Learning from ER: embolectomy for stroke

Last night on ER: Season 11 Episode 15: Alone in a Crowd
A young mother of three (Cynthia Nixon of Sex in the City) is brought in with symptoms of a potentially fatal stroke .....

Its too late for thrombolysis but the interventional radiologist carries out an embolectomy using a new technique ...

I'd not heard of this one before, so I turned to Google.
Here's the result of one Google search.

Thrombolysis nust be initiated within three hours of onset of an acute stroke, but embolectomy with the Merci retrieval system is effective up to 8 hours after onset of stroke symptoms.

A description of the technique can be found here.
For a video, click here.
The vendor's site is here.

References:

Mechanical thrombectomy of the internal carotid artery and middle cerebral arteries for acute stroke by using the retriever device.
Martinez H, Zoarski GH, Obuchowski AM, Stallmayer MJ, Papangelou A, Airan-Javia S
AJNR Am J Neuroradiol. 2004 Nov-Dec;25(10):1812-5
Abstract

MERCI 1: a phase 1 study of Mechanical Embolus Removal in Cerebral Ischemia.
Gobin YP, Starkman S, Duckwiler GR, Grobelny T, Kidwell CS, Jahan R, Pile-Spellman J, Segal A, Vinuela F, Saver JL.
Stroke. 2004 Dec;35(12):2848-54. Epub 2004 Oct 28
Abstract

And a case report published in 2000 claiming to be 'the first reported use of a snare to remove clot in the setting of thromboembolic stroke'
Transcatheter snare removal of acute middle cerebral artery thromboembolism: technical case report.
Chopko BW, Kerber C, Wong W, Georgy B.
Neurosurgery. 2000 Jun;46(6):1529-31
Abstract

Other things I've learnt from ER:

Different ways of holding and positioning a Sonosite portable ultrasound machine.

How to rule out a mandibular fracture and avoid doing an x-ray (get the patient to bite a tongue depressor, then twang it; if it doesn't hurt, there's no fracture).

I'll be submitting my ER viewing for CME credits.

Farewell to intravenous urography

We've now stopped doing IVUs in my department!

In place of IVUs, we do noncontrast CT for investigation of urinary stones, and CT urography, where indicated, for haematuria. (Indications for ultrasound are, for now, unchanged).

CT urography is a better test, and more sensitive for detecting stones, urothelial lesions and tumours. The main drawback is radiation dose. However, for stone disease, the dose from a noncontrast CT can be brought to levels similar to that of an IVU using a low-dose technique. For patients with haematuria at high risk for cancer, many of them would have ended up with a CT anyway, and if not I think the extra dose is justified by improved diagnostic confidence and accuracy. As they say, if it was me or one of my relatives .....

The technique is relatively simple, and it is easier to get consistent results than with a conventional IVU. It takes less time, and a morning's work in the IVU room can be completed in the CT scanner in about an hour. One extra radiographer has now been allocated to the CT scanner (in place of the one who used to do IVUs), which has helped to resolve some of our staffing problems. The radiographers are delighted because they didn't like doing IVUs. The urologists are pleased as well.

Our CT urography protocol, on a Toshiba Aquilion 16, consists of a low dose noncontrast run to detect stones, followed by post-contrast imaging using a split blous technique which produces a combined nephrographic and excretory phase image. Imaging is done supine, and repeated in the prone position if ureteric opacification is inadequate.

Whole-body CT screening

A whole-body CT screening centre has been in operation at a town near mine, part of a chain called Lifescan. Patients pay between £300 (for a lung scan) and £750 (whole body CT with virtual colonoscopy) for CT scans to screen for unsuspected disease. Anything that is found that might possibly be significant then needs to be followed up. Sometimes early, unsuspected cancer is found . But often, the abnormalities turn out to be insignificant and of no consequence.

