Academic Radiology - Articles in Press

Automated Diffusion Tensor Tractography: Implementation and Comparison to User-driven Tractography - Corrected Proof

2012-02-20

Rationale and Objectives: Diffusion tensor tractography offers a unique perspective of white matter anatomy, but proper delineation of white matter tracts of interest generally requires the active involvement of an expert neuroanatomist. The investigators describe the implementation of an automated tractographic method requiring no user input and compare its results to those from user-driven tractography.Materials and Methods: Fourteen healthy volunteers underwent diffusion tensor imaging at 3 T. Images were registered to a standard template, and predefined seed regions containing tract termini were transformed into subject space for use in unsupervised probabilistic tractography. The output was compared to the results of user-driven tractography performed on the same subjects.Results: After the selection of suitable smoothing kernels and thresholds, the results of automated tractography closely approximated those of user-driven tractography. The main bodies of the cingulum, inferior fronto-occipital fasciculus, and inferior longitudinal fasciculus were depicted equally well by both methods. Discrepancies mainly arose at the periphery of these tracts, where anatomic uncertainty tends to be greatest.Conclusions: Automated tractography can be used to depict white matter anatomy without need for user intervention, particularly if the main body of the tract is of greatest interest.

Knowledge of ACR Thoracic Imaging Appropriateness Criteria® among Trainees: One Institution's Experience - Corrected Proof

Allan B. Chiunda, Tan-Lucien H. Mohammed — 2012-02-20

Rationale and Objectives: Providing evidence-based appropriate imaging potentially increases diagnostic yield and prevents unnecessary imaging. The American College of Radiology's (ACR) evidence-based Appropriateness Criteria® (ACR-AC) were developed to provide imaging guidelines given various clinical scenarios. The goal of this study was to evaluate the knowledge level of the appropriate thoracic imaging study to be performed, given a clinical scenario.Methods: An online survey comprising 20 multiple-choice questions was developed on the basis of excerpts from the ACR-AC for thoracic imaging. The survey was piloted and invitations were sent out to resident trainees in radiology (n = 32), medicine (n = 119), and surgery (n = 40) and to pulmonary and critical medicine fellows (n = 16).Results: Sixty-nine trainees (33%) completed the survey. The trainees among those who completed the survey included 14 (20%) in radiology, 32 (46%) in medicine, eight (12%) in surgery, and 15 (22%) in pulmonary and critical medicine. Of the 69 trainees, most were male (n = 47 [68%]), aged 25 to 35 years (n = 65 [94%]), and in postgraduate years 1 to 3 (n = 44 [64%]). The overall median and percentage number of correct responses were 13 (interquartile range [IQR], 11–15) and 65% (n = 44), respectively. As would be expected, radiology residents performed better, with a median number of correct responses of 15 (IQR, 11–16) compared to 10 (IQR, 9–12) for medicine trainees, nine (IQR, 9–12) for surgery trainees, and 13 (IQR, 12–15) for pulmonary and critical medicine trainees. There was an increase in the median number of correct responses with years of training, ranging from 10 for postgraduate year 1 to 12 for postgraduate year 6.Conclusions: This study shows an opportunity to increase the awareness of the ACR-AC. Increasing the awareness of the ACR-AC among trainees will likely increase their use in practice and ultimately improve patient care.

Progression of Corpus Callosum Atrophy in Early Stage of Alzheimer’s Disease: MRI Based Study - Corrected Proof

Minwei Zhu, Wenpeng Gao, Xudong Wang, Chen Shi, Zhiguo Lin — 2012-02-20

Rationale and Objectives: Magnetic resonance imaging (MRI) studies reveal that atrophy of the corpus callosum (CC) is involved in early Alzheimer’s disease (AD). The aim of this study was to investigate when and how callosal changes occur in the early course of AD.Materials and Methods: The Open Access Series of Imaging Studies data sets were used in this study to investigate callosal change. High-resolution structural MRI was performed in 196 older patients. Subjects were characterized using the Clinical Dementia Rating (CDR); 98 healthy controls were not demented (CDR 0), and 98 patients had clinical diagnosis of AD in the very mild dementia stage (CDR 0.5; n = 70) and the mild dementia stage (CDR 1; n = 28). A semiautomatic segmentation method was used to extract the CC in the midsagittal plane. The total and regional areas of the CC were measured.Results: The results indicated that callosal atrophy occurred in when subjects’ CDRs were 0.5. The area of the genu and rostral body of the CC in the healthy controls (CDR 0) was significantly different from that of the subjects with very mild dementia (CDR 0.5) (P < .05). A significant difference could also be found in the area of the rostral body and midbody of the CC between subjects with very mild dementia (CDR 0.5) and those with mild dementia (CDR 1) (P < .05).Conclusions: Callosal atrophy can be detected in subjects with CDRs of 0.5. The change in the CC in the early stage of AD indicates an anterior-to-posterior atrophic process as the degree of dementia assessed by the CDR (from 0 to 0.5 to 1) increases.

Learners’ Perspectives on Competency-based Education - Corrected Proof

Richard B. Gunderman, Pauley T. Gasparis — 2012-02-20

In the last decade of the 20th century, competency garnered a great deal of attention in medical education. Spurred by broader educational trends, many medical educators, administrators, and accrediting agencies shifted their educational emphasis from inputs to outputs, focusing less on what educators teach and more on what learners should be capable of doing. This fostered a great deal of discussion regarding which competencies physicians at various levels of training should be able to demonstrate. What should all graduating fourth-year medical students be able to do? What additional abilities should radiology residents be able to demonstrate by the end of their training?

