Research (Radiology)

Original Articles

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Chest CT severity score to forecast clinical requirement of oxygen support in Covid-19 patients
Yashpal R Rana, Dinesh L Patel, Megha M Sheth, Sanjay L. Chhodvadiya, Samir G Patel, Milin N Garachh, Anand N Shukla and Krutika H Patel
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Abstract
Objectives: All over the world, attempts are made at the early prediction of disease severity of ongoing COVID-19 pandemic and catching early those patients who are likely to develop severe disease and may undergo cytokine storm. Though clinical and laboratory parameters are mainstay in diagnosing severe disease and oxygen requirements, high resolution computed tomographic (HRCT) scanning of the chest is one such promising tool to help identify such a subset of patients very early in the course of COVID-19 disease. The purpose of this research is to find an answer to a question can chest CT severity score (CTSS) on HRCT thorax scan forecast clinical requirements of oxygen support in covid-19 patients?

Methods: During the period from May 2020 to October 15, 2020, 250 patients with confirmed RT-PCR diagnosis of COVID-19 on first or repeat sample and who also underwent HRCT scan of the chest, were retrospectively assigned chest CT severity score (CTSS). Patients were categorized into mild and severe score groups and from data obtained, analysis of how many patients from both groups progress to require oxygen support and intubation?
 
Results: Out of a total of 250 patients, 175 patients were males and 75 patients were females. The average CT severity score (CTSS) was 19.5. 150 patients belong to mild CTSS group while 100 to severe CTSS group. Overall 180 patients required oxygen support, 100 belong to severe CTSS group while 80 belong to mild CTSS group. In mild CTSS group, 80 patients required low-flow oxygen. In severe CTSS group, 5 patients required low-flow oxygen, 75 required high-flow oxygen and 20 patients needed intubation. 8 out of 20 intubated patients succumbed to death. Overall 28 mortalities were reported of which 22 belong to severe CTSS group. With the Receiver operator characteristics (ROC) analysis, we found the cut off of CTS score. At the score of greater than 13 showed the significant effect on oxygen support with area under curve (AUC) 0.996 (95% CI 0.98 to 1; P <0.0001) with 94.4% sensitivity and 100% specificity. We found one another cut off of CTS score (>26) with in-hospital mortality. The Area under curve (AUC) 0.78 (95% CI 0.73 to 0.83; P <0.0001) with 70% sensitivity and 81.4% specificity. Intubation, oxygen requirement and mortality are the strongest predictors of CT score. (Regression coefficients 12.65(95% CI 10.05-15.24; P <0.0001, 11.04(95% CI 9.5-12.58; P <0.0001) and 4.1(95% CI 1.93-6.27; P <0.0001 consecutively).
 
Conclusion: CTSS may be used as a new decisive tool in triaging in-hospital COVID-19 patients. Currently, clinical and laboratory blood parameters guide the requirements of oxygen support in managing severe COVID-19 pneumonia. In the setting of patients overload, there may be delay in prompt clinical judgment and appropriate therapy may be initiated late and hence the poor outcome. Categorizing patients in mild and severe CTSS early in the disease course, even before the marked worsening of clinical parameters may save energy, health resources, help to triage severe patients, and above all may save many lives.

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Prediction of Clinical Requirement of Tocilizumab Injection in COVID-19 Patients with High Chest CT Severity Score- A Retrospective Analysis
MEGHA SHETH, YASHPAL RANA, DINESH PATEL, ANSHUL GHAI, SAMIR PATEL,MILIN GARACHH,PINKESH SHAH, KRUTIKA PATEL
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Introduction: The on-going Corona-Virus Disease 2019 (COVID-19) pandemic has spread rapidly across the globe. Tocilizumab is a recombinant monoclonal antibody to Interleukin-6 (IL-6) receptor. An increasing number of studies across the world is reporting the use of tocilizumab in treating COVID-19 patients or at risk of developing cytokine storm. Apart from clinical and laboratory parameters, High Resolution Computed Tomographic (HRCT) chest scan is a promising tool to identify patients very early in the course of COVID-19 disease.

Aim: The purpose of this retrospective research study is to find whether high chest CT Severity Score (CTSS) on HRCT thorax scan predict the clinical requirement of tocilizumab injection in COVID-19 patients.

