CRITICAL FINDINGS IN MSCT

RUSLI MULJADI
INDONESIA
Departemen Radiologi
Siloam Hospitals Lippo Village
Safer Practice Notice
Safer Practice Notice
Non-routine communications

 (1) Diseases of an acute nature, which have the

potential to greatly affect patient outcome
within a 24-hour period,
 (2) Diseases of a subacute nature, where the
observation of unanticipated findings has the
potential to affect patient health and health care
management in a subacute time frame, from
weeks to months, and
 (3) Circumstances of a change of original
(preliminary or final) interpretation that may
impact clinical care.
Category (1):

 Suggest a need for immediate or urgent

intervention and should have information
relayed to a “responsible health care worker,”
if not clinically suspected within one hour.
Generally, these cases may occur in the
emergency and surgical departments or
critical care units
 Include pneumothorax, pneumoperitoneum,
or a significantly misplaced line or tube.
Category (2):

 The radiology technologist should expedite

the delivery of the diagnostic images.
 In addition, an expedited report (preliminary
or final) should be generated by the
radiologist (resident or attending) in a
manner that reasonably ensures timely
receipt of the findings.
Examples of clinical
situations that may be
included in Category (2):
 unsuspected malignancy
 unsuspected infectious disease process
 unsuspected disease that has a progressive
nature and potential for patient debilitation
(example: inflammatory condition)
Mechanisms for Reporting

 The ordering physician or a

representative/designee should be contacted
to report any critical results or findings that
require immediate medical attention, if not
already known.
 Documentation should be made in the report
describing the physician spoken to, the date,
and time.
 If the ordering physician cannot be reached,
the physician’s representative or designated
contact should be notified
The steps in notification of
results in the “red” or “orange”
category are:
 First call to ordering physician.
 If no response after 15 minutes, call ordering physician
again.
 If no response after 30 minutes, call the number for the
ordering service.
 If the patient is an in-patient, call the nurses station and
get the physician through them.
 Radiologist documents the communication with the
physician in the radiology report.
 The steps in notification of results in the
“yellow” category are:
 Dictate that this is an urgent result in the
report.
 Findings for patients in Category (1) should be
reported within one hour of the study being
available on the PACS system.
 Findings on Head CT and Chest x-ray on
newly diagnosed stroke patients in the ED
must be reported within 45 minutes.
Category (3)

 The ordering clinician will be made aware of

the change from the original report.
 A new paragraph will be added to the report
that will be prefaced by “Addendum
Critical or unexpected findings

1. The term (without substitutions or modifications) Critical

Result or Unexpected. Finding will be used as a lead off
to the documentation statement.
2. The name of the person receiving the report and,
asserting back to the radiologist, that the nature and
implications of the communication is understood, is
documented.
3. The date and time of the communication is documented.
4. There is an assertion that the communication is
understood (this is a hospital JACHO requirement) and
while on its surface seems unnecessary it is a part of the
process that must be clearly understood by all parties
involved in such important communication.
Unexpected findings

 These are findings, typically of relatively low

acuity, but that constitute a condition that
may pose some significant proximate risk to
the patient that requires careful and relatively
prompt follow up
 This is information that cannot be left to the
routine reporting systems because of
potential danger to the health of the patient.
Examples:
Unexpected finding (high acuity must be verbally
communicated): Non calcified, previously unidentified lung nodule
on a preoperative chest x-ray; however, exercising sound clinical
judgement—this would be elevated to a critical result status if the
patient is scheduled for surgery within 24 hours.

Unexpected finding (moderate acuity must be verbally

communicated): Non calcified previously unidentified lung nodule
on a routine chest x-ray or indeterminate adrenal mass on a spinal
MRI.

Unexpected finding (low acuity and not needing verbal

communication): Incidental thyroid nodules confined to the gland
with no evidence of related cervical adenopathy or simple renal or
liver cysts that can be clearly identified as simple.
Critical findings in Head CT

 Trauma
 CVD
 Infeksi
 Tekanan intrakranial meningkat
 Tumor
Critical findings in Head CT

 Trauma
 CVD
 Infeksi
 Tekanan intrakranial meningkat
 Tumor
Skull Fractures

Skull fractures are categorized as linear

or depressed, depending on whether
the fracture fragments are depressed
below the surface of the skull.

Linear skull fracture of the right parietal

bone (arrows).
Subarachnoid Hemorrhage
A subarachnoid hemorrhage occurs with injury of
small arteries or veins on the surface of the brain.
The ruptured vessel bleeds into the space between
the pia and arachnoid matter.

