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Journal of Cardiovascular Computed Tomography (2012) 6, 232245

Review Article

Learning to interpret the extracardiac ndings on coronary CT angiography examinations


Shawn D. Teague, MDa,*, Stacy Rissing, MDa, Jothiharan Mahenthiran, MD, FACCb, Stephan Achenbach, MDc
a b

Department of Radiology, Indiana University, 550 N University Blvd, Rm 0279, Indianapolis, IN 46202, USA; Community Heart and Vascular, Indianapolis, IN, USA and cGiessen University Department of Cardiology, Giessen, Germany KEYWORDS:
Computed tomography; Coronary computed tomography; Coronary CT angiography; Extracardiac; Incidental ndings Abstract. Coronary computed tomography angiography (CTA) plays an important role in the identication of coronary artery disease in low- to intermediate-risk patients. Even with a restrictive eld of view, coronary CTA data sets will include visualization of structures adjacent to the heart, including the thoracic great vessels, pericardium, mediastinum, lungs, and bones. CT images enable detailed assessment of these structures, at times identifying a potential noncoronary cause of the patients presenting symptom. The reported incidence of extracardiac ndings on coronary CTA is as high as 53%67%. Complete evaluation of the examination requires scrutiny of the soft tissues, lung tissues, and bones, both in the chest and adjacent abdomen. It is important to adjust the CT window display settings at various stages of the interpretation process to evaluate all potential extracardiac disease. Although in-depth radiology training would be required to correctly identify and interpret all anomalies, this article serves as an overview and guide to evaluation of the extracardiac structures included on a coronary CTA examination. Correct interpretation of extracardiac ndings is critical because a false positive interpretation can lead to unnecessary testing and treatment that can be as harmful as a false negative interpretation. Most importantly, if the cardiac ndings do not explain the patients symptoms, an alternative cause should be specically sought to appropriately manage the patient. 2012 Society of Cardiovascular Computed Tomography. All rights reserved.

Introduction
Coronary computed tomography angiography (CTA) plays an important role in the identication of coronary artery disease in low- to intermediate-risk patients. Even
Conict of interest: The authors report no conicts of interest. * Corresponding author. E-mail address: sdteague@iupui.edu Submitted October 23, 2011. Accepted for publication February 27, 2012.

with a restrictive eld of view, coronary CTA data sets will include visualization of structures adjacent to the heart, including the thoracic great vessels, pericardium, mediastinum, lungs, and bones. The high-resolution CT images enable detailed assessment of these structures, at times identifying a potential noncoronary cause of the patients presenting symptom. The reported incidence of extracardiac ndings on coronary CTA is as high as 53%67%.16 Approximately 4%25% of these noncardiac ndings are considered potentially signicant and may require followup or additional investigation. Another 5%11% of these

1934-5925/$ - see front matter 2012 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2012.02.007

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ndings are considered critical ndings and require immediate evaluation or intervention.15 Furthermore, the gated images of coronary CTA reduce motion artifact and allow assessment of dynamic pathology with a greater accuracy. Current literature suggests that noncalcied pulmonary nodules (1%24%) are the most common extracardiac nding.35 Other common ndings included liver cysts, calcied pulmonary nodules, mediastinal lymphadenopathy, and hiatal hernia.18 Some important extracardiac ndings such as pneumonia, pneumothorax, gallstones, hiatal hernia, and aortic aneurysm had an effect on subsequent management of these patients.35

Extra-cardiac reading method


Windowing and leveling
For evaluation of the extracardiac structures, custom window settings are used to optimize visualization of the different body tissues. The most commonly used window settings are soft tissue, lung, and bone windows. Specic values for the center and width of these windows are set, based on Hounseld units. Soft tissue windows (Fig. 1A), used for evaluation of the mediastinum and upper abdomen, have a center of 50 and a width of 350. Lung windows (Fig. 1B), set for evaluation of the pulmonary parenchyma, have a center of 2500 and a width of 1800. Bone windows (Fig. 1C), used for evaluation of the bony structures, have a center of 500 and a width of 2000. Any pixels with a Hounseld unit above the upper limits of the width will be white, and pixels with a Hounseld unit below the lower limits of the width will be black. Values within the window width will be visualized as a shade of gray relative to the Hounseld unit. One additional window that can be helpful in cardiac CT examinations is the vascular window (Fig. 1D), used for evaluating the coronary arteries as well as other vascular structures. The center and width for evaluating vessels depend somewhat on the degree of vascular enhancement; however, suggested settings are a center of 100 and a width of 900. There are additional specialized windows for use with the liver and kidneys, but these topics are beyond the scope of the basics covered in this review.

