Introdução: nos últimos anos, foi observado um aumento significativo da incidência do diabetes e, consequentemente, o aumento de sua prevalência. As doenças cardiovasculares, sobretudo o infarto agudo do miocárdio (IAM) e o acidente vascular cerebral (AVC), são as principais responsáveis pela mortalidade nesses pacientes, sendo, muitas vezes, a primeira manifestação da doença. A ruptura da placa aterosclerótica coronariana é o mecanismo fisiopatológico de dois em cada três casos de IAM, e as características dessas placas já foram objeto de diversos estudos no campo da angiotomografia computadorizada das artérias coronárias (CCTA). Objetivo: avaliar a frequência de doença arterial coronariana e as principais características clínicas, laboratoriais, funcionais e anatômicas dos exames complementares em diabéticos tipo 2 (DM2) sem queixas cardiovasculares. Métodos: foram incluídos 98 pacientes diabéticos do tipo 2, avaliados entre junho de 2011 a janeiro de 2013, com idades entre 40 e 65 anos, cuja duração do diabetes tenha sido inferior a 10 anos, para serem submetidos às avaliações clínica e laboratorial, ao teste ergométrico, à ultrassonografia (USG) com Doppler de carótidas e vertebrais e à CCTA. Resultados: dos 98 pacientes, 44% (n = 43) apresentaram doença arterial coronária (DAC) na CCTA e 38 (39%), escore de cálcio coronário (CAC) maior do que zero. Além disso, 16 indivíduos apresentaram doença arterial coronariana significativa (obstrução luminal maior do que 50%), incluindo três com escore de cálcio coronário igual a zero. Pacientes com placas ateroscleróticas nas artérias coronárias apresentaram uma incidência maior de placas ateroscleróticas nas carótidas (58% x 38%, p = 0,01). Dos 55 pacientes com CCTA normal, 18 tinham placas nas carótidas. Dos 98 pacientes do estudo, oito pacientes tiveram o teste ergométrico positivo para isquemia miocárdica, e desses, cinco tinham estenose maior que 50%, dois tinham estenose menor que 50% e um não tinha aterosclerose coronariana. Conclusão: o paciente diabético sem sintomas cardiovasculares apresenta uma elevada frequência de doença arterial coronariana. O escore de cálcio coronário é, entre os testes estudados e em comparação com a CCTA, aquele que possui a maior sensibilidade e especificidade para predizer a DAC / Introduction: in the last years, there has been a significant increase in the incidence of diabetes and, thus, an increase in its prevalence. Cardiovascular diseases, especially acute myocardial infarction (AMI) and cerebrovascular accident (CVA), are the main causes of death in these patients, often being the first manifestation of the disease. Coronary atherosclerotic plaque rupture is the pathophysiological mechanism of two out of three cases of AMI and the characteristics of these plaques have already been the subject of several studies in the field of coronary computed tomography angiography (CCTA). Objective: to evaluate the frequency of coronary artery disease and the main clinical, laboratory, functional and anatomical characteristics of the complementary exams in type 2 diabetics without cardiovascular symptoms. Methods: we enrolled 98 type 2 diabetic patients, evaluated between June 2011 and January 2013, aged 40-65 years, duration of diabetes less than 10 years, submitted to clinical evaluation, laboratorial test, exercise treadmill test, Doppler ultrasonography of the carotid and vertebral arteries and CCTA. Results: out of the 98 patients, 44% (n = 43) had coronary artery disease (CAD) in CCTA, and 38 (39%) had a coronary artery calcium (CAC) score greater than zero. In addition, 16 subjects had significant coronary artery disease (luminal obstruction greater than 50%), including three with coronary artery calcium scores equal to zero. Patients with atherosclerotic plaques in the coronary arteries had a higher incidence of atherosclerotic plaques in the carotid arteries (58% x 38%, p = 0.01). From the 55 patients with normal CCTA, 18 had plaques in the carotid arteries. Out of the 98 patients, eight had a positive exercise treadmill test for myocardial ischemia, of whom five had stenosis greater than 50%, two had stenosis less than 50% and one had no coronary atherosclerosis. Conclusion: the diabetic patient without cardiovascular symptoms presents a high frequency of coronary artery disease. The coronary artery calcium score is, among the tests studied and in comparison to CCTA, the one that has the highest sensitivity and specificity to predict CAD

Introdução: A doença aterosclerótica intracraniana é uma das principais causas de acidente vascular cerebral isquêmico (AVCI) no mundo, porém sua prevalência parece estar subestimada na população brasileira pela carência de estudos na área. O objetivo principal deste estudo foi descrever a frequência e gravidade da estenose intracraniana nos pacientes com AVCI ou ataque isquêmico transitório (AIT), utilizando a ultrassonografia transcraniana colorida (UTC). O objetivo secundário foi correlacionar os achados deste exame com a angiotomografia de crânio (AngioTC). Métodos: estudo observacional e prospectivo, onde foram avaliados pacientes consecutivos com o diagnóstico de AVCI ou AIT admitidos no período de fevereiro de 2014 a dezembro de 2014. A avaliação inicial consistiu na coleta de dados demográficos, epidemiológicos e clínicos e em seguida os pacientes foram submetidos ao exame de UTC através das janelas