Research Presentation Session: Emergency Imaging

RPS 1317 - Hot topics in emergency radiology

March 1, 09:30 - 11:00 CET

7 min
Automated torso CT haemorrhage burden: a novel precision-medicine decision support tool for transfusion in trauma patients
Nathan Sarkar, Baltimore / United States
Author Block: N. Sarkar, L. Zhang, M. Unberath, U. Bodanapally, J. Hu, G. Li, O. Turan, A. Corkum, D. Dreizin; Baltimore, MD/US
Purpose: Torso haemorrhage is a leading cause of preventable death in traumatic injury and can be precisely quantified on whole-body CT using deep learning segmentation methods. Prior studies have shown that quantitative assessment of haemorrhage burden in individual body cavities is associated with transfusion requirement. The purpose of this study is to examine total torso CT haemorrhage burden (tCTHB) in the thorax, abdomen, and pelvis as a predictor of massive transfusion (MT).
Methods or Background: A dataset of 5060 trauma CT scans was used to select patients with hemothorax, haemoperitoneum, pelvic haematoma, or combinations thereof (n=593). A state-of-the-art deep learning method (nnU-net) was used to derive segmentation masks and volumes. tCTHB was calculated as the sum total of segmented torso haemorrhage in mL. MT, defined as at least 10 packed red blood cells (PRBCs) in 24 hours, served as the outcome. The area under curve (AUC) of shock index (SI) + tCTHB was compared to that of SI alone. Optimal tCTHB cutoff was determined by Youden J index. Spearman correlations between PRBCs and volumes were determined for tCTHB and individual intracavitary haemorrhage types.
Results or Findings: The AUC of SI + tCTHB (0.86 [95% CI: 0.75-0.97]) was higher (p=0.02) than the AUC of SI alone (0.67 [95% CI: 0.50-0.84]). 363 mL served as an optimal cut-off at peak Youden J index. The sensitivity and specificity of SI>1 and tCTHB>363 mL was 90% and 81%, whereas SI>1 alone had sensitivity and specificity of 50% and 91%. Spearman’s r was moderate for tCTHB (0.42), low for haemorrhage volume in individual compartments (0.12-0.23), and low for SI (0.28).
Conclusion: tCTHB is a promising precision medicine marker for predicting massive transfusion, significantly improving accuracy over shock index alone.
Limitations: No limitations were identified.
Funding for this study: Funding was received from NIH K08 Grant EB027141-01A1.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was reviewed and approved by the University of Maryland Baltimore Institutional Review Board (UMB IRB). It was determined by the UMB IRB to be exempt from the need for informed consent due to no more than minimal risk to patients.
7 min
Coronary calcification score in polytrauma CT of severely injured polytrauma patients as a prognostic factor for hospital mortality and intensive care unit treatment
Hans-Jonas Meyer, Leipzig / Germany
Author Block: H-J. Meyer, T. Dermendzhiev, T. Denecke, M. Struck; Leipzig/DE
Purpose: Coronary artery calcifications defined by computed tomography (CT) provide prognostic relevance for vascular disorders and coronary heart disease, whereas their prognostic relevance in severely injured trauma patients remains unclear.
Methods or Background: All consecutive trauma patients requiring emergency tracheal intubation before initial computed tomography at a level-1 trauma centre over a 12-year period (2008-2019) were reanalysed. The Weston score, a semiquantitative method to quantify the coronary calcifications, was evaluated as prognostic variable based upon whole-body trauma CT analysis.
Results or Findings: 458 patients (75% male) with a median age of 49 years, median injury severity score (ISS) of 26, and in-hospital mortality rate of 23.1% met the inclusion criteria and were analysed. Coronary artery calcification was present in 214 patients (46.7%). After adjustment with age, ASA classification ≥ III, ISS abbreviated injury scale head, and shock, the Cox proportional hazard model identified the Weston score as independent predictor for 24- hour-, 30- day-, and in-hospital mortality (HR 1.2, 95% CI 1.08 – 1.34, p= 0.001; HR 1.09, 95% CI 1.02 – 1.18, p= 0.017; and HR 1.1, 95% CI 1.02 – 1.18, p= 0.012, respectively).
Conclusion: CT-derived coronary calcification was significantly associated with hospital mortality in intubated polytrauma patients. In the subgroup of survivors, it was significantly associated with ICU LOS but not with mechanical ventilation duration.