Accuracy, Risk and the Intrinsic Value of Diagnostic Imaging: A Review of the Cost-utility Literature - Corrected Proof

Hansel J. Otero, Chi H. Fang, Meera Sekar, Robert J. Ward, Peter J. Neumann — 2012-02-20

Rationale and Objectives: The aim of this study was to systematically review the reporting of the value of imaging unrelated to treatment consequences and test characteristics in all imaging-related published cost-utility analyses (CUAs) in the medical literature.Materials and Methods: All CUAs published between 1976 and 2008 evaluating diagnostic imaging technologies contained in the CEA Registry, a publicly available comprehensive database of health related CUAs, were screened. Publication characteristics, imaging modality, and the inclusion of test characteristics including accuracy, costs, risks, and the potential value unrelated to treatment consequences (eg, reassurance or anxiety) were assessed.Results: Ninety-six published CUAs evaluating 155 different imaging technologies were included in the final sample; 27 studies were published in imaging-specialized journals. Fifty-two studies (54%) evaluated the performance of a single imaging modality, while 44 studies (46%) compared two or more different imaging modalities. The most common areas of interest were cardiovascular (45%) and neuroradiology (17%). Forty-two technologies (27%) concerned ultrasound, while 34 (22%) concerned magnetic resonance. Seventy-nine (51%) technologies used ionizing radiation. Test accuracy was reported or calculated for 90% (n = 133 and n = 5, respectively) and assumed perfect (reference test or gold-standard test without alternative testing strategy to capture false-negatives and false-positives) for 8% (n = 12) of technologies. Only 22 studies (23%) assessing 40 imaging technologies (26%) considered inconclusive or indeterminate results. The risk of testing was reported for 32 imaging technologies (21%). Fifteen studies (16%) considered the value of diagnostic imaging unrelated to treatment. Four studies incorporated it as quality-of-life adjustments, while 10 studies mentioned it only in their discussions or as a limitation.Conclusions: The intrinsic value of imaging (the value of imaging unrelated to treatment) has not been appropriately defined or incorporated in the existing cost-utility literature, which could be due to a lack of evidence on the issue. Thus, more research is needed on metrics for a more comprehensive evaluation of diagnostic imaging. Similarly, the incorporation of variations in imaging tests accuracy, inconclusive results and associated risks has lacked uniformity in the cost-utility literature. Acknowledgment of these characteristics in future cost-utility publications will enhance their value and provide results that more closely resemble routine clinical practice.

Clinicopathologic Significance of High Signal Intensity on Diffusion-weighted MR Imaging in the Ureter, Urethra, Prostate and Bone of Patients with Bladder Cancer - Corrected Proof

2012-02-20

Rationale and Objectives: The aim of this study was to determine the clinicopathologic significance of high-intensity areas in the ureter, urethra, prostate, and bone incidentally found on diffusion-weighted magnetic resonance imaging (DWI) for the staging of bladder cancer.Materials and Methods: Axial and sagittal DWI and T2-weighted imaging of the pelvis were evaluated in 157 patients with bladder cancer. Two observers assessed T2-weighted imaging with DWI independently. The observers pointed out 67 areas showing abnormal high signal intensity on DWI in the ureter (n = 17), urethra (n = 8), prostate (n = 20), and bone (n = 22). Of the 67 high-intensity areas, 33 lesions were confirmed histopathologically (ureter, n = 10; urethra, n = 7; prostate, n = 16), and 22 bone lesions were diagnosed using T1-weighted imaging and follow-up computed tomography. Thus, 55 lesions were evaluable for correlation with DWI findings.Results: Of the 55 high-intensity areas, 28 (53%) were synchronous or metastatic urothelial cancer or invasion of urothelial cancer. The remaining 27 (47%) were a ureteral clot in one, a ureteral stone granuloma in one, prostatic cancer in six, granulomatous prostatitis in three, and normal red bone marrow in 16.Conclusions: DWI is useful to comprehend the extent of bladder cancer and to detect incidentally coexisting diseases. Other imaging, endoscopic, and clinical findings would be useful to reduce false positivity.

An Automatic Method for Renal Cortex Segmentation on CT Images: Evaluation on Kidney Donors - Corrected Proof

Xinjian Chen, Ronald M. Summers, Monique Cho, Ulas Bagci, Jianhua Yao — 2012-02-17

Rationale and Objectives: The aims of this study were to develop and validate an automated method to segment the renal cortex on contrast-enhanced abdominal computed tomographic images from kidney donors and to track cortex volume change after donation.Materials and Methods: A three-dimensional fully automated renal cortex segmentation method was developed and validated on 37 arterial phase computed tomographic data sets (27 patients, 10 of whom underwent two computed tomographic scans before and after nephrectomy) using leave-one-out strategy. Two expert interpreters manually segmented the cortex slice by slice, and linear regression analysis and Bland-Altman plots were used to compare automated and manual segmentation. The true-positive and false-positive volume fractions were also calculated to evaluate the accuracy of the proposed method. Cortex volume changes in 10 subjects were also calculated.Results: The linear regression analysis results showed that the automated and manual segmentation methods had strong correlations, with Pearson's correlations of 0.9529, 0.9309, 0.9283, and 0.9124 between intraobserver variation, interobserver variation, automated and user 1, and automated and user 2, respectively (P < .001 for all analyses). The Bland-Altman plots for cortex segmentation also showed that the automated and manual methods had agreeable segmentation. The mean volume increase of the cortex for the 10 subjects was 35.1 ± 13.2% (P < .01 by paired t test). The overall true-positive and false-positive volume fractions for cortex segmentation were 90.15 ± 3.11% and 0.85 ± 0.05%. With the proposed automated method, the time for cortex segmentation was reduced from 20 minutes for manual segmentation to 2 minutes.Conclusions: The proposed method was accurate and efficient and can replace the current subjective and time-consuming manual procedure. The computer measurement confirms the volume of renal cortex increases after kidney donation.

Assessment of Splenic Perfusion in Patients with Malignant Hematologic Diseases and Spleen Involvement, Liver Cirrhosis and Controls Using Volume Perfusion CT (VPCT) A Pilot Study - Corrected Proof

2012-02-13

Rationale and Objectives: The aim of this study was to assess splenic perfusion in patients with spleen involvement in malignant hematologic diseases and liver cirrhosis and in controls without hepatosplenic disease using volume perfusion computed tomography.Materials and Methods: Between October 2009 and December 2011, 14 hematologic patients with known spleen involvement were recruited. An additional 17 consecutive patients without known splenic or liver disease were enrolled as controls, as well as 29 patients with liver cirrhosis and portal hypertension. A 40-second volume perfusion computed tomographic scan of the upper abdomen was performed. Analysis included measurement of splenic volume, blood flow (BF), blood volume (BV), Ktrans, and mean transit time (MTT).Results: In lymphoma patients, mean splenic volume and perfusion parameters were as follows: splenic volume, 1125.34 mL; BF, 61.24 mL/100 mL/min; BV, 16.53 mL/100 mL; Ktrans, 37.00 mL/100 mL/min; and MTT, 12.42 seconds. All perfusion values of patients with lymphoma and cirrhosis differed significantly, except for BV, compared to controls. For patients with lymphoma, significant correlations were found between splenic volume and BF (r = −0.683, P = .000), splenic volume and BV (r = −0.525, P = .002), and splenic volume and MTT (r = 0.543, P = .001). During treatment, significant correlations between the diameters of nodular lymphoma target lesions, splenic volume, and the perfusion parameters were present for splenic volume (r = 0.601, P = .002), BF (r = −0.777, P = .000) and BV (r = −0.500, P = .011).Conclusions: Volume perfusion computed tomography represents a novel tool for the assessment of splenic perfusion. Preliminary results in patients with spleen involvement reveal lower perfusion values compared to controls or patients with cirrhosis. Therefore, this technique might provide additional information in clinical routine.

