Jeffrey M Levsky

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

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Publications (51)214.61 Total impact

  • Udit Rawat · Stuart L Cohen · Jeffrey M Levsky · Linda B Haramati ·
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    ABSTRACT: Purpose: In 2010, the authors' department implemented a comprehensive dose reduction strategy based on the ACR white paper on radiation dose in medicine. The aim of this study was to evaluate the effectiveness of the dose reduction program. Methods: In total, 1,234 adult chest CT scans from 2007 to 2012 were analyzed retrospectively, with institutional review board approval and a waiver of the requirement for informed consent. The primary outcome was effective dose in millisieverts during the three-year periods before (2007-2009) and after (2010-2012) dose reduction implementation. Dose trends were analyzed by fitted linear modeling. The use and effects on total exposure of dose reduction strategies (high pitch, adaptive statistical iterative reconstruction [ASIR], and low tube voltage) were analyzed. Results: The overall mean dose for chest CT was 7.3 ± 5.1 mSv. The mean dose decreased by 30%, from 9.2 mSv (2007-2009) to 6.5 mSv (2010-2012) (P < .001). From 2007 to 2009, the mean dose increased by 1.2 mSv per year (P < .01). From 2010 to 2012, the mean dose decreased by 1.1 mSv per year (P < 0.01). High-pitch technique, ASIR, and low tube voltage increased significantly after dose reduction implementation. High pitch and ASIR were significantly associated with a reduced dose, whereas the effect of reduced voltage was not significant. Conclusions: Reductions in radiation exposure from medical imaging rely on ongoing technical developments and consistent, vigilant use of dose reduction strategies. This comprehensive dose reduction strategy significantly reduced radiation exposure from chest CT. Annual increases in radiation dose reversed after the strategy was implemented and continued to decline over the study period.
    Journal of the American College of Radiology: JACR 10/2015; DOI:10.1016/j.jacr.2015.07.022 · 2.84 Impact Factor

  • International journal of cardiology 10/2015; 202:344-348. DOI:10.1016/j.ijcard.2015.08.197 · 4.04 Impact Factor
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    ABSTRACT: Coronary computed tomography angiography (CCTA) plays an expanding role in the management of symptomatic patients suspected of having coronary artery disease. Prospective intermediate-term outcomes are lacking. To compare CCTA with conventional noninvasive testing. Randomized, controlled comparative effectiveness trial. Telemetry-monitored wards of an inner-city medical center. 400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic, and 37% African-American; low socioeconomic status. CCTA or radionuclide stress myocardial perfusion imaging (MPI). The primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure. Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, -2.5 percentage points [95% CI, -8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up duration was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 vs 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003). This was a single-site study, and the primary outcome depended on clinical management decisions. The CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience. American Heart Association.
    Annals of internal medicine 06/2015; 163(3). DOI:10.7326/M14-2948 · 17.81 Impact Factor
  • Netanel S. Berko · Elana T. Clark · Jeffrey M. Levsky ·
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    ABSTRACT: We describe a patient with chest pain and a nondiagnostic electrocardiogram in whom computed tomographic (CT) aortography demonstrated myocardial hypoperfusion in the distribution of the circumflex artery as well as an abrupt cutoff of contrast in the left circumflex artery. Subsequent cardiac catheterization confirmed occlusion of the circumflex artery and led to revascularization. The diagnosis of acute myocardial infarction on CT can dramatically alter the clinical management of a patient, especially in cases in which other tests are equivocal. Copyright © 2015. Published by Elsevier Inc.
    Clinical Imaging 05/2015; 39(5). DOI:10.1016/j.clinimag.2015.05.007 · 0.81 Impact Factor
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    ABSTRACT: To assess the computed tomography (CT) portion of a positron emission tomography (PET)/CT, at lower dose without breath holding, as compared to diagnostic chest CT (dCTC), performed at regular dose with breath holding, and question the necessity of both for patient care in pediatric oncology. This retrospective study included 46 pediatric patients with histologically proven malignant tumors that had a total of 119 scans. A total of 29 discrepancies were found between dCTC and PET/CT reports. In the evaluation of metastatic thoracic disease in pediatric oncology patients, the non-breath holding CT portion of PET/CT has sensitivity and specificity that approaches dCTC. Copyright © 2015. Published by Elsevier Inc.
    Clinical Imaging 05/2015; 39(5). DOI:10.1016/j.clinimag.2015.05.005 · 0.81 Impact Factor
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    ABSTRACT: The aim of this study was to compare the accuracy of coronary atherosclerosis reporting before and after the implementation of a structured reporting chest CT template. A noncardiac, noncontrast chest CT structured reporting template was developed and mandated for department-wide use at a large academic center. The template included the statement "There are no coronary artery calcifications." All noncardiac, noncontrast chest CT examinations reported over 3 days, 1 month after template implementation (structured template group), and from a 3-day period 1 year prior (control group) were retrospectively collected. Final radiology reports were reviewed and designated positive or negative for coronary calcifications. CT images were reviewed in consensus by 2 radiologists, who scored each case for the presence or absence of coronary calcifications, blinded to the original report. Statistical analysis was performed using Pearson χ(2) and Fisher exact tests. Sixty-five percent (69 of 106) of structured template group and 58% (62 of 106) of control group cases had coronary calcifications. Reports from the structured template group were more likely to correctly state the presence or absence of coronary atherosclerosis compared with those from the control group (96.2% vs 85.8%; odds ratio, 4.2; 95% confidence interval, 1.3-13.1; P = .008). Structured template group reports were less likely to be falsely negative compared with control group reports (3.8% vs 11.7%; odds ratio, 3.4; 95% confidence interval, 1.0-10.8; P = .03). Implementing a structured reporting template improves reporting accuracy of coronary calcifications. Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Radiology: JACR 05/2015; 12(8). DOI:10.1016/j.jacr.2015.03.011 · 2.84 Impact Factor
  • Shun Yu · Gopi K. Nayak · Jeffrey M. Levsky · Linda B. Haramati ·