Limitations: First, it is a single-centre retrospective study. Second, only patients requiring tracheal intubation and who underwent whole-body CT were included in this analysis. Third, although the Weston score is a semiquantitative imaging analysis, we cannot exclude investigator- related bias.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The retrospective analysis was approved by the Ethical Committee at the Medical Faculty, Leipzig University, Leipzig, Germany, (IRB00001750, project ID 441/15ek, September 14, 2020).
7 min
Prevalence and extent of blunt cervical vascular injury (BCVI): a longitudinal single-centre study over 19 years
Bianca Mazini, Lausanne / Switzerland
Author Block: B. Mazini, S. Sanson, V. Dunet, A. Denys, S. Schmidt; Lausanne/CH
Purpose: To aim of this study was to assess the prevalence and extent of blunt cervical vascular injury (BCVI) in the context of high energy trauma, and to analyse the associated radiological findings, immediate clinical management and patients’ outcome according to the extent of BCVI.
Methods or Background: This single-center retrospective study included 89 consecutive patients with acute BCVI proven by computed tomography angiography-(CTA), that were selected from 8053 polytrauma patients addressed to our emergency department within 19 years. Two radiologists blinded to all clinical information jointly reviewed images regarding location and extent of BCVI, associated radiological findings and cerebral complications (stroke). Epidemiological and clinical data, and outcomes were retrieved from patients’ medical records. Univariate and multivariate statistical analysis were performed. A p-value <0.05 was considered statistically significant.
Results or Findings: The prevalence of BCVI in our polytrauma population was 1.15% (26 females, mean age 46 years). In the 89 patients with BCVI 119 cervical arterial dissections were found. In 23 patients (25.8%) acute stroke was associated; overall mortality was 19% (n = 17). Patients’ mortality was significantly predicted by clinical factors (Glasgow coma scale, and intubation at arrival), and radiological features, such as a higher grade of vascular injury and exact length of left vertebral artery dissection. In 61 (68.5%) patients with cervical fractures the vascular injury was adjacent. However, 28 (31.5%) arterial injuries were not associated with any bone fracture.
Conclusion: BCVI is a rare but serious complication of high energy cervical trauma, with high rate of morbidity and mortality. Systematic screening of the cervical arteries with angio-CT seems necessary in all polytrauma patients since >30% of cervical arterial lesions are not associated with nearby bone fractures.
Limitations: This is a retrospective study.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable.
7 min
Computed tomography imaging in earthquake trauma patients with crush syndrome and different levels of creatine kinase: is there a correlation with renal enhancement?
Sezer Nil Yılmazer Zorlu, Ankara / Turkey
Author Block: S. N. Yılmazer Zorlu, M. Kul, A. Gürsoy Çoruh; Ankara/TR
Purpose: The objective of this study was to investigate whether varying serum creatine kinase (CK) levels in patients with crush syndrome have an impact on renal enhancement on computed tomography (CT) even in cases where renal injury is not clinically evident.
Methods or Background: Portovenous phase abdominopelvic CT scans of earthquake (Turkey, February 2023) survivors and of patients without involvement in the earthquake and with preserved renal function (control group) were retrospectively analysed. Attenuation measurements were made from the cortex and medulla of the left kidney at the level of renal hilus, abdominal aorta (level of renal artery origin) and main portal vein. The medulla-to-cortex ratio was normalised to the contrast phase using the formula: nM/C-R= (Medulla Attenuation/Cortex Attenuation)/ (Portal Vein Attenuation/Aorta Attenuation). Renal cortex/aorta (C/A) attenuation ratio was also calculated.
Earthquake survivors were categorised by serum CK levels into risk groups for acute kidney injury (AKI) (high-risk group:≥773 U/l, low-risk group:<773 U/l).
CT findings were compared between groups and correlations with laboratory findings were made.
Results or Findings: In the earthquake survivor group 33 patients were in the low-risk and 12 in the high-risk category for AKI. The control group consisted of 50 patients. None of the 95 patients had impaired renal function.
Though no significant age, gender, nC/M-R and creatinine value differences were found (p> 0,05), the high-risk group had significantly lower renal C/A attenuation ratios than the low-risk and control groups (p= 0.043; p= 0.023, respectively).
There was a negative correlation between CK and C/A attenuation ratios and a positive correlation between calcium levels and C/A attenuation ratios. The nC/M-R and serum levels for creatinine, potassium and CK did not significantly correlate.
Conclusion: Even in the absence of clinically evident AKI, cortical enhancement is diminished in patients with crush syndrome with higher CK levels.
Limitations: Laboratory follow up of patients could not be made.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Research Ethics Committee of Ankara University Faculty of Medicine.
