GUEST EDITORIAL
Cardiothoracic Emergency Imaging Evolution of the Evaluation Sanjeev Bhalla, MD and Ioannis Vlahos, MRCP, FRCR
T
he perennial top four discharge diagnoses for emergency department (ED) visits in the United States and the developed world center on chest–related conditions. These include the familiar culprits of cardiac disease (both ischemic and non-ischemic), chest pain and pneumonia.1 Coupled with the continued incremental utilization of CT, with CT scanners often now located in the ED, it comes as no surprise that radiologists have seen a tremendous growth in the number of Chest CT examinations in the past 10–15 years.2,3 A plethora of technological innovations have brought beneficial adaptions in contrast, spatial and temporal resolution to our imaging of cardiothoracic emergencies, particularly for angiographic imaging. In turn, not only has the imaging of established clinical indications such as pulmonary embolism and acute aortic diseases improved, but the acute evaluation of coronary arterial disease has become a pragmatic proposition. A byproduct of the use of such multidetector CT systems is the current near ubiquitous availability of isotropic datasets and hence the ability to concomitantly offer multiplanar volumetric high-resolution CT (HRCT) lung parenchymal imaging. In essence, the on-call ED radiologist has been converted into a full service cardiothoracic radiologist interpreting studies with lung images rivalling those obtained in dedicated HRCT examinations. In trying to perform the task of providing a clinically directed, comprehensive cardiopulmonary evaluation, the cardiothoracic or ED radiologist faces a formidable challenge. Not only must he or she be abreast of our changing technical imaging capability, but the practitioner must also be aware of advances in our understanding of the basic pathophysiology of these common diseases. However, as radiologists imaging patients with acute cardiothoracic diseases, we are also aware of wider imaging utilization concerns. Even in the era of increased radiation awareness, only a modest decrease in CT use in the ED has been witnessed in recent years.4 As radiologists we must strive to best use radiation reduction mechanisms that do not impair our ability to accurately diagnose diseases that may have profound acute effects. Of course one of the best ways to reduce radiation exposure overall is not to perform radiological examinations that do not impact clinical outcome or to consider non-ionizing radiation alternatives. The counterpart of course is the need to perform additional examinations where these can alter clinical management pathways or to provide a level of detail that assists clinical stratification or patient management. In this special issue of the Journal of Thoracic Imaging, we have aimed to address these trends in cardiothoracic imaging, namely a comprehensive angiographic assessment of the vasculature and HRCT assessment of the lung parenchyma, an optimization not only of technique and interpretation, but also a realization that the ED radiologist is often at the forefront of emergent treatment planning requiring a current understanding of pathology, clinical pathways and relevance. Every article in this two-part symposium has been carefully constructed to address these issues. Dr Devaraj and colleagues5 have brought us up to date with the clinicoradiological stratification of pulmonary embolism and highlighted how CT pulmonary angiography use interacts with some of the most advanced clinical decision support rules (Geneva, PERC and Wells). Dr Raptis and colleagues highlight important imaging features of traumatic aortic injuries to guide assessment for interventional endovascular or surgical therapy including emerging clinical and radiological concepts with regards to minimal aortic injuries.6 In a companion article Dr Ridge and colleagues address our evolving understanding of the interconnected diagnoses of non-traumatic acute aortic syndromes and how these impact our interpretation and management planning.7 Completing the vascular theme Dr White and colleagues assess the status of imaging of coronary artery syndromes,
From the Mallinckrodt Institute of Radiology, St Louis, MO. The authors declare no conflicts of interest. Correspondence to: Sanjeev Bhalla, MD, Mallinckrodt Institute of Radiology, St Louis, MO (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Thorac Imaging
Volume 30, Number 3, May 2015
www.thoracicimaging.com |
165
J Thorac Imaging
Guest Editorial
highlighting the role of coronary CTA in the ED in 2015 and the utility of the triple rule out CTA, including some of the insights gained from coronary CT angiography trials.8 Two wide ranging articles address the issues of acute pulmonary parenchymal disease. These articles will be published in print in the second part of this symposium in July 2015 and are available now as published-ahead-of-print content at www.thoracicimaging.com. Dr Sharma et al provide a practical approach to acute lung disease in the ED.9 Their approach allows the interpreter to provide a useful, clinically relevant differential diagnosis for what can appear to be a complex wide variety of pulmonary parenchymal diseases. Finally, Drs. Carter and Erasmus provide a comprehensive current understanding of the variety of acute thoracic diseases that are encountered in patients with known oncological disease, an increasing problem in patients undergoing ever more complex new therapeutic algorithms.10 In preparation of this special issue, it is remarkable that despite addressing some diseases and imaging topics that may seem commonly familiar, a wealth of new information has been provided that has certainly educated us. We anticipate that this set of articles will appeal as a resource to both the cardiothoracic expert and the more general emergency imager alike. More widely, we envisaged a symposium that would be all encompassing, addressing not only pertinent imaging findings of the emergency conditions but also the wider clinical impact of our emergency imaging. We would like to thank all the contributing authors whose expertise, experience and endeavor has resulted in this excellent symposium, which we hope fulfils that vision.
