Scottish branch meeting: recent advances in diagnostic imaging

Recent advances in diagnostic imaging Meeting organised by the Scottish Branch of The British Institute of Radiology Friday 14 February 2014 Royal College of Physicians and Surgeons of Glasgow 08:30

Registration, tea and coffee

Chair

Dr Khalid Ali, Meeting Organiser, BIR Scottish Branch

09:00

Interventional radiology – a completely different animal!

Professor Jon Moss, Consultant Interventional Radiologist, Gartnavel General Hospital

09:40

Update in cardiac CT Dr Ross MacDuff, Consultant Radiologist, Glasgow Royal Infirmary

10:20

Update in thoracic imaging Dr John Reid, Consultant Radiologist, Borders General Hospital

Incorporated by Royal Charter Patron - Her Majesty The Queen

President Prof Andrew Jones BSc MSc FIPEM CSci FBIR Chief Executive Ms Jacqueline Fowler BA, MInstF(Cert)

The British Institute of Radiology 48-50 St John Street London EC2M 4DG

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11:00

Future directions of the BIR and the implications for education Professor Andrew Jones, President, BIR

11:10

Refreshments

11:30

Glasgow oxygen level dependent (GOLD) technology: Novel metabolic MRI techniques to identify the penumbra Dr Celestine Santosh, Consultant Neuroradiologist, Institute of Neurological Sciences

12:10

Brain imaging in cognitive impairment and dementia what, when and how?

Professor Alison Murray, Professor of Radiology, University of Aberdeen

12:50

Lunch

13:50

Update in GI imaging Dr Peter MacLean, Consultant Radiologist, Western General Hospital

14:30

Selected applications of SPECT-CT Dr Dilip Patel, Consultant Radiologist, Royal Infirmary of

Edinburgh 15:10

Refreshments

15:40

Imaging of groin pain: Inguinal disruption Dr Scott McKie, Consultant MSK Radiologist, Royal Infirmary of Edinburgh

16:20

Stiffness and slices: the new tools in breast imaging Professor Andrew Evans, Professor of Breast Imaging,

e

University of Dundee Honorary Consultant Radiologist, NHS Tayside 17:00

Close of meeting

CPD: 6 credits Please complete the meeting evaluation survey online at: https://www.surveymonkey.com/s/Recent_advances We will email your CPD certificate upon collation of your feedback.

We are most grateful to

For supporting this conference

Speaker profiles and abstracts (where supplied) Abstract Professor Jon Moss, Consultant Interventional Radiologist, Gartnavel General Hospital Interventional radiology – a completely different animal!

Medicine continues to superspecialise and radiology is no exception. A major split is occurring between diagnostic and interventional radiology with IR now having subspecialty status in the U.K. and several other countries. The waters are murky however with little clear guidance for trainees and many deciding to stick with diagnostic radiology. From a strategic high point some years ago IR now faces a less certain path with inadequate training numbers, unfilled consultant posts and other specialities looking to take advantage of this situation. This is all happening at a time when the number of IR techniques and the evidence base for their use has never been higher.

Biography Dr Ross MacDuff, Consultant Radiologist, Glasgow Royal Infirmary Having trained in the West of Scotland I took up a Consultant post at Glasgow Royal Infirmary and Stobhill Hospital in 2010. I have a subspecialist interest in cardiothoracic imaging including cardiac CT and MRI. Abstract Update in cardiac CT Over the past decade technological advances in CT have allowed rapid development in CT imaging of the heart. CT coronary angiography has become a recognised and validated technique in the assessment of coronary artery disease. The role of CTCA is expanding and more patient subgroups are being investigated with this technique. Its use in emergency departments is expanding and has been suggested to allow rapid discharge and significant cost savings. In this talk we will review the current indications for CT coronary angiography and look at potential developments in cardiac CT.

Educational aims: 

To review current indications for cardiac CT



Assess the utility of triple rule out scanning



Introduce the role of CT myocardial perfusion

Biography Dr John Reid, Consultant Radiologist, Borders General Hospital Consultant Radiologist at Borders General Hospital from 1996 to present.