Shape-based Assessment of Vertebral Fracture Risk in Postmenopausal Women Using Discriminative Shape Alignment - Corrected Proof

Alessandro Crimi, Marco Loog, Marleen de Bruijne, Mads Nielsen, Martin Lillholm — 2012-02-10

Rationale and Objectives: Risk assessment of future osteoporotic vertebral fractures is currently based mainly on risk factors, such as bone mineral density, age, prior fragility fractures, and smoking. It can be argued that an osteoporotic vertebral fracture is not exclusively an abrupt event but the result of a decaying process. To evaluate fracture risk, a shape-based classifier, identifying possible small prefracture deformities, may be constructed.Materials and Methods: During a longitudinal case-control study, a large population of postmenopausal women, fracture free at baseline, were followed. The 22 women who sustained at least one lumbar fracture on follow-up represented the case group. The control group comprised 91 women who maintained skeletal integrity and matched the case group according to the standard osteoporosis risk factors. On radiographs, a radiologist and two technicians independently performed manual annotations of the vertebrae, and fracture prediction using shape features extracted from the baseline annotations was performed. This was implemented using posterior probabilities from a standard linear classifier.Results: The classifier tested on the study population quantified vertebral fracture risk, giving statistically significant results for the radiologist annotations (area under the curve, 0.71 ± 0.013; odds ratio, 4.9; 95% confidence interval, 2.94–8.05).Conclusions: The shape-based classifier provided meaningful information for the prediction of vertebral fractures. The approach was tested on case and control groups matched for osteoporosis risk factors. Therefore, the method can be considered an additional biomarker, which combined with traditional risk factors can improve population selection (eg, in clinical trials), identifying patients with high fracture risk.

Evaluating Imaging and Computer-aided Detection and Diagnosis Devices at the FDA - Corrected Proof

2012-02-06

This report summarizes the Joint FDA-MIPS Workshop on Methods for the Evaluation of Imaging and Computer-Assist Devices. The purpose of the workshop was to gather information on the current state of the science and facilitate consensus development on statistical methods and study designs for the evaluation of imaging devices to support US Food and Drug Administration submissions. Additionally, participants expected to identify gaps in knowledge and unmet needs that should be addressed in future research. This summary is intended to document the topics that were discussed at the meeting and disseminate the lessons that have been learned through past studies of imaging and computer-aided detection and diagnosis device performance.

Semiquantitative Analysis of Maximum Standardized Uptake Values of Regional Lymph Nodes in Inflammatory Breast Cancer: Is There a Reliable Threshold for Differentiating Benign from Malignant? - Corrected Proof

2012-02-03

Rationale and Objectives: The aim of this study was to determine an optimum standardized uptake value (SUV) threshold for identifying regional nodal metastasis on 18F–fluorodeoxyglucose (FDG) positron emission tomographic (PET)/computed tomographic (CT) studies of patients with inflammatory breast cancer.Materials and Methods: A database search was performed of patients newly diagnosed with inflammatory breast cancer who underwent 18F-FDG PET/CT imaging at the time of diagnosis at a single institution between January 1, 2001, and September 30, 2009. Three radiologists blinded to the histopathology of the regional lymph nodes retrospectively analyzed all 18F-FDG PET/CT images by measuring the maximum SUV (SUVmax) in visually abnormal nodes. The accuracy of 18F-FDG PET/CT image interpretation was correlated with histopathology when available. Receiver-operating characteristic curve analysis was performed to assess the diagnostic performance of PET/CT imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using three different SUV cutoff values (2.0, 2.5, and 3.0).Results: A total of 888 regional nodal basins, including bilateral axillary, infraclavicular, internal mammary, and supraclavicular lymph nodes, were evaluated in 111 patients (mean age, 56 years). Of the 888 nodal basins, 625 (70%) were negative and 263 (30%) were positive for metastasis. Malignant lymph nodes had significantly higher SUVmax than benign lymph nodes (P < .0001). An SUVmax of 2.0 showed the highest overall sensitivity (89%) and specificity (99%) for the diagnosis of malignant disease.Conclusions: SUVmax of regional lymph nodes on 18F-FDG PET/CT imaging may help differentiate benign and malignant lymph nodes in patients with inflammatory breast cancer. An SUV cutoff of 2 provided the best accuracy in identifying regional nodal metastasis in this patient population.

Assessing First Year Radiology Resident Competence Pre-call: Development and Implementation of a Computer-based Exam before and after the 12 Month Training Requirement - Corrected Proof

Rihan Khan, Elizabeth Krupinski, J. Allen Graham, Les Benodin, Petra Lewis — 2012-02-02

Rationale and Objectives: Whether first-year radiology residents are ready to start call after 6 or 12 months has been a subject of much debate. The purpose of this study was to establish an assessment that would evaluate the call readiness of first-year radiology residents and identify any individual areas of weakness using a comprehensive computerized format. Secondarily, we evaluated for any significant differences in performance before and after the change in precall training requirement from 6 to 12 months.Materials and Methods: A list of >140 potential emergency radiology cases was given to first-year radiology residents at the beginning of the academic year. Over 4 years, three separate versions of a computerized examination were constructed using hyperlinked PowerPoint presentations and given to both first-year and second-year residents. No resident took the same version of the exam twice. Exam score and number of cases failed were assessed. Individual areas of weakness were identified and remediated with the residents. Statistical analysis was used to evaluate exam score and the number of cases failed, considering resident year and the three versions of the exam.Results: Over 4 years, 17 of 19 (89%) first-year radiology residents passed the exam on first attempt. The two who failed were remediated and passed a different version of the exam 6 weeks later. Using the oral board scoring system, first-year radiology residents scored an average of 70.7 with 13 cases failed, compared to 71.1 with eight cases failed for second-year residents who scored statistically significantly higher. No significant difference was found in first-year radiology resident scoring before and after the 12-month training requirement prior to call.Conclusions: An emergency radiology examination was established to aid in the assessment of first-year radiology residents’ competency prior to starting call, which has become a permanent part of the first-year curriculum. Over 4 years, all first-year residents were ultimately judged ready to start call. Of the variables assessed, only resident year showed a significant difference in scoring parameters. In particular, length of training prior to taking call showed no significant difference. Areas of weakness were identified for further study.