Scope of need for training


The potential clinical signicance of these incidental ndings necessitates readers of coronary CTA to recognize and interpret important extracardiac ndings. Radiology training routinely incorporates cross-sectional imaging and review of all extracardiac structures systematically on a CT examination. Currently, many cardiologists are trained to read coronary CTA with limited emphasis on recognition or interpretation of extracardiac ndings. Because studies are often ordered for the evaluation of acute chest pain, cardiologists are increasingly expected to identify and diagnose noncardiac causes of chest pain. At present, there are various published training requirements that qualify readers to independently interpret extracardiac ndings on a coronary CTA examination. The American College of Radiology Practice Guidelines on performing and interpreting cardiac CT state that a reader must complete 200 hours of Category I continuing medical education (CME) in CT and interpret and report 500 CT cases under supervision and complete R30 hours of Category I CME in cardiac imaging.9 The 2008 revision of the cardiology fellowship training guidelines recommends review of 150 cardiac CT cases for incidental ndings and a review of a dedicated teaching le of 25 cardiac CT cases that feature the presence of signicant noncardiac pathology.10 This experience is designed to serve as an introduction to recognition of these extracardiac ndings but cannot provide expertise in the full spectrum of pathology found in the thorax and upper abdomen included in the scan. Current opinions are diverse for the need and the scope of expertise required for evaluation of extracardiac ndings.5,8,11 There are several models of shared versus single trained reader paradigms to accomplish comprehensive assessment of this issue. Regardless, recognition of extracardiac ndings on a coronary CTA remains important and crucial to patient care. It requires dedicated additional training and interpretation skills by the reader(s). This article outlines a systematic approach to interpretation of common extracardiac ndings. Examples are provided and may serve as a tool to improve identication and interpretation of extracardiac ndings on a coronary CTA examination.

Planes
Most disease pathology is best evaluated with an axial plane of cross-sectional imaging. This is the primary plane in which CT images are acquired and displayed for interpretation. With the advent of faster computers, images are often reconstructed into coronal (Fig. 2A) and sagittal (Fig. 2B) planes as well. These additional planes can highlight specic disease pathology or anatomical ndings. For example, the sagittal plane is helpful when evaluating the spine for disease. The coronal images often best display the anatomy of the tracheobronchial tree. Coronal images can also be useful when evaluating pulmonary pathology, such as the anatomic lobe and segment of a lung nodule or area of consolidation.

Field of view
Although the craniocaudal dimensions of a cardiac CT scan are limited, the entire thorax, from chest wall to chest wall, is exposed to radiation. To improve spatial resolution of the inherently small coronary arteries on a coronary CT angiogram, the nal images for coronary evaluation usually exclude the chest wall and a portion of the lungs. However, images can be reconstructed to show the entire cross-section

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Figure 1 (A) Soft tissue window image with center of 50 and width of 350 allows for optimal evaluation of the chest and upper abdominal soft tissues. This axial image shows normal mediastinal and chest wall structures. However, this window should be used to look for lymphadenopathy, thyroid nodules, and subcutaneous nodules among other soft tissue disease. (B) Lung window image with center of 2500 and width of 1800 allows for optimal evaluation of the lung parenchyma. This image shows normal lung parenchyma. However, this window should be used to look for pulmonary nodules and masses, infection, and emphysema among other lung parenchymal diseases. (C) Bone window image with center of 500 and width of 2000 allows for optimal evaluation of the bony thorax. This image shows normal bony structures. However, this window should be used to look for degenerative changes of the spine, rib, or vertebral compression fractures, and suspicious lytic or sclerotic bone lesions among other bone diseases. (D) Vascular window image with center of 100 and width of 900 allows for optimal evaluation of the chest vasculature. This image shows the normal appearance of the vessels. However, this widow should be used to look for aortic aneurysm, aortic dissection, and pulmonary embolus among other vascular diseases.