This ends up being very expensive, and a team from the Massachusets General Hospital concluded that CT screening was not cost-effective.
Cost-Effectiveness of Whole-Body CT Screening
Beinfield, Wittenberg, Gazelle, Radiology 2005 Feb;234:415-422

If the patient pays directly, this is not too much of a problem (at least for the health care providers), but medical insurers do not cover CT screening, and in many countries, the state ends up bearing the cost.

Here is what others have said:

Prof Adrian Dixon of Cambridge University, Warden of the Faculty of Clinical Radiology (the Royal College of Radiologists)
Another topical issue is the question of walk-in screening centres offering to "save lives" by whole-body CT screening, sometimes for profit. In the UK, the National Screening Committee has suggested that the National Health Service should not offer such screening at present (Muir Gray, personal communication). Many sources suggest that a radiologist's private practice should mirror their NHS practice. The current radiological and radiographic workforce can barely cope with the existing workload, let alone such new ventures. It will be interesting to hear what other countries recommend. Several observers have noted that such walk-in centres are usually located in relation to educated health-conscious consumers who can afford such procedures! ....... Hard facts from primary research are urgently needed. But I cannot see too many grant giving bodies rushing to assess what is currently viewed as a somewhat opportunistic and entrepreneurial endeavour.
Whole-body CT health screening.
Dixon AK. Br J Radiol. 2004 May; 77(917):370-1

A group from the Mayo Clinic
CT screening for lung cancer offers the possibility of reducing mortality from lung cancer. Our preliminary results do not support this possibility and may raise concerns that false-positive results and overdiagnosis could actually result in more harm than good .....
Our data do not suggest a mortality benefit; whether CT for lung cancer meets the criteria for an effective screening test remains to be proved .....
Our preliminary mortality results should cause physicians to pause and reexamine their positions if they are performing routine CT screening outside of a clinical trial.
CT Screening for Lung Cancer:Five-year Prospective Experience
Swensen et al. Radiology 2005 April ;235:259-265.

A group from Stanford (with regard to the situation in the United States)
Direct-to-consumer marketing of self-referred imaging services, in both print advertisements and informational brochures, fails to provide prospective consumers with comprehensive balanced information vital to informed autonomous decision making. Professional guidelines and oversight for advertising and promotion of these services are needed.
Advertising, Patient Decision Making, and Self-referral for Computed Tomographic and Magnetic Resonance Imaging
Illes et al. Archives of Internal Medicine, December 13, 2004; 164(22): 2415 - 2419.

Could a computer report rheumatology clinic films, please?

We radiologists just love reporting rheumatology clinic films, meticulously comparing one hand with another to see if there are new erosions..... yeah sure.

Now that radiographers are reporting skeletal films, perhaps they might like to expand their role to include the rheumatology clinics. And when they get bored, perhaps this product will be ready for use:

Computer aided diagnosis (CAD) in rheumatoid arthritis
P. Peloschek, G. Langs, F. Kainberger, H. Bischof, W.G. Kropatsch, H. Imhof ECR 2005

Digital Bone Age Atlas

Our departmental copy of the Greulich and Pyle atlas always seems to go missing, and I had been wondering if a digital version was available. Perhaps someone, somewhere might have scanned it and saved it as a pdf (probably highly illegal).

Then I saw this pocket-sized paperback at the ECR.

Hand Bone Age A Digital Atlas of Skeletal Maturity
V Gilsanz and O Ratib
Springer 2005. Approx 110 pp. 90 illus. With CD-ROM formatted for PC, PDA version for PALM and Pocket PC. Softcover $79.95 ISBN 3-540-20951-4
"This atlas integrates the key morphological features of ossification in the bones of the hand and wrist and provides idealized, sex- and age-specific images of skeletal development. This computer-generated set of images should serve as a reasonable alternative to the reference books currently available".

It is pretty cheap, as far as illustrated medical books go, looks easier to use than the G&P atlas (less text), and I can't see any reason why we shouldn't use it. It does not seem to have appeared on the Sprnger website yet, but a Google search brought out an abstract on this project presented by the authors at RSNA 2003.

Viennese film bags

A selection of film bags from Viennese clinics. Click on thumbnails for larger images.