Formerly Consultant Cardiothoracic Radiologist at Edinburgh Royal Infirmary from 1986-1996.

I was a Nycomed Scholar studying cardiac imaging and cardiac intervention in Stockholm and Oslo in 1986.

Clinical Tutor at Edinburgh University 1986-present.

I have an interest in all aspects of cardiothoracic imaging and in all modalities from thoracic CT to cardiac MRI. My main sphere of expertise is in the diagnosis of thromboembolic disease and lung cancer. I have co-authored the British Thoracic Society guidelines on the diagnosis and management of pulmonary embolism and chaired the United Nations Atomic Energy Experts Group on the utility of scintigraphy for the diagnosis of PE. I was a contributor to the SIGN guideline on the diagnosis and management of lung cancer.

Abstract Update in thoracic imaging Today’s presentation will provide an update on selected topics in thoracic imaging.

These will include a review of the current thinking on the diagnosis and follow up of pulmonary embolism. Recent improvements in CT technology have created a wealth of new data concerning this common condition. Particular reference will be paid to the place of CT perfusion imaging.

Idiopathic interstitial pneumonias confuse everyone. The America Thoracic Society and the European Respiratory have just issued guidance on the classification of this group of conditions and I shall review what this new guidance means for thoracic radiologists and give a brief overview of the radiological features of IIPs. Next up: pulmonary nodules. This vexed issue is becoming even more important with the rising tide of thoracic CT and I shall review the current thinking on nodule follow up.

With pulmonary nodules in mind, I shall conclude my presentation with a review of the worrying rise of litigation against radiologists. This will have an emphasis on thoracic imaging and the phenomenon known as hindsight bias.

Update of classification of IIPs Am J Crit Care Med 2013,188:733-48 Missed Lung Cancer on Chest Radiography and Computed Tomography Fardanesh M, White C. Seminars in Ultrasound, CT and MRI 2012, 33:280-7 Hindsight bias. Roese, N. J., & Vohs, K. D. 2012. Perspectives on Psychological Science, 7:411-26

Biography Dr Celestine Santosh, Consultant Neuroradiologist, Institute of Neurological Sciences I graduated in Medicine in 1982 and have been working in Neuroradiology since 1987. I am currently a Consultant Neuroradiologist at the Institute of Neurological Sciences in Glasgow. I also have an Honorary appointment as a Clinical Associate Professor, College of Medical, Veterinary and Life Sciences, University of Glasgow.

I have been working with the animal 7.1 MRI scanner since 2004. I have been the lead in developing novel metabolic MRI techniques using perflourocarbons to visualize the penumbra in stroke, now know as Glasgow Oxygen Level Dependent (GOLD) techniques. Some of this work has been recognised by the scientific community having received the Astra-Zeneca prize at the ISMRM British Chapter in 2008, the Integrated Mammalian Biology Poster Prize in 2009 and the Scottish Life Sciences Awards 2013 for the best innovation originating within NHS Scotland. We

also had the privilege of being invited to present this work at the 2012 Gordon Conference on Brain.

Discosure: I am a founding member and the Chief Medical Officer for Aurum Biosciences Limited, which is a spinout company to take GOLD into clinical practice.

Abstract

Glasgow oxygen level dependent (GOLD) technology: Novel metabolic MRI techniques to identify the penumbra One in six people have a stroke in their lifetime. Actilyse, (aka rt-PA & only licensed therapy for acute stroke), is a thrombolytic with a 4.5hrs from onset treatment window. However, <7% of patients receive Actilyse. Inability to characterise individual pathophysiology with imaging excludes many patients from treatment: 75% on time criteria.

Existing brain scanning methods are impractical for urgent clinical use or give no information about the affected brain ability to use oxygen, the critical indicator of whether it will survive. Glasgow Oxygen Level Dependent (GOLD) techniques comprises an intravenous perflurocarbon (PFC) oxygen carrier, increased inspired oxygen and three novel MRI techniques to identify the penumbra. The PFC also protects the penumbra.

