Jeffrey M Levsky

Albert Einstein College of Medicine, New York City, New York, United States

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Publications (39)136.99 Total impact

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    ABSTRACT: This work was conducted to determine whether non-contrast-enhanced CT (NECT) of patients with suspected acute aortic syndrome (AAS) can identify patients with a very low likelihood of a positive diagnosis. In the derivation phase, patients who received both NECT and contrast-enhanced CT angiography (CTA) for suspected AAS were identified. Two readers blinded to CTA results analyzed NECTs from AAS positive and negative cases, recording maximal aortic diameters and qualitative findings of aortic disease. Logistic regression analysis was performed to identify independent positive predictors for AAS; those predictors were then used to create a decision rule. For the validation phase, NECTs from patients evaluated for AAS at a second institution were reviewed by two independent readers who recorded the presence of decision rule predictors while blinded to CTA results. In the derivation phase, 34 CTA positive and 83 CTA negative cases were reviewed. Measurements of aortic diameter alone achieved mean sensitivity and specificity of 82 % and of 83 %, respectively. Logistic regression identified aortic diameter, displaced calcifications, high attenuation aortic wall and abnormal aortic contour as independent predictors of AAS. The decision rule incorporating these findings achieved higher mean sensitivity (93 %), negative predictive value (96 %), and moderate reader agreement (kappa = 0.59). For the validation phase, application of the decision rule to 35 AAS positive and 45 AAS negative cases at the second institution yielded sensitivity of 100 % and specificity of 74 % for both readers. NECT can identify patients with a very low likelihood of AAS and potentially mitigate the urgency of performing CTA.
    Emergency Radiology 06/2014;
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    ABSTRACT: To evaluate whether non-gated CT can assess left ventricular (LV) function, 101 patients with both CT and echocardiography were selected, with EF < 50% on echocardiography used as a reference standard. CTs were blindly reevaluated, and qualitative assessment of LV dysfunction on CT correlated with echocardiographic dysfunction, odds ratio of 21.0 (95%CI = 6.55-71.0), specificity of 86% (56/65). Systolic and diastolic images were identified on CT, and the ratio of systolic to diastolic LV internal diameters, and ratio of LV to RV internal diameter, were performed, both showing correlation with LV dysfunction on echocardiography (p < 0.0001). Non-gated CT can be used to predict LV dysfunction.
    Clinical imaging 01/2014; · 0.73 Impact Factor
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    ABSTRACT: To evaluate qualitative and simple quantitative measures of all 4 cardiac chamber sizes on computed tomography (CT) in comparison with transthoracic echocardiography (TTE). We retrospectively identified 104 adults with electrocardiographically gated cardiac CT and TTE within 3 months. Axial early diastolic (75% R-R) CT images were reviewed for qualitative chamber enlargement, and each chamber was measured linearly. Transthoracic echocardiography was reviewed for linear, area, and volume measurements. Interrater agreement was calculated using Cohen κ and Pearson correlation. There were significant correlations between linear left atrium and left ventricle sizes by CT and TTE (r = 0.686 and r = 0.709, respectively). Correlations for right atrium and right ventricle measurements were lower (r = 0.447 and r = 0.492, respectively). Agreement between CT and TTE for qualitative chamber enlargement was poor (highest κ = 0.35). Computed tomography sensitivity was ≤ 62% for enlargement of all chambers. Linear CT measurements of left-sided chamber sizes correlate well with TTE. Right heart measurements and qualitative assessments agreed poorly with TTE.
