Browsing by Subject "Diagnostic Radiology"

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    A retrospective review of computed tomography pulmonary angiography image quality and the impact on diagnostic outcome at a tertiary South African hospital
    (2022) Holtzhausen, Jeanette; Moosa, Sulaiman E I; Esmail, Aliasgar
    Background: Computed Tomography Pulmonary Angiography (CTPA) is a key diagnostic imaging modality for pulmonary embolism. These studies are technically challenging to perform. Degraded image quality may result from inadequate pulmonary artery contrast opacification, motion- or streak artefact as well as patient factors. Literature suggests that poor quality scans could lead to indeterminate outcomes and suboptimal clinical decisions with risk of increased mortality. Objective: The study aimed to benchmark the image quality and diagnostic outcomes of CTPA studies in the setting of a tertiary Southern African hospital. The relationships between CTPA image quality and diagnostic and clinical outcomes, as well as related variables such as health risk factors and effective dose, were also explored. Methods: A retrospective cross-sectional study evaluated consecutive CTPA studies performed at Groote Schuur hospital, Cape Town, South Africa, over a six-month period from 1 July 2018 to 31 December 2018. All studies performed for suspected acute or chronic pulmonary embolism (PE) in patients 18 years and older were included. Records were reviewed regarding image quality and diagnostic and clinical outcomes. Correlation tests were performed between continuous variables and chisquare tests among categorical variables. Results: During the study period, 231 CTPA studies were performed, of which 226 were included. The sample comprised 69 % females and 31 % males, with median age of 45 years (range 19-84 years). In 204 (90.3 %) of studies, adequate contrast opacification ≥ 211 HU was obtained. Inadequate contrast opacification was present in 9.7% of cases, in line with previous research. Motion and/ or streak artefacts were present in 45.6%. PE was confirmed in 22% and excluded in 65 % of cases. The number of scans with indeterminate diagnostic results only comprised 30 out of the 226 scans reviewed, however, the percentage was higher than previously reported (13.3% vs mean of 6.4 % in published literature). Amongst these, inadequate contrast opacification occurred in 15 (50 %) of studies and artefacts degraded image quality in 24 (80 %). Patients with a diagnosis of PE had higher mortality, compared to patients with negative and indeterminate scans. Clinicians interpreted indeterminate scans as negative, however, this did not impact adversely on mortality. Conclusions It was encouraging that the percentage of studies with adequate contrast opacification met published bench-marks. Although the higher-than-expected percentage of indeterminate studies may partially be explained by the prevalence of artefacts, it requires further investigation. This did not, however, translate into adverse mortality outcomes.
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    Assessment of airway compression on chest radiographs in children with pulmonary tuberculosis
    (2018) Richter-Joubert, Lisel
    Study rationale: Diagnosis of pulmonary tuberculosis (PTB) in children relies heavily on chest radiography as sputum samples are difficult to obtain and only yield positive results in 30-74% of children treated for PTB. However, radiological signs between lower respiratory tract infections (LRTI) and PTB overlap considerably and there is a wide inter-observer agreement in the detection of lymphadenopathy, considered the hallmark of PTB. Small pliable paediatric airways are easily compressed by enlarged lymph nodes. Unlike lymph nodes, however, the lucent airways contrast against the surrounding mediastinal structures on radiographs, thus airway compression may serve as a more objective criterion for diagnosing PTB. Many studies have reviewed the radiographic features of PTB in children but few included airway compression or used a control group and none have evaluated inter-observer agreement. Objective: To investigate frequency and inter-observer agreement of airway compression on chest radiographs in children with PTB