High density blood (arrowheads) fills the

sulci over the
right cerebral convexity in this
subarachnoid hemorrhage.
 The hypodense region (arrow) within the
high density hematoma (arrowheads)
Subdural hematom may indicate active bleeding.
 Epidural hematoma (arrowheads),
deep to the parietal skull fracture (arrow).
Hemorrhage of the posterior limb of the Hemorrhage in the corpus callosum (arrow).
internal capsule (arrow) and hemorrhage of
the thalamus (arrowhead).
Contusio Cerebri : Multiple foci of high density corresponding to
hemorrhage (arrows) in an area of low density
(arrowheads) in the left frontal lobe due to cerebral contusion.
Fraktur vertebra
Critical findings in Head CT

 Trauma
 CVD
 Infeksi
 Tekanan intrakranial meningkat
 Tumor
Hemorrhagic Stroke

Hemorrhagic strokes
account for 16% of all
strokes. There are two
major categories of
hemorrhagic stroke.
Intracerebral hemorrhage
is the most common,
accounting for 10% of all
strokes. Subarachnoid
hemorrhage, due to
rupture of a cerebral
aneurysm, accounts for 6%
of strokes overall.
Hemorrhage in the cerebellum (arrow).
Intracerebral Hemorrhage

The most common cause

of non-traumatic
intracerebral hematoma is
hypertensive hemorrhage.

Thalamic hemorrhage (arrow) extending into

the left lateral ventricle (arrowheads).
 The CT on the left shows hemorrhage (arrow) due to underlying AVM
(arrowheads). The arteriogram on the right shows the tangle of vessels
(arrowheads) of the AVM. This lesion would be considered for intravascular
embolic therapy.
High density blood fills the cisterns (arrowheads) in this
patient with hemorrhage from the left middle cerebral artery.
Note the middle cerebral artery aneurysm (arrows).
Critical findings in Head CT

 Trauma
 CVD Iskemik
 Infeksi
 Tekanan intrakranial meningkat
 Tumor
Hyperdense Vessel Sign

A hyperdense vessel is defined

as a vessel denser than its
counterpart and denser than any
non-calcified vessel of similar
size.

High density in the right middle cerebral

artery (arrowheads).
Compare it with the normal left middle
cerebral artery (arrow).
Basilar Thrombosis

Thrombosis of the
basilar artery is a
common finding in
stroke patients. CT
findings include a
dense basilar artery
without contrast
injection.

Dense basilar artery (arrow).

Compare this to the normal internal
carotid artery (arrowhead).
Lentiform Nucleus Obscuration
Lentiform nucleus
obscuration is due to
cytotoxic edema in the
basal ganglia. This sign
indicates proximal middle
cerebral artery occlusion,
which results in limited
flow to lenticulostriate
arteries.

Hypodensity in the left hemisphere (arrows)

involving the caudate
nucleus and lentiform nuclei (globus pallidus
and putamen).
Insular Ribbon Sign

The insular ribbon sign is the loss

of the gray-white interface in the
lateral margins of the insula..

The cortex of the left insular ribbon is

not visualized (arrow).
Diffuse Hypodensity and Sulcal
Effacement
Diffuse hypodensity and sulcal
effacement is the most
consistent sign of infarction.
Extensive parenchymal
hypodensity is associated with
poor outcome.

Hypodensity and sulcal effacement

(arrowheads) in the right middle cerebral artery
distribution.
Infark subakut

After a stroke, edema

progresses, and brain density
decreases proportionately.

Sharply circumscribed hypodense

edema (arrowheads) in the right
middle cerebral artery territory.
This image was taken 4 hours after the This image, from the same patient, was
infarction. taken 2 days after the infaction.
Critical findings in Head CT

 Trauma
 CVD Iskemik
 Infeksi
 Tekanan intrakranial meningkat
 Tumor
Meningitis

There are three subtypes of

meningitis. Acute pyogenic
meningitis is usually bacterial.
Lymphocytic meningitis is
usually viral, benign and self-
limited. Chronic meningitis is
often seen in
immunocompromised hosts and
may be fungal or parasitic.
 In the left image notice the rim enhancing epdural fluid collection (arrowheads). In the
right image, notice the opacification of the left frontal sinus due to acute sinusitis (arrow).
Notice the heterogeneous subdural fluid In the same patient, post contrast
collection. administration, notice the patchy
enhancement of the fluid collection.
Abses submandibula
Critical findings in Head CT

 Trauma
 CVD Iskemik
 Infeksi
 Tekanan intrakranial meningkat
 Tumor
In these sections from the same patient notice the enlagement of the ventricles and cisterns
that occurs with hydrocephalus.
Critical findings in Head CT