    Journal of computer assisted tomography 12/2013; · 1.38 Impact Factor
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    ABSTRACT: Comparative effectiveness research (CER) has become a major focus of cardiovascular disease investigation to optimize diagnosis and treatment paradigms and decrease healthcare expenditures. Acute chest pain is a highly prevalent reason for evaluation in the Emergency Department (ED) that results in hospital admission for many patients and excess expense. Improvement in noninvasive diagnostic algorithms can potentially reduce unnecessary admissions. To compare the performance of treadmill stress echocardiography (SE) and coronary computed tomography angiography (CTA) in ED chest pain patients with low-to-intermediate risk of significant coronary artery disease. This is a single-center, randomized controlled trial (RCT) comparing SE and CTA head-to-head as the initial noninvasive imaging modality. The primary outcome measured is the incidence of hospitalization. The study is powered to detect a reduction in admissions from 28% to 15% with a sample size of 400. Secondary outcomes include length of stay in the ED/hospital and estimated cost of care. Safety outcomes include subsequent visits to the ED and hospitalizations, as well as major adverse cardiovascular events at 30 days and 1 year. Patients who do not meet study criteria or do not consent for randomization are offered entry into an observational registry. This RCT will add to our understanding of the roles of different imaging modalities in triaging patients with suspected angina. It will increase the CER evidence base comparing SE and CTA and provide insight into potential benefits and limitations of appropriate use of treadmill SE in the ED.
    Echocardiography 12/2013; · 1.26 Impact Factor
  • Shun Yu, Gopi Nayak, Jeffrey Michael Levsky, Linda Broyde Haramati
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    ABSTRACT: PURPOSE It is unclear which patient or radiologist-related variables are associated with limitations in a radiologist’s ability to exclude pulmonary embolism (PE) on CT. The present study examines factors and outcomes associated with qualification of negative PE reports as “limited.” METHOD AND MATERIALS Reports of all CTs performed in 2011-2012 at our inner city hospital were reviewed and categorized based on report impression as: 1) positive, 2) definitive negative, 3) limited negative or 4) non-diagnostic. Limited negative reports excluded PE only to the central or segmental level, or had a limitation mentioned in the impression. We evaluated the relationship of the report impression to radiologist subspecialty (cardiothoracic vs. other), inpatient status, age, gender, ethnicity, BMI, Charlson score, other comorbidities, and vital signs, using univariate and multivariate analysis. RESULTS CTs were performed on 2652 patients (mean age 55yrs, 66% W): 269 (10%) were positive, 1459 (55%) definitive negative, 269 (33%) limited negative, and 56 (2%) non-diagnostic for PE. The most common limitations reported were motion (45%) and poor opacification (32%). Patients with limited negatives were more likely to be obese (p<0.001), intubated (p = 0.003), tachypneic (p = 0.03) and have a higher Charlson score (p = 0.005) compared to patients with definite negatives. Multivariate analysis did not demonstrate a relationship between reader cardiothoracic subspecialization and rate of limited negatives, after adjusting for gender, pulmonary disease, CHF, intubation, Charlson score, and inpatient status (ORadj 1.05, 95% CI 0.84-1.33). Patients with limited negatives were more likely to be started on anticoagulation (p < 0.001) and undergo additional V/Q scanning (p = 0.001). The false negative rate (PE/DVT diagnosis within 90 days) was 1.6% for both definitive and limited negative groups. CONCLUSION Limited negative impressions on CT reports are strongly associated with patient-related factors such as obesity, tachypnea, mechanical ventilation and higher comorbidity status, but not with radiologist subspecialization. Patients with limited negative CTs are more likely to receive anticoagulation and undergo additional V/Q scans. CLINICAL RELEVANCE/APPLICATION Limited negative CT reports for PE have a false negative rate similar to definitive negative reports. The clinical value of these patients’ higher anticoagulation rates should be explored.