Technique 1: Is based on Blood Oxygen Level Dependent (BOLD) T2* signal. The penumbra can be defined by a T2* oxygen challenge (OC) imaging, by an increased oxygen extraction fractions (OEF) and oxygen utilisation (Santosh et al, 2008).

Technique 2: Lactate change imaging, detects changes in lactate co-incident with increased oxygen delivery during an oxygen challenge (OC) to identify the penumbra (Holmes et al, 2012). This technique is able to identify hypoxic tissues with anaerobic metabolism but still have potential for aerobic metabolism and survival, ie the penumbra.

Technique 3: With this technique the penumbra is identified during the injection of PFC, hyperoxia and a T2* sequence. This is identified as a sharp dip and occurs only in the penumbra and it is due to repolarisation, which follows a peri-infarct depolarisation wave.

Biography Professor Alison Murray, Professor of Radiology, University of Aberdeen Alison Murray is the Roland Sutton Professor of Radiology at the University of Aberdeen. She is Director of the Aberdeen Biomedical Imaging Centre www.abdn.ac.uk/ims/research/abic, Lilian Sutton Building, University of Aberdeen, Foresterhill Health Campus. This houses the Philips 3T research magnetic resonance imaging (MRI) scanner. Research MRI facilities are located within the acute NHS hospital and are immediately adjacent to the John Mallard Positron Emission Tomography (PET) Centre and the NHS Department of Nuclear Medicine, facilitating combined studies of brain structure and function. She leads clinical brain imaging research in structural and functional imaging correlates of cognitive ageing and dementia and work includes MRI in the Aberdeen 1936 Birth Cohort, and MRI, regional cerebral blood flow SPECT and FDG PET in clinical trials of novel Tau Aggregation Inhibitor therapies in Alzheimer's disease. Particular interests are the relative contributions of vascular risk factors and subclinical Alzheimer's disease to cognitive ageing and contributors to cognitive reserve and resilience to dementia.

She is also involved in brain imaging research in other diseases, including CNS correlates of fatigue in chronic inflammatory diseases and satiety in type 2 diabetes, using quantitative assessment of disease burden, brain volumes and function.

She has extensive NHS experience of brain imaging in dementia, being responsible for most NHS referrals for structural and molecular brain imaging including CT, regional cerebral blood flow SPECT CT and FP-CIT studies.

She is a founding member and executive member of the Scottish Imaging Network: A Platform for Scientific Excellence (SINAPSE) www.sinapse.ac.uk a successful brain imaging pooling initiative funded by the Scottish Funding Council and participating universities to develop state of the art brain imaging research training and resources across Scotland.

Abstract Brain imaging in cognitive impairment and dementia - what, when and how?

This presentation will review evidence for brain imaging in cognitive impairment and dementia, referring to research results, current evidence and national and international guidelines. The aim is to update participants with new information and

to give a pragmatic overview of whether brain imaging is appropriate in patients with dementia, if so, when brain imaging should be used and what is practical in a cost constrained NHS. Three main learning points will be made initially: 

Most dementia related neuropathology is mixed



Most evidence ignores baseline



Currently we cannot diagnose dementia on a scan – even a PET scan!

Following a rapid review of the results of brain imaging research in the Aberdeen Birth Cohorts, a description of cognitive reserve and how this is crucial to understand in cognitive ageing and dementia research, what we can and cannot tell from routine brain images and recent drug development in Alzheimer’s disease, the presentation will conclude with examples of where brain imaging is useful in dementia and neurodegenerative diseases and with three more learning points: 

Imaging increases diagnostic accuracy



In future role of imaging is likely to be validation of cheaper tests



If we could “bottle” cognitive reserve it would have as much impact as an effective new drug

Biography Dr Peter MacLean, Consultant Radiologist, Western General Hospital Having trained as a Radiologist in Glasgow, I was appointed a Consultant in Edinburgh in 2007. As a major cancer centre, approximately 50% of my workload is related to oncology, particularly in the abdomen and pelvis. I have a major interest in imaging of the small bowel and colon, especially with MR and CT.

