ER Multiple Rule-Out Scan of a Patient With Disturbance of Consciousness and Without Breath-Hold.
SOMATOM Definition Flash Scanning
Junichiro Nakagawa, MD,* Isao Ukai, MD*, Osamu Tasaki, MD, PhD*, Tomoko Fujihara**
and Katharina Otani, PhD *** | 13-12-2010
* 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
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.
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.
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).
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