More than 70% of COVID-19 patients develop long-term sequelae Chest CT Scans

More than 70% of COVID-19 patients develop long-term sequelae

By Kate Madden Yee, staff writer

July 28, 2021 — More than 70% of patients who contract COVID-19 show thickened lung tissue on chest CT exams performed six months later, a group of researchers from Italy reported in an article published online July 27 in Radiology.

And combining clinical data with baseline chest CT exam findings is an effective way to predict which COVID-19 patients are at higher risk of these types of long-term effects, wrote a team led by Dr. Damiano Caruso, PhD, of Sapienza University of Rome.

“[Our study found that] at six-month follow-up, 72% of patients showed late sequelae, in particular fibrotic-like changes,” the team wrote. “Baseline LSS [Lung Severity Score] and QCCT [quantitative chest CT] of well-aerated lung showed an excellent performance in predicting [these] changes at six-month chest CT.”

Chest CT findings for COVID-19 have been thoroughly explored, but mostly as they manifest in the short- and midterm of disease progression, the team noted. Further research on the disease’s long-term effects is needed.

Caruso’s group sought to add to the knowledge base regarding COVID-19’s lasting sequelae and to investigate whether baseline chest CT findings and/or clinical data could help predict whether patients will have lung thickening at six-month follow-up.

The team conducted a study that included 118 patients who had moderate to severe COVID-19 disease between March and May 2020 (all patients’ disease was confirmed by reverse transcription polymerase chain reaction [RT-PCR] testing). All underwent baseline chest CT exams and follow-up exams at six-months; the researchers assessed the exams’ qualitative findings, LSS, and QCCT measures, comparing them with baseline CT exam findings. The team assessed three strategies for predicting long-term COVID-19 effects: clinical data alone, radiological data alone, and a combination of the two methods.

At six-month chest CT follow-up, 72% of patients had fibrotic-like changes in their lungs and 42% showed ground-glass opacities. The investigators found that baseline LSS and QCCT scores were effective predictors of fibrotic-like changes at this follow-up exam.

Baseline and six-month follow-up coronal thin-section unenhanced chest CT scans of 79-year-old man, admitted to the emergency department presenting fever, dyspnea, and cough

(a,b) Baseline and (c,d) six-month follow-up coronal thin-section unenhanced chest CT scans of 79-year-old man, admitted to the emergency department presenting fever, dyspnea, and cough; COVID-19 was confirmed by RT-PCR testing. (a) Chest CT scan shows bilateral ground-glass opacities tending to consolidation (black arrow). (b) The same scan after QCCT analysis highlighted in light-blue well-aerated lung (1.5 liters, 50%) and in yellow pulmonary injury of COVID-19 pneumonia. (c) Six-month follow-up scan shows residual fibrotic-like changes (white arrows) and persisting of low-density ground glass (asterisks). (d) The same scan after QCCT analysis highlighted in light-blue well-aerated lung (3.5 liters, 82%) and in yellow residual findings of COVID-19 pneumonia at six months follow-up. Images and caption courtesy of the RSNA.
Performance of three different strategies for predicting fibrotic changes in COVID-19 patients at six-month follow-up 
Measure Clinical data Radiological data Combination
Area under the curve 0.89 0.81 0.92
Sensitivity 82% 84% 100%
Specificity 93% 67% 73%

However, in an accompanying editorial, Dr. Athol Wells and colleague Dr. Anand Devaraj, both of Imperial College London in the U.K., suggested that Caruso and colleagues may not be approaching assessment of post-COVID-19 lung changes in the most effective way.

“Each and every participant with residual disease at six months had a positive ‘fibrotic-like’ score: Quite simply, the prediction of ‘fibrotic-like’ abnormalities from baseline data was no more than a prediction of the presence of residual disease,” they wrote. “The apparent increase in the prevalence of [these changes] at six months is highly deceptive, as baseline scans were performed at admission, not when the disease was most severe. … A more progressive lung fibrosis hypothesis post-COVID would instead require evaluating change from baseline CT performed at discharge from intensive care or hospital discharge.”

