopsies offer a promising strategy to reduce unnecessary cancer diagnoses and avoid overtreatment in prostate cancer screening. Clinicians should consider integrating MRI into prostate cancer screening algorithms, especially in cases with elevated PSA but no MRI-detected lesions. This approach may also decrease biopsy-related complications and patient anxiety.

Study Strengths and Limitations: Strengths of this trial include its population-based design, large sample size, and thorough follow-up. Limitations include its single-center setting in Sweden, which may limit generalizability to more diverse populations, and a modest participation rate of 50%.

Future Research: Further studies should assess the cost-effectiveness of widespread MRI use in prostate cancer screening and explore its utility in diverse populations. Investigations into novel biomarkers that could further refine patient selection for MRI-targeted biopsy are also warranted.

Reference: Hugosson J., et al. (2024). Results after Four Years of Screening for Prostate Cancer with PSA and MRI. N Engl J Med. DOI: https://doi.org/10.1056/NEJMoa2406050

 

Retrospective Study: AI Tool Accurately Excludes Pathology in Up to 52.7% of Unremarkable Chest Radiographs with Low Critical Misses – Radiology

24 Aug, 2024 | 16:14h | UTC

Study Design and Population: This retrospective study assessed the effectiveness of a commercial AI tool in correctly identifying unremarkable chest radiographs, thus potentially reducing the workload in radiology departments. The study analyzed 1,961 chest radiographs from adult patients (median age: 72 years) across four Danish hospitals. The radiographs were labeled as remarkable or unremarkable by thoracic radiologists, and the AI tool’s performance was evaluated at varying sensitivity thresholds.

Main Findings: The AI tool demonstrated a specificity of 24.5% to 52.7% at sensitivity thresholds of 99.9% to 98.0%, respectively, effectively excluding pathology in unremarkable chest radiographs. At sensitivities of 95.4% or higher, the AI had equal or lower rates of critical misses compared to radiology reports, with the AI missing only 2.2% of critical findings compared to 1.1% by radiologists at similar sensitivity levels.

Implications for Practice: The results suggest that AI tools could autonomously report up to 52.7% of unremarkable chest radiographs, potentially reducing radiologist workload without compromising patient safety. However, prospective studies are necessary to confirm these findings and optimize AI deployment in clinical practice.

Reference: Plesner LL, Müller FC, Brejnebøl MW, et al. (2024). Using AI to Identify Unremarkable Chest Radiographs for Automatic Reporting. Radiology, 312(2), e240272. DOI: https://doi.org/10.1148/radiol.240272

 

Cohort Study: One-Fourth of MS Relapses Occur Without MRI Activity, Highlighting ACES Phenomenon – JAMA Neurol

18 Aug, 2024 | 19:16h | UTC

Study Design and Population: This multicenter observational cohort study examined 637 clinical relapse events in 608 patients with relapsing-remitting multiple sclerosis (RRMS) from the French MS registry, spanning January 2015 to June 2023. The study included relapses with brain and spinal cord MRI performed within 12-24 months before and 50 days after the event.

Main Findings: Approximately 26% of relapses were classified as acute clinical events with stable MRI (ACES), showing no new T2 or gadolinium-enhanced T1 lesions. ACES were more likely in patients on highly effective disease-modifying therapies (DMTs), with longer disease duration, or with fatigue. ACES were associated with increased rates of relapse, confirmed disability accrual, and progression to secondary progressive MS, though their MRI stability was unaffected by DMTs.

Implications for Practice: The study suggests that MRI alone may not fully capture disease activity in RRMS, highlighting the need for comprehensive clinical assessment in therapeutic decision-making and clinical trial designs.

Reference: Gavoille, A., Rollot, F., Casey, R., et al. (2024). Acute clinical events identified as relapses with stable magnetic resonance imaging in multiple sclerosis. JAMA Neurology, 81(8), 814-823. DOI: 10.1001/jamaneurol.2024.1961.

