No abstract available.
Diagnosis ; Ductus Arteriosus, Patent ; Endarteritis ; Pulmonary Embolism

While there is a high prevalence of patent foramen ovale in adults, paradoxical embolism via a patent foramen ovale is rare. Previous echocardiographic studies indicated that paradoxical embolism might only occur in patients with high-risk features of patent foramen ovale (i.e., large defect size, presence of a Eustachian valve, and high right atrial pressure). Here, we present a case of patent foramen ovale with high-risk CT features for paradoxical embolism.

While there is a high prevalence of patent foramen ovale in adults, paradoxical embolism via a patent foramen ovale is rare. Previous echocardiographic studies indicated that paradoxical embolism might only occur in patients with high-risk features of patent foramen ovale (i.e., large defect size, presence of a Eustachian valve, and high right atrial pressure). Here, we present a case of patent foramen ovale with high-risk CT features for paradoxical embolism.

This article presents specific examples of delayed diagnosis of acute coronary syndrome, acute aortic dissection, and pulmonary embolism resulting from evaluating patients with nonspecific acute chest pain who did not undergo immediate dedicated coronary CT angiography (CTA) or triple rule-out protocol (TRO). These concrete examples of delayed diagnosis may advance the concept of using cardiac CTA (i.e., dedicated coronary CTA versus TRO) to triage patients with nonspecific acute chest pain. This article also provides an overall understanding of how to choose the most appropriate examination based on the specific clinical situation in the emergency department (i.e., dedicated coronary CTA versus TRO versus dedicated pulmonary or aortic CTA), how to interpret the CTA results, and the pros and cons of biphasic versus triphasic administration of intravenous contrast material during TRO examination. A precise understanding of various cardiac CTA protocols will improve the diagnostic performance of radiologists while minimizing hazards related to radiation exposure and contrast use.
Acute Coronary Syndrome ; Angiography ; Chest Pain ; Delayed Diagnosis ; Emergencies ; Humans ; Pulmonary Embolism ; Thorax ; Tomography, X-Ray Computed ; Triage

Objective: To assess the incremental prognostic value of coronary computed tomography angiography (CCTA) in comparison toa clinical risk model (Framingham risk score, FRS) and coronary artery calcium score (CACS) for future cardiac events in ischemicstroke patients without chest pain. Materials and Methods: This retrospective study included 1418 patients with acute stroke who had no previous cardiac diseaseand underwent CCTA, including CACS. Stenosis degree and plaque types (high-risk, non-calcified, mixed, or calcified plaques) wereassessed as CCTA variables. High-risk plaque was defined when at least two of the following characteristics were observed:low-density plaque, positive remodeling, spotty calcification, or napkin-ring sign. We compared the incremental prognosticvalue of CCTA for major adverse cardiovascular events (MACE) over CACS and FRS. Results: The prevalence of any plaque and obstructive coronary artery disease (CAD) (stenosis ≥ 50%) were 70.7% and 30.2%,respectively. During the median follow-up period of 48 months, 108 patients (7.6%) experienced MACE. Increasing FRS, CACS,and stenosis degree were positively associated with MACE (all p< 0.05). Patients with high-risk plaque type showed the highestincidence of MACE, followed by non-calcified, mixed, and calcified plaque, respectively (log-rank p< 0.001). Among theprediction models for MACE, adding stenosis degree to FRS showed better discrimination and risk reclassification compared toFRS or the FRS + CACS model (all p< 0.05). Furthermore, incorporating plaque type in the prediction model significantly improvedreclassification (integrated discrimination improvement, 0.08; p= 0.023) and showed the highest discrimination index(C-statistics, 0.85). However, the addition of CACS on CCTA with FRS did not add to the prediction ability for MACE (p> 0.05). Conclusion Assessment of stenosis degree and plaque type using CCTA provided additional prognostic value over CACS andFRS to risk stratify stroke patients without prior history of CAD better.