Impact of Self-citation on the H Index in the Field of Academic Radiology - Corrected Proof

Arash Ehteshami Rad, Leili Shahgholi, David Kallmes — 2012-01-30

Rationale and Objectives: The Hirsch Index (H index) is widely applied as a metric of scientific productivity. The purpose of this study was to evaluate the role of self-citation on the H index in academic radiology.Materials and Methods: Through the National Resident Matching Program's Web site, one third (47/139) of radiology residency programs were selected randomly. All chairpersons and full professors were included. Using the Scopus database, we calculated the H index as well as the number of cumulative citations with and without inclusion of self-citations. We determined the proportion of academic staff in which H index increased by one, two, or greater than two integers. We also correlated the proportional increase in H index before and after inclusion of self citations with the number of publications.Results: A total of 487 academic staff (47 chair and 440 professors) was identified. Because of self-citation, mean ± SD of the H index increased from 13.7 ± 9.9 to 14.0 ± 10.2; mean ± SD of cumulative citations increased from 1804 ± 1889 to 1870 ± 1971. H index numbers did not change in 376/487 (77%) authors as a result of self-citation. There was no correlation between number of publications and proportional change of H index.Conclusion: The effect of self-citation is minimal in academic radiology, as evidenced by the fact that cumulative citations increase by only 2% and the large majority of H index values do not change by even a single integer after inclusion of self-citation.

Risk Factors for Non-calcified Plaques in Asymptomatic Population - Corrected Proof

Min Li, Gang Sun, Juan Ding, Li Li, Zhao-hui Peng, Xiang-sen Jiang — 2012-01-30

Rationale and Objectives: The aims of this study were to assess the prevalence of noncalcified coronary plaques in asymptomatic patients and to investigate the risk factors.Materials and Methods: In this study, 584 patients were recruited prospectively. Patients were classified as having low, intermediate, or high pretest likelihoods of coronary artery disease according to the Morise score. Coronary computed tomographic angiography was performed in all patients using a 320–detector row dynamic-volume computed tomographic scanner. Imaging reconstruction was performed, and the postprocessed data were analyzed. Logistic regression analysis was used to evaluate the relationship between risk factors and the presence of noncalcified plaque.Results: Coronary computed tomographic angiography revealed noncalcified plaques in 38.3% of all patients (224 of 584). The prevalence of noncalcified plaques was significantly higher in patients with calcium scores > 0 (P < .001). Significant differences were found between the degrees of luminal stenosis among patients with low, intermediate, and high pretest likelihoods of coronary artery disease (P = .001), while the prevalence of noncalcified plaques did not differ with the Morise score (P = .08). Noncalcified plaque was associated with hypercholesterolemia (P = .02) and diabetes mellitus (P = .002). Age (P = .47), gender (P = .58), estrogen status (P = .55), smoking (P = .22), hypertension (P = .27), and family history (P = .09) did not differ between patients with and those without noncalcified plaques.Conclusions: Hypercholesterolemia and diabetes mellitus are high risk factors for the prevalence of noncalcified plaques for asymptomatic patients.

Liver Perfusion Imaging in Patients with Primary and Metastatic Liver Malignancy: Prospective Comparison between 99mTc -MAA SPECT and Dynamic CT Perfusion - Corrected Proof

2012-01-30

Rationale and Objectives: To prospectively analyze the correlation between parameters of liver perfusion from technetium99m-macroaggregates of albumin (99mTc-MAA) single photon emission computed tomography (SPECT) with those obtained from dynamic CT perfusion in patients with primary or metastatic liver malignancy.Materials and Methods: Twenty-five consecutive patients (11 women, 14 men; mean age 60.9 ± 10.8; range: 32–78 years) with primary (n = 5) or metastatic (n = 20) liver malignancy planned to undergo selective internal radiotherapy underwent dynamic contrast-enhanced CT liver perfusion imaging (four-dimensional spiral mode, scan range 14.8 cm, 15 scans, cycle time 3 seconds) and 99mTc-MAA SPECT after intraarterial injection of 180 MBq 99mTc–MAA on the same day. Data were evaluated by two blinded and independent readers for the parameters arterial liver perfusion (ALP), portal venous perfusion (PVP), and total liver perfusion (TLP) from CT, and the 99mTc-MAA uptake-ratio of tumors in relation to normal liver parenchyma from SPECT.Results: Interreader agreements for quantitative perfusion parameters were high for dynamic CT (r = 0.90–0.98, each P < .01) and 99mTc -MAA SPECT (r = 0.91, P < .01). Significant correlation was found between 99mTc-MAA uptake ratio and ALP (r = 0.7, P < .01) in liver tumors. No significant correlation was found between 99mTc-MAA uptake ratio, PVP (r = −0.381, P = .081), and TLP (r = 0.039, P = .862).Conclusion: This study indicates that in patients with primary and metastatic liver malignancy, ALP obtained by dynamic CT liver perfusion significantly correlates with the 99mTc-MAA uptake ratio obtained by SPECT.