CT lung cancer screening guidelines are changing

CT lung cancer screening guidelines are changing

By Sandy Coffta, contributing writer

July 27, 2021 — Based on revised recommendations from the U.S. Preventive Services Task Force (USPSTF), the U.S. Centers for Medicare and Medicaid Services (CMS) is considering an adjustment to its reimbursement policy for low-dose CT lung cancer screening.

Sandy Coffta

Sandy Coffta.

CMS expects to complete its decision-making process before February 2022. In the meantime, many commercial payors have already expanded coverage by adopting the new recommendations.

Current Medicare reimbursement criteria requires that all of the following conditions are met:

  • Age 55-77 years
  • No signs or symptoms of lung cancer
  • Either a current smoker or have quit smoking within the last 15 years
  • Have a tobacco smoking history of at least 30 pack-years
  • Screening must be ordered by a physician following a lung cancer screening counseling and shared decision-making visit.

Most commercial payors follow the same guidelines with occasional slight differences.

The new eligibility criteria recommended by the USPSTF lowers the recommended starting age for screening to 50 years and the smoking history to 20 pack-years (an average of one pack of cigarettes per day for 20 years).

In an unusual turn, commercial payors are ahead of Medicare in expanding coverage. We found that the following payors have already adopted the new guidelines, or are about to do so:

  • GHI/Emblem
  • Humana
  • Healthfirst of New York
  • Amerigroup/Wellmed
  • Horizon BCBS of New Jersey
  • BCBS of Delaware
  • Horizon NJ Health
  • United Healthcare (as of September 1, 2021)
  • Oxford Health Plan (as of September 1, 2021)

This is not an exhaustive list, and others will likely be added especially once Medicare coverage is approved. Commercial coverage guidelines have been changed online at eviCore and AIM Specialty Health.

Low-dose CT (LDCT) Lung Cancer Screening is billed using current procedural terminology (CPT) code 71271, “Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s),” which replaced Healthcare Common Procedure Coding System (HCPCS) code G0297 as of January 1, 2021.

The code G0296, “Counseling visit to discuss need for lung cancer screening using LDCT (service is for eligibility determination and shared decision-making)” is still used for the initial counseling and shared decision-making visit required by Medicare.

Medicare will reimburse CPT 71271 and G0296 when billed with the following International Classification of Diseases (ICD-10) diagnosis codes:

For a former smoker:

  • Z87.891, Personal history of tobacco use/personal history of nicotine dependence

For a current smoker:

  • F17.210 Nicotine dependence, cigarettes, uncomplicated
  • F17.211 Nicotine dependence, cigarettes, in remission
  • F17.213 Nicotine dependence, cigarettes, with withdrawal
  • F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders
  • F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders

The evidence reviewed by the USPSTF shows that “screening can help many more people who are at high risk for lung cancer,” said USPSTF member Dr. Michael J. Barry in a press release. “By screening people who are younger and who have smoked fewer cigarettes, we can save more lives and help people remain healthy longer.”

Reports indicate that low-dose CT screening has been underutilized since its coverage was approved in 2015, perhaps due in part to the “shared decision-making process” that the American College of Radiology (ACR) and other interested groups would like to have eliminated in the revised Medicare criteria.

Compliance with recommended follow-up is a problem whether it is related to specific screening or when findings are incidental to other imaging. Radiology Business reports that less than two-thirds of lung cancer screening patients receive timely follow-up care, especially among Black, low-income or patients with mental health disorders, and the ACR has just issued new recommendations for managing incidental lung findings.

We will continue to monitor the adoption of this new standard, including actions taken by CMS that affect Medicare coverage.

MRI, histopathologic features boost glioma survival prediction accuracy

MRI, histopathologic features boost glioma survival prediction accuracy

By Kate Madden Yee, staff writer

July 27, 2021 — Combining MRI and digital histopathologic imaging features boosts the accuracy of predictions for overall glioma survival compared to using either of these features alone, according to research published July 23 in Radiology: Imaging Cancer.