transtemporais e suboccipital, com o intuito de avaliar a presença de estenose intracraniana. Estenose intracraniana foi graduada em moderada (50- 70%), grave (70-99%) e suboclusão/oclusão (>= 99%). Foram considerados sintomáticos os casos em que houve uma associação entre os novos sinais e sintomas e uma nova área de infarto ao exame de neuroimagem no território da artéria envolvida ou quando o quadro neurológico correspondeu ao território da artéria envolvida. Os pacientes que possuíam UTC e AngioTC em sua avaliação foram comparados de forma cega quanto ao grau de estenose intracraniana seguindo a mesma classificação. Resultados: Foram avaliados 271 pacientes com o diagnóstico de AVCI ou AIT agudos (149 homens, com média de idade de 65,8 ± 12,5), 263 (97%) foram submetidos a exame de circulação intracraniana, sendo a ultrassonografia transcraniana colorida realizada em 168 casos (61,9%). Apenas 25 indivíduos (14,9%) foram excluídos devido a janela transtemporal insuficiente. Dentre os 143 pacientes que puderam ser avaliados adequadamente pela ultrassonografia transcraniana, a prevalência de estenose arterial intracraniana foi de 38,5% (55 casos); sendo sintomática em 25,2% dos casos. A média de idade dos pacientes era de 64 ± 11 anos, 26,9 % eram brancos e 29,4% hipertensos. Os pacientes com estenose intracraniana apresentaram maior pontuação na escala do NIH: 10 (IQ 4 - 19) vs 6 (IQ 3 - 13), maiores níveis de pressão arterial sistólica na admissão: 160 (IQ 145-170) vs 140 (IQ 130 - 155) e menores taxas de HDL: 32 (IQ 27 - 39) vs 36 (IQ 30 - 45). Após análise multivariada, o fator de risco independentemente associado à estenose intracraniana foi a hipertesão arterial sistêmica na admissão (p=0,006). Nos 100 pacientes com ambos os exames, a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo da UTC comparada a AngioTC para detecção de estenoses intracranianas moderadas-graves foi de 60%, 73%, 73% e 60%, respectivamente. Conclusões: Encontramos alta frequência de estenose arterial intracraniana entre os pacientes com AVCI agudo e AIT na nossa população, especialmente entre indivíduos portadores de hipertensão arterial sistêmica. A UTC é uma ferramenta não-invasiva que pode ser utilizada para investigação da doença moderada-grave com acurácia moderada quando comparada a AngioTC / Background: Intracranial atherosclerotic disease is a major cause of ischemic stroke in the world, but its prevalence seems to be underestimated in our population by the lack of studies in the area. The aim of this study was to describe the frequency and severity of intracranial stenosis in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA), using the transcranial color-coded sonography (TCCS). The secondary objective was to correlate the TCCS test results with the findings on CT angiography on the same patients. Methods: Prospective observational study that evaluated consecutive patients admitted with a diagnosis of ischemic stroke or TIA during the period February 2014 to December 2014. The initial evaluation consisted of collection of demographic, epidemiological and clinical data and then the patients underwent the examination TCCS through transtemporal and suboccipital windows, in order to assess the presence of intracranial stenosis. Intracranial stenosis was graded moderate (50-70%), severe (70-99%) and subocclusion/occlusion (>= 99%). The cases were considered symptomatic when there was an association between new symptoms and signs and a new infarct area on neuroimaging in the territory of the stenotic artery or when the neurological status corresponded to the territory of that artery. Patients who had TCCS and intracranial angiography in their assessment were blindly compared for the degree of intracranial stenosis following the same classification. Results: We evaluated 271 patients with diagnosis of acute ischemic stroke and TIA (149 men, mean age 65.8 ± 12.5), 263 (97%) underwent examination of intracranial circulation, with the TCCS held in 168 cases (61.9%). Only 25 individuals (14.9%) were excluded due to insufficient transtemporal window. Among the 143 patients who could be evaluated properly by transcranial ultrasound, the prevalence of intracranial arterial stenosis was 38.5% (55 cases); with 25,2% symptomatic cases. The average age of patients was 64 ± 11 years, 26.9% were white and 29.4% hypertensive. Patients with intracranial stenosis had higher scores on the NIHSS: 10 (IR 4-19) vs 6 (IR 3- 13), higher levels of systolic blood pressure at entry: 160 (IR 145-170) vs 140 (IR 130 - 155) and lower HDL rates: 32 (IR 27-39) vs 36 (IR 30-45). After multivariate analysis, the risk factor independently associated with intracranial stenosis was systemic arterial hypertension at admission (p = 0.006). In the 83 patients with both tests, the sensitivity, specificity, positive predictive value and negative predictive value of TCCS compared to CT angiography for detection of intracranial stenosis moderate-severe was 60%, 73%, 73% e 60%, respectively, Conclusions: We found a high frequency of intracranial artery stenosis in patients with acute ischemic stroke and TIA in our population, especially among individuals with hypertension. TCCS is a non-invasive tool that can be used to study moderate-severe disease with moderate accuracy compared to CT angiography

