Scielo RSS <![CDATA[SA Journal of Radiology ]]> vol. 26 num. 1 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Spinal Chloroma - Herald of blast crisis in a patient with chronic myeloid leukaemia: A case report</b>]]> Myeloid sarcoma or chloroma is a localised tumour characterised by extramedullary proliferation of precursor myeloid cells. Commonly occurring in association with acute myeloid leukaemia, chloroma can occasionally be seen in myeloproliferative disorders with subsequent blastic transformation. Imaging plays an important role in the diagnosis and evaluation of this entity. A case of chloroma involving the dorso-lumbar vertebral region is presented in a patient with chronic myeloid leukaemia with subsequent blastic transformation. <![CDATA[<b>A case of carotid web: Cause of stroke in healthy and young patients</b>]]> Carotid webs are important, often undiagnosed causes of cryptogenic and recurrent strokes. CT angiography and digital subtraction angiography adequately demonstrate webs as linear filling defects in the carotid bulb. However, findings are overlooked unless viewed in optimal planes and easily misdiagnosed as dissection flaps or atheromatous plaques, altering management and outcome. A case of unilateral carotid web is presented, detected during imaging in a young lady presenting with hemiparesis without other risk factors for stroke. <![CDATA[<b>Chest radiography evaluation in patients admitted with confirmed COVID-19 infection, in a resource limited South African isolation hospital</b>]]> BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the subsequent global outbreak (coronavirus disease 2019 [COVID-19]) was declared a public health emergency in January 2020. Recent radiologic literature regarding COVID-19 has primarily focused on Computed Tomography (CT) chest findings, with chest radiography lacking in comparison. OBJECTIVES: To describe the demographic profile of adult patients with COVID-19 pneumonia requiring hospital admission. To describe and quantify the imaging spectrum on chest radiography using a severity index, and to correlate the severity of disease with prognosis METHOD: Retrospective review of chest radiographs and laboratory records in patients admitted to a South African tertiary hospital with confirmed COVID-19 infection. The chest X-rays were systematically reviewed for several radiographic features, which were then quantified using the Brixia scoring system, and correlated to the patient's outcome. RESULTS: A total of 175 patients (mean age: 53.34 years) admitted with COVID-19 were included. Ground glass opacification (98.9%), consolidation (86.3%), and pleural effusion (29.1%) was commonly found. Involvement of bilateral lung fields (96.6%) with no zonal predominance (61.7%), was most prevalent. Correlation between the Brixia score and outcome was found between severe disease and death (odds ratio [OR]: 12.86; 95% confidence interval [CI]: 1.58-104.61). Many patients had unknown TB (71.4%) and HIV (72.6%) statuses. CONCLUSION: In this study population, ground glass opacification, consolidation, and pleural effusions, with bilateral lung involvement and no zonal predominance were the most prevalent findings in proven COVID-19 infection. Quantification using the Brixia scoring system may assist with timeous assessment of disease severity in COVID-19 positive patients, as an overall predicator of clinical outcome. <![CDATA[<b>An audit of CT brain findings in adults with new-onset seizures in a resource restricted setting in South Africa</b>]]> BACKGROUND: Globally, adults presenting with seizures account for 1% - 2% of visits to emergency departments (EDs), of which 25% are new-onset seizures. Neuroimaging is essential as part of the initial workup. Multiple studies have demonstrated abnormal CT brain (CTB) findings in these patients. OBJECTIVES: To review the CTB findings in adults presenting with new-onset seizures in a resource restricted setting. METHOD: A retrospective review of 531 CTBs was conducted at a tertiary hospital in Gauteng on adults presenting to the ED with new-onset seizures. RESULTS: The mean age of the patients was 45.6 ± 17.1 years, and the male to female ratio was 1.2:1. Generalised and focal seizure types were almost equally represented. Of the total 531 patients, 168 (31.6%) were HIV positive. The CTB findings were abnormal in 257 (48.4%) patients, albeit vascular pathology accounted for 21.9%. Infective pathology accounted for 14.1% with a statistically significant association with HIV (p = 0.003). Trauma related pathology was 2.4%, whilst neoplastic pathology was seen in 3.0%. Other causes included congenital pathology, calcifications, atrophy and gliosis. Clinical factors associated with abnormal CTB findings were age ≥ 40 years, HIV infection, hypertension, focal seizures, low Glasgow Coma Scale (GCS), raised cerebrospinal fluid (CSF) protein and presence of lymphocytes. CONCLUSION: A high yield of abnormal CTB findings was noted in adult patients who presented with new-onset seizures, supporting the use of urgent CTB in patients with certain clinical risk factors. Patients without these risk factors can be scanned within 24-48 h in a resource