Deep Questioning and Deep Learning - Corrected Proof

Richard Gunderman — 2012-01-30

Examine the types of questions teachers ask in classrooms, and you will find that most of them are what might be called, “Guess what I am thinking” questions.Neil Postman, Teaching as a Subversive Activity

A New Approach to Assess Intracranial White Matter Abnormalities in Glaucoma Patients: Changes of Fractional Anisotropy Detected by 3T Diffusion Tensor Imaging - Corrected Proof

2012-01-27

Rationale and Objectives: The aims of this study was to evaluate, using 3-T diffusion tensor imaging, changes of fractional anisotropy (FA) in the orbital and intracranial part of the optic nerve (ON), the optic chiasm, the lateral geniculate nucleus, and different parts of the optic radiation (OR) in patients with glaucoma compared to controls and to determine whether FA correlates with disease severity.Materials and Methods: Twenty patients with glaucoma and 22 age-matched controls were examined using 3-T diffusion tensor imaging. Regions of interest were positioned on the FA maps, and mean values were calculated for each ON, optic chiasm, lateral geniculate nucleus, and OR. Results were compared to those from controls and correlated with ON atrophy and reduced spatial-temporal contrast sensitivity of the retina.Results: Compared to controls, FA in patients with glaucoma was significantly lower in the intracranial part of the ON (0.48 ± 0.15 vs 0.66 ± 0.12, P < .05) and in the OR (0.40 ± 0.16 to 0.48 ± 0.17 vs 0.53 ± 0.20 to 0.64 ± 0.11, P < .05). A high correlation between reduced FA in the intracranial ON and OR and ON atrophy and spatial-temporal contrast sensitivity of the retina was observed (r > 0.81). Otherwise, there was no significant difference in FA between patients with glaucoma and controls measured in the orbital part of the ON, optic chiasm, and lateral geniculate nucleus.Conclusions: Diffusion tensor imaging at 3 T allows robust FA measurements in the intracranial part of the ON and the OR. FA is significantly reduced in patients with glaucoma compared to controls, with a good correlation with established ophthalmologic examinations.

Small Masses on Breast MR: Is Biopsy Necessary? - Corrected Proof

Sughra Raza, Meera Sekar, Eugene M.W. Ong, Robyn L. Birdwell — 2012-01-27

Rationale and Objectives: To evaluate outcome of magnetic resonance (MR)-detected biopsied breast lesions ≤5 mm by correlating imaging characteristics with pathology.Methods and Materials: Institutional review board–approved retrospective review of 565 lesions biopsied with MR guidance between March 2004 and February 2009 found 68 lesions ≤5 mm in 61 patients. Lesions evaluated were those prospectively recommended for biopsy based on clinical setting, suspicious lesion morphology, and kinetics. Two study radiologists, blinded to final pathology, reviewed MR exams recording patient age, exam indication (staging, surveillance, diagnostic, or follow-up), mass location, size, morphology, T2-weighted signal, and kinetics. Chart review provided final pathology.Results: Of 68 masses ≤5 mm, 14 (20.6%) were malignant. Of 32 <5 mm, 32 (28.1%) were malignant. Of 14 malignancies, 7 (50%) were in patients with recently diagnosed breast cancer, 6 in the same breast, of which 4 (66.7%) were in same quadrant. Higher likelihood of malignancy based on proximity to known cancer was statistically significant (P = .01). No significant difference in proportion of malignancies was found based on age, T2-weighted signal, morphology, or kinetics.Conclusion: For MR-detected biopsied masses, the positive predictive value for malignancy of those ≤5 mm was 20.6%. The highest prevalence of cancers was in the same quadrant as a newly diagnosed breast cancer. The decision to biopsy small masses should be based on carefully assessed MR features, and in the context of exam indication, not solely on size.

Effects of Covert and Overt Paradigms in Clinical Language fMRI - Corrected Proof

2012-01-27

Rationale and Objectives: The aim of this study was to assess the intrasubject and intersubject reproducibility of functional magnetic resonance imaging (fMRI) language paradigms on language localization and lateralization.Materials and Methods: Fourteen healthy volunteers were enrolled prospectively and underwent language fMRI using visually triggered covert and overt sentence generation (SG) and word generation (WG) paradigms. Semiautomated analysis of all functional data was performed using Brain Voyager on an individual basis. Regions of interest for Broca's area, Wernicke's area, and their contralateral homologues were drawn. The Euclidean coordinates of the center of gravidity (x, y, and z) of the respective blood oxygenation level–dependent (BOLD) activation cluster, and the correlation of the measured hemodynamic response to the applied reference function (r), relative BOLD signal change as BOLD signal characteristics were measured in each region of interest. Regional lateralization indexes were calculated for Broca's area, Wernicke's area, and their contralateral homologues separately. Wilcoxon's signed-rank test was applied for statistical comparisons (P values < .05 were considered significant). Ten of the 14 volunteers had three repeated measurements to test intrasession reproducibility and intersession reproducibility.Results: Overall activation rates for the four paradigms were 89% for covert SG, 82% for overt SG, 89% for covert WG, and 100% for overt WG. When comparing covert and overt paradigms, language localization was significantly different in 17% (Euclidean coordinates) and 19% (BOLD signal characteristics), respectively. Language lateralization was significantly different in 75%. Intrasubject and intersubject reproducibility was excellent, with 3.3% significant differences among all five parameters for language localization and 0% significant differences for language lateralization using covert paradigms.Conclusions: Covert language paradigms (SG and WG) provided highly robust and reproducible localization and lateralization of essential language centers for scans performed on the same and different days. Their overt counterparts achieved confirmatory localization but lower lateralization capabilities. Reference data for presurgical application are provided.

The Method and Efficacy of 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography for Diagnosing the Lymphatic Metastasis of Colorectal Carcinoma - Corrected Proof

Lijuan Yu, Mohan Tian, Xuan Gao, Dalong Wang, Yu Qin, Jingshu Geng — 2012-01-24

Rationale and Objectives: The aim of this study was to analyze the morphologic and functional features of metastatic lymph nodes of colorectal carcinoma on 18F-fluorodeoxyglucose positron emission tomographic (PET)/computed tomographic (CT) images and correlate these with pathologic results to explore the best diagnostic performance.Methods: Sixty-eight patients without any previous treatment underwent 18F-fluorodeoxyglucose PET/CT examinations and subsequent operations. All lymph nodes were evaluated by recording short diameter and maximum standardized uptake value (SUVmax) on axial images and were carefully verified on the surgically resected specimens. The radiologic diagnostic efficacies on the basis of different diagnostic criteria were compared and evaluated with pathologic results.Results: There was a significant difference for SUVmax between metastatic and benign juxtaintestinal lymph nodes (F = 96.836, P = .000) and a correlation between size and SUVmax in metastatic juxtaintestinal lymph nodes (r = 0.352, P = .038). Diagnosing according to short diameter ≥ 10 mm and SUVmax ≥ 2.5, the sensitivity, specificity, positivity prediction value (PPV), and negative prediction value (NPV) were 10.00%, 98.26%, 66.67%, and 75.84% and 82.50%, 90.43%, 75.00%, and 93.69%, respectively. Considered together, the sensitivity, specificity, PPV, and NPV were 10.00%, 99.13%, 80.00%, and 76.00%, respectively. Receiver-operating characteristic curves showed that the best cutoff values for SUVmax and short diameter were 2.0 and 4.85 mm, respectively; the corresponding sensitivity, specificity, PPV, and NPV, were 91.43%, 87.83%, 69.57%, and 97.12% and 85.71%, 60.87%, 40.00%, and 98.2%, respectively. Considered together, the sensitivity, specificity, PPV, and NPV were 95.00%, 86.96%, 71.70%, and 98.04%, respectively.Conclusions: Fluorine-18-fluorodeoxyglucose uptake was a more reliable indicator in diagnosing malignant juxtaintestinal lymph node of colorectal carcinoma. The optimal diagnostic efficacy could be reached by considering morphologic and functional features together.