compared to those with another LRTI. Methods: Chest radiographs of children admitted to Red Cross War Memorial Children’s Hospital with suspected PTB were read by two readers according to a standardised format and a 3rd when there was disagreement. Radiographs of children with definite PTB were compared to those with another LRTI. Frequency and location of airway compression were evaluated. Findings were correlated with human immunodeficiency virus (HIV) infection and age. Inter-observer agreement was assessed using kappa statistic. Results: Radiographs of 505 children (median age 25.9 months [IQR 14.3-62.2]) were reviewed; 97/505 (19%) children were HIV-infected. Airway compression occurred in 54/188 (28.7%) definite PTB cases versus 24/317 (7.6 %) of other LRTI cases (OR 4.9; 95%CI 2.9–8.3). The left main bronchus was most affected in 51/493 (10.3%). A higher frequency of airway compression occurred in infants at 22/101 (21.8%) compared to 56/404 (13.9%) in older children (OR 1.7; 95%CI 1.00–3.00). No association between airway compression and HIV infection was found. Inter-observer agreement ranged from none to fair (kappa of 0.0-0.4). Discussion: The overall frequency of airway compression in definite PTB is compatible with reports in the literature. Although airway compression used alone is not a specific sign, if seen on radiographs, there is a strong correlation with PTB compared to other LRTI with infants at higher risk due to their smaller airways. Contradictory to other studies, our study showed the left main bronchus to be affected twice more commonly than the bronchus intermedius in both age groups. This is thought to be due to different patient selection. Confirming reports in the literature, no significant association between airway compression and HIV status was found. A disappointing finding was the poor inter-observer agreement. Contributing aspects include the lack of standardised criteria in the definition of airway compression and suboptimal visualisation of the airways on standard chest radiographs due to patient, technical and post processing factors. Conclusion: There is a strong association between airway compression on chest radiographs and definite PTB, particularly in infants, irrespective of HIV status. However, its clinical use as an objective criterion in the diagnosis of PTB is limited by poor inter-observer agreement.
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    Corpus callosum morphology in children on mid-sagittal MR imaging
    (2018) Raubenheimer, Lauren; Andronikou, Savvas; Kilborn,Tracy
    Background: There is little published research on the wide variation of corpus callosum (CC) morphology in children, the assessment of which is made difficult by the complex alteration of its appearance in childhood. Objective: The purpose of our study was to assess the morphology of the CC on mid-sagittal T1- weighted magnetic resonance imaging (MRI) in a large number of children and correlate the findings with demographic and clinical criteria. Materials and methods: We reviewed all brain mid-sagittal T1-weighted MRI’s performed from July to December 2015 and obtained relevant demographic and clinical information from the accompanying report and laboratory system. The CC morphology was analysed by three radiologists and compared using cross tabulation with the chi-square test and ANOVA. Interobserver correlation was assessed using Kappa coefficient of conformance. Results: 257 patients with mean age 72±60 months were included, 142 were male (55%). In abnormal MRI’s the CC was less likely to have an identifiable isthmus and was more likely to be convex, thin and have separation of the fornix insertion (all p<0.01). In young children (< 5 years) the CC was also less likely to have an identifiable isthmus (p=0.01) and was more likely to be convex (p=0.04) but the fornix was more likely to insert normally (p<0.01). Children with tuberous sclerosis had significantly thinner splenia (p=0.02). Conclusion: There is a distinct pathological appearance of the CC. The immature appearance of the corpus callosum can mirror this but is distinguished by normal insertion of the fornix and normal quantitative measurements. Splenial thinning in children with tuberous sclerosis warrants further investigation.