Anatomical variants of hepatic arteries are frequent. One of the most common origins of aberrant (atypically branching) hepatic arteries is superior mesenteric artery. Many physiologic and pathologic features influence hemodynamics of the latter artery. There were some sporadic cases in literature about the influence of aberrant hepatic artery arising from superior mesenteric artery to the hemodynamics of the latter artery, but no evidence based large extent studies were performed. Therefore the aim of this study was to evaluate how significant the aberrant hepatic artery branching from the superior mesenteric artery influences the hemodynamics of superior mesenteric artery. Anatomical variants of the hepatic arteries were evaluated by computed tomography angiography also the candidates for Doppler ultrasound were selected. Doppler ultrasound was used to evaluate the hemodynamics of the superior mesenteric artery in patients with aberrant hepatic artery arising from the superior mesenteric artery and in those with typical hepatic artery anatomy. The influence of the aberrant hepatic artery arising from superior mesenteric artery to the hemodynamics (resistance) of the superior mesenteric artery was assessed. The results of the investigation show that anatomical variants of the hepatic arteries are frequent. The aberrant hepatic artery arising from superior mesenteric artery significantly lowers resistance of the superior mesenteric artery. Practical recommendations were set... [to full text] / Kepenų arterijų anatominiai variantai yra dažni. Viena dažniausių aberantinių (netipiškai atsišakojančių) kepenų arterijų atsišakojimo vietų yra viršutinė pasaito arterija. Pastarosios arterijos kraujotaka yra įtakojama daugybės fiziologinių ir patologinių veiksnių. Literatūroje taip pat aprašyti pavieniai atvejai apie iš viršutinės pasaito arterijos atsišakojančios aberantinės kepenų arterijos įtaką viršutinės pasaito arterijos hemodinamikai, tačiau didesnės apimties įrodymais pagrįstų tyrimų šioje srityje iki šiol nebuvo atlikta. Todėl šio tyrimo tikslas buvo įvertinti, ar aberantinė kepenų arterija, atsišakojanti iš viršutinės pasaito arterijos, reikšmingai įtakoja pastarosios kraujagyslės hemodinamiką. Šiame tyrime kompiuterinės tomografijos angiografijos pagalba įvertinti kepenų arterijų anatominiai variantai, atrinkti pacientai doplerio ultragarso tyrimams. Pastaruoju metodu tirta viršutinės pasaito arterijos kraujotaka pacientams, kurių vieni turėjo aberantinę kepenų arteriją, atsišakojančią iš viršutinės pasaito arterijos, o kiti turėjo įprastą kepenų arterijų anatomiją. Vertinta aberantinės kepenų arterijos, atsišakojančios iš viršutinės pasaito arterijos, įtaka pastarosios arterijos hemodinamikai (rezistentiškumui). Remiantis tyrimo duomenimis nustatyta, kad kepenų arterijų anatominiai variantai yra dažni. Aberantinė kepenų arterija, atsišakojanti iš viršutinės pasaito arterijos, reikšmingai mažina pastarosios arterijos rezistentiškumą. Pateiktos praktinės... [toliau žr. visą tekstą]

Introdução: A doença aterosclerótica intracraniana é uma das principais causas de acidente vascular cerebral isquêmico (AVCI) no mundo, porém sua prevalência parece estar subestimada na população brasileira pela carência de estudos na área. O objetivo principal deste estudo foi descrever a frequência e gravidade da estenose intracraniana nos pacientes com AVCI ou ataque isquêmico transitório (AIT), utilizando a ultrassonografia transcraniana colorida (UTC). O objetivo secundário foi correlacionar os achados deste exame com a angiotomografia de crânio (AngioTC). Métodos: estudo observacional e prospectivo, onde foram avaliados pacientes consecutivos com o diagnóstico de AVCI ou AIT admitidos no período de fevereiro de 2014 a dezembro de 2014. A avaliação inicial consistiu na coleta de dados demográficos, epidemiológicos e clínicos e em seguida os pacientes foram submetidos ao exame de UTC através das janelas transtemporais e suboccipital, com o intuito de avaliar a presença de estenose intracraniana. Estenose intracraniana foi graduada em moderada (50- 70%), grave (70-99%) e suboclusão/oclusão (>= 99%). Foram considerados sintomáticos os casos em que houve uma associação entre os novos sinais e sintomas e uma nova área de infarto ao exame de neuroimagem no território da artéria envolvida ou quando o quadro neurológico correspondeu ao território da artéria envolvida. Os pacientes que possuíam UTC e AngioTC em sua avaliação foram comparados de forma cega quanto ao grau de estenose intracraniana seguindo a mesma classificação. Resultados: Foram avaliados 271 pacientes com o diagnóstico de AVCI ou AIT agudos (149 homens, com média de idade de 65,8 ± 12,5), 263 (97%) foram submetidos a exame de circulação intracraniana, sendo a ultrassonografia transcraniana colorida realizada em 168 casos (61,9%). Apenas 25 indivíduos (14,9%) foram excluídos devido a janela transtemporal insuficiente. Dentre os 143 pacientes que puderam ser avaliados adequadamente pela ultrassonografia transcraniana, a prevalência de estenose arterial intracraniana foi de 38,5% (55 casos); sendo sintomática em 25,2% dos casos. A média de idade dos pacientes era de 64 ± 11 anos, 26,9 % eram brancos e 29,4% hipertensos. Os pacientes com estenose intracraniana apresentaram maior pontuação na escala do NIH: 10 (IQ 4 - 19) vs 6 (IQ 3 - 13), maiores níveis de pressão arterial sistólica na admissão: 160 (IQ 145-170) vs 140 (IQ 130 - 155) e menores taxas de HDL: 32 (IQ 27 - 39) vs 36 (IQ 