restricted setting. <![CDATA[<b>CT pulmonary angiography findings in HIV-infected patients referred for suspected pulmonary thrombo-embolic disease</b>]]> BACKGROUND: South Africa bares a significant burden of HIV and imaging is commonly performed as part of the workup for respiratory distress. OBJECTIVES: The aim of this study was to document the prevalence of pulmonary thrombo-embolic disease (PTED) and other findings in HIV-infected patients referred for CT pulmonary angiography (CTPA) for suspected PTED. METHOD: Forty CTPA studies of documented HIV-infected individuals investigated for suspected PTED during a 1-year period were retrieved, anonymised and interpreted by three consultant radiologists. Inter-reader reliability was calculated using Free Marginal multi-rater Kappa. RESULTS: Fourteen of the forty cases (35%) were positive for PTED. In the pulmonary embolism (PE)-positive group, 57.14% had peripheral disease and 42.86% had both peripheral and central disease. Associated findings in the PE-positive cases were pulmonary infarcts (17.5%), mosaic attenuation (17.5%) and linear atelectasis (7.5%). The most common incidental findings were solid pulmonary nodules (52.5%), non-wedge-shaped consolidation (45%), cardiomegaly (52.5%) and enlarged intra-thoracic lymph nodes (52.5%). Thirty per cent of the study population had findings related directly to the presence of PTED, whilst most cases in the study (77.5%) had pulmonary findings unrelated to PTED. In the PE-negative cases, 55% reported emergent findings that warranted immediate or urgent medical attention CONCLUSION: Computed tomography pulmonary angiography imaging is critical for diagnosing PE. However, further investigation into the judicious application of CTPA in HIV-infected patients with suspected PTED is required, as CTPA findings in most of the cases in this study were unrelated to PE. <![CDATA[<b>A review of teleradiology in Africa - Towards mobile teleradiology in Nigeria</b>]]> eHealth is promoted as a means to strengthen health systems and facilitate universal health coverage. Sub-components (e.g. telehealth, telemedicine, mhealth) are seen as mitigators of healthcare provider shortages and poor rural and remote access. Teleradiology (including mobile teleradiology), widespread in developed nations, is uncommon in developing nations. Decision- and policy-makers require evidence to inform their decisions regarding implementation of mobile teleradiology in Nigeria and other sub-Saharan countries. To gather evidence, Scopus and PubMed were searched using defined search strings (September 2020). Duplicates were removed, and titles and abstracts reviewed using specified selection criteria. Full-text papers of selected resources were retrieved and reviewed against the criteria. Insight from included studies was charted for eight a priori categories of information: needs assessment, implementation, connectivity, evaluation, costing, image display, image capture and concordance. Fifty-seven articles were identified, duplicates removed and titles and abstracts of remaining articles reviewed against study criteria. Twenty-six papers remained. After review of full-texts, ten met the study criteria. These were summarised, and key insights for the eight categories were charted. Few papers have been published on teleradiology in sub-Saharan Africa. Teleradiology, including mobile teleradiology, is feasible in sub-Saharan Africa for routine X-ray support of patients and healthcare providers in rural and remote locations. Former technical issues (image quality, transmission speed, image compression) have been largely obviated through the high-speed, high-resolution digital imaging and network transmission capabilities of contemporary smartphones and mobile networks, where accessible. Comprehensive studies within the region are needed to guide the widespread introduction of mobile teleradiology. <![CDATA[<b>Fatal non-accidental injury in South Africa: A Gauteng hospital's perspective on the incidence and fracture types in post-mortem skeletal surveys</b>]]> BACKGROUND: In its severest form, non-accidental injury (NAI) in children is fatal. South Africa has been reported to have double the global average of child homicides. Autopsy is the main investigation in fatal NAI with post-mortem skeletal surveys (PMSS) playing an adjunctive role. Whilst fracture patterns associated with NAI in living patients have been established, this has not been investigated in PMSS in South Africa. OBJECTIVES: To determine the incidence and characteristics of fractures in suspected fatal NAI cases. To calculate the incidence of fractures according to high-, moderate- and low-specificity fracture locations for NAI. METHODS: A retrospective review of all PMSS performed between 01 January 2012 and 03 December 2018 was conducted at the Charlotte Maxeke Johannesburg Academic Hospital. RESULTS: Of the 73 PMSS, 33 (45.2%) demonstrated fractures. No statistical significance in sex was found: 38 (52.1%) were male and 35 (47.9%) were female (p > 0.05). The mean age of those who sustained fractures was 28 months (standard deviation [s.d.]: 21 months). A total of 115 fractures were sustained, of that the