 

Retrospective Cohort Study: Rheumatoid Arthritis Linked to Over 50% Increased Lung Cancer Risk, with a Three-Fold Risk in RA-Associated Interstitial Lung Disease – Arthritis Rheumatol

18 Aug, 2024 | 18:58h | UTC

Study Design and Population: This retrospective matched cohort study examined the risk of lung cancer in 72,795 patients with rheumatoid arthritis (RA) and 757 patients with RA-associated interstitial lung disease (RA-ILD) from the Veterans Health Administration database, compared with 633,937 non-RA controls. The study spanned from 2000 to 2019, with patients matched on age, gender, and enrollment year.

Main Findings: The study found that RA was associated with a 58% increase in lung cancer risk (adjusted hazard ratio [aHR] 1.58). The risk was significantly higher in RA-ILD patients, with a more than three-fold increase (aHR 3.25) compared to non-RA controls. Even among never smokers, RA patients showed a 65% increased lung cancer risk, indicating that factors beyond smoking contribute to the elevated risk.

Implications for Practice: The study underscores the significant increase in lung cancer risk among patients with RA, particularly those with RA-ILD. While this elevated risk is notable, further research is necessary to determine the most effective strategies for monitoring and managing this risk. Clinicians should be aware of these findings and consider them when evaluating the overall health and risk factors of patients with RA, especially those with additional pulmonary complications like ILD. Enhanced awareness and individualized risk assessments may help in early detection and management of lung cancer in this high-risk population.

Reference: Brooks RT, Luedders B, Wheeler A, et al. (2024). The Risk of Lung Cancer in Rheumatoid Arthritis and Rheumatoid Arthritis–Associated Interstitial Lung Disease. Arthritis & Rheumatology, 0(0), 1-9. DOI: 10.1002/art.42961.

 

Study Shows High Prevalence of Solid Lung Nodules in Nonsmoking Adults – Radiology

14 Aug, 2024 | 13:14h | UTC

Study Design and Population: This cohort study examined the prevalence and size distribution of solid lung nodules in a nonsmoking population from the Northern Netherlands. A total of 10,431 participants aged 45 years and older, predominantly nonsmokers, were included in the Imaging in Lifelines (ImaLife) study. The study utilized low-dose chest CT scans to detect and measure lung nodules.

Main Findings: Lung nodules were present in 42% of participants, with a higher prevalence in males (47.5%) than females (37.7%). The prevalence of clinically relevant nodules (≥100 mm³) was 11.1%, and actionable nodules (≥300 mm³) were found in 2.3% of individuals. Both prevalence and nodule size increased with age, and male participants consistently showed a higher prevalence and larger nodule sizes compared to females.

Implications for Practice: While 42% of nonsmoking adults in this Northern European cohort were found to have solid lung nodules, the incidence of lung cancer within this population is notably low. This suggests that many of the clinically relevant and even actionable nodules identified in nonsmokers are likely benign. These findings highlight the need to refine nodule management strategies for individuals at low risk of lung cancer, potentially reducing unnecessary follow-up and interventions in nonsmoking populations. Future research on lung cancer outcomes in this cohort could further inform and optimize guidelines for nodule management in low-risk groups.

Reference: Cai, J., Vonder, M., Pelgrim, G. J., Rook, M., Kramer, G., Groen, H. J. M., de Bock, G. H., & Vliegenthart, R. (2024). Distribution of solid lung nodules: Presence and size by age and sex in a Northern European nonsmoking population. Radiology, 312(2), e231436. DOI: 10.1148/radiol.231436.

 

RCT: Eliminating Fasting Before Contrast-Enhanced CT in Outpatients Reduces Nausea and Vomiting Without Increasing Acute Adverse Reactions – Insights Imaging

11 Aug, 2024 | 13:41h | UTC

Study Design and Population: This single-center, randomized clinical trial was conducted in Spain with 1,103 adult outpatients undergoing non-emergency contrast-enhanced CT scans. Patients were randomized into two groups: one group fasted for at least 6 hours (control), while the other group had no food restrictions (intervention). The primary aim was to assess whether eliminating fasting affects the incidence of acute adverse reactions (AARs), such as nausea and vomiting.