30 - 45). Após análise multivariada, o fator de risco independentemente associado à estenose intracraniana foi a hipertesão arterial sistêmica na admissão (p=0,006). Nos 100 pacientes com ambos os exames, a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo da UTC comparada a AngioTC para detecção de estenoses intracranianas moderadas-graves foi de 60%, 73%, 73% e 60%, respectivamente. Conclusões: Encontramos alta frequência de estenose arterial intracraniana entre os pacientes com AVCI agudo e AIT na nossa população, especialmente entre indivíduos portadores de hipertensão arterial sistêmica. A UTC é uma ferramenta não-invasiva que pode ser utilizada para investigação da doença moderada-grave com acurácia moderada quando comparada a AngioTC / Background: Intracranial atherosclerotic disease is a major cause of ischemic stroke in the world, but its prevalence seems to be underestimated in our population by the lack of studies in the area. The aim of this study was to describe the frequency and severity of intracranial stenosis in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA), using the transcranial color-coded sonography (TCCS). The secondary objective was to correlate the TCCS test results with the findings on CT angiography on the same patients. Methods: Prospective observational study that evaluated consecutive patients admitted with a diagnosis of ischemic stroke or TIA during the period February 2014 to December 2014. The initial evaluation consisted of collection of demographic, epidemiological and clinical data and then the patients underwent the examination TCCS through transtemporal and suboccipital windows, in order to assess the presence of intracranial stenosis. Intracranial stenosis was graded moderate (50-70%), severe (70-99%) and subocclusion/occlusion (>= 99%). The cases were considered symptomatic when there was an association between new symptoms and signs and a new infarct area on neuroimaging in the territory of the stenotic artery or when the neurological status corresponded to the territory of that artery. Patients who had TCCS and intracranial angiography in their assessment were blindly compared for the degree of intracranial stenosis following the same classification. Results: We evaluated 271 patients with diagnosis of acute ischemic stroke and TIA (149 men, mean age 65.8 ± 12.5), 263 (97%) underwent examination of intracranial circulation, with the TCCS held in 168 cases (61.9%). Only 25 individuals (14.9%) were excluded due to insufficient transtemporal window. Among the 143 patients who could be evaluated properly by transcranial ultrasound, the prevalence of intracranial arterial stenosis was 38.5% (55 cases); with 25,2% symptomatic cases. The average age of patients was 64 ± 11 years, 26.9% were white and 29.4% hypertensive. Patients with intracranial stenosis had higher scores on the NIHSS: 10 (IR 4-19) vs 6 (IR 3- 13), higher levels of systolic blood pressure at entry: 160 (IR 145-170) vs 140 (IR 130 - 155) and lower HDL rates: 32 (IR 27-39) vs 36 (IR 30-45). After multivariate analysis, the risk factor independently associated with intracranial stenosis was systemic arterial hypertension at admission (p = 0.006). In the 83 patients with both tests, the sensitivity, specificity, positive predictive value and negative predictive value of TCCS compared to CT angiography for detection of intracranial stenosis moderate-severe was 60%, 73%, 73% e 60%, respectively, Conclusions: We found a high frequency of intracranial artery stenosis in patients with acute ischemic stroke and TIA in our population, especially among individuals with hypertension. TCCS is a non-invasive tool that can be used to study moderate-severe disease with moderate accuracy compared to CT angiography

Computed tomography angiography (CTA) of the brain poses challenges on the imaging system; the contrast between blood vessels and surrounding soft tissue is very low, and to render small intricate vessel structures high spatial resolution is needed. Higher precision angiography would facilitate more accurate diagnosis of pathological conditions. The aim of this work was to analyze the factors which contribute to the image quality in cerebrovascular imaging contexts and make a comparison between state-of-the-art energy-integrating and photon counting CT systems. A geometrical model was devised to mimic the conditions of cerebral angiography. Different parameters and detectors were used to reconstruct images of a spherical head phantom. Compton noise was added to several image acquisitions after a Monte Carlo study was used to estimate the scatter to primary ratio (SPR) with a spherical phantom. The images were evaluated qualitatively and quantitatively. A real phantom was scanned with an experimental photon counting detector and compared with the simulated approach. The work resulted in qualitative reconstructed images, a decrease in SPR when introducing air gaps and improved resolution but worsened contrast as a result of smaller detector sizes. The SPR was shown to be higher in cone-beam geometry than fan-beam geometry. Electronic noise present with energy integrating detectors was shown to degrade image quality significantly in low dose imaging, reducing contrast when imaging vascular-like structures. Photon counting detectors without electronic noise could provide greater image quality and better diagnostic information.