Abstract

Update in GI imaging Scotland has a very high incidence of early onset disease.

Faecal Calprotectin (FC) now used routinely in specialist centres to stratify risk, monitor response.

MR perfectly placed to image this group – often young and requiring repeated imaging studies with extra-intestinal manifestations and complications.

Technique overview with brief discussion on IV contrast, DWI, motility studies.

Important signs: mural thickening with stricture, mural oedema and contrast enhancement.

Recent work on correlating ileal disease with FC shows positive results.

SIGGAR Trial •

Largest randomised controlled trial of CT colon (CTC) vs optical colonoscopy (OC) and Ba enema in symptomatic patients in the diagnosis of colonic carcinoma.

•

Unique study design with 2 arms.

•

CTC much more sensitive than BaE.

•

CTC comparable to OC.

•

Increased rates of further colonic investigation and apparent drawback of CTC.

Biography Dr Dilip Patel, Consultant Radiologist, Royal Infirmary of Edinburgh Dilip Patel has been a Consultant Radiologist at the Royal Infirmary of Edinburgh for the past 15 years and is responsible for the Radionuclide Imaging service at that hospital.

He is Lead Radiologist for the NHS Lothian PET/CT service.

His clinical interests include Upper GI, hepatobiliary, transplant and endocrine imaging.

Abstract

Selected applications of SPECT-CT Whilst nuclear medicine imaging techniques provide functional information, historically this has been at the expense of low anatomical resolution making the imaging difficult to interpret and utilise for clinicians and non nuclear medicine radiologists.

The development of high resolution gamma cameras latterly combined with MDCT scanners has allowed integrated image fusion thus combining the unique functional information obtained by nuclear medicine with the high resolution anatomical information derived from CT. The aim of this presentation is to outline the technique and some of the practical applications in current clinical use.

Biography Dr Scott McKie, Consultant MSK Radiologist, Royal Infirmary of Edinburgh I a Consultant MSK Radiologist in the Royal Infirmary of Edinburgh (3 years), and prior to this a consultant in NHS Fife (6 years). Radiology trained in Edinburgh and MSK fellowship in Leeds. Initially embarked on orthopaedic surgical career before seeing the light. I have a special interest in sports injuries, imaging of the groin and MSK intervention. Member of British Skeletal Society and Royal College of Physicians and Surgeons of Glasgow.

Abstract Imaging of groin pain: Inguinal disruption Imaging of the groin in the sportsperson is difficult due to the complex anatomy, with many important structures converging on a very small area which often has preexisting abnormalities. This is compounded by the fact that the nomenclature has been confusing and contradictory. In January 2014 a consensus was published by the British Hernia Society retiring the diagnosis of "sportsman's hernia" and instead advising the term "inguinal disruption- ID", referring to the specific diagnosis of external ring dilatation, conjoint tendon damage, and tears of the inguinal ligament.

This presentation will explain the imaging features of ID on MRI and Ultrasound, and pictorially review the other potential causes of groin pain in the sportsperson including osteitis pubis, rectus/adductor tendinosis, stress injuries, ischiofemoral impingement, true hernias, neural impingement, and referred pain.

In addition there will be a brief outline of the different surgical options and radiological interventional procedures, although the use of these techniques remains contentious and controversial.

Biography Professor Andrew Evans, Professor of Breast Imaging, University of Dundee Honorary Consultant Radiologist, NHS Tayside Andy Evans is a graduate of Birmingham Medical School and after gaining his MRCP trained in Diagnostic Radiology in Nottingham gaining the FRCR. He became a Consultant Radiologist with a special interest in breast imaging in 1992. He was appointed Director of the Nottingham International Breast Education Centre in 2006.

In 2009 Andy moved to Dundee to become Professor of Breast Imaging. He is the author of over 120 peer reviewed papers, 4 books and 14 book chapters. He is the current chairman of the British Society of Breast Radiology. Andy plays the french horn and is a successful composer of classical music.

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Optimisation in CT 18 June 2014 Edinburgh

IRMER update 29 September 2014 London

VISIT: WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER!

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