166 | www.thoracicimaging.com
Volume 30, Number 3, May 2015
REFERENCES 1. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables. Accessible at http:// www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed 2008.pdf. 2. Levin DC, Rao VM, Parker L, et al. Continued growth in emergency department imaging is bucking the overall trends. J Am Coll Radiol. 2014;11:1044–1047. 3. Larson DB, Johnson LW, Schnell BM, et al. National Trends in CT Use in the Emergency Department: 1995–2007. Radiology. 2011;258:164–173. 4. Raja AS, Ip IK, Sodickson AD, et al. Radiology utilization in the emergency department: trends of the past 2 decades. AJR Am J Roentgenol. 2014;203:355–360. 5. Devaraj A, Sayer C, Sheard S, et al. Diagnosing acute pulmonary embolism with computed tomography: imaging update. J Thorac Imaging. 2015;30:176–192. 6. Raptis CA, Hammer MM, Raman KG, et al. Acute traumatic aortic injury: practical considerations for the diagnostic radiologist. J Thorac Imaging. 2015;30:202–213. 7. Ridge CA, Litmanovich DE. Acute aortic syndromes: current status. J Thorac Imaging. 2015;30:193–201. 8. Ropp A, Lin CT, White CS. Coronary computed tomography angiography for the assessment of acute chest pain in the emergency department: evidence, guidelines, and tips for implementation. J Thorac Imaging. 2015;30:169–175. 9. Levesque MH, Montesi SB, Sharma A. Diffuse parenchymal abnormalities in acutely dyspneic patients: a pattern-based approach. J Thorac Imaging. [epub ahead of print February 26, 2015.] doi: 10.1097/RTI.0000000000000133. 10. Carter BW, Erasmus JJ. Acute thoracic findings in oncologic patients. J Thorac Imaging. [epub ahead of print March 24, 2015.] doi: 10.1097/RTI.0000000000000148.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Cardiothoracic Emergency Imaging Evolution of the Evaluation Sanjeev Bhalla, MD and Ioannis Vlahos, MRCP, FRCR
T
he perennial top four discharge diagnoses for emergency department (ED) visits in the United States and the developed world center on chest–related conditions. These include the familiar culprits of cardiac disease (both ischemic and non-ischemic), chest pain and pneumonia.1 Coupled with the continued incremental utilization of CT, with CT scanners often now located in the ED, it comes as no surprise that radiologists have seen a tremendous growth in the number of Chest CT examinations in the past 10–15 years.2,3 A plethora of technological innovations have brought beneficial adaptions in contrast, spatial and temporal resolution to our imaging of cardiothoracic emergencies, particularly for angiographic imaging. In turn, not only has the imaging of established clinical indications such as pulmonary embolism and acute aortic diseases improved, but the acute evaluation of coronary arterial disease has become a pragmatic proposition. A byproduct of the use of such multidetector CT systems is the current near ubiquitous availability of isotropic datasets and hence the ability to concomitantly offer multiplanar volumetric high-resolution CT (HRCT) lung parenchymal imaging. In essence, the on-call ED radiologist has been converted into a full service cardiothoracic radiologist interpreting studies with lung images rivalling those obtained in dedicated HRCT examinations. In trying to perform the task of providing a clinically directed, comprehensive cardiopulmonary evaluation, the cardiothoracic or ED radiologist faces a formidable challenge. Not only must he or she be abreast of our changing technical imaging capability, but the practitioner must also be aware of advances in our understanding of the basic pathophysiology of these common diseases. However, as radiologists imaging patients with acute cardiothoracic diseases, we are also aware of wider imaging utilization concerns. Even in the era of increased radiation awareness, only a modest decrease in CT use in the ED has been witnessed in recent years.4 As radiologists we must strive to best use radiation reduction mechanisms that do not impair our ability to accurately diagnose diseases that may have profound acute effects. Of course one of the best ways to reduce radiation exposure overall is not to perform radiological examinations that do not impact clinical outcome or to consider non-ionizing radiation alternatives. The counterpart of course is the need to perform additional examinations where these can alter clinical management pathways or to provide a level of detail that assists clinical stratification or patient management. In this special issue of the Journal of Thoracic Imaging, we have aimed to address these trends in cardiothoracic imaging, namely a comprehensive angiographic assessment of the vasculature and HRCT assessment of the lung parenchyma, an optimization not only of technique and interpretation, but also a realization that the ED radiologist is often at the forefront of emergent treatment