Radiographers reporting CT colonography?

In a multicentre European trial, after training with 50 cases, non-experts were pretty good compared to experts at polyp measurement and size categorisation on CT colonography.

The non-experts, who had been trained on 50 cases, were radiologists and radiographers. The performance of non-expert radiologists and radiographers was about the same .

ECR 3/7/2005, B-696 Polyp measurement and size categorisation by CT colonography: Agreement with colonoscopy and effect of observer experience
D. Burling, &. ESGAR CT colonography study GROUP investigators; St. Mark's Hospital, London/GB

Here is the abstract

In Britain, we have radiographers trained to perform and report barium enemas, which they do to a high standard. Barium enemas will be obsolete in a few years' time.

So....

Spinzoo: Animations of MRI spins

Do you find the drawings of MR spins hard to figure out? Have a look at these animations.

Some people believe that spins are just a quantum mechanical property of nuclei. However, spins are very small but lovely animals. And they like magnetic fields.We have collected some spins that used to live in our MR scanner, and we put them into our spin zoo.During the spin zoo tour you can see different aspects of the spin life, and how they react on MR sequences.
MR-Physik , Departement Medizinische RadiologieUniversitätsspital / Universität Basel

http://pages.unibas.ch/dmr/mr_physik/spinzoo/spin.htm

ECR exhibit: CPU vs GPU for workstation graphics processing (????)

3mensio http://www.3mensio.com is a workstation company founded by Frank Wessels, who is one of the co-founders of Applicare (who originally made RadWorks, which we still use for teleradiology to our neurosurgery centre).

According to what he told me, current 3D workstations (Vitrea, Voxar, Leonardo, etc) utilise the computer's central processing unit, or CPU (e.g. Pentium Processor) for graphics processing. The 3mensio workstation, 3viseon (sic), utilises the graphics processing unit, or GPU, which I understand to be the graphics card. These need to be cheap because they are made for kids to play games with, so that the computer used for the workstation can also be very cheap (about $1000) . It then becomes feasible for orthopaedic and vascular surgeons to have a 3D workstations in their offices (and radiologists too, of course).

You read the abstract from the ECR presentation here

I really am not in a position to assess the technical side of things, but I had a play with the workstation, running on a standard PC with about 1G of RAM, and it was pretty good, and fast.

It makes you wonder
(a) why the other manufacturers have not adopted the same approach, if it is feasible
(b) why Nintendo have not diversified into the medical imaging sector

Worth keeping an eye on, I think.

Cerefy Brain Atlas

Something else I came across at the ECR. I just picked up a leaflet, as there was nobody around at the time to explain the product.

If I have understood correctly, it is an electronic brain atlas that allows you to place anatomical labels on your CT or MRI scans automatically.

Here's an article about it I found via Google.

Some of the products are free and can be downloaded from the website http://www.cerefy.com .

I'l have to try it out when I get back.

Barium enemas are on the way out...

It was only about 6 years ago at the Leeds GI Radiology course, that I attended a lecture by Frans-Thomas Fork, who is professor of radiology and endoscopy at Malmö, where he showed how you could pick up small polyps and other subtle lesions on barium enemas by a combination of good technique and attention to detail. It was pretty impressive stuff from a guy who was clearly very good.

Today (Friday) at the ECR, in a lecture on imaging rectal cancer, he said that the barium enema should probably be discarded... It's just not sensitive enough for polyp detection compared to endoscopy or CT colonography.

It probably has another five or ten years left, before being completely superseded by CT colonography (or even MR, who knows?).

Something for the barium radiographers to consider. Enjoy it while it lasts.

Off to the ECR

I'm leaving for Vienna tonight, for the European Congress of Radiology.



I'll be staying with my friend Danielle, who tells me that Vienna is colder than usual, with the wind chill factor making the effective temperature about -15 degrees Celsius. Recent weather forecasts seem a bit more optimistic (but still sub zero). I'm reminded about a story I heard about new arrivals in Siberia being supplied with mink underwear.