Screen-detected Lung Cancer - Corrected Proof

Koichi Kurishima, Maki Kanashiki, Hiroaki Satoh — 2012-01-24

We read with great interest the article by Dhopeshwarkar et al on screen-detected lung cancer. In their discussion, the authors stated that not a small percentage of screen-detected lung cancers on computed tomography (CT) were indolent and that there may be so-called overdiagnosis in mass screening using chest CT, which was suggested by Lindell et al . We agree with this estimation. In their article, however, Dhopeshwarkar et al reported that only 8.3% of lung cancers had doubling times > 400 days in a screening program using chest CT. This very low rate is almost the same as in the Mayo Lung Project and in a study at the Memorial Sloan-Kettering Cancer Center, evaluated using chest radiography . Also, this low rate was apparently different from those in studies by Hasegawa et al and Sone et al , evaluated using chest CT, as in the study by Dhopeshwarkar et al. We are very interested in these differences in rates. We would like to hear from the authors regarding why these differences were observed and the reason for the difference among them, although these recent studies were evaluated using chest CT.

Retrospective Study on the Use of Different Protocols for Repeated Transarterial Chemoembolization in the Treatment of Patients with Hepatocellular Carcinoma - Corrected Proof

2012-01-24

Purpose: To evaluate local tumor control and survival rate after repeated transarterial chemoembolization using two different protocols in hepatocellular carcinoma (HCC) patients.Materials and Methods: A total of 190 patients (mean, 68 years) with HCC were repeatedly treated with transarterial chemoembolization in 4-week intervals. The chemotherapy protocol consisted of mitomycin C alone (n = 111) and mitomycin C with gemcitabine (n = 79). Embolization was performed with lipiodol and microspheres. Tumor response was evaluated by magnetic resonance imaging using Response Evaluation Criteria In Solid Tumors (RECIST) criteria. Survival rates were calculated using Kaplan-Meier method.Results: In the mitomycin C–only group, we observed partial response in 38.8% (43/111), stable disease in 27% (30/111), and progressive disease in 34.2% (38/111). In the mitomycin C/gemcitabine group (n = 79), partial response was observed in 43% (34/79), stable disease in 16.5% (13/79) and progressive disease in 40.5% (32/79). The overall 1- and 2-year survival rates were 56% and 28%, respectively. The overall median survival time from the start of transarterial chemoembolization treatment was 15 months. The median survival of patients treated with mitomycin C was 16.5 months and it was 12 months for patients treated with a combination of mitomycin C and gemcitabine. No statistically significant difference between the two groups was observed (P = .7).Conclusion: Chemoembolization is an effective minimally invasive therapy option for palliative treatment of HCC patients. Mitomycin C only proves to be effective, the addition of gemcitabine was not advantageous.

Baseline SUVmax at PET-CT in Stage IIIA Non-small-cell Lung Cancer Patients Undergoing Surgery after Neoadjuvant Therapy: Prognostic Implication Focused on Histopathologic Subtypes - Corrected Proof

2012-01-24

Rationale and Objectives: To evaluate the prognostic significance of maximum standardized uptake value (SUVmax) at 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography in patients with stage IIIA non-small-cell lung cancer (NSCLC) who underwent surgical resection after neoadjuvant chemoradiotherapy, focused on the relationship between SUVmax values and tumor histology.Materials and Methods: We retrospectively evaluated the initial SUVmax of 205 patients (112 adenocarcinomas, 82 squamous cell carcinomas [SCCs], and 11 of other histology) with a stage IIIA NSCLC who underwent surgical resection after neoadjuvant chemoradiotherapy, and who were followed for up to 6 years. Clinical data, including histologic type, pathologic response, and treatment, were reviewed, and the relationship between the SUVmax and patient overall survival was examined.Results: Overall, the 2-year survival rate was 68%. Between the two histologic subtypes of adenocarcinoma and SCC, we noted significant differences in all variables of gender (male predominance in SCC), initial SUVmax (greater in SCC), pathologic response (more complete remission in SCC), and overall survival (better in SCC) (all P values, < .05). SUVmax remained as a sole independent factor for survival in multivariate analysis in whole series (SUVmax cutoff, 13; median survival, 3.0 years vs. 4.0 years; P = .016) and in adenocarcinomas (SUVmax cutoff, 11.5; median survival, 2.6 years vs. 3.6 years; P = .045), but not in SCCs.Conclusion: The initial SUVmax is a sole significant prognostic factor in patients with a surgically resected NSCLC after neoadjuvant chemoradiotherapy, particularly in patients with an adenocarcinoma.

Impact of Ventricular Contrast Medium Attenuation on the Accuracy of Left and Right Ventricular Function Analysis at Cardiac Multi Detector-row CT Compared with Cardiac MRI - Corrected Proof

2012-01-09

Rationale and Objectives: The aim of this study was to investigate the impact of ventricular contrast medium attenuation on the accuracy of left ventricular (LV) and right ventricular (RV) function analysis on coronary computed tomographic angiographic (CCTA) imaging compared to cardiac magnetic resonance imaging (CMR).Materials and Methods: Thirty patients (mean age, 61.9 ± 11.2 years; 14 men) underwent CCTA imaging and CMR. For both the right and left ventricles, end-diastolic volume (EDV), end-systolic volume (ESV), and stroke volume (SV) were computed using multiphase image reconstruction of CCTA data. The accuracy of CCTA imaging was determined by subtracting CCTA measurements from CMR measurements. The accuracy of CCTA imaging was then correlated with the level of LV and RV contrast medium attenuation using regression analysis.Results: In the right ventricle, there was strong correlation between the accuracy of CCTA functional assessment of EDV (R2 = 0.78, P 176 Hounsfield units; n = 15), these values were 13.6 ± 10, 8.0 ± 5.28, and 13 ± 4.96 mL, respectively. In the left ventricle, there was weak correlation between functional CCTA accuracy and LV attenuation (mean, 358.31 ± 68.71 Hounsfield units), and there was excellent correlation with CMR for LV EDV (R2 = 0.86, P < .001), ESV (R2 = 0.85, P < .001), and SV (R2 = 0.51, P < .001).Conclusions: If computed tomographic evaluation of RV function is desired, attention should be paid to the contrast injection protocol, because the accuracy of RV function analysis depends on the level of contrast medium attenuation. The high contrast medium attenuation that is typically achieved in the left ventricle routinely enables highly accurate measurements compared to CMR.