The results could help clinicians better care for brain cancer patients, wrote a team led by Saima Rathore, PhD, of the University of Pennsylvania in Philadelphia.

“Although the currently applicable treatment options, which include surgical resection, radiation therapy, chemotherapy, and advanced combination treatment, have expanded during the last couple of decades, the prognosis for patients with high-grade glioma … remains poor, with disease generally recurring after seemingly successful initial treatment,” the team noted. “The survival duration without treatment and the response to treatment vary substantially across individuals, as do the molecular and imaging profiles of the tumors. Hence, there is a need to develop imaging-based markers that are prognostic of patient outcome to potentially assist in building comprehensive and patient-centric treatment plans.”

To this end, Rathore’s group conducted a study that included multiparametric MRI and histopathologic images from 171 patients with either high-grade or low-grade glioma; data were taken from the Cancer Imaging Archive for the years 1983 to 2008.

The authors found that patients’ overall median survival was 467 days, 350 days for those with high-grade glioma, and 595 days for those with low-grade disease. The team identified 14 MRI and 12 histopathologic imaging features that were predictive for overall survival for patients with both high- and low-grade glioma. It also found that the MRI plus histopathologic image models had a higher overall concordance index compared to either of these imaging datasets alone (0.79 compared with 0.70 for MRI and 0.67 for histopathologic imaging); the combination also performed better for predicting overall survival in both high-grade and low-grade glioma patients, the team found.

Comparison of predictive models for overall glioma survival
Concordance index MRI + histopathologic features MRI features alone Histopathologic features alone
All patients 0.79 0.70 0.67
High-grade glioma patients 0.78 0.68 0.64
Low-grade glioma patients 0.88 0.62 0.62

The study findings confirm other research that has also shown the benefit of combining MRI and histopathologic imaging features to predict outcomes in glioma patients, according to the team.

“[Previous studies have shown] that integrated features improved survival prediction compared with those of clinical and radiographic features alone,” the group concluded. “In consensus with these studies, we consistently found that integrating MRI and histopathologic features improved the performance of the prognostic model.”

3D liver segmentation detects fatty liver on cardiac CT Scans

3D liver segmentation detects fatty liver on cardiac CT

By Erik L. Ridley, staff writer

July 26, 2021 — A 3D liver segmentation method can be utilized to rapidly diagnose and measure fatty liver on cardiac CT exams, according to research presented at the annual meeting of the Society of Cardiovascular Computed Tomography (SCCT).

Researchers from the Lundquist Institute at Harbor-UCLA Medical Center in Torrance, CA, performed both 3D and 2D segmentation in over 100 patients receiving serial noncontrast cardiac CT exams. They found that the 3D method was stable and reproducible for measuring liver fat.

“The measure can serve as an imaging biomarker to understand mechanistic correlations between atherosclerosis, fatty liver, and cardiovascular disease risk,” said presenter Dr. Suvasini Lakshmanan, an advanced cardiac imaging fellow.

Nonalcoholic fatty liver disease (NAFLD) shares multiple risk factors with cardiovascular disease and independently predicts increased risk of cardiovascular disease and its associated adverse outcomes, according to Lakshmanan.

“The liver is routinely imaged during CT acquisition of the heart, and hence it may be beneficial to report fatty liver while reading coronary [artery] calcium,” Lakshmanan said.

Liver fat measures generated by 2D segmentation on cardiac CT have been correlated with the gold standard of invasive liver biopsy and used in research studies. But the 2D method is inaccurate for diagnosing low fat content and lacks stability with repeat measures, she said.

As a result, the researchers sought to evaluate the reproducibility of a 3D liver volume segmentation technique for identifying fatty liver in 68 participants who had received serial noncontrast cardiac CT exams during the previously conducted Effect of Vascepa on Improving Coronary Atherosclerosis in People with High Triglycerides Taking Statin Therapy (EVAPORATE) trial. They also wanted to compare the 3D method with a previously validated 2D segmentation technique for measuring liver fat.