    Radiological Society of North America 2013 Scientific Assembly and Annual Meeting; 12/2013
  • Larry Latson, Jeffrey M Levsky, Linda B Haramati
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    ABSTRACT: Adults with congenital heart disease (CHD) represent an increasing population both because anomalies that might have remained undiagnosed in the past are now being diagnosed later in life on imaging and because significant therapeutic advances have resulted in survival to adulthood of patients with complex CHD. In this article, we discuss simple and common complex congenital anomalies that are encountered in general practice including their incidence, associations, and expected postoperative appearances. We will describe an approach to segmental anatomy and situs evaluation and details of some of the common vascular anomalies, simple shunts, and complex CHDs to refine the imaging strategies and diagnostic acumen of radiologists interested in CHD who may not be practicing in specialized adult CHD centers. Key imaging appearances on chest radiography, protocoling tips for answering clinically relevant questions on computed tomography and magnetic resonance imaging, and the specific imaging appearances and common complications related to long-standing CHD in the adult and complications of treatment are reviewed for each entity.
    Journal of thoracic imaging 11/2013; 28(6):332-46. · 1.42 Impact Factor
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    ABSTRACT: Patients with suspected acute aortic syndromes (AAS) often undergo computed tomography (CT) with negative results. We sought clinical and diagnostic criteria to identify low-risk patients, an initial step in developing a clinical decision rule. We retrospectively identified all adults presenting to our emergency department (ED) from January 1, 2006, to August 1, 2010, who underwent CT angiography for suspected AAS without prior trauma or AAS. A total of 1465 patients met inclusion criteria; a retrospective case-controlled review (ratio 1:4) was conducted. Cases were diagnosed with aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, or ruptured aneurysm. Of the patients who underwent CT, 2.7% (40/1465) had an AAS; 2 additional cases were diagnosed after admission (ED miss rate, 5% [2/42]). Patients with AAS were significantly older than controls (66 vs 59 years; P = .008). Risk factors included abnormal chest radiograph (sensitivity, 79% [26/33]; specificity, 82% [113/137]) and acute chest pain (sensitivity, 83% [29/35]; specificity, 71% [111/157]). None of the 19 patients with resolved pain upon ED presentation had AAS. These data support a 2-step rule: first screen for ongoing pain; if present, screen for acute chest pain or an abnormal chest radiograph. This approach achieves a 54% (84/155) reduction in CT usage with a sensitivity for AAS of 96% (95% confidence interval, 89%-100%), negative predictive value of 99.8% (99.4%-100%), and a false-negative rate of 1.7% (1/84). Our results demonstrate a need to safely identify patients at low risk for AAS who can forgo CT. We developed a preliminary 2-step clinical decision rule, which requires validation.
    The American journal of emergency medicine 09/2013; · 1.54 Impact Factor
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    ABSTRACT: Fibrin sheaths may develop around long-term indwelling central venous catheters (CVCs) and remain in place after the catheters are removed. We evaluated the prevalence, computed tomographic (CT) appearance, and clinical associations of retained fibrin sheaths after CVC removal. We retrospectively identified 147 adults (77 men and 70 women; mean age 58 y) who underwent CT after CVC removal. The prevalence of fibrin sheath remnants was calculated. Bivariate and multivariate analyses were performed to assess for associations between sheath remnants and underlying diagnoses leading to CVC placement; patients' age and sex; venous stenosis, occlusion, and collaterals; CVC infection; and pulmonary embolism. Retained fibrin sheaths were present in 13.6% (20/147) of cases, of which 45% (9/20) were calcified. Bivariate analysis revealed sheath remnants to be more common in women than in men [23% (16/70) vs. 5% (4/77), P=0.0018] and to be more commonly associated with venous occlusion and collaterals [30% (6/20) vs. 5% (6/127), P=0.0001 and 30% (6/20) vs. 6% (7/127), P=0.0003, respectively]. Other variables were not associated. Multivariate analysis confirmed the relationship between fibrin sheaths and both female sex (P=0.005) and venous occlusion (P=0.01). Retained fibrin sheaths were seen on CT in a substantial minority of patients after CVC removal; nearly half of them were calcified. They were more common in women and associated with venous occlusion.
    Journal of thoracic imaging 07/2013; · 1.42 Impact Factor
  • Article: Response.