Materials and Methods: In this retrospective study, during the period from May 2020 to July, 2020, 250 patients with confirmed Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) diagnosed of COVID-19 on first or repeat sample and who also underwent HRCT scan of the chest, were assigned chest CTSS. From data obtained, patients were categorised into two groups based on mild and severe CTSS. Patients with higher CTSS have a higher future possibility of developing the cytokine storm and hence the requirement of tocilizumab can be reliably predicted. All statistical analysis was performed in IBM SPSS version 20.

Results: Out of a total of 250 patients, 72 patients were given tocilizumab injection. The average CTSS was 29.8±6.38 in the tocilizumab injection group. Only 8% of patients with mild CTSS received tocilizumab injection while 60% of patients with severe CTSS received tocilizumab injection (p<0.001). Out of 72 patients who received tocilizumab injection, 16.7% had mild CTSS while 83.3% had severe CTSS (p<0.001). Average values of inflammatory markers like CRP, D-Dimer, Ferritin, LDH, and IL-6; were significantly higher in severe CTSS and tocilizumab group (p<0.001).

Conclusion: CTSS may be used as a new decisive tool in triaging in-hospital COVID-19 patients. Categorising patients in mild and severe CTSS early in the disease course, even before the marked worsening of laboratory parameters and development of cytokine storm may help initiate early treatment and thereby save many lives.

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Double outlet of right ventricle: imaging spectrum on multi-slice computed tomography.
Yashpal R. Rana, Dinesh L. Patel, Megha M. Sheth, Nitisha A Jain, Samir G. Patel, Milin N. Garachh
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Abstract

Background: Multi-slice computed tomography (MSCT) is the main stay of pre-operative assessment of many complex congenital heart diseases (CHD) in current clinical practice, one of them is double outlet of right ventricle (DORV). DORV is one of the conotruncal anomalies that encompasses a wide spectrum of anatomic malformations in which both the aorta and pulmonary arterial trunk arise entirely or predominantly from the morphologically right ventricle (RV). Purpose of this article is to understand spectrum of DORV and associated types of ventricular septal defect (VSD) on MSCT imaging with special emphasis of usefulness of 3-D volume rendered (VR) images in pre surgical evaluation.

Methods: A total of 500 paediatric patients (<18 years old), who had undergone MSCT were studied during the period 2014 to 2019 at the tertiary cardiac care centre.

Results: 500 patients having primary/suspicious diagnosis of DORV on echocardiography during the said period were enrolled in the study. All the patients who underwent MSCT scan, were studied in detail for: DORV spectrum, associated types of VSD and its relationship to the semilunar valves. Out of 500 total subjects, subaortic VSD was the most common type of VSD observed (53%), followed by subpulmonic VSD (22%), non-committed VSD (18%) and doubly committed VSD (7%). Associations of pulmonary stenosis, subaortic stenosis and aortic co-arctation with various types of VSDs were addressed. Associated other anomalies were also analysed.

Conclusions: Advances in MSCT technology has revolutionized pre-surgical diagnosis, management approach and post-operative follow-up of DORV patients. Excellent image qualities along with 3D volume rendered images help surgeon understand complex morphology of DORV variants and associated types of VSD. Significant reduction in intra and post-operative mortality in DORV patients in current era is result of MSCT technology.

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Ultrasound-guided Compression Repair of Post Catheterisation Femoral Artery Pseudoaneurysm: A Retrospective Study from a Tertiary Cardiac Institute.
Milin N Garachh, Yashpal R Rana, Megha M Sheth, Dinesh L Patel, Samir G Patel, Shreya K Vora.
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Introduction:

Femoral Artery Pseudoaneurysm (FAP) is a rare complication after catheterisation however due to huge workload of interventional procedures in a nodal cardiac institute; they are seen with relatively increasing frequency.

Aim: To share high volume cardiac institute’s experience of Ultrasound-Guided Compression Repair (UGCR) technique, results and probable predictive factors of failed compression.

Materials and Methods: A retrospective study was conducted from 2012 to 2019 in which 310 patients diagnosed with FAP on ultrasound study were enrolled. All the patients who were diagnosed on same day of the procedure were given tight compression bandage and re-evaluated after 24 hours to look for presence or absence of spontaneous thrombosis. Those patients in whom pseudoaneurysm were still present 24 hours after the procedure were given compression. Manual compression was given with a 10 MHz linear probe until complete thrombosis was achieved or maximum four cycles were attempted before labelling patient as failure. In those patients where complete thrombosis was achieved, follow-up study was obtained at 24 hours and after one month to detect any recurrence. All statistical studies were carried out using IBM SPSS program version 20. Quantitative variables were expressed as mean±standard deviation and qualitative variables were expressed as percentage (%).