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    Diagnostic yield of ultrasound-guided fine needle aspiration biopsy (US-guided FNAB) and post-surgical histopathological correlation of thyroid nodules in the Department of Radiology, Groote Schuur Hospital, Cape Town, South Africa over a two-year period
    (2022) Matimati, Bornaventure; Ahmed, Nazir
    Background: Nodular thyroid disease is common worldwide, and the incidence of thyroid nodules is increasing globally. Ultrasound (US)-guided thyroid nodule fine needle aspiration biopsy (FNAB) is a reliable and cost-effective method of distinguishing between benign and malignant nodules before major surgery is performed. Aims: The study aimed to establish the diagnostic yield of US-guided thyroid FNAB's done at Groote Schuur Hospital over two years and to correlate findings with histopathological results in those patients that underwent thyroidectomy. Objectives: The objectives were to establish the number of US-guided FNABs performed, the number of repeat FNABs and the number of patients who subsequently had thyroidectomy over two years. A further objective was to evaluate the diagnostic yield by comparing the cytology and histology results for patients that underwent thyroidectomy. Methods: This was a retrospective study of all patients referred for US-guided FNAB from 1 January 2018 to 31 December 2019. All patients with cytology results after FNAB and histology results after thyroidectomy, were included in the study. US-guided FNAB data was collected from the Picture Archiving and Communication System (PACS) and Radiology Information System (RIS), while cytology and histology data were obtained from the National Health Laboratory Services (NHLS). Results: A total of 236 patients were included in the study (220 females and 16 males), with ages ranging from 19 to 82 years. The diagnostic yield was 34-% on the first, 36-% on the second and 48-% on the third FNAB. Most of the US-guided FNABs were non-diagnostic (66- % on the first, 64-% on the second and 52-% on the third FNAB). A total of 107 patients (45 %) had a repeat FNAB, while 23 patients (9.7-%) had a second repeat FNAB. A total of 48 patients (20.3-%) underwent thyroidectomy. Cancer was detected in 29/236 (12.3-%), of which 17/29 (59-%) were papillary thyroid carcinomas. There was no significant correlation between FNAB results and post-surgical histopathological results in patients who underwent thyroidectomy, with a p value of .15. Conclusion: The overall cancer rate of 12.3-% was comparable with that of other institutions. 66-% of US-guided FNABs were non-diagnostic, while 34-% were diagnostic on the first FNAB with 45-% requiring a repeat second FNAB. The assistance of a cytopathologist during the biopsy has been known to result in fewer non-diagnostic results, avoiding repeat attempts. Further diagnostic and cost-effective analysis of cytopathology assistance in the US-guided FNAB for characterising thyroid nodules is advised.
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    Endovascular treatment of post-traumatic carotid-cavernous fistulae with latex detachable balloons
    (2002) Szkup, Piotr; Beningfield, Stephen James
    Carotid cavernous fistula (CCF) is an abnormal connection between the carotid artery and the cavernous sinus. The CCF's are usually classified in three ways: 1. Pathologically, as spontaneous or traumatic; 2. Hemodynamically, into high-flow or low-flow; or 3. Angiographically, as direct or indirect. The Barrow angiographic classification is most commonly used. It is based on the pattern of arterial supply and has therapeutic implications.
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    Evaluating the yield of brain CT examinations in patients presenting with first onset seizures at the Groote Schuur Hospital, Cape Town
    (2019) Ncube, Innocent Vusumusi; Ahmed, Nazir
    Background: Seizures are a frequent and potentially significant presenting complaint to the emergency department (ED). Determining the underlying cause for seizures is important in guiding further clinical management of patients. ED physicians at Groote Schuur Hospital, Cape Town, South Africa routinely request Computed Tomography (CT) brain scans in the work-up of patients presenting with first onset seizures. Objectives: To determine the number and proportion of CT scan examinations with abnormal findings in patients presenting with first onset seizures at the Groote Schuur Hospital ED, Cape Town, South Africa and to identify the range of CT abnormalities. Method: A retrospective study was carried out in the Division of Radiology, Groote Schuur Hospital. Patients who presented to the ED with first onset seizures and who underwent brain CT examination as part of their work up between 1 January 2013 and 31 December 2016 were enrolled. All patients presenting to the ED with first onset focal or grand mal seizures were included. Patients with recent trauma and those with previously diagnosed epilepsy were excluded. Results: A total of 200 patients were eligible for the study. Of these, 92 (46%) patients with first onset seizures had an abnormality or abnormalities on brain CT scan. Of those patients whose HIV status was known, 50% of HIV positive and 53% of HIV negative patients had abnormal CT scans. 54% of patients with focal seizures and 38% with generalised seizures had an abnormality on CT scan. Abnormalities found on CT scans included chronic cerebral infarction (7.5%), acute or subacute cerebral infarction (4.5%), neurocysticercosis (7.0%), other infections (6.5%), haemorrhage and other vascular lesions (6.5%), post-traumatic encephalomalacia (6.5%), primary brain tumours and metastases (based on CT characteristics) (7.0%). Conclusion: Forty-six (46%) of patients presenting to the Groote Schuur Hospital ED, Cape Town, South Africa with first onset seizures had an abnormality on their brain CT scans. Brain CT scan is therefore recommended in patients presenting to the ED department with first-onset seizures, irrespective of their HIV/ neurological status.