7 min
Portal venous contrast enhancement ratio of the adrenal glands and spleen as prognostic marker of mortality in patients with acute mesenteric ischaemia
Felix Alexander Pfister, Leipzig / Germany
Author Block: F. A. Pfister, M. Mehdorn, C. Schwartner, D. Seehofer, H-M. Tautenhahn, M. Struck, T. Denecke, H-J. Meyer; Leipzig/DE
Purpose: Contrast enhancement of the adrenal gland defined by computed tomography (CT) was previously analysed as a prognostic factor for critically ill patients due to various diseases. However, no study investigated this quantitative parameter in patients with acute mesenteric ischaemia, a potentially lethal disease. Therefore, the aim of this study was to evaluate the prognostic value of the contrast enhancement of the adrenal glands in patients with clinically suspected AMI.
Methods or Background: All patients with clinically suspected AMI were retrospectively assessed between 2016 to 2020. All patients underwent surgical exploration. Overall, 134 patients (52 female patients, 38.8%) with a mean age of 69.2 ± 12.4 years were included into the present analysis. For all patients, the preoperative CT was used to calculate the contrast media enhancement of the adrenal glands and the spleen.
Results or Findings: Overall, 27 (20.1%) patients died within the 24-hour period, and 94 (70.1%) within 30 days. There were statistically significant differences regarding the mean values for adrenal-to-spleen ratio for 24h-mortality (p= 0.001) and 30-day mortality (p= 0.004), whereas the radiodensity of the inferior vena cava and the radiodensity of the spleen was statistically significant between survivors and non-survivors after 30-days (p= 0.037 and p= 0.028, respectively). In cox regression analysis mean adrenal radiodensity was associated with mortality after 24h with an HR of 1.09 (95% CI 1.02-1.16, p= 0.01).
Conclusion: The contrast media enhancement of the adrenal gland is associated with the 24h- and 30-day mortality in patients with AMI. However, the identified associations are worse compared to previous analyses regarding other critical diseases.
Limitations: First, it is a retrospective single-centre study with known inherent bias. Second, despite the quantitative nature of the measurements, there can still be some intrareader variability.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable.
7 min
Comparison of brain injury in patients with and without facial fractures
Iulia Tatiana Lupașcu, Bucharest / Romania
Author Block: I. T. Lupașcu, S. Hostiuc, C. Adrian, B. Popa, C. A. Minoiu; Bucharest/RO
Purpose: This study aimed to examine the association between facial fractures and brain injury and to compare brain injuries in facial fracture patients with non-facial fracture patients.
Methods or Background: Cerebral CT of 492 polytrauma patients, who were admitted to the hospital between January 2019 to July 2023, were retrospectively evaluated.
Results or Findings: From the total of 492 patients, 129 (26%) had facial fractures (102 men, 27 women, mean age 45 ±,17 years) and 363 (74%) were without facial fractures (253 men, 110 female, mean age 46 ±,17 years).
Facial fractures were significantly correlated with brain injuries (p< .001), showing a greater incidence of brain lesions (54%, n= 68), compared to the non-facial fractures group (31%, n= 111). Subdural hematoma was the most frequent lesion (29%, n= 44) in the facial fracture group, while intracerebral haemorrhage was the most frequent lesion (33%, n= 73) in the non-facial fracture group.
The zygomatic bone was the most frequently fractured (28%, n= 67) and it was significantly correlated to the presence of intracerebral haemorrhage, subdural and subarachnoid haemorrhage, but also with pneumocephalus and diffuse brain swelling (p< .05).
Frontal sinus fracture (12%, n= 29) and its right or left side location were correlated with the presence and location of epidural haematoma and intracerebral haemorrhage (p< .05).
Maxillary fractures were observed in 27% (n= 65) patients, nasal bones in 25% (n= 58) and mandible fractures in 8% (n= 19).
In the facial fractures group, diffuse brain swelling was present in 18% (n= 23) patients, pneumocephalus in 10% (n= 12) and brain herniation in 6% (n= 8), while in the non-facial fractures group, diffuse brain swelling was observed in 7% (n= 27), pneumocephalus in 2% (n= 6) and brain herniation in 3% (n= 10) of patients.
Conclusion: There is a significant association between facial fractures and traumatic brain injury, with zygomatic bone being the most frequently fractured and subdural hematoma the most associated brain lesion.
Limitations: The limitation of the study was the retrospective design.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable.