The EVAPORATE trial offered a unique opportunity to establish the prevalence and progression of NAFLD on cardiac CT in a high-risk population, according to Lakshmanan. Followed over 18 months, the patients in the EVAPORATE trial were on stable statin therapy with low-density lipoprotein cholesterol levels (40 to 115 mg/dl) and persistently high triglyceride levels.

In the new study, fatty liver was diagnosed based on liver attenuation of less than 40 Hounsfield units. Both 2D and 3D liver segmentation was performed on the noncontrast cardiac CT images using software from Philips Healthcare, according to Lakshmanan.

3D liver segmentation performance in diagnosing and measuring fatty liver
Inter-reader reproducibility of mean 3D liver Hounsfield unit measurements 96%
Mean 2D and 3D liver Hounsfield unit measurements 93%
Change in mean 2D and 3D liver Hounsfield units from first to third CT scan 94%

What’s more, the researchers found a kappa of 88% when 2D and 3D liver measurements both identified fatty liver, indicating excellent agreement, she said.

Future studies will need to compare the sensitivity and stability of low liver fat content measures from 3D segmentation with those calculated via current 2D segmentation methodology, according to Lakshmanan.

Nonetheless, “serial assessments of NAFLD on cardiac CT will allow for future research to evaluate the effect of anti-inflammatory or anti-atherosclerotic therapies on cardiovascular disease and fatty liver,” she concluded.

MRI Brain Scan finds brain structure changes in elite rugby players

MRI finds brain structure changes in elite rugby players

By Erik L. Ridley, staff writer

July 26, 2021 — Advanced MRI sequences have revealed that a significant proportion of active elite rugby players experience changes in brain white matter from their participation in the sport, according to research published online July 22 in Brain Communications.

After evaluating 44 adult elite rugby players with diffusion-tensor imaging (DTI) and susceptibility-weighted imaging (SWI), researchers from the U.K. found either axonal injury or diffuse vascular injury in nearly one-fourth of the players, as well as abnormalities of fractional anisotropy and other diffusion measures in nonacutely injured patients. In a subgroup of 18 patients who were followed over time, volumetric MRI showed unexpected mean reductions in white-matter volume.

“Our research using advanced magnetic resonance imaging suggests that professional rugby participation can be associated with structural changes in the brain that may be missed using conventional brain scans,” said senior author Dr. David Sharp of the Imperial College London in a statement.

The study involved 41 male players and three female players between July 2017 and September 2019. Of the players, 21 were assessed shortly after sustaining a mild traumatic brain injury.

The researchers used DTI to assess for diffuse axonal injury and SWI to evaluate for diffuse vascular injury. These findings were then compared with control subjects consisting of 15 athletes in noncollision sports and 32 nonathletes.

The investigators found that 10 (23%) of the rugby players had evidence of either axonal injury or diffuse vascular injury. These changes were observed in players with and without a recent head injury.

In the 18 players who participated in longitudinal testing, volumetric structural imaging revealed abnormal mean changes in white-matter volume between the baseline and follow-up MRI scans performed an average of a year later. These changes were not related to self-reported head injury or neuropsychological test scores and might indicate excess neurodegeneration in white-matter tracts affected by injury, according to the researchers.

“The implications on an individual level of the brain changes associated with elite rugby participation are unclear, although obviously it is concerning to see these changes in some of the players’ brains,” said first author Karl Zimmerman of Imperial College London in a statement. “It is important to note that our results in adult professional rugby union and league players are not directly comparable to those who play at local or youth levels. The overall health [benefits] of participating in sports and physical exercise have been well established including the reduction in mortality and chronic diseases such as dementia.”

Notably, brain function assessments such as memory tests completed by the players found that players with abnormalities in their brain structures did not perform worse than those players without abnormalities.