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    Evaluation of the utility of specific CXR features for diagnosis of pulmonary tuberculosis in young children using multiple readers
    (2015) Ho-Yee, Ruschka; Andronikou, Savvas; Beningfield, Stephen J; Hatherill, Mark
    INTRODUCTION: The diagnosis of childhood pulmonary tuberculosis (TB) can be notoriously difficult. The chest X-ray (CXR) is a significant diagnostic resource in the detection of PTB in children. However, non-specific radiological features combined with variable inter-observer assessment s contribute to diagnostic uncertainty. The CXR would be of most value when used specifically to evaluate those features of childhood TB that it shows best and where expert observers agree, namely those signs indicating lymphadenopathy. AIM: To identify simple and reliable CXR features of primary TB in children by determining signs and anatomical sites of best observer agreement. METHOD: This is a retrospective descriptive study within a clinical trial performed by the South African TB Vaccine Initiative (SATVI). Healthy BCG-vaccinated newborn infants in a high TB prevalence rural area in Worcester, near Cape Town, South Africa, were followed for a minimum of two years for possible incident al pulmonary TB. Three independent, blinded, expert paediatric radiologists reported the resultant CXR images using a standardised data collection tick sheet, on which the specific anatomical sites and signs of pathology consistent with pulmonary TB were recorded. The first 200 original data collection tick sheets were sampled and recorded in a pre-compiled data spreadsheet for our study. The sampled data were t hen analysed using kappa statistics. RESULTS: The overall combined agreement for airway compression (by presumed lymphadenopathy) was 0.5%. Five % of the CXR's had soft tissue densities reflecting lymphadenopathy on the frontal view and 5% on the lateral view. The most common site reflecting lymphadenopathy through airway narrowing or displacement was the left main bronchus. The hilar region (kappa 0.27) on the frontal CXR and behind bronchus intermedius (kappa 0.18) on the lateral were the most common sites of soft tissue densities reflecting lymphadenopathy. There were no positive findings for cavitation or pleural effusion. The overall decisions reflecting PTB (lymphadenopathy or miliary) by each individual reader were 27.6% by Reader 1, 8.5% by Reader 2 and 24.6 % by Reader 3. Abnormal findings not specific for PTB were found in 3.5 % by Reader 1, 10.5% by Reader 2 and 3.5% by Reader 3.68. 3 % of the radiographs were reported as normal by Reader 1, 81.9% by Reader 2 and 66.8 % by Reader 3. Only 5% of the radiographs were found to be unreadable by one reader. The overall agreement of all three readers on PTB was 14.6 % and for normal CXR 49.2%. CONCLUSIONS: The fair degree of agreement amongst expert readers suggests that the CXR alone is not a reliable tool for detecting pulmonary TB and should be utilised in conjunction with the clinical features and/or skin tests and blood results. Soft tissue masses rather than airway compression are a more reliable sign for lymphadenopathy, with the most agreed upon sites on the frontal projection for soft tissue mass detection being the right hilar region, followed by the left hilum. Unfortunately, this study could not confirm the usefulness of the CXR in subcategorising PTB into severe and non-severe groups due to the absence of any positive features for severe PTB in the selected sample. The use of prescribed tick-sheets with specified features for detecting lymphadenopathy did not have the expected impact of promoting interobserver consensus of CXR findings in children in terms of detection of TB. The absence of a credible reference standard for lymphadenopathy remains a significant limitation.
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    Imaging displacement and strain in the medial gastrocnemius muscle during ankle-joint motion using 2D-ciné DENSE MRI
    (2011) Lawson, Andrew James; Beningfield, Stephen J; Spottiswoode, Bruce Shawn
    Skeletal muscle structure has been defined on both macro and microscopic levels by gross dissection, light- and electron-microscopy. The basic physiological building blocks involve the electromechanical coupling between interlinking actin and myosin fibres. Detailed intramuscular behaviour during contraction can be clearly defined when examining a single isolated muscle. However, there are few areas in the human body where single muscles act independently to affect motion. This thesis attempts to address the compounded effect that muscles have on each other, while working synergistically in a group, such as the calf muscle.