7 min
Assessment of Syngo.CT LVO: detection in photon counting CT and conventional CT
Jan Boriesosdick, Porta Westfalica / Germany
Author Block: J. Boriesosdick, N. Haag, S. Saeed, C. Mönninghoff, J. Borggrefe, J. R. Kroeger; Minden/DE
Purpose: Syngo.CT LVO detection (SIEMENS Healthineers) is a prototype for AI-assisted detection of large vessel occlusion in the anterior circulation area in patients with suspected ischaemic stroke. We investigated the sensitivity and specificity of the algorithm in photon counting CT (PCCT; NAEOTOM Alpha) and conventional CT (SOMATOM GoTop/X.ceed/GoAll). Furthermore, we investigated whether there were differences in detection rate between proximal (internal carotid artery, M1 segment of middle cerebral artery) and distal (M2 segment) vessel occlusions.
Methods or Background: We retrospectively analysed 443 cases with CT-Angiography of the head (Bv44-Kernel) with Syngo.CT LVO Detection. 176 cases showed vascular occlusion in the anterior circulation area. 150 cases were investigated with the PCCT with a total of 50 occluded vessels, 293 cases were investigated in conventional CT scanners with a total of 126 occluded vessels.
Results or Findings: The algorithm showed an overall sensitivity of 70.5% and a specificity of 98.5%. Thereby, we found significant differences (p= 0.013) in sensitivity between PCCT (84%) and conventional CT (65.1%). Proximal vessel occlusions were detected significantly better than M2- occlusions in all scanners with a sensitivity of 86.2% versus 26.1% (p< 0.001). While sensitivity regarding proximal vessel occlusions did not differ significantly between scanners (90.2% versus 84.3%; p= 0.359), sensitivity regarding M2- occlusions showed a significant difference in favor of PCCT (55.6% versus 18.9%; p= 0.039).
Conclusion: Syngo.CT LVO detection could assist radiologists in the rapid detection of large vessel occlusions as a triage tool in clinical routine. Thereby, the algorithm seems to work better with PCCT data, especially for M2-occlusions, probably due to a higher image quality compared to conventional detectors. Overall, the algorithm should be further trained specifically regarding the detection of M2- occlusions.
Limitations: The sign of the study was monocentric, and cases were prone to selection bias. Furthermore, there were only a few cases with M2- occlusions in PCCT.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Ethics Committee of the Ruhr-University Bochum (19 July 2021, reference number 2021-827).
7 min
Incidence of contrast-induced acute kidney injury (CI-AKI) in trauma patients undergoing contrast-enhanced computed tomography using iso-osmolar contrast agent
Minji Gim, Suwon-si, Gyeonggi-do / Korea, Republic of
Author Block: M. Gim, H. S. Lee, K. Lee, J. K. Kim, J. Huh; Suwon/KR
Purpose: In trauma patients, no report has been published on the preventive effect of iso-osmolar contrast agent for contrast-induced acute kidney injury (CI-AKI). We aimed to evaluate the incidence and severity of CI-AKI, and its predictive factors in trauma patients.
Methods or Background: From the trauma registry in a regional trauma centre in Korea, patients who underwent CT scans with iodixanol and were followed up for at least 72 hours were consecutively included. Patient demographic details, co-morbidities, and laboratory test results were collected. CI-AKI was defined by the 2012 kidney disease improving global outcomes guideline. The severity of CI-AKI was classified by the RIFLE criteria. Trauma severity was assessed by the injury severity score (ISS) category. Predictive factors of CI-AKI were evaluated by univariate and multivariate logistic regression.
Results or Findings: Of 1115 patients who underwent CT with iodixanol, 799 were included in this study. The incidence of CI-AKI was 3.80% (30/799). Severe renal failure according to RIFLE criteria was 2.87% (23/799). Incidence of CI-AKI according to the ISS was 1.52% (9/592) in the minor group, 3.95% (7/177) in the moderate group, 42.30% (11/26) in the serious group, and 75.0% (3/4) in the severe group. In univariate analysis, significant predictive factors of CI-AKI based odds ratio (OR) included hypertension (2.87), heart disease (4.06), ISS serious category (47.50), and ISS severe category (194.33). In multivariate analysis, significant predictive factors were the ISS serious category [16.70 (95% CI, 16.70-138.96], and ISS severe category [245.22 (95% CI, 21.88-2748.38)].
Conclusion: In trauma patients who underwent CT with iodixanol, the overall incidence of CI-AKI of 3.8% (30/799) was considerably low. The main predictive factors of CI-AKI involved hypertension, heart diseases, and the ISS serious and severe categories, but its incidence and severity largely relied on the severity of trauma.