Results: Out of 310 pseudoaneurysms, 53 of them were of small size and thrombosed spontaneously on 24 hours follow-up and tight compression bandage and seven patients fell in exclusion criteria. Remaining 250 patients were attempted for UGCR. Successful thrombosis of the pseudoaneurysm was achieved in 235 (94%) patients. The mean largest dimension of the pseudoaneurysms sac was 3.5 cm (range 1-8 cm) and mean sac area was 9 cm2 (range 1-36 cm2). The mean length of pseudoaneurysm neck was 11 mm (1-26 mm) while mean width of neck was 2.3 mm (range 0.5-6 mm). The mean compression time of the successful compressions was 26 minutes (range 6-110 min). Successful thrombosis of the pseudoaneurysm was achieved in 60° angle (27.3%).

Conclusion: UGCR is a safe, reliable and cost-effective treatment for post catheterisation FAP. Width, and angle of the pseudoaneurysm neck were major predictive factor of technical success.

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CORRELATION BETWEEN CHEST CT SEVERITY SCORE AND INFLAMMATORY BLOOD MARKERS.
Milin N. Garachh,Samir G. Patel,Megha M. Sheth,Yashpal R. Rana,Dinesh L. Patel,Payal P. Tripathi,Iva V. Patel
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Objectives: With the ongoing COVID-19 pandemic, attempts are made to identify early those patients likely to undergo cytokine storm. Apart from clinical and laboratory parameters, a high resolution computed tomographic (HRCT) chest scan is a promising tool to identify patients very early in the course of COVID-19 disease. The purpose of this research is to nd a correlation between high chest CT severity score (CTSS) on HRCTthorax scan and the clinical course and worsening in COVID-19 patients.

Methods: During the period from May 2020 to October 15, 2020, 250 patients with conrmed RT-PCR diagnosis of COVID-19 on rst or repeat sample and who also underwent HRCT scan of the chest, were retrospectively assigned chest CT severity score (CTSS). Patients were categorized into mild and severe score groups. Inammatory blood parameters of these patients like CRP, Ferritin, LDH, D-dimer, and IL-6 were also studied. Results: Out of a total of 250 patients, 150 patients were in the mild group and 100 patients were in the severe group. Average values of inammatory markers namely C-reactive protein level, Ferritin, LDH, D-dimer, and IL-6 levels were signicantly higher in the severe CTSS group (p < 0.001).

Conclusion: CTSS may be used as a new decisive tool in triaging in-hospital COVID-19 patients. CTSS showed strong correlations with laboratory inammatory markers, suggesting that CT analysis might be an effective and important method for assessing the severity of COVID-19, and may provide additional guidance for planning clinical treatment strategies.

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HRCT FINDINGS IN COVID-19 IN CARDIAC PATIENTS – A PERSPECTIVE FROM TERTIARY CARDIAC CARE CENTRE
Megha M. Sheth,Yashpal R. Rana,Dinesh L. ,Samir G. Patel,Milin N. Garachh,Sibasis Sahoo,Sanjay Patel
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Objective. The increasing number of cases of conrmed coronavirus disease (COVID-19) in India is striking. The purpose of this study was to study the chest CT ndings in COVID-19 pneumonia in patients who also had underlying cardiac disease. Materials and Methods. Data on 42 cases of patients with underlying cardiac morbidity and conrmed COVID-19 pneumonia were retrospectively collected from U.N. Mehta Institute of Cardiology and Research Centre, India. Basic clinical characteristics, demographics and detailed imaging features were evaluated.

Results. Patients 20–78 years old who had underlying cardiac condition and were studied also infected with Covid. Most patients with COVID-19 pneumonia had typical imaging features, such as predominant peripheral ground-glass opacities (GGO) (39 [92.8%]) with multifocal multilobar involvement. A signicant nding that was found in patients with underlying cardiac condition was pleural effusion (10 [23.8%]).