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    Radiation dose optimization in interventional radiology and cardiology using diagnostic reference levels
    (2016) De Vos, Hendrik Johannes; Trauernicht, Christoph Jan; Kotzé, T C
    The International Commission of Radiological Protection (ICRP) advises that in principle Diagnostic Reference Levels (DRL) could be used in fluoroscopically guided interventional procedures to avoid unnecessary stochastic radiation risk. The increase in complexity of interventional procedures, combined with a lack of specialist training on radiation techniques, poses a significant risk to patients. These risks have not gone unnoticed by government authorities worldwide and in 2015 the South African Department of Health: Directorate Radiation Control issued requirements to license holders of interventional fluoroscopy units, requiring that a medical physicist optimize their radiation usage using DRLs. The Dose Area Product (DAP) quantity measured for each patient represents a dosimetry index, the value of which for the purpose of improvement should be optimized against the DRL. In this dissertation, I aim to establish if DRLs in the South African private healthcare interventional theatres are high compared to international levels and whether DRLs will optimize the doses used.
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    Radiological features of psoriatic arthritis
    (2011) Davis, Razaan; Kalla, A A
    Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis. Psoriasis is a dermatological condition that affects 1-2% of the population. Approximately 10-15% of patients with skin manifestations of psoriasis develop PsA and 0.3-1% of the general population. Moll and Wright defined PsA as psoriasis associated with inflammatory arthritis and usually a negative serological test for rheumatoid factor (RF).
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    Retrospective comparison of hydrostatic and pneumatic reduction of childhood intussusception at Red Cross Children's Hospital (1989-1997)
    (1998) De Villiers, Jean Pierre; Fisher, R M
    In accordance with consensus of the current literature, we have been using pneumatic reduction by preference at Red Cross Children's Hospital (RCCH) since the early 1990's. The aim of this study is to evaluate the results of our experience since 1989 as we have gradually moved from the hydrostatic method to the pneumatic method. This study will present results of 100 cases seen over a seven year period at the Red Cross Children's Hospital. The results of the respective reduction techniques will be discussed with special attention on complication rates, efficiency and cost implications.
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    A retrospective study of CT angiography versus digital subtraction angiography in penetrating neck trauma
    (2013) Scholtz, Paul Victor John; Candy, S; Beningfield, S
    BACKGROUND. Penetrating neck trauma is commonly encountered in South African trauma units, and is associated with high mortality and morbidity rates. The imaging protocol for stable patients with penetrating neck trauma remains controversial. There is only sparse data validating the use of Computed Tomography Angiography (CTA) in the evaluation of penetrating neck trauma. OBJECTIVES. To assess the sensitivity and specificity of CTA versus Digital Subtraction Angiography (DSA) in detecting arterial injury and secondarily evaluate the ability of CT to assess non-arterial injury.
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    A review of the Groote Schuur hospital experience of low-velocity non-missile penetrating orbital and transorbital stab wounds
    (2004) Welman, Chris; Beningfield, Stephen J
    The aim of this study is to perform a retrospective review of all cases of low-velocity non-missile penetrating orbital trauma with intracranial complications presenting at Groote Schuur Hospital over the 5 year period between 1997 and 2001.
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    The role of abdominal ultrasound in the investigation of suspected extrapulmonary and disseminated tuberculosis
    (2007) Patel, Maya Nathu; Beningfield, Stephen J; Burch, Vanessa
    The primary objective was to undertake a prospective study in order to determine whether abdominal lymphadenopathy detected at ultrasound examination could be used as an indicator of the presence of active extrapulmonary and/or disseminated TB.