“Further well-designed large-scale studies are needed to understand the impact of both repeated sports-related head impacts and head injuries on brain structure, and to clarify whether the abnormalities we have observed are related to an increased risk of neurodegenerative disease and impaired neurocognitive function following elite rugby participation,” the authors wrote.

Funded by the Drake Foundation, the research was performed by Imperial College London in collaboration with the University College London. Additional support was provided by the National Institute for Health Imperial Biomedical Research Centre in London, the UK Dementia Research Institute, and the Rugby Football Union.

Analysis Supports Coronary Artery Calcium Scans for Personalizing Statin Use

Analysis Supports CAC for Personalizing
Statin Use

Richard Mark Kirkner

July 21, 2021

In patients with intermediate risk of atherosclerotic cardiovascular diseasealong with risk-enhancing factors, coronary artery calcium scoring may help more precisely calculate their need for statin therapy.

Furthermore, when the need for statin treatment isn’t so clear and patients need additional risk assessment, the scoring can provide further information to personalize clinical decision making, according to a cross-sectional study of 1,688 participants in the Multi-Ethnic Study of Atherosclerosis(MESA) published in JAMA Cardiology.

And regardless of coronary artery calcium (CAC), a low ankle brachial index (ABI) score is a marker for statin therapy, the study found.

The study looked at CAC scoring in the context of ABI and other risk-enhancing factors identified in the 2018 American Heart Association/American College of Cardiology cholesterol management guidelines: a family history of premature atherosclerotic cardiovascular disease (ASCVD), lipid and inflammatory biomarkers, chronic kidney disease, chronic inflammatory conditions, premature menopause or preeclampsia, and South Asian ancestry.

“The novel risk-enhancing factors are not perfect,” said lead author Jaideep Patel, MD, director of preventive cardiology at Johns Hopkins Heart Center at Greater Baltimore Medical Center. He noted that the 2018 dyslipidemia guidelines suggested the risk for cardiovascular events rises when new risk-enhancing factors emerge, and that it was difficult to predict the extent to which each enhancer could change the 10-year risk.

Utility of CAC

“In this setting, the most significant finding that supports the utility of CAC scoring is when CAC is absent — a CAC of 0 — even in the setting of any of these enhancers, whether it be single or multiple, the 10-year risk remains extremely low — at the very least below the accepted threshold to initiate statin therapy,” Patel said.

Plaque burden predicts higher risk for heart disease patients

Plaque burden predicts higher risk for heart disease patients

By Will Morton, staff writer

July 22, 2021 — Measuring arterial plaque with cardiac CT in addition to established tests for heart disease can help predict which patients may suffer life-threatening events, according to a presentation at the virtual 2021 Society of Cardiovascular Computed Tomography (SCCT) meeting.

The researchers analyzed data on patients with severe coronary artery disease (CAD) who had already undergone cardiac CT angiography (CCTA) and SPECT tests. When they added scores that measured coronary plaque, they found they could better predict patients’ risk for events such as stroke or death.

“Our results suggest that in high-risk patients with suspected CAD, plaque burden adds incremental prognostic value over established measures in predicting incident cardiovascular outcomes,” said SCCT presenter Dr. Ahmed Ibrahim Ahmed of Houston Methodist DeBakey Heart and Vascular Center in Houston, Texas.

CCTA and SPECT myocardial perfusion imaging are established tests for evaluating ischemia and stenosis in patients with heart disease. CCTA-derived measures of plaque, such as segment involvement score (SIS), or the percentage of plaques in affected arteries, also independently predict severe events.

However, most studies have focused on diagnostic accuracy of the imaging tests without accounting for coronary atherosclerotic burden, according to Ahmed and colleagues.

In this study, the researchers aimed to assess the incremental prognostic value of plaque burden in a high-risk CAD group of patients who had undergone both CCTA anatomic assessment and SPECT physiologic assessment tests.