Introdução: Pacientes com doença renal crônica terminal (DRCT) apresentam elevada prevalência de doença cardiovascular, sendo esta a principal causa de óbitos na população em diálise e após o transplante renal. Entretanto, a doença arterial coronária (DAC) é frequentemente assintomática em pacientes com DRCT e os exames não invasivos apresentam baixa acurácia diagnóstica nesses pacientes em relação à população geral. Objetivos: Determinar a performance diagnóstica da angiotomografia de artérias coronárias combinada à perfusão miocárdica pela tomografia (TC-AP) em pacientes com DRCT. Métodos: Estudo prospectivo, aberto, unicêntrico. Foram incluídos pacientes com DRCT em terapia de substituição renal, candidatos ao transplante renal com mais um fator de risco cardiovascular: idade >= 50 anos, diabetes ou história de doença cardiovascular. Todos os pacientes foram submetidos à coronariografia invasiva (CI) e à TC-AP. A aquisição das imagens tomográficas foi realizada durante estresse com dipiridamol e em repouso. Os resultados obtidos na TC-AP foram comparados aos da CI, considerada o padrão-ouro para diagnóstico de DAC. Foi realizada medida da reserva de fluxo fracionada (FFR) durante a CI em lesões obstrutivas classificadas visualmente como intermediárias. Baseado nos resultados da TC-AP e da CI (±FFR), os pacientes foram classificados como portadores ou não de DAC significativa e a análise foi feita por paciente. Os investigadores responsáveis pela análise da TC-AP não tiveram acesso aos resultados da CI (±FFR). Resultados: Entre julho de 2015 e janeiro de 2018, 64 pacientes (idade média 56,9 ± 9,2 anos; 67,2% do sexo masculino; 85,9% diabéticos) realizaram CI e TC-AP. A prevalência de DAC significativa na CI foi de 34,4%. Na comparação com a CI, os valores de sensibilidade e especificidade, valor preditivo positivo, valor preditivo negativo e a acurácia da TC-AP foram, respectivamente, 95,5%, 88,1%, 80,8%, 97,4% e 90,6%. As razões de verossimilhança positiva e negativa foram de 8,02 e 0,05, respectivamente. Conclusão: Um único exame baseado na tomografia computadorizada, associando angiografia coronária e perfusão miocárdica, apresentou elevada acurácia no diagnóstico de DAC obstrutiva significativa na população com DRCT candidata ao transplante renal. Essa estratégia poderá ser considerada na avaliação de DAC em pacientes com DRCT / Introduction: Patients with end-stage renal disease (ESRD) have a high prevalence of cardiovascular disease, which is the main cause of death in patients on dialysis or after kidney transplantation. However, coronary artery disease (CAD) is often asymptomatic in patients with ESRD, and noninvasive tests have a lower diagnostic accuracy in this scenario when compared to that in the general population. Objective: To determine the diagnostic performance of computed tomography (CT) angiography combined with myocardial perfusion (CT-AP) in the diagnosis of CAD in patients with ESRD. Methods: This was a prospective, single-center study. Patients with ESRD on renal replacement therapy, candidates for kidney transplantation, with at least one additional risk factor for cardiovascular disease (age >= 50 years, diabetes or previous cardiovascular disease) were included. All patients underwent invasive coronary angiography (ICA) and CT-AP. CT image acquisition was performed during dipyridamole-induced stress and at rest. Results of CT-AP were compared to those obtained on ICA, considered the gold standard for diagnosis of CAD. Fractional flow reserve (FFR) was measured during ICA for obstructive lesions visually graded as intermediate. Based on the results of CT-AP and ICA (±FFR), patients were classified as having significant or nonsignificant obstructive CAD, and analyses were performed at the patient level. Investigators responsible for the analysis of CT-AP were blinded to the findings of ICA (±FFR). Results: Between July 2015 and January 2018, 64 patients (mean age 56.9 ± 9.2 years; 67.2% male; 85.9% with diabetes) underwent ICA and CT-AP. Significant CAD was observed in 34.4% of patients on ICA. Compared to ICA, the sensitivity, specificity, positive and negative predictive values, and accuracy of CT-AP were 95.5%, 88.1%, 80.8%, 97.4%, and 90.6%, respectively. Positive and negative likelihood ratios were 8.02 and 0.05, respectively. Conclusion: A single test based on CT angiography and myocardial perfusion had a high accuracy for the diagnosis of significant obstructive CAD in patients with ESRD being evaluated for kidney transplantation. This strategy may be considered in the assessment of CAD in patients with ESRD

Introdução: A doença arterial coronariana (DAC) persiste com alta morbimortalidade. Várias modalidades diagnósticas não-invasivas estão disponíveis para sua avaliação, incluindo escore de cálcio coronariano (EC), angiotomografia coronariana (AngioTC) e tomografia por emissão de pósitrons com rubídio (PET-CT82Rb), com ótimas sensibilidade e especificidade. A integração destes métodos em um exame híbrido permite delinear extensão anatômica e funcional da aterosclerose, possibilitando diagnósticos mais corretos. Objetivo: Avaliar anatomia coronariana e perfusão miocárdica de pacientes suspeitos ou portadores de DAC com tecnologia híbrida (PETCT82Rb e AngioTC/EC), testando a hipótese da maior acurácia do método híbrido em relação aos métodos isolados, correlacionando com desfecho de IAM/óbito cardíaco após 24 meses. Métodos: Foram incluídos 54 pacientes dos ambulatórios de cardiologia do Instituto do Coração (InCor-HCFMUSP), que realizaram estudo híbrido no departamento de Medicina Nuclear do InCor entre maio e outubro de 2013. A carga aterosclerótica coronariana foi contabilizada pelo escore de cálcio; a quantidade de lesões coronarianas, o grau de redução luminal e a composição das placas foram avaliados através da