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ER Multiple Rule-Out Scan of a Patient With Disturbance of Consciousness and Without Breath-Hold.

SOMATOM Definition Flash Scanning

Author: Junichiro Nakagawa, MD,* Isao Ukai, MD*, Osamu Tasaki, MD, PhD*, Tomoko Fujihara**
and Katharina Otani, PhD ***

* Trauma and Acute Critical Care Center, Osaka University Hospital, Osaka, Japan
**CT Marketing Department, Healthcare, Siemens Japan K.K., Tokyo, Japan
***Research & Collaboration Development Department, Healthcare, Siemens Japan K.K., Tokyo, Japan

 

History

An 89-year-old female patient with disturbance of consciousness (DOC) and respiratory arrest was brought to the Trauma and Acute Critical Care Center of Osaka University Hospital. She was in shock, her level of consciousness (LOC) was E1V1M2 (Glasgow Coma Scale), her heart rate was 74 bpm. Her anamnesis included hypertension, and she was on oral medication for diabetes. Her spontaneous breathing was coming back, but her DOC continued, prompting us to perform tracheal intubation and to administer an infusion of vasopressors. She was pulled out of shock.
Chest X-ray showed marked enlargement of the cardiac silhouette and a mediastinal shadow suggesting congestive heart failure. For a multiple rule-out of coronary disease, aortic disease and cerebrovascular lesions, we took a Dual Source CT scan in Flash mode (non-ECG-triggered mode) from head to thoracic region.
 

Diagnosis

The Dual Source CT images showed heart enlargement, pericardial effusions and left ventricle myocardial hypertrophy (Fig. 1). None of the three major coronary arteries had stenoses (Fig. 2) and no significant abnormity of the aorta or cerebrovascular region (Fig. 3, 4 and 5) was found. With these results, acute coronary syndrome, aortic dissection and stroke could be ruled out. The pericardial effusion was diagnosed as chronic on echocardiography. Based on the left ventricle myocardial hypertrophy finding, we suspected hypertrophic obstructive cardiomyopathy.
 

Follow up process

A diuretic worked well to improve cardiac function and respiratory condition. After performing tracheotomy, the patient’s respiratory status gradually improved and she could be weaned from ventilatory support after 43 days in the hospital. Her level of consciousness (LOC) came back to E4VTM6 and oxygenation could be stopped. On the 48th day in the hospital, the patient was transferred to another hospital to receive rehabilitation.
 

Comments

Dual Source CT Flash spiral was used for long range CT-Angiography (Fig. 6). It gave us necessary information to rule out critical acute coronary syndrome, thoracic aortic dissection and cerebrovascular lesions. The Flash mode is an extremely useful tool, in particular for ruling out life-threatening disorders at initial treatment phase without having to subject the patient to additional invasive examinations such as cardiac catheterization. As the Flash scan mode has an ultra-fast pitch of 2.3 (up to pitch 3.4) and temporal resolution of 75 ms (even for non ECG gated scans), diagnostic images can be acquired even of patients who cannot hold their breath which is especially useful at Trauma and Acute Critical Care Centers (Fig. 7).
 

The Dual Source CT images showed heart enlargement, pericardial effusions and left ventricle myocardial hypertrophy.
None of the three major coronary arteries had stenoses.
None of the three major coronary arteries had stenoses.
None of the three major coronary arteries had stenoses.
No significant abnormity of the aorta.
Dual Source CT Flash was used for long range CT angiography.
The fast pitch of 2.3 and temporal resolution of 75 ms allows acquiring motion free images who cannot hold their breath.

Examination Protocol

Scanner SOMATOM Definition Flash
Scan mode Flash Thorax
Scan area Head Thorax
Scan length 570.5 mm
Scan direction Caudo-Cranial
Scan time 2.07 s
Tube voltage 120 kV / 120 kV
Tube current 162 eff. mAs
Dose modulation CARE Dose4D
CTDIvol 9.06 mGy
Rotation time 0.28 s
Pitch 2.3
Slice collimation 0.6 mm
Slice width 1.0 mm
Reconstruction increment 1.0 mm
Reconstruction kernel B35f
Contrast  
Volume 95 ml
Flow rate 4.0 ml/s
Start delay 28 sec

The information presented in this case study is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Medical Systems to be used for any purpose in that regard.


The drugs and doses mentioned herein are consistent with the approval labeling for uses and/or indications of the drug. The treating physician bears the sole responsibility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating the CT System. The source for the technical data is the corresponding data sheets. Results may vary.

Date: 2010-12-13


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