Conclusion. Patients with conrmed COVID-19 pneumonia have typical imaging features that can be helpful in early screening of highly suspected cases and in evaluation of the severity and extent of disease. Most patients with COVID-19 pneumonia have GGO or mixed GGO and consolidation and vascular enlargement in the lesion. Patients with underlying cardiac cause have additional imaging nding in form of pleural effusion, which is not a common nding in those with COVID-19 pneumonia alone

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MSCT imaging of various shunts and grafts in post operative cases of congenital heart diseases
Dinesh L. Patel, Yashpal R. Rana, Megha M. Sheth, Samir G. Patel, Milin N. Garachh, Kamal K. Parikh
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Background: Multi-slice computed tomography (MSCT) plays an important role in clinical practice in assessing post-operative patients with complex CHD when echocardiography is not contributory.  Despite the great capabilities of MR imaging for anatomic and functional assessment of the heart, it is time-consuming and may require a lengthy period of patient sedation; hence its use in seriously ill or uncooperative patients is often limited. CT has the advantages of widespread availability and short acquisition times. It is imperative for a radiologist to be aware of various palliative as well as corrective procedures and their various imaging findings. Aim of this article is to demonstrate and make one aware of various checklists and imaging findings in paediatric patients who have undergone various shunts and grafts at our tertiary cardiac care centre, their immediate as well as long term complications.

Methods: We studied a total of 100 paediatric patients (<12 years old), who had undergone some sort of palliative or corrective shunt or graft placement, on MSCT during the period 2014 to 2018 at our tertiary cardiac care centre.

Results: We try to outline details of various shunts and grafts used in congenital heart diseases correction, MSCT technique and imaging appearances and appearances of abnormal post-operative findings.

Conclusions: Advances in computed tomography (CT) scanners and electrocardiographic gating techniques have resulted in superior image quality of the aorta and pulmonary arteries for evaluating postoperative congenital heart disease. MSCT is an excellent non-invasive modality for post-operative evaluation of various shunts and grafts.

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MSCT coronary angiography in non-invasive assessment of coronary artery bypass grafts patency
Dinesh L. Patel, Yashpal R. Rana, Megha M. Sheth, Samir G. Patel, Milin N. Garachh
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Background: Coronary artery disease (CAD) is one of the leading cause of the morbidity and mortality in India and worldwide and last decade has seen a steep rise in incidence of CAD in India and its treatment as bypass surgery. Direct visualization of the grafts and native coronary arteries by invasive catheterization is now being replaced by non-invasive CT coronary angiography with higher slice machines and newer technology as it has good temporal resolution, high scanning speed as well as low radiation dose. We share our experience of graft imaging on 128 slice CT machine.

Methods: This is a retrospective, single-center, observational study. We included 500 symptomatic patients who have undergone CT study between the year 2014 to 2018 post bypass surgery.

Results: Arterial grafts have a better patency rate than venous grafts. (88% vs. 64.1%). Amongst the individual arterial grafts RIMA had the best patency rate (100%) followed by LIMA (90.8%), RA (68.7%). LAD was the most commonly involved artery (91%).

Conclusions: Significant absolute concordance between CT and catheter angiographic findings have been documented for all arterial and venous grafts patency in the literature. The MSCT with retrospective gating permits an accurate and non-invasive evaluation of patent and diseased arterial and vein grafts and could replace conventional angiography for the follow-up of symptomatic, stable patients. Moreover, an optimal diagnostic accuracy was also documented in the appraisal of native vessels distal to the graft anastomoses.

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MSCT Imaging Of Ascending Aorta – Special Emphasis on Post-Operative Imaging
Yashpal Rana, Dinesh Patel, Megha Sheth, Samir Patel, Milin Garachh, Kamal Parikh
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Abstract

Background: MSCT is an excellent modality for noninvasive imaging of ascending aorta pathologies and post-operative status. Techniques for repair of the aorta currently include open and endovascular methods, hybrid approaches, minimally-invasive techniques, and aortic branch vessel reimplantation or bypass. Hence collaboration among radiologists and cardiothoracic vascular surgeons is essential. An awareness of the various surgical techniques, expected postoperative appearance, and potential complications is essential for radiologists. Methods: We studied a total of 100 patients on MSCT during the period 2014 to 2018. Results: This study is aimed at detail MSCT imaging appearances of Ascending Aorta abnormalities and special emphasis on appearances of post-operative Ascending Aorta – Normal findings as well as complications. The value of three-dimensional image evaluation will also be emphasized. Conclusions: Advances in MSCT scanners and ECG gating techniques have resulted in superior image quality of the ascending aorta and increased the use of CT angiography for evaluating the postoperative ascending aorta. Familiarity with these procedures and their imaging features are required to identify normal postoperative appearances and complications.[Rana Y Natl J Integr Res Med, 2019; 10(2):35-40]