Follow-up Frequency and Compliance in Women with Probably Benign Findings on Breast Magnetic Resonance Imaging - Corrected Proof

Ariela L. Marshall, Susan M. Domchek, Susan P. Weinstein — 2012-01-09

Rationale and Objectives: Six-month short-interval follow-up is recommended for probably benign findings on breast magnetic resonance imaging (MRI). We wanted to examine patient adherence to follow-up recommendation for Breast Imaging-Reporting and Data System (BI-RADS) category 3 lesions at a tertiary care medical center.Materials and Methods: We performed a retrospective review of frequency and adherence rates to follow-up recommendation for women with an initial BI-RADS 3 breast MRI between 2005 and 2007.Results: A total of 132 women with BI-RADS 3 breast MRI recommendations were included. Ninety-six of 132 (72.7%) women adhered to the first follow-up recommendation or elected to have tissue diagnosis; 78/132 (59.1%) had follow-up MRI and 18/132 (13.6%) had tissue diagnosis. Thirty-six of 132 (27.3%) women did not return for follow-up. Nine of nine (100%) of BRCA carriers returned for follow-up or had tissue diagnosis, compared to 87/123 (70.7%) of non-BRCA carriers. A total of 35/41 (85.4%) of patients with a prior history of breast cancer returned for follow-up or had tissue diagnosis, compared to 61/91 (67%) of patients without a history of breast cancer. Only 5/15 (33%) of patients undergoing MRI for symptom alone adhered to follow-up recommendations.Conclusion: Adherence to BI-RADS category 3 follow-up recommendation is often low. Women with a history of breast cancer or who were BRCA carriers were significantly more likely to adhere to follow-up recommendation than women without a history of breast cancer or women undergoing MRI for symptoms alone. Strategies to improve adherence should be developed.

Exposure Creep in Computed Radiography: A Longitudinal Study - Corrected Proof

Dale J. Gibson, Robert A. Davidson — 2012-01-09

Purpose: Exposure creep is the gradual increase in x-ray exposures over time that results in increased radiation dose to the patient. It has been theorized as being a phenomenon that results from the wide-exposure latitude of computed radiography (CR) and direct/indirect digital radiography (DR). This project evaluates radiographic exposures over 43 months to determine if exposure creep exists and if measures can be applied to halt or reverse exposure creep trends.Methods: Exposure indices were initially recorded over 29 months between August 2007 and December 2009 from the intensive and critical care unit (ICCU) and the emergency department (ED) departments where manual CR exposures were used. The data from this period were then assessed and the exposure indexes (EI) values from the radiographic images were compared to the radiology department criteria of EI values between 1400 to 1800 as being in the optimal exposure range. EI values below this were considered underexposed and over this as overexposed. An intervention was required to be used in ICCU and implemented in January 2010 to halt a noted trend of overexposure. The EI value for each chest x-ray (CXR) was recorded in the patients' ICCU records and was to be used by radiologic technologists/radiographers in determine exposure factors in subsequent CXR. After the intervention, EI values were recorded and evaluated for an additional 15 months between February 2010 and March 2011.Results: Between August 2007 and December 2009, 17,678 ICCU CXR images and 69,327 ED x-ray examinations were evaluated for over- and underexposure. A trend was noted in ICCU that showed a significant increase (P = .023) in EI values from the beginning to the end of the evaluation. No such trend was seen in the ED EI values (P = .120). After the intervention in ICCU, the overexposure trend was halted.Conclusions: Exposure creep has been show to exist. It is surmised that this occurs where judgment in determine the correct radiographic exposure factors is need when taking into account a large range of patient sizes. It has also been shown that providing radiologic technologists/radiographers with previous EI values for the same x-ray examination can halt a trend of exposure creep.

Optimal Setting of Automatic Exposure Control Based on Image Noise and Contrast on Iodine-enhanced CT - Corrected Proof

2012-01-06

Rationale and Objectives: The aim of this study was to investigate variations in image noise and contrast using automatic exposure control (AEC) and different tube voltages on nonenhanced and iodine-enhanced hepatic computed tomography.Materials and Methods: Nonenhanced and iodine-enhanced simulated liver phantoms and AEC were used. Tube current was automatically adjusted with the noise index. Two types of assessments were performed: at a fixed noise index of 10 Hounsfield units and at different noise indexes, keeping the same contrast-to-noise ratio at different tube voltages (100, 120, and 130 kV). Image noise was measured, and contrast between the computed tomographic number of the simulated liver and nodule was computed.Results: At a fixed noise index, image noise on iodine-enhanced images was 10% to 13% higher than on nonenhanced images at the same tube voltage. At 130 and 100 kV, contrast was 33.86 and 46.90 Hounsfield units, respectively, and image noise was almost the same. Contrast-to-noise ratios at 100, 120, and 130 kV were 3.31, 3.22, and 3.37, respectively, and volume computed tomographic dose index fell from 22.94 to 12.49 mGy with decreasing tube voltage.Conclusions: With AEC, image noise on iodine-enhanced images was higher than on nonenhanced images despite identical noise index settings. As tube voltage decreased, contrast on iodine-enhanced images increased. Considering noise index and contrast variations at different tube voltages, the optimal use of AEC on iodine-enhanced computed tomography facilitates a reduction in x-ray tube output while maintaining contrast-to-noise ratio.