The researchers included 956 patients (54% men) with suspected CAD who had undergone CCTA and SPECT myocardial imaging at Houston Methodist between January 2016 and June 2020. The SIS was defined as the sum of segments with plaque, irrespective of the degree of stenosis, using an 18-segment coronary artery model. Patients were followed for major adverse cardiovascular events.

A 56-year-old patient with a clinical history of hypertension, diabetes, and dyslipidemia. Cardiac CT angiography showed obstructive stenosis. The segment involvement score was 11

A 56-year-old patient with a clinical history of hypertension, diabetes, and dyslipidemia. Cardiac CT angiography showed obstructive stenosis. The segment involvement score was 11. Image courtesy of Dr. Ahmed Ibrahim Ahmed.

After a median follow-up of 31 months, 102 patients experienced a major event. An analysis showed SIS significantly predicted outcomes and improved risk discrimination in patients with CCTA obstructive stenosis (hazard ratio, 1.15) and SPECT ischemia (hazard ratio, 1.14). The CCTA hazard ratio was statistically significant, while the SPECT one was not.

“Plaque burden was associated with primary outcome, with hazard ratios showing each additional [SIS] segment added 15% increase in risk for incident events,” Ahmed said.

The fact that patients had received both CCTA and SPECT myocardial perfusion imaging for clinical indications limits generalizing the findings in patients with similar characteristics, Ahmed noted.

Ultimately, the results suggest that in high-risk patients with suspected CAD, plaque burden adds incremental prognostic value over established measures in predicting incident cardiovascular outcomes, Ahmed et al concluded.

Coronary CT Scans may Guide Primary Prevention Statins in Nonobstructive Coronary Artery Disease

CTA May Guide Primary Prevention Statins in Nonobstructive CAD

Anna Goshua

July 19, 2021

The relative risk of death or myocardial infarction (MI) went down with statin therapy in a cohort study of patients with either nonobstructive coronary artery disease (CAD) or no CAD at computed tomographic angiography (CTA). The absolute benefit of statins was directly proportional to CAD burden at imaging.

The findings speak to the effectiveness of statin therapy in patients without obstructive CAD at CTA and the evaluation of coronary artery calcium (CAC) for suspected CAD, and support a greater role for CTA and CAC scoring in deciding whether to initiate statins for primary prevention, proposes a report published online July 14 in JACC: Cardiovascular Imaging.

“Previously, there was a lack of evidence about how statins could possibly influence the outcomes of these patients,” said first author Kristian A. Øvrehus, MD, PhD, Odense University Hospital, Odense, Denmark, in an interview with | Medscape Cardiology.

“The higher the cardiovascular risk, the more absolute benefits there are. That could possibly give us a tool in the future to help physicians and patients to decide whether to start preventive therapy not only based on risk factors but also visualized coronary artery disease,” Øvrehus said.

The researchers identified 33,552 adult patients with suspected CAD in the Western Denmark Cardiac Computed Tomography registry from 2008 to 2017 who were found not to have obstructive CAD at CTA.

Of the total, 19,669 patients had no CAD at imaging and 13,883 had nonobstructive CAD, defined as an absence of coronary stenoses 50% severity.

Their CAC scores were compared with the cohort’s use of statins 90 days before and after the imaging procedure and compared with cardiovascular events over a median follow-up of 3.5 years, with statin use and outcomes based on data from other registries.

Their CAD burden by CAC score was directly proportional to their rate of MI or death, expressed as events per 1000 patient-years:

  • 4.13 in patients with no CAD
  • 7.74 in those with mild CAD (score 0-99),
  • 13.72 in patients with moderate CAD (score 100-399)
  • 32.47 in those with severe CAD (score 400 and higher)

For concussion patients, CTs offer window into recovery

For concussion patients, CTs offer window into recovery

Study matches brain imaging with prognosis, showing lingering impairment for some

July 19, 2021
University of California – San Francisco
CT scans for patients with concussion provide critical information about their risk for long-term impairment and potential to make a complete recovery – findings that underscore the need for physician follow-up.