AngioTC; isquemia/fibrose pelo PET-CT82Rb foi contabilizada através do SDS (summed difference score) do estresse e repouso e a reserva de fluxo coronariana (RFC) foi considerada reduzida quando menor que 2mL/min/g. Após 24 meses, foi realizado contato telefônico e avaliação do prontuário dos pacientes, sendo pesquisado infarto agudo do miocárdio/óbito cardíaco como desfecho clínico principal. Resultados: Dentre os participantes, houve predomínio de homens (61,3%), com idade média de 55,5 ± 12,3 anos. A maioria apresentava sobrepeso/obesidade (76%), hipertensão arterial sistêmica (70,4%) e/ou dislipidemia (61,1%). O protocolo durou uma média de 52,2 ± 3,5 min e a dose total média de radiação foi 12,29 ± 2,88 mSv. A média do EC total foi 127,3 ± 249,0, sendo que 24% da amostra possuíam EC maior que 100. Houve predomínio de placas de ateroma mistas (51,3%), com 13% dos pacientes apresentando lesões angiograficamente significativas ( >= 50%). Oito pacientes apresentaram resultado alterado na análise perfusional qualitativa/semiquantitativa (14,8%), metade com isquemia e metade com fibrose. A RFC estava reduzida globalmente em 18,5% dos pacientes e de forma segmentar em 5,6%. Após 24 meses, 9,3% dos pacientes apresentaram infarto, 60% destes fatais. Houve concordância no máximo moderada dos métodos avaliados com a RFC (Kappa = 0,514; p= 0,001). Quanto ao desempenho dos métodos para ocorrência de IAM em 24 meses, foi demonstrada elevada acurácia da RFC para tal finalidade, com AUROC de 0,963 (IC95% 0,912 - 1,000; p= 0,001), com melhor ponto de corte de 1,975 mL/min/g. Não foi identificada alteração na sensibilidade ou no valor preditivo negativo quando a RFC foi agregada aos outros métodos, inclusive houve redução do valor preditivo positivo e da especificidade em relação à RFC isoladamente. Conclusão: O método híbrido não apresentou maior acurácia que a RFC pelo PET-CT82Rb isoladamente na predição de IAM em dois anos de acompanhamento, todavia, a tomografia cardíaca agrega informações importantes capazes de influenciar a conduta clínica nos pacientes não isquêmicos e possivelmente modifica desfechos em médio/longo prazo / Introduction: Coronary artery disease (CAD) persists with high morbidity and mortality. Several non-invasive diagnostic imaging modalities are available for its evaluation, including coronary calcium score (CS), coronary CT angiography (AngioCT) and positron emission tomography with rubidium (82Rb PET-CT), with excellent sensitivity and specificity. The integration of these methods into a hybrid examination allows delineating the anatomical and functional impact of atherosclerosis, enabling more accurate diagnoses. Objective: To evaluate coronary anatomy and myocardial perfusion of patients with suspected or known CAD with hybrid technology (82Rb PET-CT and AngioCT/CS), testing the hypothesis of the greater accuracy of the hybrid method in relation to the isolated methods, correlating with myocardial infarction/cardiac death outcome after 24 months. Methods: Fifty-four consecutive patients referred from the Cardiology outpatient clinics of the Heart Institute (InCor-HCFMUSP) to perform CAD assessment in a hybrid study in the Department of Nuclear Medicine of InCor, between May and October 2013, were enrolled. The coronary atherosclerotic burden was accounted by CS; the amount of coronary lesions, stenosis severity and plaque composition were evaluated through AngioCT; 82Rb PET-CT perfusional analysis was evaluated through the rest and dipyridamole stress summed difference score (SDS) and the coronary flow reserve (CFR) was considered impaired when < 2mL/min/g. After 24 months, the composite outcome of myocardial infarction and cardiac death was evaluated through telephone contact and patient\'s medical records. Results: From the 54 enrolled patients, mean age was 55.5 ± 12.3 years and 61% were male. Most patients presented overwheight/obesity (76%), systemic arterial hypertension (70%) and/or dyslipidemia (61%). The protocol lasted an average of 52.2 ± 3,5 min and mean radiation dose was 12.29 ± 2,88 mSv. The mean total CS was 127.3 ± 249.0, and 24% of the patients were above 100. There was a predominance of patients with mixed atheroma plaques (51.3%) and 13% presented angiographically significant lesions ( >= 50%). Eight patients presented perfusion impairment in the qualitative/semi-quantitative perfusion analysis (14.8%), half with ischemia and half with fibrosis. The CFR was globally reduced in 18.5% of the sample and in a segmental manner in 5.6%. After 24 months of follow-up, 9.3% of the patients had a myocardium infarction, 60% of these were fatal. A maximum of moderate agreement was found between the methods and CFR (Kappa = 0.514, p= 0.001). Regarding the performance of the different methods for predicting infarction in 24 months, CFR reached high accuracy, with AUROC of 0.963 (95% CI 0.912 - 1.0; p= 0.001), with a cutoff point of 1.975 mL/min/g. No variation in neither sensitivity nor negative predictive value was identified when the other methods were added to CFR, instead, there was a reduction in positive predictive value and specificity in relation to unaided CFR. Conclusion: There was no incremental value of the hybrid method when compared to isolated CFR 82Rb PET-CT for the prediction of myocardial infarction in two years follow-up. However, cardiac CT aggregates important information capable of influencing clinical management of nonischemic patients and possibly modifies medium/long-term cardiac outcomes