    Jeffrey M Levsky, Matthew P Moy, Linda B Haramati
    Chest 06/2013; 143(6):1839-40. · 7.13 Impact Factor
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    ABSTRACT: There is no standardized system to grade pleural effusion size on CT scans. A validated, systematic grading system would improve communication of findings and may help determine the need for imaging guidance for thoracentesis. CT scans of 34 patients demonstrating a wide range of pleural effusion sizes were measured with a volume segmentation tool and reviewed for qualitative and simple quantitative features related to size. A classification rule was developed using the features that best predicted size and distinguished among small, moderate, and large effusions. Inter-reader agreement for effusion size was assessed on the CT scans for three groups of physicians (radiology residents, pulmonologists, and cardiothoracic radiologists) before and after implementation of the classification rule. The CT imaging features found to best classify effusions as small, moderate, or large were anteroposterior (AP) quartile and maximum AP depth measured at the midclavicular line. According to the decision rule, first AP-quartile effusions are small, second AP-quartile effusions are moderate, and third or fourth AP-quartile effusions are large. In borderline cases, AP depth is measured with 3-cm and 10-cm thresholds for the upper limit of small and moderate, respectively. Use of the rule improved interobserver agreement from κ = 0.56 to 0.79 for all physicians, 0.59 to 0.73 for radiology residents, 0.54 to 0.76 for pulmonologists, and 0.74 to 0.85 for cardiothoracic radiologists. A simple, two-step decision rule for sizing pleural effusions on CT scans improves interobserver agreement from moderate to substantial levels.
    Chest 04/2013; 143(4):1054-9. · 7.13 Impact Factor
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    ABSTRACT: OBJECTIVE. The purpose of this article is to assess the diagnostic performance of the unenhanced and contrast-enhanced phases separately in patients imaged with CT for suspected acute aortic syndromes. MATERIALS AND METHODS. All adults (n = 2868) presenting to our emergency department from January 1, 2006, through August 1, 2010, who underwent unenhanced and contrast-enhanced CT of the chest and abdomen for suspected acute aortic syndrome were retrospectively identified. Forty-five patients with acute aortic syndrome and 45 healthy control subjects comprised the study population (55 women; mean age, 61 ± 16 years). Unenhanced followed by contrast-enhanced CT angiography (CTA) images were reviewed. Contrast-enhanced CTA examinations of case patients and control subjects with isolated intramural hematoma were reviewed. Radiation exposure was estimated by CT dose-length product. RESULTS. Forty-five patients had one or more CT findings of acute aortic syndrome: aortic dissection (n = 32), intramural hematoma (n = 27), aortic rupture (n = 10), impending rupture (n = 4), and penetrating atherosclerotic ulcer (n = 2). Unenhanced CT was 89% (40/45) sensitive and 100% (45/45) specific for acute aortic syndrome. Unenhanced CT was 94% (17/18) and 71% (10/14) sensitive for type A and type B dissection, respectively (p = 0.142). Contrast-enhanced CTA was 100% (8/8) sensitive for isolated intramural hematoma. Mean radiation effective dose was 43 ± 20 mSv. CONCLUSION. Unenhanced CT performed well in detection of acute aortic syndrome treated surgically, although its performance does not support its use in place of contrast-enhanced CTA. Unenhanced CT may be a reasonable first examination for rapid triage when IV contrast is contraindicated. Contrast-enhanced CTA was highly sensitive for intramural hematoma, suggesting that unenhanced imaging may not always be needed. Acute aortic syndrome imaging protocols should be optimized to reduce radiation dose.
