1. Incidental findings in CT angiography performed in acute stroke patients and change of management: single center observation Sabou TC., Höltje J., Bonk F, Pohlmann C., Urban P.P., Brüning R. EP #72 Radiology and Neuroradiology, Asklepios Klinik Barmbek, 22291 Hamburg, Germany

2. Purpose In the diagnostic process of acute stroke in most centers computed tomography (CT) is established as a combination of unenhanced cranial CT, plus CT angiography and CT- based perfusion measurements. Aim of this retrospective evaluation was to evaluate the percentage of incidental findings during this CTA scans (from aortic arch), and to evaluate changes in therapy based on these observations. 2

3. Materials and Methods We have retrospectively selected from the PACS-Database 100 patients which underwent an unenhanced cranial CT examination and a CT-Angiography between 20.3. and 06.08.2012 (median age 74y, 31y-95y; 52 males, 48 females). CTA scan range was from the aortic arch to scull in all cases at an injection of 80 - 130 cc contrast (body weight adapted). The raw data (Philips Brilliance 40 and GE Optima 660) were reconstructed in axial, sagittal and coronal planes with a 2-3 mm slice thickness. Image acquisition was followed by a consensual evaluation and classification (resident and neuroradiologist) according to a predefined score (e.g. in category 1 for pulmonary lesions)= dissection, bronchial carcinoma, pulmonary embolism). From the hospital’s SAP database a possible change of patient management was retrospectively evaluated. 3

4. Results The following secondary findings were observed in a total of 73/100 patients: pulmonary section: 20% (for example pulmonary carcinoma, pulmonary artery embolism); Vascular: 44% (i.e. dissection, figure 1), intracranial findings: 19% (for example hypophyseal adenoma) musculoskeletal findings: 11% (for example epidural hemaotma in the cervical spine, figure 3): ENT-section: 5%. Secondary findings which altered the treatment strategy such as central pulmonary embolism, acute pulmonary edema (figure 2a) or lung carcinoma (figure 2c) were observed in 14 patients. 4

5. Figure 1 86 years old female patient: the CT angiography shows a Stanford B aortic dissection with a partially thrombosed lumen (1a- 1c). 5

6. Figure 2 In the partially depicted, apical lung segments one could see secondary findings such as pulmonary edema (2a), pleural effusion with pneumonic infiltration (2b) and a lesion suspected to be tumor (2c), 6

7. Figure 3 In an 68 year old patient the CT scan revealed a space occupying lesion in the cervical spinal canal (3a, arrow); with suspicion of epidural hematoma in the MRI study next morning (3b) 7

8. 8 PulmonaryVesselsIntracranialSkelettalNeck Pulmonary embolism 1Aneurysm3Lymphoma1Disc herniation1Enlarged lymph nodes 2 Pulmonary mass1dissection (ACI/Stanford B) 3Meningeoma2Fractures1Tumor ENT1 Lymph nodes mediastinal 1Stenosis of internal carotid artery (NASCET <49% 1) or subclavian artery 3Cavernoma1Fracture1Thyroid enlargement 3 Pleural effusion6Cerebral sinus or vein thrombosis 1DVA1Spinal canal stenosis > Kang I 5Mass other1 Pulmonary edema 2Lymphoma1Ventro-lithesis1 Intrapolmonary noduloes 3Adenoma1Compression fracture 1 Emphysema4Chronic subdural hematma 1Neuroforamina l stenosis 3 Pulmonary inflammation 4ICB, SAB9Osseous lesion1 Hemorhagic transformation 1 Posttraumatic bleeding2 TOTAL73

9. Literature 1.William B. Hall, MD; Sherstin G. Truitt, MD; Leslie P. Scheunemann, MD; Sidharth A. Shah, MD; M. Patricia Rivera, MD; Leonard A. Parker, MD; Shannon S. Carson, MD; The Prevalence of Clinically Relevant Incidental Findings on Chest Computed Tomographic Angiograms Ordered to Diagnose Pulmonary Embolism. Arch Intern Med. 2009;169(21):1961-1965. doi:10.1001/archinternmed.2009.360; 2.Hoffstetter P1, Herold T, Daneschnejad M, Zorger N, Jung EM, Feuerbach S, Schreyer AG. Non- trauma-associated additional findings in whole-body CT examinations in patients with multiple trauma. Rofo. 2008 Feb;180(2):120-6. Epub 2007 Nov 16. Broderick JP, Palesch YY, Demchuk AM, et.al.; 3.von Kalle T, Fabig-Moritz C, Heumann H, Winkler P. Incidental findings in paranasal sinuses and mastoid cells: a cross-sectional magnetic resonance imaging (MRI) study in a pediatric radiology department. Rofo. 2012 Jul;184(7):629-34. doi: 10.1055/s-0032-1312861. Epub 2012 May 22. 4.Weber C, Grzyska U, Lehner E, Adam G. Clinical relevance of cranial CT under emergency conditions--basic neuroradiologic investigations. Rofo. 2003 May;175(5):654-62. 9

10. Conclusion A high number of examination in acute stroke patients yielded incidental findings within the examined region. In our single center analysis, in 14% patients had an alternative treatment strategy based on CT findings, especially chest findings. For questions please contact t.sabou@asklepios.com 10