Introdução: A doença arterial coronariana (DAC) persiste com alta morbimortalidade. Várias modalidades diagnósticas não-invasivas estão disponíveis para sua avaliação, incluindo escore de cálcio coronariano (EC), angiotomografia coronariana (AngioTC) e tomografia por emissão de pósitrons com rubídio (PET-CT82Rb), com ótimas sensibilidade e especificidade. A integração destes métodos em um exame híbrido permite delinear extensão anatômica e funcional da aterosclerose, possibilitando diagnósticos mais corretos. Objetivo: Avaliar anatomia coronariana e perfusão miocárdica de pacientes suspeitos ou portadores de DAC com tecnologia híbrida (PETCT82Rb e AngioTC/EC), testando a hipótese da maior acurácia do método híbrido em relação aos métodos isolados, correlacionando com desfecho de IAM/óbito cardíaco após 24 meses. Métodos: Foram incluídos 54 pacientes dos ambulatórios de cardiologia do Instituto do Coração (InCor-HCFMUSP), que realizaram estudo híbrido no departamento de Medicina Nuclear do InCor entre maio e outubro de 2013. A carga aterosclerótica coronariana foi contabilizada pelo escore de cálcio; a quantidade de lesões coronarianas, o grau de redução luminal e a composição das placas foram avaliados através da AngioTC; isquemia/fibrose pelo PET-CT82Rb foi contabilizada através do SDS (summed difference score) do estresse e repouso e a reserva de fluxo coronariana (RFC) foi considerada reduzida quando menor que 2mL/min/g. Após 24 meses, foi realizado contato telefônico e avaliação do prontuário dos pacientes, sendo pesquisado infarto agudo do miocárdio/óbito cardíaco como desfecho clínico principal. Resultados: Dentre os participantes, houve predomínio de homens (61,3%), com idade média de 55,5 ± 12,3 anos. A maioria apresentava sobrepeso/obesidade (76%), hipertensão arterial sistêmica (70,4%) e/ou dislipidemia (61,1%). O protocolo durou uma média de 52,2 ± 3,5 min e a dose total média de radiação foi 12,29 ± 2,88 mSv. A média do EC total foi 127,3 ± 249,0, sendo que 24% da amostra possuíam EC maior que 100. Houve predomínio de placas de ateroma mistas (51,3%), com 13% dos pacientes apresentando lesões angiograficamente significativas ( >= 50%). Oito pacientes apresentaram resultado alterado na análise perfusional qualitativa/semiquantitativa (14,8%), metade com isquemia e metade com fibrose. A RFC estava reduzida globalmente em 18,5% dos pacientes e de forma segmentar em 5,6%. Após 24 meses, 9,3% dos pacientes apresentaram infarto, 60% destes fatais. Houve concordância no máximo moderada dos métodos avaliados com a RFC (Kappa = 0,514; p= 0,001). Quanto ao desempenho dos métodos para ocorrência de IAM em 24 meses, foi demonstrada elevada acurácia da RFC para tal finalidade, com AUROC de 0,963 (IC95% 0,912 - 1,000; p= 0,001), com melhor ponto de corte de 1,975 mL/min/g. Não foi identificada alteração na sensibilidade ou no valor preditivo negativo quando a RFC foi agregada aos outros métodos, inclusive houve redução do valor preditivo positivo e da especificidade em relação à RFC isoladamente. Conclusão: O método híbrido não apresentou maior acurácia que a RFC pelo PET-CT82Rb isoladamente na predição de IAM em dois anos de acompanhamento, todavia, a tomografia cardíaca agrega informações importantes capazes de influenciar a conduta clínica nos pacientes não isquêmicos e possivelmente modifica desfechos em médio/longo prazo / Introduction: Coronary artery disease (CAD) persists with high morbidity and mortality. Several non-invasive diagnostic imaging modalities are available for its evaluation, including coronary calcium score (CS), coronary CT angiography (AngioCT) and positron emission tomography with rubidium (82Rb PET-CT), with excellent sensitivity and specificity. The integration of these methods into a hybrid examination allows delineating the anatomical and functional impact of atherosclerosis, enabling more accurate diagnoses. Objective: To evaluate coronary anatomy and myocardial perfusion of patients with suspected or known CAD with hybrid technology (82Rb PET-CT and AngioCT/CS), testing the hypothesis of the greater accuracy of the hybrid method in relation to the isolated methods, correlating with myocardial infarction/cardiac death outcome after 24 months. Methods: Fifty-four consecutive patients referred from the Cardiology outpatient clinics of the Heart Institute (InCor-HCFMUSP) to perform CAD assessment in a hybrid study in the Department of Nuclear Medicine of InCor, between May and October 2013, were enrolled. The coronary atherosclerotic burden was accounted by CS; the amount of coronary lesions, stenosis severity and plaque composition were evaluated through AngioCT; 82Rb PET-CT perfusional analysis was evaluated through the rest and dipyridamole stress summed difference score (SDS) and the coronary flow reserve (CFR) was considered impaired when < 2mL/min/g. After 24 months, the composite outcome of myocardial infarction and cardiac death was evaluated through telephone contact and patient\'s medical records. Results: From the 54 enrolled patients, mean age was 55.5 ± 12.3 years and 61% were male. Most patients presented overwheight/obesity (76%), systemic arterial hypertension (70%) and/or dyslipidemia (61%). The protocol lasted an average of 52.2 ± 3,5 min and mean radiation dose was 12.29 ± 2,88 mSv. The mean total CS was 127.3 ± 249.0, and 24% of the patients were above 100. There was a predominance of patients with mixed atheroma plaques (51.3%) and 13% presented angiographically significant lesions ( >= 50%). Eight patients presented perfusion impairment in the qualitative/semi-quantitative perfusion analysis (14.8%), half with ischemia and half with fibrosis. The CFR was globally reduced in 18.5% of the sample and in a segmental manner in 5.6%. After 24 months of follow-up, 9.3% of the patients had a myocardium infarction, 60% of these were fatal. A maximum of moderate agreement was found between the methods and CFR (Kappa = 0.514, p= 0.001). Regarding the performance of the different methods for predicting infarction in 24 months, CFR reached high accuracy, with AUROC of 0.963 (95% CI 0.912 - 1.0; p= 0.001), with a cutoff point of 1.975 mL/min/g. No variation in neither sensitivity nor negative predictive value was identified when the other methods were added to CFR, instead, there was a reduction in positive predictive value and specificity in relation to unaided CFR. Conclusion: There was no incremental value of the hybrid method when compared to isolated CFR 82Rb PET-CT for the prediction of myocardial infarction in two years follow-up. However, cardiac CT aggregates important information capable of influencing clinical management of nonischemic patients and possibly modifies medium/long-term cardiac outcomes