 Trauma
 CVD Iskemik
 Infeksi
 Tekanan intrakranial meningkat
 Tumor
Notice the ill-defined low density in the An image post contrast administration in
right frontal region. the same patient reveals patchy
enhancement, a portion of which is
crossing the corpus callosum (arrow).
Bone windows confirm calcification within Axial, post contrast CT demonstrating broad
the mass. based enhancing extra-axial mass.
CHEST PAIN
CHEST PAIN

 Keluhan nyeri dada akut sering dijumpai

dalam kegawatdaruratan

 Nyeri dada akut non trauma mempunyai

spektrum penyebab yang luas.
Pendekatan awal nyeri dada
Menyingkirkan kemungkinan penyebab yang
mengancam jiwa seperti
- Sindrom koroner akut
- Sindrom aorta akut
- Emboli Paru
- Pneumotoraks
- Pneumomediastinum
- Perikarditis
- Perforasi Esofagus.
  Diagnosis dan terapi yang cepat sangatlah
penting

  Diagnostik Imejing menjadi ESSENTIAL

 Foto toraks masih menjadi pemeriksaan awal
yang diperlukan.

 CT Scan berpotensi sebagai pemeriksaan

yang mencakup semua (‘‘all-in-one’’ test )
pada kasus nyeri dada
1. Sindrom Koroner Akut
 Ruptur mendadak plak aterosklerosis yang
mengakibatkan oklusi arteri koronaria
Beberapa pasien Sindrom koroner Akut tidak
menunjukkan abnormalitas EKG dan
peningkatan troponin

 CT sangat membantu.
Sindrom Koroner Akut (CT)
Sindrom Koroner Akut
Hypoperfusi
2. Sindrom Aorta Akut

Terdiri dari
 Diseksi Aorta
 Intramural hematoma (IMH)
 Penetrating atherosclerotic ulcer.
 Aneurisma aorta ruptur.
2.1. Diseksi Aorta
 Laserasi lapisan intima, sehingga darah memasuki lapisan
media dan menimbulkan false lumen
Tipe Diseksi Aorta
Dissection Type
Type A Type B
2.2. Intramural Hematoma
 Perdarahan spontan vasa vasorum membentuk hematoma
sepanjang lapisan media
IMH pada noncontrast CT tampak hiperdens
crescentic sesuai hematoma pada
intramural
2.3. Penetrating Atherosclerotic
Ulcer
 Ulserasi plak aterosklerosis, menembus intima sampai
media, menyebabkan perdarahan dinding aorta bahkan
ruptur aorta
PAU

 Kontras mengisi
kantong pada dinding
aorta.
2.4. Aneurisma Aorta

 Dilatasi aorta.
 Aneurisma melibatkan ketiga lapisan
dinding aorta
Aneurisma Aorta
Ruptur Aneurisma Aorta
3. Emboli Paru
 Lepasnya trombus, biasanya dari vena pelvis atau femoral
 4. PeriKarditis
 Inflamasi perikardium
  Efusi
  Penebalan Perikardium
  Penyangatan
  Kalsifikasi bila kronik
Acute Pericarditis
Pericardial Effusion 
Tamponade
Hematothorax kiri loculated
anterior dan hematopericardium
Hematothorax kiri loculated
anterior dan hematopericardium
5. Pneumothorax dan
Pneumomediastinum
6. Ruptur esofagus
6. Ruptur esofagus
7. Pneumoni
Abses paru
8. Hernia diafragmatika
ACUTE ABDOMEN

 Obstruksi usus
 Perforasi
 Perdarahan intraabdominal
 Abses
 Nyeri abdomen
ACUTE ABDOMEN

 Obstruksi usus
 Perforasi
 Perdarahan intraabdominal
 Abses
 Nyeri abdomen
Obstruksi usus akibat hernia
inguinal kanan
Volvulus sigmoid
ACUTE ABDOMEN

 Obstruksi usus
 Perforasi
 Perdarahan intraabdominal
 Abses
 Nyeri abdomen
Pneumoperitoneum
ACUTE ABDOMEN

 Obstruksi usus
 Perforasi
 Perdarahan intraabdominal
 Abses
 Nyeri abdomen
Perdarahan intraabdominal
akibat corpus luteum ruptur
Perdarahan intraabdominal
akibat corpus luteum ruptur
KET
ACUTE ABDOMEN

 Obstruksi usus
 Perforasi
 Perdarahan intraabdominal
 Abses
 Nyeri abdomen
Abses intraabdomal dengan
fistula kutaneus
Abses Hepar
ACUTE ABDOMEN

 Obstruksi usus
 Perforasi
 Perdarahan intraabdominal
 Abses
 Nyeri abdomen
Iskemi Mesenterik
Aneurisma Aorta Abdominal
Aortic Dissection
Appendicitis acute
Limfoma Maligna
Batu Ureter
TERIMA KASIH