    JAMA Internal Medicine 03/2015; 175(3). DOI:10.1001/jamainternmed.2014.7202 · 13.12 Impact Factor
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    Journal of the American College of Cardiology 03/2015; 65(10):A1178. DOI:10.1016/S0735-1097(15)61178-0 · 16.50 Impact Factor
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    ABSTRACT: The aim of this meta-analysis was to compare the diagnostic accuracy of cardiac computed tomographic angiography (CCTA), stress echocardiography (SE) and radionuclide single photon emission computed tomography (SPECT) for the assessment of chest pain in emergency department (ED) setting. A systematic review of Medline, Cochrane and Embase was undertaken for prospective clinical studies assessing the diagnostic efficacy of CCTA, SE or SPECT, as compared to intracoronary angiography (ICA) or the later presence of major adverse clinical outcomes (MACE), in patients presenting to the ED with chest pain. Standard approach and bivariate analysis were performed. Thirty-seven studies (15 CCTA, 9 SE, 13 SPECT) comprising a total of 7800 patients fulfilled inclusion criteria. The respective weighted mean sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and total diagnostic accuracy for CCTA were: 95%, 99%, 84%, 100% and 99%, for SE were: 84%, 94%, 73%, 96% and 96%, and for SPECT were: 85%, 86%, 57%, 95% and 88%. There was no significant difference between modalities in terms of NPV. Bivariate analysis revealed that CCTA had statistically greater sensitivity, specificity, PPV and overall diagnostic accuracy when compared to SE and SPECT. All three modalities, when employed by an experienced clinician, are highly accurate. Each has its own strengths and limitations making each well suited for different patient groups. CCTA has higher accuracy than SE and SPECT, but it has many drawbacks, most importantly its lack of physiologic data. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    International journal of cardiology 01/2015; 187(1):565-580. DOI:10.1016/j.ijcard.2015.01.032 · 4.04 Impact Factor
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    ABSTRACT: Purpose: To compare the diagnostic utility of computed tomography pulmonary angiography (CTPA) in pregnant/postpartum women with age-matched controls. Materials: We performed a retrospective case-control series of pregnant/postpartum women and control women who underwent CTPA from 2008 to 2011. Results: The study included 34 pregnant women, 16 postpartum women, and 50 controls. CTPAs were positive in 2% of pregnant/postpartum women and 16% of controls (P=.003). The main pulmonary artery mean opacification was 271 Hounsfield units (HU) for pregnant/postpartum women vs. 303 HU (P=.12). Radiation exposure was high in both groups but lower in pregnant/postpartum women, 10 vs. 14 mSv (P=.003). Conclusion: CTPA in pregnant and postpartum women had low yield and remained high dose.
    Clinical Imaging 11/2014; 39(2). DOI:10.1016/j.clinimag.2014.11.006 · 0.81 Impact Factor
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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 09/2014; 38(5). DOI:10.1016/j.clinimag.2014.03.015 · 0.81 Impact Factor
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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; 22(1). DOI:10.1007/s10140-014-1239-8
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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; 38(1). DOI:10.1097/RCT.0b013e3182a75fbe · 1.41 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; 31(6). DOI:10.1111/echo.12464 · 1.25 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. DOI:10.1097/RTI.0000000000000051 · 1.74 Impact Factor
  • Andrew J Lovy · Eran Bellin · Jeffrey M Levsky · David Esses · Linda B Haramati ·
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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; 31(11). DOI:10.1016/j.ajem.2013.06.005 · 1.27 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; 29(2). DOI:10.1097/RTI.0b013e318299ff22 · 1.74 Impact Factor
  • Article: Response.
    Jeffrey M Levsky · Matthew P Moy · Linda B Haramati ·

    Chest 06/2013; 143(6):1839-40. DOI:10.1378/chest.13-0569 · 7.48 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. DOI:10.2214/AJR.12.8797 · 2.73 Impact Factor

Publication Stats

980 Citations
214.61 Total Impact Points


  • 2002-2015
    • Albert Einstein College of Medicine
      • • Cardiology
      • • Department of Radiology
      • • Department of Anatomy and Structural Biology
      New York, New York, United States
  • 2008-2013
    • Montefiore Medical Center
      • Department of Radiology
      New York, New York, United States