    American Journal of Roentgenology 04/2013; 200(4):805-11. · 2.90 Impact Factor
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    ABSTRACT: CT myocardial perfusion imaging is an emerging diagnostic modality that is under intensive study but not yet widely used in clinical practice. The purpose of this study is to evaluate the performance of resting 64-MDCT in revealing ischemia identified on radionuclide myocardial perfusion imaging (MPI). We retrospectively identified 35 patients (20 women and 15 men; mean age, 52 years) with myocardial ischemia found on MPI who underwent retrospectively gated CT within 90 days of MPI. Myocardial perfusion on CT was evaluated using both a visual (n = 35) and an automated (n = 34) method. For the visual method, myocardial segments were evaluated qualitatively in systole and diastole. For the automated method, subendocardial perfusion of the standard 17 American Heart Association segments was measured using a commercially available tool in both systole and diastole. Differences between systolic and diastolic perfusion were computed. Five hundred eighty myocardial segments were evaluated, 152 of which were ischemic on MPI. Visual analysis had a sensitivity of 16% (24/152), specificity of 92% (393/428), positive predictive value of 40% (24/60), and negative predictive value of 75% (392/520) in systole, and a sensitivity of 18% (27/152), specificity of 89% (382/428), positive predictive value of 37% (27/73), and negative predictive value of 75% (382/507) in diastole, as compared with MPI. There was no significant difference in subendocardial perfusion between ischemic and nonischemic segments by the automated method. There was no significant difference in CT perfusion between patients with and without obstructive coronary artery disease on CT angiography using the visual or automated methods. Resting 64-MDCT is unsuitable for clinical use in revealing ischemia seen on MPI.
    American Journal of Roentgenology 02/2013; 200(2):337-42. · 2.90 Impact Factor
  • Jeffrey Michael Levsky
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    ABSTRACT: LEARNING OBJECTIVES 1) To recognize the imaging appearance of adults with repaired tetralogy of Fallot, transposition of the great arteries and single functional ventricle states. 2) To understand the appearances of common complications of these complex congenital heart diseases. 3) To understand the contributions of CT and MR to modern, evidence-based practice in adult congenital heart disease. ABSTRACT Patients with complex congenital heart disease currently have longer life spans, largely due to improvements in surgical management, interventional procedures and cardiovascular pharmacotherapy. It is not uncommon to encounter adults with severe defects such as tetralogy of Fallot, transposition of the great vessels and single functional ventricle states. In addition, patients with prior palliative or surgical procedures commonly present with complications or residual abnormalities later in life. This refresher course aims to familiarize learners with the cross-sectional imaging features of these adult congenital cardiac diseases. In addition, we highlight key complications of the disease processes as well as treatment sequellae. The goal of this presentation is to improve the CT and MR interpretations of patients with adult congenital heart disease with an emphasis on how imaging can be used for problem solving and an aid to evidence-based practice.
    Radiological Society of North America 2012 Scientific Assembly and Annual Meeting; 11/2012
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    ABSTRACT: PURPOSE To compare the diagnostic utility of CT pulmonary angiography (CTPA) in pregnant and non-pregnant women. METHOD AND MATERIALS We performed a retrospective case-control series of pregnant and post-partum patients within 2 weeks of birth who underwent CTPA from 2008-2011 and their controls. Controls were women aged 25-40 who underwent CTPA immediately after the pregnant patient. Results of CTPA, opacification of the main pulmonary artery (MPA) in HU and radiation exposure (effective dose conversion factor (k) =18 μSv/mGy • cm2) were noted. RESULTS The study population comprised 50 pregnant patients and 50 controls, mean age of 30 and 31 years, respectively. CTPAs were positive in 2% (1/50) of pregnant women and 16% (8/50) of controls (p=0.003). Mean opacification of the MPA showed a trend toward lower values in pregnant women than controls [270 vs. 303 HU, respectively, (p=0.12)]. Radiation exposure was lower in pregnant women than in controls, 10 (SD=3.9) vs 14 (SD=9.2) mSv (p=0.003). CONCLUSION CTPA in pregnant women had a very low yield compared with non-pregnant women of childbearing age and remain high dose, despite dose reduction strategies. Re-evaluation of the prominent use of CTPA is necessary in light of these results and recent guidelines which advocate a step-wise approach that de-emphasizes CTPA. CLINICAL RELEVANCE/APPLICATION These results support the need for radiologists to educate our colleagues in more appropriate evaluation of pregnant women for suspected pulmonary embolism.