Main Findings: The study found no significant difference in the overall incidence of acute adverse reactions between the fasting and non-fasting groups (3.21% vs. 2.30%; p = 0.36). However, the non-fasting group had a significantly lower incidence of nausea and vomiting (0.92% vs. 2.86%; p = 0.02). Multivariate logistic regression identified fasting, age, allergies, neurological diseases, and contrast media concentration as independent risk factors for nausea and vomiting.

Implications for Practice: The findings suggest that the traditional practice of fasting before contrast-enhanced CT scans is unnecessary and may increase the risk of nausea and vomiting. Therefore, unrestricted food intake should be allowed for most contrast-enhanced CT exams, reserving fasting only for specific imaging procedures.

Reference: Zitan Saidi et al. (2024). Fasting before contrast-enhanced CT and the incidence of acute adverse reactions: a single-center randomized clinical trial. Insights into Imaging, 15(195). DOI: 10.1186/s13244-024-01767-9.

 

IDSA 2024 Guidelines for Managing Complicated Intra-abdominal Infections – Clin Infect Dis

10 Aug, 2024 | 22:10h | UTC

Introduction: The Infectious Diseases Society of America (IDSA) has updated its clinical practice guidelines for managing complicated intra-abdominal infections in adults, children, and pregnant individuals. The update focuses on risk assessment, diagnostic imaging, and microbiological evaluation, with recommendations grounded in systematic literature reviews and the GRADE approach for rating evidence.

Key Points:

1 – Risk Stratification:

– For adults with complicated intra-abdominal infections, the APACHE II score is recommended for risk stratification within 24 hours of hospital or ICU admission. The WSES Sepsis Severity Score is an acceptable alternative.

– No specific severity scoring system is recommended for pediatric patients.

2 – Diagnostic Imaging for Appendicitis:

– In non-pregnant adults, CT is suggested as the initial imaging modality for suspected acute appendicitis.

– For children, an abdominal ultrasound (US) is preferred initially, with MRI or CT recommended if the US is inconclusive.

– In pregnant individuals, US or MRI can be considered, with MRI suggested if initial US results are inconclusive.

3 – Imaging for Acute Cholecystitis and Cholangitis:

– For non-pregnant adults, US is recommended initially. If inconclusive, a CT scan is suggested.

– For pregnant individuals, US or MRI can be used, but the guidelines do not specify a preferred modality due to a knowledge gap.

4 – Blood Cultures:

– Blood cultures are recommended in adults and children with suspected intra-abdominal infections presenting with severe symptoms such as hypotension or tachypnea, especially when antibiotic-resistant organisms are a concern.

– Routine blood cultures are not recommended for patients without these risk factors.

5 – Intra-abdominal Fluid Cultures:

– In complicated intra-abdominal infections requiring source control procedures, obtaining intra-abdominal cultures is advised to guide antimicrobial therapy.

– In uncomplicated appendicitis cases, routine cultures are not recommended unless the patient is immunocompromised or complicated disease is suspected during surgery.

Conclusion: These guidelines provide evidence-based recommendations to improve the management of complicated intra-abdominal infections, emphasizing appropriate risk stratification, targeted diagnostic imaging, and the selective use of cultures to guide therapy.

Reference: Bonomo, R. A., et al. (2024). “2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation in Adults, Children, and Pregnant People.” Clinical Infectious Diseases. DOI: 10.1093/cid/ciae346.

 

Retrospective Study: Automated Multiorgan CT Markers Predict Diabetes and Cardiometabolic Comorbidities – Radiology

10 Aug, 2024 | 21:36h | UTC

Study Design and Population: This retrospective study analyzed data from 32,166 Korean adults (mean age, 45 years) who underwent health screenings, including fluorodeoxyglucose PET/CT scans, between 2012 and 2015. The study aimed to evaluate the predictive ability of automated CT-derived markers, such as visceral and subcutaneous fat, muscle area, bone density, liver fat, and aortic calcification, for diabetes and associated cardiometabolic conditions.