top five bones fractured were the ribs 37 (32.2%), parietal bone 13 (11.3%), ulna 13 (11.3%), femur 13 (11.3%), and radius 11 (9.6%). High-specificity fracture locations accounted for 40/133 (30.1%). CONCLUSION: The fracture types in PMSS were similar to those in live skeletal surveys. Our study's fracture rate was higher in comparison to international studies. The PMSS is a valuable adjunct to autopsy in detecting occult fractures of the limbs. We recommend that PMSS be performed in suspected fatal NAI cases at least in children up to 24 months of age. <![CDATA[<b>A retrospective review of CT pulmonary angiogram confirmed pulmonary emboli in COVID-19 patients admitted to Groote Schuur Hospital, Cape Town</b>]]> BACKGROUND: A high incidence of thromboembolic phenomena has been widely reported in patients with coronavirus disease 2019 (COVID-19) pneumonia. There is, however, a paucity of data detailing the incidence and characteristics of pulmonary emboli (PE) in COVID-19 patients in the South African setting OBJECTIVES: To describe the incidence and characteristics of PE confirmed by CT pulmonary angiogram (CTPA) in patients with COVID-19 pneumonia admitted to a tertiary hospital in the Western Cape, South Africa METHODS: This was a retrospective-, descriptive study of all adult patients with COVID-19 pneumonia confirmed by polymerase chain reaction (PCR) undergoing CTPA for suspected PE while admitted to Groote Schuur Hospital. The study period was from 01 April 2020 to 30 September 2020 RESULTS: The study cohort consisted of 116 patients, 59% being female, of whom 29% were pregnant or in the postpartum period. The median age for both genders combined was 49.5 years. The overall incidence of PE was 19%, with 20% in our subset of pregnant and postpartum patients. The majority (64%) of PE's were reported as being segmental in anatomical location CONCLUSION: The noteworthy cohort included patients with pulmonary tuberculosis (PTB), HIV as well as pregnant and postpartum patients. The overall incidence of PE was 19% with no significant differences in demographics, comorbidities or D-dimer levels between patients with or without PE. The importance of a high clinical index of suspicion together with the role of CTPA in diagnosing PE in hospitalised COVID-19 patients is emphasised <![CDATA[<b>Otosyphilis: A rare cause of acute bilateral sensorineural hearing loss in a HIV-negative patient</b>]]> Bilateral acute hearing loss is rare, and the aetiology is poorly defined. Less common treatable pathologies such as otosyphilis must be part of the differential diagnosis and should be actively excluded. We present a case of a 23-year-old woman who developed acute bilateral hearing loss due to otosyphilis, confirmed on audiometry and laboratory tests. In this article, the CT, MRI and clinical findings are presented and discussed. <![CDATA[<b>Concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients</b>]]> BACKGROUND: The incidence of concurrent traumatic brain injury (TBI) and cervical spine injury (c-spine) is relatively high, with a variety of risk factors. OBJECTIVES: The purpose of this study was to determine the incidence and related factors associated with combined cranial and c-spine injury in TBI patients by assessing their demographics and clinical profiles. METHOD: A retrospective study of patients attending the Trauma Centre at the Inkosi Albert Luthuli Hospital as post head trauma emergencies and their CT brain and c-spine imaging performed between January 2018 and December 2018. RESULTS: A total of 236 patients met the criteria for the study; 30 (12.7%) patients presented with concurrent c-spine injury. Most TBI patients were males (75%) and accounted for 70% of the c-spine injured patients. The most common mechanism of injury with a relationship to c-spine injury was motor vehicle collisions (MVCs) and/or pedestrian vehicle collisions (70%). The risk factors associated with c-spine injury in TBI patients were cerebral contusions (40%), traumatic subarachnoid haematomas (36%) and skull fractures (33.3%). The statistically significant intracranial injury type more likely to have an associated c-spine injury was diffuse axonal injury (p = 0.04). CONCLUSION: The results suggest that concurrent TBI and c-spine injury should be considered in patients presenting with a contusion, traumatic subarachnoid haematoma and skull fracture. The high incidence of c-spinal injury and more than 1% incidence of spinal cord injury suggests that c-spine scanning should be employed as a routine for post MVC patients with cranial injury. <![CDATA[<b>An audit of the adequacy of contrast enhancement in CT pulmonary angiograms in a South African tertiary academic hospital setting</b>]]> BACKGROUND: Undiagnosed pulmonary embolism carries high mortality and morbidity. Computed tomography pulmonary angiogram (CTPA) is the diagnostic method of choice for accurate diagnosis. Inadequate contrast opacification is the second most common cause of indeterminate CTPAs. OBJECTIVES: Audit the adequacy of CTPA contrast enhancement and determine whether inadequate enhancement is affected by the size and site of the intravenous cannula, flow rate, contrast