    Radiological Society of North America 2012 Scientific Assembly and Annual Meeting; 11/2012
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    ABSTRACT: PURPOSE There is no standardized system to quantify pleural effusion size on CT. A validated quantification system would improve communication and may lead to a more appropriate use of imaging guidance for thoracentesis. METHOD AND MATERIALS Thirty-four CTs chosen to demonstrate a wide range of pleural effusion sizes were evaluated with a volume segmentation tool. The effusion volume was normalized by dividing by the hemi-thorax volume to yield an effusion percentage (%). The same CTs were then reviewed by two cardiothoracic radiologists in consensus for qualitative and simple quantitative features related to effusion size. Bivariate and multivariate regressions were used to ascertain the relationship between these features and effusion %. A classification rule was developed using the features that best predicted size and distinguished between small (<20%), moderate (20-40%), and large (>40%) effusions. Inter-reader agreement for effusion size was assessed on the CTs for three groups of physicians (PGY-3 radiology residents, experienced pulmonologists, and cardiothoracic radiologists), both before and after implementation of the classification rule. RESULTS The CT features that best divided effusions into small, moderate and large sizes were anteroposterior (AP) quartile (p=.048) and maximum AP depth, in cm, at the mid-clavicular line (p=.042). According to the decision rule, 1st AP quartile effusions are small, 2nd AP quartile effusions are moderate and 3rd/4th AP quartile effusions are large. In borderline cases, AP depth is measured with 3cm and 10cm thresholds for the upper limit of small and moderate, respectively. Small effusions measured 328 mL or less, representing a relative contraindication to thoracentesis per published guidelines. Use of the rule improved inter-observer agreement from κ=0.56 to 0.79 for all physicians (p<0.0001), 0.59 to 0.73 for radiology residents, 0.54 to 0.76 for pulmonologists and 0.74 to 0.85 for cardiothoracic radiologists. CONCLUSION A simple, two-step decision rule improves inter-observer agreement for pleural effusion quantification among various physicians. After training, pulmonologists and PGY-3 radiology residents achieved similar agreement to cardiothoracic radiologists at baseline. CLINICAL RELEVANCE/APPLICATION A simple, validated system for quantifying pleural effusions on CT provides a basis to improve physician agreement, communication of findings, and may aid in guiding management.
    Radiological Society of North America 2012 Scientific Assembly and Annual Meeting; 11/2012
  • Seminars in roentgenology 07/2012; 47(3):289-301. · 0.70 Impact Factor
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    ABSTRACT: PURPOSE Patients with suspected acute aortic syndromes (AAS) often undergo CT with negative results. We sought clinical and diagnostic criteria that could be useful to identify low risk patients in order to reduce CT radiation exposure. METHOD AND MATERIALS We retrospectively identified all adults who presented to our emergency department (ED) and underwent a CT angiography for a suspected AAS based on clinical indication noted in the radiology report from 1/1/2006 - 8/1/2010, without history of trauma or AAS. Positive cases were defined as the presence of aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer and ruptured aneurysm. 1488 (60 yrs, 42% male) patients met inclusion criteria and formed the overall population. A detailed chart review using a case-control design was performed, with 4 controls for each case of AAS. RESULTS 2.6% (39/1488) of CTs were positive for AAS. An additional 6 cases, not identified in the ED, were diagnosed by CT after admission, a miss rate of 13% (6/45). The 39 AAS diagnosed in the ED (66 yrs, 44% Male) were significantly older than the 172 controls (59 yrs, 40% Male) (p=0.01). Risk factors associated with AAS included abnormal chest x-ray [OR=16.8, p<0.001; Sens 78.1% (25/32), Spec 82.5% (113/137)] and acute onset chest pain [OR =14.0, p<0.001; Sens 85.3% (29/34), Spec 70.7% (111/157)], which, when both absent, had a 3.7% (1/27) probability of AAS. All patients with AAS had continuous pain upon presentation to ED, a sensitivity of 100%. Additionally, AAS was refuted in all 19 subjects with non-continuous pain upon ED presentation. Hypertension was present in a large majority of both