Radiology

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Life threatening haemoptysis : a clinical and radiological study.
(2003) Corr, Peter David.; Lalloo, Umesh Gangaram.
The investigation and management of patients with life threatening haemoptysis is a common clinical problem in South African Hospitals. Establishing the aetiology and origin of the haemorrhage and treating these patients is both difficult and expensive in terms of human and financial resources. The purpose of this study was to identify common local aetiologies for severe haemoptysis, review the investigation and treatment of these patients at Wentworth Hospital, Durban and to formulate a plan of management. Retrospective and prospective studies of consecutive patients treated at Wentworth Hospital were performed. In the prospective study a new embolic material gelatin linked acryl microspheres (embospheres) was used for bronchial artery embolization (BAE). The study demonstrated a change in the spectrum of aetiologies of haemoptysis, from bronchiectasis following tuberculosis to destructive pneumonias. The chest radiograph was always the initial imaging investigation but was found to be inaccurate in detecting the origin of the bleeding. High resolution computed tomography of the lungs (HRCT) was the single best investigation to detect the cause and origin of the haemoptysis. HRCT detected focal bronchiectasis and intracavitatory aspergillomas that were undetected on the chest radiograph. Pleural thickening detected on CT was a good indicator of the presence of transpleural collaterals. The major limitation with HRCT was that it could not be performed if the patient was too dyspnoeic to cooperate during the scan. The role of bronchoscopy appears limited in patients with severe haemoptysis to those patients who are potential surgical candidates. I found that bronchoscopy was not accurate in detecting the source of bleeding in the few patients in which it was performed. Bronchial arteriography remains the gold standard in the detecting the source of haemorrhage. Bleeding sites were detected on angiography in the presence of focal hypervascularity, neovascularity and the presence of broncho-pulmonary shunts. Bronchial arteries were hypertrophied in bronchiectasis but were normal in size in some patients who had acute pneumonias. Bronchial artery embolization was the treatment of choice for severe haemoptysis in the patients studied. The use of gelatin cross linked micro spheres has significantly improved the initial success rate following the procedure with less complications compared to the use of polyvinyl alcohol particles (PVA). It is important to identify systemic transpleural collaterals at arteriography and to embolize them to reduce recurrent haemoptysis. Patients with aspergillomas responded well to embolization. Recurrent haemoptysis remains the major limitation of BAE but is reduced with the use of micro spheres as embolic agents and thorough embolization of systemic collaterals on the affected side. Surgical resection was an option for a limited number of patients with focal disease in one lung and good respiratory reserve. The major limitation of the study was the absence of long term follow up to detect those patients with late recurrent haemoptysis.
The impact of HIV infection when superimposed on pulmonary tuberculosis (either active or sequelae tuberculosis) on the success of bronchial artery embolisation.
(2011) Govind, Mayuri.; Maharajh, Jainendra.