planning requiring a current understanding of pathology, clinical pathways and relevance. Every article in this two-part symposium has been carefully constructed to address these issues. Dr Devaraj and colleagues5 have brought us up to date with the clinicoradiological stratification of pulmonary embolism and highlighted how CT pulmonary angiography use interacts with some of the most advanced clinical decision support rules (Geneva, PERC and Wells). Dr Raptis and colleagues highlight important imaging features of traumatic aortic injuries to guide assessment for interventional endovascular or surgical therapy including emerging clinical and radiological concepts with regards to minimal aortic injuries.6 In a companion article Dr Ridge and colleagues address our evolving understanding of the interconnected diagnoses of non-traumatic acute aortic syndromes and how these impact our interpretation and management planning.7 Completing the vascular theme Dr White and colleagues assess the status of imaging of coronary artery syndromes,
From the Mallinckrodt Institute of Radiology, St Louis, MO. The authors declare no conflicts of interest. Correspondence to: Sanjeev Bhalla, MD, Mallinckrodt Institute of Radiology, St Louis, MO (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Thorac Imaging
Volume 30, Number 3, May 2015
www.thoracicimaging.com |
165
J Thorac Imaging
Guest Editorial
highlighting the role of coronary CTA in the ED in 2015 and the utility of the triple rule out CTA, including some of the insights gained from coronary CT angiography trials.8 Two wide ranging articles address the issues of acute pulmonary parenchymal disease. These articles will be published in print in the second part of this symposium in July 2015 and are available now as published-ahead-of-print content at www.thoracicimaging.com. Dr Sharma et al provide a practical approach to acute lung disease in the ED.9 Their approach allows the interpreter to provide a useful, clinically relevant differential diagnosis for what can appear to be a complex wide variety of pulmonary parenchymal diseases. Finally, Drs. Carter and Erasmus provide a comprehensive current understanding of the variety of acute thoracic diseases that are encountered in patients with known oncological disease, an increasing problem in patients undergoing ever more complex new therapeutic algorithms.10 In preparation of this special issue, it is remarkable that despite addressing some diseases and imaging topics that may seem commonly familiar, a wealth of new information has been provided that has certainly educated us. We anticipate that this set of articles will appeal as a resource to both the cardiothoracic expert and the more general emergency imager alike. More widely, we envisaged a symposium that would be all encompassing, addressing not only pertinent imaging findings of the emergency conditions but also the wider clinical impact of our emergency imaging. We would like to thank all the contributing authors whose expertise, experience and endeavor has resulted in this excellent symposium, which we hope fulfils that vision.
166 | www.thoracicimaging.com
Volume 30, Number 3, May 2015
REFERENCES 1. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables. Accessible at http:// www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed 2008.pdf. 2. Levin DC, Rao VM, Parker L, et al. Continued growth in emergency department imaging is bucking the overall trends. J Am Coll Radiol. 2014;11:1044–1047. 3. Larson DB, Johnson LW, Schnell BM, et al. National Trends in CT Use in the Emergency Department: 1995–2007. Radiology. 2011;258:164–173. 4. Raja AS, Ip IK, Sodickson AD, et al. Radiology utilization in the emergency department: trends of the past 2 decades. AJR Am J Roentgenol. 2014;203:355–360. 5. Devaraj A, Sayer C, Sheard S, et al. Diagnosing acute pulmonary embolism with computed tomography: imaging update. J Thorac Imaging. 2015;30:176–192. 6. Raptis CA, Hammer MM, Raman KG, et al. Acute traumatic aortic injury: practical considerations for the diagnostic radiologist. J Thorac Imaging. 2015;30:202–213. 7. Ridge CA, Litmanovich DE. Acute aortic syndromes: current status. J Thorac Imaging. 2015;30:193–201. 8. Ropp A, Lin CT, White CS. Coronary computed tomography angiography for the assessment of acute chest pain in the emergency department: evidence, guidelines, and tips for implementation. J Thorac Imaging. 2015;30:169–175. 9. Levesque MH, Montesi SB, Sharma A. Diffuse parenchymal abnormalities in acutely dyspneic patients: a pattern-based approach. J Thorac Imaging. [epub ahead of print February 26, 2015.] doi: 10.1097/RTI.0000000000000133. 10. Carter BW, Erasmus JJ. Acute thoracic findings in oncologic patients. J Thorac Imaging. [epub ahead of print March 24, 2015.] doi: 10.1097/RTI.0000000000000148.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