cases (81.6%) and controls (74.4%) (p=0.35). CONCLUSION 97.4% of CT angiograms for suspected AAS scans in the ED were negative, yet 13% of AAS were missed in the ED and diagnosed after admission. Patients whose chest pain resolved on ED presentation and those with neither abnormal chest x-ray nor acute onset of chest pain were very unlikely to have AAS. Pretest probability criteria for patients with suspected AAS needs to be refined in order to diagnose patients expeditiously and reduce radiation exposure. CLINICAL RELEVANCE/APPLICATION Although of AAS is notoriously difficult, radiation exposure from negative CT scans cannot be ignored. We provide initial data for developing a targeted approach to CT utilization.
    Radiological Society of North America 2011 Scientific Assembly and Annual Meeting; 12/2011
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    ABSTRACT: PET cannot distinguish between bronchogenic carcinoma and granuloma, but positive scans may prompt surgery. We systematically evaluated the CT appearance of resected carcinomas and granulomas to identify features that could be used to reduce granuloma resections. We retrospectively identified 93 consecutive patients between January 2005 and November 2008 who had resection of a pulmonary nodule pathologically diagnosed as bronchogenic carcinoma or granuloma and preoperative imaging with CT and PET. Each nodule was evaluated on CT for size, doubling time, location, borders, shape, internal characteristics, calcification, clustering, air bronchograms, and cavitation. A diagnostic impression was rendered. Bivariate and logistic regression analyses were performed. Pre-PET data regarding the proportion of resected granulomas and carcinomas between January 1995 and December 1996 were reviewed. Sixty-eight percent (65/96) of nodules were carcinomas and 32% (31/96) were granulomas. The CT impression was benign in 65% (20/31) of granulomas and 5% (3/65) of carcinomas (p < 0.0001; negative predictive value [NPV], 87% [20/23]). Specific CT features significantly associated with granuloma were clustering, cavitation, irregular shape, lack of pleural tags, and solid attenuation. The combination of nonspiculated borders, irregular shape, and solid attenuation had an NPV of 86% (12/14). Granulomas represented 18% (9/50) of resected nodules in 1995 and 1996 (p = 0.066). CT findings reduce but cannot eliminate the possibility that a nodule is malignant. Outcomes-based clinical trials are needed to determine whether CT features of benignity can guide less-invasive initial management and reverse a concerning trend in granuloma resection.
    American Journal of Roentgenology 04/2011; 196(4):795-800. · 2.90 Impact Factor
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    ABSTRACT: Computed tomography (CT) of the heart is increasingly used to characterize not only the coronary arteries but also cardiac structure and function. The performance of CT in depicting myocardial perfusion is under active investigation. We describe the pattern of normal myocardial perfusion on resting 64-detector cardiac CT. Patients (n = 33; 20 women, 13 men; mean age, 52 years) with normal radionuclide myocardial perfusion imaging and normal coronary arteries on CT angiography (120 kVp) comprised the study population. Segmental myocardial perfusion on CT was measured in Hounsfield units (HU) with manual and semiautomated methods for the 17-segment American Heart Association model in both systole and diastole. Segments were aggregated into coronary artery territories, from apex to base and by myocardial wall. The relationships between myocardial perfusion and various patient factors were evaluated. Overall mean myocardial perfusion was 98 HU in systole and 94 HU in diastole with the manual method (P = .011) and 92 HU in systole and 95 HU in diastole with the automated method (P = .001). The septum showed significantly higher mean attenuation values than the other walls in systole and diastole with both methods. Generally, attenuation values were lower in the left circumflex artery territory and in the apex. Bivariate analysis showed higher mean myocardial attenuation values for women than men, although this difference did not persist on multivariate analysis adjusted for patient size. Normal mean resting myocardial perfusion correlates with CT attenuation values of approximately 92-98 HU on CT angiography in the coronary arterial phase. The septum consistently shows greater attenuation values than the other walls.