ABSTRACT Pulmonary Tuberculosis (PTB) rates in Kwa Zulu Natal (KZN) is amongst the highest in the South Africa and is often associated with Human Immunodeficiency Virus (HIV) co-infection. Bronchial Artery Embolisation (BAE) is an expensive, time consuming procedure requiring operator skill and is accompanied by risk to both patient and operator. Aim: To investigate the impact of HIV infection when superimposed on PTB (active or sequelae) on the success of BAE. Method: A retrospective cross sectional study with descriptive and analytical components of the BAE procedure between January 2006 and December 2007 was performed on sequential BAE studies. These were analyzed for procedural and clinical outcome and reasons for procedural failure were investigated. The impact of CD4 level on procedural and clinical failure was investigated for a subset of cases. Cases were included if they presented with massive or life threatening haemoptysis with a diagnosis of previous or active PTB (made clinically, radiologically or microbiologically) in whom HIV status is known and where the clinician assessed a need for BAE, but excluded any third or more attempt at the procedure for that patient. Results: The final sample size after exclusion of 91 cases is 107. Each attempt at BAE was viewed as an individual case. The study population is made up of 74 HIV positive and 33 HIV negative cases. The median CD4 level is 176 cells / microlitre. Statistically, procedural success does not imply clinically successful outcome.HIV status does not correlate significantly with clinical or procedural results of BAE.CD4 level does not correlate significantly with clinical or procedural results of BAE. There is no technical reason of statistical significance that impacts on the success of the procedure when correlated with HIV status. These include being unable to select, unable to subselect, unable to engage securely, reflux, presence of fistulae and the presence of spinal feeder arteries. The complication rate is not statistically significant when correlated with HIV status. The differences in follow up of clinically unsuccessful cases were not significant when correlated with HIV status. On imaging, all cases demonstrated pathology. No particular zone is significant when correlated with HIV status. The most common finding is parenchymal architectural distortion followed closely by features of active tuberculous infection and no statistical significance is attributed to either when correlated with HIV status. The detection of lymphadenopathy is noted in 19.1% of HIV positive cases and 42.4% of HIV negative cases, and is the only feature of significance when correlated with HIV status. Interpretation: Coinfection with HIV does not have an impact on the success of BAE in patients with active or sequelae PTB who present with massive or life threatening haemoptysis. The rate of technical failure of the procedure suggests that this needs to be performed by persons that are adequately trained. Technical success does not imply clinical success but this finding was not statistically significant when correlated with HIV status. Re-evaluation of the procedure technique and improvements in local practice may produce results that correlate better with international standards.
Utilization of computed tomographic pulmonary angiography in clinically suspected acute pulmonary thrombo-embolism at Inkosi Albert Luthuli Central Hospital.
(2014) Mbatha, Wonder-boy Eumane.; Maharajh, Jainendra.
Abstract available in PDF file.
A review of FCRad Diag (SA) examination results over ten years.
(2016) Ramoorthy, Vishnu.; Du Plessis, Vicci Clark.
Over the past few decades, there have been major technological advancements in the field of diagnostic radiology, as imaging has become indispensible to patient diagnosis and management. Not only are multiple imaging modalities now available, but digital image capturing, storage, and transmission have resulted in a filmless modern hospital setting. Coupled with the ever-widening spectrum of disease, radiologists require a broader and more detailed knowledge base, while facing an increased workload. Consequently, South African postgraduate radiology training programmes have had to adapt. Current radiological examination formats need to encompass multiple imaging modalities, a digital platform, a wider disease spectrum, and a more pressured work environment. In addition, continued research into the field of medical education has lead to several key roleplayers desiring an evaluation of the current examination format, as there is, to date, a profound lack of research on this topic in the South African context. The purpose of this retrospective audit and historical study was to determine whether recent changes in the formats of the FCRadDiag (SA) examinations have impacted on candidate success rates, as well as determining which formats created the most impact on candidate success rates. This was done by evaluating the candidate results for the Part I and II College of Radiology examinations over a ten-year period from September 2003 to March 2013, and comparing the success rates of candidates before and after several key changes in the examination format over this time period. It is hoped that this information will serve as a useful guide to medical educators and radiology examiners in the College of Radiology in the development of a fair, valid and reliable examination structure; as well as directing radiology examinees with the development of a blueprint of radiology examinations which could be used to guide training, learning and examination preparation.
Post -trauma MRI knee interpretation: our experience with a mechanism-based approach in South African setting.
(2017) Stutterheim, James.; Goodier, Matthew David Meriton.; Aldous, Colleen Michelle.