volume, contrast leakage and day shift versus after hours services. METHOD: Retrospective and prospective audits of the adequacy of contrast enhancement of CTPAs at the Charlotte Maxeke Johannesburg Academic Hospital were conducted using the Royal College of Radiologists guidelines (≤ 11% of studies with < 210 HU). Protocol variables were collected prospectively from questionnaires completed by radiographers performing the CTPAs. Adequate versus inadequate groups were analysed. RESULTS: A total of 63 (retrospective) and 130 (prospective) patients were included with inadequate contrast enhancement rates of 19% (12/63) and 20.8% (27/130), respectively. The majority of CTPAs were performed during the day 56.2% (73/130) with a 20G cannula 66.2% (86/130) in the forearm 33.8% (44/130) injecting 100 mL - 120 mL contrast 43.1% (56/130) at 3 mL/s 63.1% (82/130). The median flow rate (3 mL/s) and contrast volume (80 mL) were identical in both adequate and inadequate groups, while the remaining variables showed no statistical difference. CONCLUSION: The rate of inadequately enhanced CTPAs in this study was high. The protocol variables did not have a significant influence on the rate of inadequate enhancement. Further research, particularly using flow rates &gt; 4 mL/s, is required for protocol optimisation <![CDATA[<b>Primary giant cell tumour of the breast with recurrence: A rare case report</b>]]> Giant cell tumour (GCT) arising from the soft tissues of the breast is a rare disease with only eight cases previously reported in the literature. We present a case of histologically proven GCT of the breast, which demonstrated recurrence a few months after resection. <![CDATA[<b>A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting</b>]]> BACKGROUND: Bilious vomiting in children requires an urgent evaluation with upper gastrointestinal (UGI) fluoroscopy as it may herald life-threatening midgut malrotation with volvulus (MMWV). There are no published data available on the duration of time-critical UGI workflow steps. OBJECTIVES: A digital audit of workflow in emergency UGI contrast studies performed on children with bile-stained vomiting at a large South African teaching hospital. METHOD: A retrospective study was conducted from 01 May 2012 - 31 May 2019. A customised search of the institutional radiology information system (RIS) defined all children with bilious vomiting who underwent emergency UGI fluoroscopy. Extracted RIS timestamps were used to calculate the median duration of the 'approval', 'waiting', 'study' and 'reporting' times. One-way analysis of variance and Chi-squared tests assessed the association between key parameters and the duration of workflow steps, with 5% significance (p < 0.05) RESULTS: Thirty-seven patients (n = 37) with median age 0.8 months were included, of whom 20 (54%) had an abnormal C-loop. The median 'total time' from physician request to report distribution was 107 min (interquartile range [IQR]: 67−173). The median 'approval' (6 min; IQR: 1-15) and 'reporting' (38 min; IQR: 17-91) times were the shortest and longest workflow steps, respectively. Abnormal C-loops (p = 0.04) and consultant referrals (p = 0.03) were associated with shorter 'approval' times. The neonatal 'waiting' time was significantly longer than that for older patients (p = 0.02). CONCLUSION: The modern RIS is an excellent tool for time-critical workflow analyses, which can inform interventions for improved service delivery. <![CDATA[<b>Paediatric minor head injury applied to Paediatric Emergency Care Applied Research Network CT recommendations: An audit</b>]]> BACKGROUND: Traumatic brain injury (TBI) is a common cause of paediatric morbidity and mortality, with higher TBI rates in low- and middle-income countries. Non-contrast brain CT is the gold standard for diagnosing intracranial injuries; however, it exposes patients to ionising radiation. The Paediatric Emergency Care Applied Research Network (PECARN) clinical decision rule (CDR) aids clinicians in their decision-making processes whilst deciding whether a patient at very low risk of a clinically important TBI (ciTBI) requires a CT scan. OBJECTIVES: To establish whether the introduction of the PECARN CDR would affect CT utilisation rates for paediatric patients presenting with minor blunt head injuries to an academic hospital in Gauteng, South Africa. METHOD: This was an audit of paediatric patients who presented with minor blunt head injuries and were referred for CT imaging at an academic hospital in Gauteng, compared with PECARN CDR recommendations, over a 1-year period. RESULTS: A total of 100 patients were referred for CT imaging. Twenty patients were classified as very low risk, none of whom had any CT findings of a TBI or ciTBI (p < 0.01). A total of 61 patients were classified as intermediate risk and 19 as high risk. In all, 23% of the intermediate and 47% of the high-risk patients had CT features of a TBI, whilst 8% and 37% had a ciTBI, respectively. CONCLUSION: Computed tomography brain imaging may be omitted in patients classified as very low risk without missing a clinically important TBI. Implementing the PECARN CDR in appropriate patients would reduce CT utilisation rates.