CT scans for patients with concussion provide critical information about their risk for long-term impairment and potential to make a complete recovery — findings that underscore the need for physician follow-up.

In a study led by UC San Francisco, researchers looked at the CT scans of 1,935 patients, ages 17 and over, whose neurological exams met criteria for concussion, or mild traumatic brain injury (TBI), at hospitals throughout the nation. While links between CT imaging features and outcome have already been established in moderate and severe TBI, the researchers believe this is the first time the link has been identified in patients with concussion, disputing earlier research that found no prognostic significance of specific types of CT abnormalities.

“Radiologists who routinely read trauma scans know intuitively that patterns of intracranial injury on CT are not random,” said first author, Esther Yuh, MD, PhD, of the UCSF Department of Radiology and Biomedical Imaging. “We showed there are patterns of injury, that some of these are associated with worse outcome than others, and that they provide a window into mechanisms of injury that is reproducible across large studies.”

The study appears online in JAMA Neurology on July 19, 2021.

“Although concussions are referred to as mild traumatic brain injuries, there is nothing mild about some concussions,” said senior author Geoffrey Manley, MD, PhD, professor and vice chair of neurological surgery at UCSF and chief of neurosurgery at Zuckerberg San Francisco General Hospital. “Patients with concussion may suffer from prolonged headache, poor sleep and impaired concentration, and they are at higher risk of self-medicating with drugs and alcohol. Concussion can also contribute to depression and anxiety, and increase the risk for suicide. We need to view concussion not as an event but as a disease requiring physician follow-up after a patient is discharged from the hospital.”

The participants were enrolled by the brain injury research initiative TRACK-TBI, of which Manley is the principal investigator. To enrich the number of so-called complicated concussions, the researchers drew exclusively from patients who had been seen at hospitals with level 1 trauma centers. This meant 37 percent of study participants had a positive CT, significantly more than the 9 percent of positive CTs from patients in U.S. emergency departments.

Baseball Whacks May Have Better Outcomes than Other Injuries

The most common patterns of injury, affecting more than half of CT-positive patients, were combinations of subarachnoid hemorrhage (SAH), subdural hematoma (SDH), and/or contusion, which may be caused by injuries such as falls from standing. Approximately 7 percent had intraventricular hemorrhage (IVH) or petechial hemorrhage, caused by rotation of the head, occurring in some sporting, scooter and automobile accidents; and 5 percent were found to have epidural hematoma (EDH) in which blood accumulates between the skull and the membrane covering the brain, often seen in sports injuries such as being hit with a baseball.

The patients, whose average age was 41 and of whom 66 percent were male, were assessed at two weeks, and at three-, six- and 12 months following injury. The researchers found that patients in the SAH/SDH/contusion group failed to make a complete recovery at 12 months post-injury and had impairments across the outcome spectrum, from mild to more severe.

Patients in the IVH/petechial hemorrhage group tended toward more severe impairments, in the lower-moderate disability range, a level that potentially affects multiple areas of function, such as employment, social and leisure activities, up to 12 months post-injury. Patients with the EDH phenotype fared significantly better and demonstrated complete recovery by their six-month assessment.

Results of the study were validated by CENTER-TBI, a parallel brain injury research group that had enrolled 2,594 participants at European trauma centers. “The confirmation of the findings in an independent cohort confirms the fidelity of our results,” said Manley, adding that patients with EDH were one exception. CENTER-TBI found their incomplete recovery lingered for months longer than those patients followed by TRACK-TBI, but more severe outcomes were not seen at any point in either study.

The researchers noted that even among concussion patients who had a positive CT scan, just 39 percent receive follow-up care, including simple interventions like providing educational material at discharge. Follow-up should be routine for all 5 million concussion patients seen annually in the nation’s emergency departments, including those without abnormal CT features, who would have milder symptoms and more complete recoveries, they said.