Limitations: This was a retrospective study.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by IRB of Ajou University Hospital.
7 min
Utilising dual-layer detector spectral CT to predict clinical risk stratification in the diagnosis of acute pulmonary embolism
Yuhan Zhou, Zhengzhou / China
Author Block: Y. Zhou, Z. Wang, L. Lei, W. Cao, S. Dong, S. W. Yue, Z. Zhou; Zheng Zhou/CN
Purpose: The research utilised the iodine density map in conjunction with the effective atomic number map (ID-Z-eff map) to evaluate the rate of emboli detection in individuals diagnosed with acute pulmonary embolism (PE). Additionally, the study quantitatively assessed the burden of pulmonary thrombosis to predict the clinical risk stratification in these patients.
Methods or Background: This prospective study comprised a cohort of 83 individuals diagnosed with PE who underwent CTPA utilising dual-layer detector spectral CT (DLCT). The spectral data were reconstructed to generate conventional CT images (CI) and ID-Z-eff maps. The number of identified emboli in both cohorts was quantified, and the diagnostic efficacy was assessed. The distribution of emboli was analysed using deep-learning lung segmentation. The severity of pulmonary embolism was evaluated using the Qanadli and Mastora scores. The receiver operating characteristic (ROC) curves were used to assess each score in distinguishing clinical risk stratification.
Results or Findings: 202 and 243 emboli were detected in conventional CT images (CI) and ID-Z-eff maps, respectively. The ID-Z-eff map demonstrated superior embolus detection capabilities compared to CI images (p< 0.05). 42/35 patients were categorized as low-/intermediate risk. There was a significant difference in pulmonary embolism index between the low-risk and medium-risk groups (Qanadli: 14.8%, 39.5%, p< 0.001; Mastora: 11.2%, 34.3%, p< 0.001). The pulmonary embolism index Qanadli and Mastora scores demonstrated promising discrimination in the low-/intermediate-risk groups (Qanadli: AUC=0.876, Mastora: AUC=0.875).
Conclusion: The ID-Z-eff map can enhance the sensitivity and accuracy of acute pulmonary embolism emboli detection. The pulmonary embolism index based on the ID-Z-eff map utilising DLCT can accurately predict the clinical risk stratification of acute pulmonary embolism.
Limitations: The sample size in this research is relatively limited.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Institutional Review Board
7 min
BRIXIA score, laboratory findings and vaccination status for prediction of mortality in severe COVID-19 pneumonia
Valentina Opancina, Kragujevac / Serbia
Author Block: V. Opancina1, M. Muto2, N. Zdravkovic1, E. Ciceri3; 1Kragujevac/RS, 2Naples/IT, 3Milan/IT
Purpose: The aim of our study was to investigate correlations between main laboratory parameters, vaccination status, and Brixia score, as well as to confirm if the Brixia score is a significant independent predictor of an unfavourable outcome (death) in hospitalised COVID-19 patients.
Methods or Background: Chest X-ray has verified its role as a crucial tool in COVID-19 assessment due to its practicability, especially in emergency units. Likewise, the Brixia score has proven itself as a useful tool for COVID-19 pneumonia grading. The study was designed as a cross-sectional multicentric study. It included patients with a diagnosed COVID-19 infection who were hospitalised between September 2021 and February 2022 and had RT-PCR-confirmed COVID-19 and initial CXR and laboratory results.
Results or Findings: This study included a total of 279 patients with a median age of 62 years. The only significant predictor of an unfavourable outcome (death) was the Brixia score (adjusted odds ratio 1.148, p= 0.022). Also, the results of the multiple linear regression analysis (R2= 0.334, F= 19.424, p< 0.001) have shown that male gender (B= 0.903, p= 0.046), severe COVID-19 (B=1.970, p< 0.001), and lactate dehydrogenase (B=0.002, p< 0.001) were significant positive predictors, while albumin level (B=–0.211, p< 0.001) was a significant negative predictor of the Brixia score.
Conclusion: Our results provide important information about factors influencing the Brixia score and its usefulness in predicting unfavourable outcomes in COVID-19 patients. These findings have clinical relevance, especially in epidemic and emergency circumstances. In order to monitor these patients effectively and to achieve efficient patient management, CXR is a great tool due to its wide availability. Also, the application of the Brixia score is clear and simple and benefits clinicians in daily praxis.
Limitations: The limitations of the study are its small sample size and the lack of a control group.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Ethics Committee of University Clinical Center Kragujevac, 62/2022.

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