Main Findings: Visceral fat index showed the highest predictive performance for both prevalent and incident diabetes, with an AUC of 0.70 for men and 0.82 for women in cross-sectional analyses. Combining visceral fat, muscle area, liver fat, and aortic calcification improved prediction, yielding a C-index of 0.69 for men and 0.83 for women. Additionally, the study found that these CT markers were effective in identifying metabolic syndrome, fatty liver, coronary artery calcium scores >100, sarcopenia, and osteoporosis, with AUCs ranging from 0.80 to 0.95.

Implications for Practice: Automated CT-derived markers can effectively predict diabetes and multiple cardiometabolic comorbidities, surpassing traditional anthropometric measures. These findings suggest that integrating such automated assessments into routine clinical practice could enhance risk stratification and preventive care, particularly through opportunistic screening during routine CT scans.

Reference: Chang Y, Yoon SH, Kwon R, et al. (2024). Automated Comprehensive CT Assessment of the Risk of Diabetes and Associated Cardiometabolic Conditions. Radiology, 312(2), e233410. DOI: https://doi.org/10.1148/radiol.233410.

 

Deep Learning Model Noninferior to Radiologists in Detecting Clinically Significant Prostate Cancer at MRI – Radiology

10 Aug, 2024 | 21:31h | UTC

Study Design and Population: This retrospective study evaluated the performance of a deep learning (DL) model for detecting clinically significant prostate cancer (csPCa) using multiparametric MRI (mpMRI) images from 5215 patients (5735 examinations) with a mean age of 66 years. The study included patients who underwent prostate MRI between January 2017 and December 2019 at a single academic institution. The DL model was trained on T2-weighted, diffusion-weighted, and contrast-enhanced MRI sequences, with pathologic diagnosis as the reference standard.

Main Findings: The DL model achieved an area under the receiver operating characteristic curve (AUC) of 0.89 on the internal test set and 0.86 on an external test set, demonstrating noninferiority to radiologists, who had AUCs of 0.89 and 0.84, respectively. Additionally, the combination of the DL model and radiologists improved diagnostic performance (AUC of 0.89). Gradient-weighted class activation maps (Grad-CAMs) effectively localized csPCa lesions, overlapping with true-positive cases in 92% of internal test set and 97% of external test set cases.

Implications for Practice: The DL model showed comparable performance to experienced radiologists in detecting csPCa at MRI, suggesting its potential to assist radiologists in improving diagnostic accuracy and reducing interobserver variability. Future research should focus on integrating the model into clinical workflows and assessing its impact on biopsy targeting.

Reference: Cai JC, Nakai H, Kuanar S, et al. (2024). Fully Automated Deep Learning Model to Detect Clinically Significant Prostate Cancer at MRI. Radiology, 312(2): e232635. DOI: https://doi.org/10.1148/radiol.232635.

 

Cohort Study: Efficacy of first-line color doppler ultrasound in diagnosing giant cell arteritis – Ann Intern Med

25 May, 2024 | 19:39h | UTC

This prospective multicenter study aimed to evaluate the efficacy of using color Doppler ultrasound of the temporal arteries as the first-line diagnostic tool for Giant Cell Arteritis (GCA) in 165 elderly patients with high clinical suspicion of the disease. The study followed participants over two years, comparing ultrasound results with temporal artery biopsy (TAB) and physician-based clinical diagnosis including other imaging tests. Key findings indicate that ultrasound confirmed GCA in 44% of cases, which was higher compared to TAB (17%) and clinical expertise (21%). The study showed that using ultrasound first can avoid the need for further invasive tests like TAB in patients with positive ultrasound results. The limitations of the study include its small sample size, unblinded test results, and the absence of a universally accepted objective diagnostic standard. However, it highlights the potential of ultrasound in the early and non-invasive diagnosis of GCA, potentially reducing the risk of severe complications by expediting treatment initiation.

 

Reference (link to abstract – $ for full-text):

Guillaume Denis et al. (2023). Diagnostic Strategy Using Color Doppler Ultrasound of Temporal Arteries in Patients With High Clinical Suspicion of Giant Cell Arteritis: A Prospective Cohort Study. Annals of Internal Medicine. DOI: 10.7326/M23-3417.