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    The risks of medical imaging: a survey of doctors' knowledge and consenting practice
    (2018) Nair, Tamiya; Andronikou, Savvas
    Background: Diagnostic imaging forms an integral part of patient evaluation and its use has increased dramatically. Not only is medical imaging a source of increased radiation dose, but also poses other risks such as those related to the procedure performed, the contrast and drugs administered, acoustic and heat deposition and para-magnetic risks. While many studies have assessed doctors' knowledge of radiation risk, data regarding doctors' knowledge of the remaining risks of medical imaging and doctors' attitudes toward consenting practice for imaging is lacking. Aim: To survey and compare the levels of knowledge between referring clinicians and radiologists regarding the risks to patients undergoing medical imaging and to explore doctors' attitudes toward consenting practice. Method: A cross sectional, observational, descriptive study design was employed. The study was conducted using a non-validated, piloted, self-administered three-page questionnaire. The questionnaire was distributed to doctors in various stages of their medical careers at a tertiary level hospital. The questionnaire was constructed in sections including demographics, risks of medical imaging and consent practice. The maximum score potentially attainable was 79, with a point given for each correct answer. No points were given for incorrect, unsure or blank responses. Results: A total of 431 questionnaires were distributed but only 85 doctors (19 radiologists and 66 clinicians) returned a completed survey, yielding a response rate of 19,7%. Older respondents with more years of experience had greater levels of knowledge regarding the risks of medical imaging. There were no significant differences according to gender or university. Although the levels of knowledge of risk was poor overall, radiologists had greater levels of knowledge (mean knowledge score expressed as a percentage =79% compared to that of clinicians= 71%). The largest proportion of doctors' (49%) were of the opinion that clinicians should be responsible for obtaining consent for medical imaging. Only 18% of doctors (radiologists and clinicians) and 5% of clinicians admitted to feeling adequately prepared to obtain consent for medical imaging. Conclusion: We successfully surveyed and compared the levels of knowledge of medical imaging risks amongst doctors and determined their attitudes toward responsibility for consent. The levels of knowledge of the risks of medical imaging is inadequate among radiologists and poor amongst non-radiologists. While statutory body guidelines recommend that the performing health care provider obtain consent, there remains varying opinion as to who should obtain consent. The largest proportion of doctors' were of the opinion that clinicians should obtain consent for medical imaging - this despite clinicians' feelings of inadequacy when consenting patients to the risks of imaging. It is therefore important to take into consideration the levels of knowledge and comfort when making decisions as to who is best suited to obtain consent for medical imaging. With the increased dependence on medical imaging as part of the diagnostic work up, awareness of the risks of medical imaging is of tantamount importance. It is essential to review educational curricula and local policies in order to improve the levels of knowledge of risks of medical imaging amongst healthcare providers, thereby ensuring improved patient safety.
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    Value of follow-up CT in head injury assessment
    (2015) Owen, Jeannine Margaret; Andronikou, Savvas
    INTRODUCTION: The question of when and if to perform follow- up CT scanning of the brain in a patient with a proven head injury remains pertinent, and the answer is not clear cut. This is even more so compounded when one tries to compare and equate what happens in a developed country with that of a developing country such as South Africa. AIM: To evaluate referral patterns, associated time-delays and findings of follow-up CT as well as patient outcomes in patients with head injury at Groote Schuur Hospital. METHOD: A retrospective review, over a 6 month time period, of the CT scans and folders belonging to patients who underwent follow-up CT scanning of the brain after blunt trauma to the head. RESULTS: There were 313 follow-up studies performed in 212 patients, of which the majority, 135 /313 (43.1%) were referred for neurological reasons, whilst 103/313 (32.9%) were referred for conservative management reasons and 75/313 (24%) were referred as part of their post-surgical check-up. There were significant time delays from arrival of patients in casualty to their initial CT scan (mean 18.74 hours) as well as between the initial CT and the first follow-up scan (mean 121.78 hours). There was a significant amount of data missing regarding the time of actual injury for many patients. There were 74 neurosurgical interventions that took place as a result of CT scans performed. Of these, 54 (73%) took place after the initial CT scan, whilst only 20 (27%) occurred after a follow-up CT. Of those surgical interventions performed after a follow- up study, 6 (30%) were performed as a result of a scan performed for post-surgical check- up. 12 (60%) were performed as a result of a scan performed for neurological reasons. Two (10%) neurosurgical interventions occurred as a result of a scan performed for conservative management reasons (thus routine follow-up imaging). CONCLUSIONS: A routine single follow-up CT may be a reasonable approach with further follow-up imaging reserved for patients who have undergone surgery, those with possibly surgically manageable findings on initial CT (that do not undergo surgery) and those with new neurology. The routine use of follow-up CT beyond the first follow-up CT is unlikely to lead to a change in management when the above clinical, and prior CT findings are absent. However, the time delays across all aspects of imaging traumatic brain injuries in our setting are unpredictable and represent a major problem in standardising when CT scans are performed.