A mechanism-based approach to the interpretation of complex knee injuries at magnetic resonance imaging (MRI) is cited by several authors to provide increased reporting accuracy and efficiency by allowing accurate prediction of injury to at-risk structures. We took interest in the clinical benefits proposed for such an approach, and set out to assess the approach’s validity in our local South African setting. We identified in the recent literature a consolidated mechanism-based pattern approach to complex post-trauma MRI knee interpretation compiled by Hayes et al., which showed high validity of 85% in a North American setting, and set out to test this approach in our resource-constrained South African setting. We found a low percentage (average 19%) of knee injuries classifiable by mechanism using the Hayes et al. classification. Statistically there was fair agreement between the two observers. We conclude, based on remediable limiting factors, that the clinical benefit of a mechanism-based interpretation approach could be optimised in our resource constrained setting by focusing its application on cases imaged within a time window when key injury findings such as bone bruising and soft tissue injury will be optimally detectable, as well as in patients injured in sporting and similar athletic activities. We advocate that the development of a digital MRI image reference tool for the implementation of the Hayes et al. classification could simplify and enhance its application.
What is the association between the Glasgow Coma Scale score, mechanism of injury and computed tomography findings in neurosurgically relevant head injury patients.
(2017) Sewnarain, Kavishka.; Maharajh, Jainendra.
Background: There is extremely limited literature that provides patterns of CT findings at the various GCS levels, and finding the association between mechanism of trauma and CT findings. Most studies done are on patients with GCS of 13, 14, and 15. In addition there are no South African studies on GCS and mechanism of injury as a predictor of CT findings in head injury patients. This study aims to correlate the GCS presentation and mechanism of injury in neurosurgically relevant patients with CT findings and therefore assist to determine the severity and urgency for which patients should be transferred to regional and tertiary hospitals with imaging and neurosurgical facilities. The hypothesis is that GCS and mechanism of injury can be used to predict CT findings to triage patients into risk categories. Objectives: The objective of this study is to compare patients GCS at presentation, mechanism of injury and CT findings in neurosurgically relevant head injury patients and thus assist clinicians on initial contact to determine the severity of head injury. This is especially relevant in rural areas to determine the severity and urgency for which patients should be transferred to regional and tertiary hospitals. Further objectives include to determine the patterns of CT findings at various GCS ranges, i.e.: GCS 3-6; 6-9; 9-12; 12-15 and to determine the patterns of CT findings in patients with various mechanisms of injuries and compare this to relevant literature. The study should determine the likelihood of various types of CT findings in relation to the GCS and mechanism of injury. Method: A retrospective chart review was done of 100 randomized patients, between the ages of 18 and 65 years, with blunt head trauma seen at Inkosi Albert Luthuli Central Hospital (IALCH) over a one year period. Medical records were analyzed to determine the patients who met the inclusion criteria. In patients with blunt head trauma, the initial GCS, mechanism of injury, CT imaging findings and if neurosurgical intervention was required, were recorded. Results: A total of 100 randomly selected patients were included in this study. From this study, 48% of patients presented to hospital due to assault, 21% from MVA, 12% due to a fall, 17% from PVA and 2% from other uncategorised injuries. From the 100 patients in this study, 15% of patients presented with a GCS between 3-6, 23% between 7-9, 22% between 10-12 and 40% presented with GCS between 13-15. Further assessment showed no significant correlation between GCS at presentation and CT findings in neurosurgically relevant head injury patients (P>0,05). There is furthermore no significant correlation of mechanism of injury and CT findings with the exception of subarachnoid haemorrhage. There is a significant correlation with the presence of subarachnoid haemorrhage on CT and history of assault or pedestrian vehicle accident (P=0,015). Conclusion: There should be a high index of suspicion of intracranial injury in patients with a history of assault or pedestrian vehicle accident. It is advised that patients with history of assault or pedestrian vehicle accident, as a mechanism of injury, receive CT imaging. Due to there being no significant correlation between GCS at presentation and CT findings, a GCS between 13-15 in a patient should not be seen as an exclusion criteria for imaging.
Multidetector computed tomography has replaced conventional intravenous excretory urography in imaging of the kidneys: a scoping review of multidetector computed tomography findings in renal tuberculosis.
(SA Journal of Radiology, 2018) Mthalane, Ntombizakhona Bongekile Angel.; Dlamini, Nondumiso Nokwanda Matutu.
Abstract available in pdf.

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