Lung Image Quality with 320-row Wide-volume CT Scans: The Effect of Prospective ECG-gating and Comparisons with 64-row Helical CT Scans - Corrected Proof

2012-01-06

Rationales and Objectives: To evaluate the image quality of 320-row wide-volume (WV) computed tomography (CT) scans in comparison with 64-row helical scans for the lung.Materials and Methods: The Institutional Review Board of each institution approved this prospective, multicenter study and informed consent was obtained. A total of 73 subjects underwent two types of chest CT, including 320-row WV scans and 64-row helical scans. Both scans used the same tube voltage, tube current, exposure time setting, and slice thickness. The helical scans were not electrocardiogram (ECG)-gated. For the WV scans, prospective ECG-gating was used for 38 subjects, whereas the other 35 subjects did not have ECG-gating. Using a 5-point scale from 1 (nondiagnostic) to 5 (excellent), three blinded observers independently evaluated image quality for five lobes and the lingula. The differences in the scores between WV scans and helical scans were compared using Wilcoxon’s signed-rank test.Results: The WV scans with ECG-gating had significantly higher scores than 64-row helical scans for all lobes and lingula (right lower lobe, P < .01; other lobes and lingula, P < .0001, respectively). The 320-row WV scans without ECG-gating also had significantly higher scores than 64-row helical scans (P < .05), except for nonsignificant differences for the left upper lobe.Conclusions: Lung image quality of ECG-gated WV scans, which do not require any additional radiation exposure, is better than that of non–ECG-gated 64-row helical scans. Non–ECG-gated 320-row WV scans are comparable or slightly superior to non–ECG-gated 64-row helical scans.

Measurement of Focal Ground-glass Opacity Diameters on CT Images: Interobserver Agreement in Regard to Identifying Increases in the Size of Ground-Glass Opacities - Corrected Proof

2012-01-06

Purpose: To evaluate interobserver agreement in regard to measurements of focal ground-glass opacities (GGO) diameters on computed tomography (CT) images to identify increases in the size of GGOs.Materials and Methods: Approval by the institutional review board and informed consent by the patients were obtained. Ten GGOs (mean size, 10.4 mm; range, 6.5–15 mm), one each in 10 patients (mean age, 65.9 years; range, 58–78 years), were used to make the diameter measurements. Eleven radiologists independently measured the diameters of the GGOs on a total of 40 thin-section CT images (the first [n = 10], the second [n = 10], and the third [n = 10] follow-up CT examinations and remeasurement of the first [n = 10] follow-up CT examinations) without comparing time-lapse CT images. Interobserver agreement was assessed by means of Bland-Altman plots.Results: The smallest range of the 95% limits of interobserver agreement between the members of the 55 pairs of the 11 radiologists in regard to maximal diameter was −1.14 to 1.72 mm, and the largest range was −7.7 to 1.7 mm. The mean value of the lower limit of the 95% limits of agreement was −3.1 ± 1.4 mm, and the mean value of their upper limit was 2.5 ± 1.1 mm.Conclusion: When measurements are made by any two radiologists, an increase in the length of the maximal diameter of more than 1.72 mm would be necessary in order to be able to state that the maximal diameter of a particular GGO had actually increased.

Critical Care Radiology - Corrected Proof

Vivek Manchanda — 2012-01-06

This first edition of Critical Care Radiology aims for interdisciplinary interpretation of adult and pediatric radiologic studies in intensive care setting. The book is a good and easy read for radiology residents taking call in general and pulmonary, body and pediatric radiology fellows in particular. The book is also very useful for the internists and intensivists who participate in critical care of patients in intensive care units around the world.

High-resolution Diffusion-weighted Magnetic Resonance Imaging in Patients with Locally Advanced Breast Cancer - Corrected Proof

2011-12-26

Rationale andObjectives: The aim of this study was to evaluate differences in tumor depiction and measured tumor apparent diffusion coefficient (ADC) with the use of a high-resolution diffusion-weighted (DW) magnetic resonance imaging (MRI) sequence, compared to a standard DW MRI sequence, in patients with locally advanced breast cancer.Materials and Methods: Patients with locally advanced breast cancer were scanned with a reduced–field of view (rFOV) DW MRI sequence (high resolution) and a standard–field of view diffusion sequence (standard resolution), and differences between the two sequences were evaluated quantitatively (by calculating tumor ADC distribution parameters) and qualitatively (by radiologists’ visual assessments of images).Results: Although the mean tumor ADC for both sequences was similar, differences were found in other parameters, including the 12.5th percentile (P = .042) and minimum tumor ADC (P = .003). Qualitatively, visualization of tumor morphologic detail, heterogeneity, and conspicuity was improved with rFOV DW MRI, and image quality was higher.Conclusions: Differences in ADC distribution parameters and qualitative image features suggest that the sequences differ in their ability to capture tumor heterogeneity. These differences are not apparent when the mean is used to evaluate tumor ADC. In particular, differences found in lower ADC values are compatible with reduced partial voluming in rFOV DW MRI, suggesting that rFOV DW MRI may be valuable in imaging the lower ADCs expected to correspond to viable tumor in most invasive breast cancers.

Incidental Aortic Valve Calcification on CT Scans: Significance for Bicuspid and Tricuspid Valve Disease - Corrected Proof

Michael D. Hope, Thomas H. Urbania, John-Paul J. Yu, Sam Chitsaz, Elaine Tseng — 2011-11-21

Rationale and Objectives: The aim of this study was to evaluate the role of incidental aortic valve calcification on routine computed tomographic scans as a marker for stenosis, as assessed by echocardiography, in patients with bicuspid aortic valve (BAV) and tricuspid aortic valve.Materials and Methods: Computed tomographic and echocardiographic studies were retrospectively reviewed for 182 consecutive, unselected patients and 426 patients identified by a record search for “aortic valve calcification.” Location and severity of valve calcification were correlated with aortic valve morphology and stenosis. Differences between subgroups were assessed using χ2 or Fisher’s exact tests.Results: In unselected patients, calcification was present in 25.8% with tricuspid aortic valves (46 of 178) and 75% (three of four) with BAV. In patients selected for valve calcification, the average age of those with tricuspid aortic valves (n = 395) was 14.3 years older than those with BAV (n = 31). Patients with BAV were more likely to have severe calcification (87% vs 50%, P < .001), and if severe calcification was present, it was more likely to involve only the valve leaflets (41% vs 9%, P < .001) and result in aortic stenosis (85% vs 58%, P = .006). Patients aged < 60 years with severe calcification were more likely to have BAV (56% vs 7%; odds ratio, 7.9; 95% confidence interval, 3.4–18.7).Conclusions: Aortic valve calcification was found 14 years earlier in patients with BAV and was more severe and strongly linked to aortic stenosis. Valve calcification on computed tomographic scans should be considered a marker for BAV if found before the seventh decade.