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INTRODUCTION Les anévrismes cérébraux représentent une condition potentiellement mortelle. Ils sont traités par voie chirurgicale (« clipping ») ou endovasculaire (dont le « coiling »), et plusieurs essais cliniques randomisés comparant ces traitements utilisent les résultats angiographiques comme mesure du succès du traitement. Le développement d'une classification standardisée et applicable aux deux traitements et aux trois modalités angiographiques (conventionnelle, angioscan et angio-IRM) est nécessaire. Nos objectifs furent de revoir systématiquement les classifications existantes, d’évaluer la fiabilité inter/intra-observateur d’une nouvelle classification angiographique commune, et d’en vérifier la pertinence clinique. MÉTHODES Deux revues systématiques furent effectuées dans 5 bases de données pour recenser les classifications (et leur fiabilité, lorsque rapportée) pour chaque traitement. Les résultats d’angiographie conventionnelle post-clipping (n=30) ou coiling (n=30) de 60 patients furent évalués de manière indépendante, à l’aide d’une nouvelle classification à 3 catégories, par 19 cliniciens ayant diverses pratiques et expériences. Les observateurs devaient également indiquer la prise en charge clinique appropriée pour chaque cas: un suivi espacé, étroit, ou un retraitement. Quinze lecteurs ont procédé à une 2e évaluation des cas (présentée selon un ordre permuté) à 1 mois d’écart. Le même travail fut reconduit, dans un deuxième temps, par 24 observateurs avec 60 cas évalués par angioscan (n=30) ou angio-IRM (n=30). Les accords inter/intra-observateurs furent estimés avec la statistique Alpha de Krippendorff (aK); la corrélation entre le choix de classe et la prise en charge fut calculée avec un test V de Cramer. RÉSULTATS Soixante-dix classifications (44 post-clipping, 26 post-coiling) furent recensées dans la littérature. La fiabilité variait de 0.12 à 1.00, avec une hétérogénéité significative en termes d’observateurs et de patients. L’accord inter-observateur pour la classification retenue était substantiel pour les résultats d’angiographie conventionnelle (aK=0.76; 0.67–0.83) et des autres modalités (aK=0.63; 0.55–0.70); peu importe le traitement, la spécialité ou l’expérience des évaluateurs. La classe est fortement corrélée à la prise en charge (V de Cramer de 0,77 à 0,80 selon la modalité angiographique; p<0,001). CONCLUSION La classification proposée est fiable et pertinente cliniquement. Elle servira d’outil valide pour évaluer les résultats angiographiques d’anévrismes dans les futurs essais cliniques comparant les deux traitements, peu importe la modalité d’imagerie utilisée. / INTRODUCTION Intracranial aneurysms are a medical condition associated with serious morbidity and mortality when ruptured. They are mainly treated with surgical clipping or endovascular coiling, and randomized clinical trials comparing both treatments often use angiographic results as a surrogate outcome of treatment success. The development of a standardized, reliable method to report angiographic results, applicable to both treatments using any angiographic modality (Conventional [CA], Computed tomography [CTA], or magnetic resonance [MRA] angiography) is needed. We sought to systematically review existing methods of classifying treated aneurysms and to assess the inter-/intra-rater reliability of a new angiographic grading scale, as well as its clinical relevance. METHODS We conducted two separate systematic reviews in 5 databases to collect post-clipping and post-coiling grading scales, along with their reliability when reported. The CA of 60 cases of clipped (n=30) and coiled (n=30) aneurysms were independently evaluated by 19 raters of various backgrounds and experiences using a new 3-grade scale. Raters were also asked how they would manage each case (delayed, close follow-up, or retreatment). Fifteen raters performed a 2nd evaluation of the same cases (in a permuted order) at least one month apart. The same methodology was used to study the reliability of the scale when 60 noninvasive angiography cases of clipped (30 CTA) or coiled (30 MRA) aneurysms were evaluated by 24 raters. Inter and intra-rater agreements were assessed using Krippendorff’s Alpha statistics (aK), and the relationship between occlusion grade and clinical management using Cramer’s V test. RESULTS The systematic reviews found 70 grading scales (44 post-clipping, 26 post-coiling) with significant heterogeneity in terms of reliability (kappa values from 0.12 to 1.00), raters, and patients. Overall inter-rater agreement for the grading scale was substantial for CA results (aK=0.76; 0.67–0.83) as well as for noninvasive results (aK=0.63; 0.55–0.70); regardless of background, experience, or treatment used. A strong relationship was found between angiographic grades and management decisions (V=0.80±0.12 for CA; V=0.77±0.14 for CTA/MRA [p<0.001]). CONCLUSION A standardized 3-grade scale was found to be a reliable and clinically meaningful tool to compare the results of clipping and coiling of aneurysms using any angiographic modality. It could be used as a valid tool to adjudicate results of comparative randomized trials, and to standardize the reporting of aneurysm treatments.