 

Meta-Analysis: Efficacy of MRI in prostate cancer screening for reducing unnecessary biopsies

28 Apr, 2024 | 20:13h | UTC

This meta-analysis evaluated the effectiveness of incorporating magnetic resonance imaging (MRI) into prostate cancer screening pathways, compared to prostate-specific antigen (PSA)–only screening strategies. Analyzing data from 80,114 men across 12 studies, the findings demonstrate that MRI-based screening, particularly when using a sequential approach and a PI-RADS score ≥3 cutoff for biopsy, significantly increases the odds of detecting clinically significant prostate cancers (OR, 4.15) while reducing unnecessary biopsies (OR, 0.28) and detection of clinically insignificant cancers (OR, 0.34). Implementing a higher PI-RADS score of ≥4 further decreased the detection of insignificant cancers and biopsies performed, without impacting the detection rate of significant cancers. These results support the integration of MRI into screening programs to enhance diagnostic precision and reduce patient harm.

 

Reference (link to abstract – $ for full-text):

Tamás Fazekas et al. (2024). Magnetic Resonance Imaging in Prostate Cancer Screening:  A Systematic Review and Meta-Analysis. JAMA Oncol, Published online April 5, 2024. DOI: 10.1001/jamaoncol.2024.0734

 

Pictorial Review | Watch out for the early killers: imaging diagnosis of thoracic trauma

9 Aug, 2023 | 15:02h | UTC

Watch Out for the Early Killers: Imaging Diagnosis of Thoracic Trauma – Korean Journal of Radiology

 

Pictorial Review | Occupational lung diseases: spectrum of common imaging manifestations

9 Aug, 2023 | 14:51h | UTC

Occupational Lung Diseases: Spectrum of Common Imaging Manifestations – Korean Journal of Radiology

 

Determination of “borderline resectable” pancreatic cancer – A global assessment of 30 shades of grey

8 Aug, 2023 | 13:22h | UTC

Determination of “borderline resectable” pancreatic cancer – A global assessment of 30 shades of grey – HPB

 

Commentary on Twitter

 

RCT | Mammography screening with AI reduces workload by 44.3% without loss in detection efficacy

4 Aug, 2023 | 12:13h | UTC

Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study – The Lancet Oncology (link to abstract – $ for full-text)

News Release: First randomized trial finds AI-supported mammography screening is safe and almost halves radiologist workload – Lancet

Commentaries:

Large Mammography Study Shows Significant Benefits with AI-Aided Screening – Diagnostic Imaging

Expert reaction to interim safety analysis of randomised trial on AI-supported mammography screening – Science Media Centre

 

Study | AI use in lung cancer screening enhances prediction of lung cancer death, CVD death, and all-cause death

1 Aug, 2023 | 14:31h | UTC

AI Body Composition in Lung Cancer Screening: Added Value Beyond Lung Cancer Detection – Radiology (free for a limited period)

Commentary: Study: AI Assessment of Chest CT May Predict Multiple Mortality Risks – Diagnostic Imaging

 

Study | New deep learning model effectively detects type 2 diabetes from chest X-rays

28 Jul, 2023 | 14:15h | UTC

Opportunistic detection of type 2 diabetes using deep learning from frontal chest radiographs – Nature Communications

 

Commentary on Twitter

 

New Cochrane handbook for systematic reviews of diagnostic test accuracy

25 Jul, 2023 | 14:02h | UTC

Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy – Cochrane Library

Editorial: Evaluating medical tests: introducing the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy – Cochrane Library

News Release: Introducing the new Cochrane Handbook for Diagnostic Test Accuracy – Cochrane Library

 

Consensus Paper | Lung ultrasound in acute and chronic heart failure

24 Jul, 2023 | 13:06h | UTC

Lung ultrasound in acute and chronic heart failure. A Clinical Consensus Statement of the European Association of Cardiovascular Imaging (EACVI) – European Heart Journal – Cardiovascular Imaging

 

Review | Radiomics-based fertility-sparing treatment in endometrial carcinoma

24 Jul, 2023 | 13:00h | UTC

Radiomics-based fertility-sparing treatment in endometrial carcinoma: a review – Insights into Imaging

 

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