    Journal of cardiovascular computed tomography 01/2011; 5(1):52-60. · 2.55 Impact Factor
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    ABSTRACT: To assess the diagnostic performance of computed tomographic (CT) and radiographic (as seen on CT topograms) signs of cecal volvulus. In this institutional review board-approved, HIPAA-compliant retrospective study, the CT and CT topogram findings in 11 patients (one man, 10 women; age range, 26-100 years) with surgically confirmed cecal volvulus and 12 control patients were reviewed. The control subjects had suspicious radiographs, had undergone CT within 24 hours of radiography, and had received a clinical diagnosis other than cecal volvulus. Three radiologists independently evaluated the CT topograms for cecal distention, the coffee bean sign, cecal apex location, and distal colon decompression. CT images were analyzed for cecal distention, cecal apex location, distal colon decompression, and presence or absence of the whirl, ileocecal twist, transition point(s), the X-marks-the-spot, and the split wall. Sensitivity, specificity, and predictive values were computed. Baseline statistical values for the cecal volvulus and control groups were analyzed by using a two-tailed Z test to compare proportions with a threshold confidence interval of 95%. CT findings of bowel ischemia (free air or fluid, pneumatosis intestinalis, portal venous gas, mesenteric stranding) were correlated with pathology report findings. On CT topograms, greater than 10-cm cecal distention, coffee bean sign, and left upper quadrant cecal apex had sensitivities of 45% (five of 11 patients), 27% (three of 11 patients), and 45% (five of 11 patients), respectively, and specificities of 100% (12 of 12 control subjects), 92% (11 of 12 control subjects), and 100% (12 of 12 control subjects), respectively. Distal colon decompression had sensitivities and specificities of 91% (10 of 11 patients) and 83% (10 of 12 control subject), respectively, on topograms and of 91% (10 of 11 patients) and 92% (11 of 12 patients), respectively, on CT images. On cross-sectional CT images, greater than 10-cm cecal distention, left upper quadrant cecal apex, whirl, ileocecal twist, transition point(s), X-marks-the-spot, and split wall had sensitivities of 45% (five of 11 patients), 36% (four of 11 patients), 73% (eight of 11 patients), 54% (six of 11 patients), 82% (nine of 11 patients), 27% (three of 11 patients), and 54% (six of 11 patients), respectively; each had 100% specificity. Pneumatosis intestinalis and free air had 100% (four of four control subjects) specificity. Overall, CT signs of bowel ischemia correlated poorly with pathology report findings. When cecal volvulus is suspected, the absence of distal colonic decompression on CT topograms makes the diagnosis very unlikely. Whirl, ileocecal twist, transition points, X-marks-the-spot, and split wall have high specificity for cecal volvulus.
    Radiology 07/2010; 256(1):169-75. · 6.34 Impact Factor

Publication Stats

700 Citations
136.99 Total Impact Points

Institutions

  • 2002–2014
    • Albert Einstein College of Medicine
      • • Department of Radiology
      • • Department of Anatomy and Structural Biology
      • • Department of Medicine
      New York City, New York, United States
  • 2013
    • Mount Sinai Medical Center
      New York City, New York, United States
  • 2008–2009
    • Montefiore Medical Center
      • • Albert Einstein College of Medicine
      • • Department of Radiology
      New York City, NY, United States