Test for Blood-Markers is Safer, More Sensitive

The researchers cautioned that these results should not be interpreted as a call to increase the use of CT, which exposes patients to radiation and increases cancer risk. Currently CTs are recommended for patients with a known or suspected concussion and loss of consciousness or amnesia and/or factors like older age, evidence of physical trauma and severe headache.

In fact, CTs may become less widely used with the recent approval by the Food and Drug Administration of a rapid hand-held blood test that Manley found was more sensitive than CT in detecting concussion. The blood test measures biomarkers associated with TBI, which were close to 52 times higher in concussion patients than in healthy participants when verified by MRI, a more definitive but costlier and less accessible scan than CT.

In addition to challenging the belief that CT features in concussion are not relevant, the researchers are also challenging the idea that concussion is “what the patient brings to the injury,” said Manley, who is also affiliated with the UCSF Weill Institute for Neurosciences. “In moderate and severe TBI, it is anecdotally taught that outcome is determined by ‘what the injury brings to the patient,’ while concussion is determined by baseline characteristics like age, sex and years of education. While the study confirms the importance of these characteristics, we show that in some concussion cases, poor outcomes are also attributed to ‘what the injury brings to the patient.'”

Story Source:

Materials provided by University of California – San Francisco. Original written by Suzanne Leigh. Note: Content may be edited for style and length.

Journal Reference:

  1. Esther L. Yuh et al. Pathological Computed Tomography Features Associated With Adverse Outcomes After Mild Traumatic Brain Injury. JAMA Neurology, 2021; DOI: 10.1001/jamaneurol.2021.2120

Continue reading “For concussion patients, CTs offer window into recovery”

How has the COVID-19 pandemic affected CT Coronary Artery Calcium testing?

How has the COVID-19 pandemic affected CT CAC testing?

By Kate Madden Yee, staff writer

July 20, 2021 — The COVID-19 pandemic caused a significant dip in heart disease screening with CT coronary artery calcium (CAC) scoring, particularly between March and May of last year, according to a poster presentation at the virtual 2021 Society of Cardiovascular Computed Tomography (SCCT) meeting.

A team led by Dr. Mrinali Shetty of the University of Chicago in Evanston found a dramatic decrease in CT CAC testing during that time period, although the group did discover that patients at highest risk of heart disease still received statin therapy during the acute phase of the pandemic.

The most current cholesterol management guideline from the American College of Cardiology and the American Heart Association recommends that intermediate-risk patients undergo CT CAC testing when the decision about whether to begin statin therapy is unclear, the group wrote. Statin therapy tends to be the first line of treatment for preventing heart disease in patients with a CAC score of more than 100.

Shetty and colleagues used electronic medical record data from a four-hospital, community-based health system. They tracked patients’ CAC scores, monthly volume of studies between January 2019 and February 2021, and start of statin therapy within six months of a patient undergoing CAC scoring (the system had instituted a $50 CAC test in June 2019 to boost uptake, and it saw a significant increase in the number of these tests ordered). The study included orders for 2,806 CAC score tests.

The pandemic hit Illinois in March 2020, the authors noted. They found a 7.7 percentage point decrease in CAC tests after that time, although the number of CAC scans began to bounce back later in the year, and the rate of statin initiation actually hit a higher level further into the pandemic than the pre-COVID-19 time frame.

Effect of COVID-19 pandemic on rates of statin therapy initiation in patients at risk of heart disease
Measure Before March 2020 March to May 2020 June 2020 to February 2021
Rate of statin therapy initiation 30.6% 22.9% 32.1%

Despite the dip in the initiation of statin therapy during the pandemic’s acute phase, the group did find that patients with CAC scores higher than 100 had high rates of statin prescription. In fact, more than three-quarters of patients with high CAC scores received a prescription for statins in February 2021.

“[For patients with CAC [scores greater than] 100, rate of initiation of statin therapy was not affected by the COVID-19 pandemic,” the group wrote. “It is reassuring that despite the pandemic, the highest-risk individuals based on CAC [scores] still received statin therapy.”