Figure 2 The coronal plane divides anterior from posterior. (A) This image shows the utility of the coronal plane for evaluation of tracheobronchial anatomy. (B) This image shows the anatomic location of a right middle lobe nodule (arrow) on a coronal image. (C) The sagittal plane divides right from left and shows the utility of the sagittal plane for evaluation of the thoracic spine. (D) This image shows the anatomic location of the same right middle lobe nodule (arrow) as in panel B, highlighting the appearance of the lung ssures on the sagittal plane.

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Figure 3 (A) Axial image (soft tissue window) shows a densely calcied subcarinal lymph node (arrow), consistent with old granulomatous infection, probably histoplasmosis. (B) Axial image shows a small, slightly eccentric calcication (arrow) within an enlarged noncalcied subcarinal lymph node. This small amount of calcication is not enough to ensure a benign cause, and, given the large size of the lymph node, further evaluation or follow-up imaging is suggested. (C) Axial image (soft tissue window) shows a 1.3-cm short-axis paratracheal lymph node. This lymph node contains a low-density fatty hilum (arrow), characteristic of a benign lymph node. (D) Axial image shows an enlarged subcarinal lymph node (arrow), and (E) axial image in shows an enlarged left hilar lymph node (arrow). These lymph nodes show heterogeneous enhancement and lack calcication. The appearance raises concern for malignant lymphadenopathy, and further evaluation is necessary.

of the chest at any scan level. The diameter of the displayed image (eld of view) is usually around 250280 mm for a cardiac CT study. This diameter is large enough to show the entire heart but limited for optimal spatial resolution of the coronary arteries. A eld of view smaller than 250 mm may

exclude vital structures from visualization and often only results in magnication of the image without improved spatial resolution. Regardless of the eld of view used, it is important to evaluate all the additional structures that are included within the chosen eld of view.

Figure 4 (A) Axial image (soft tissue window) shows a large hypodense nodule in the left thyroid lobe (arrow). The borders of the lesion are irregular, and further evaluation with thyroid ultrasound scanning is recommended. (B) This axial image shows an enlarged, heterogeneous thyroid gland (arrow), which results in rightward tracheal deviation and lateral displacement of the great vessels. The appearance is classic for thyroid goiter.

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Figure 5 (A) Axial image (vascular window) shows a dilated main pulmonary artery (arrow) that measures 4.5 cm in diameter. Pulmonary artery dilatation should raise the possibility of pulmonary artery hypertension, especially in patients with underlying lung disease. (B) This image shows an enhancing tubular structure that courses to the left of the aortic arch, consistent with a left superior vena cava (SVC). (C) This image is more inferior and shows the left SVC located along the left aspect of the left atrium. The left SVC in this case eventually drains into the coronary sinus. (D) The coronal image shows the left SVC along the left upper mediastinum. There is no typical right SVC in this example. (EG) These images show partial anomalous pulmonary venous return (PAPVR) with drainage of the left upper lobe pulmonary veins into the left innominate vein via a vertical vein. (E) This image shows an enhancing vascular structure along the left mediastinum (arrow), similar to the appearance of a left SVC. In the case of left PAPVR, however, the branching left upper lobe pulmonary veins can be seen draining into the vertical vein. (F) This image shows the vertical vein (arrow) draining into the left innominate vein. (G) Coronal image shows the left upper lobe pulmonary veins draining into the vertical vein (arrow), with ow directed toward the left innominate vein. (H and I) These images show anomalous drainage of the right upper lobe pulmonary veins into the SVC. (H) The arrow indicates the anomalous right upper lobe pulmonary vein. (I) The arrow indicates the SVC. This patient also had a sinus venous atrial septal defect accounting for the large right atrium.

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Figure 5 (Continued). (J) Axial image shows a dilated ascending thoracic aorta, measuring up to 4.9 x 5.0 cm in diameter. For the ascending aorta, diameter . 4.0 cm is considered dilated or ectatic, and diameter . 4.5 cm is considered aneurysmal. The presence of an ascending thoracic aortic aneurysm should be noted in this case, and follow-up imaging should be obtained to evaluate for interval increase in aortic dimensions. Axial images show the intimal ap of an aortic dissection (arrow) at the level of the arch (K) and lower descending thoracic aorta (L). The intimal ap separates the true lumen (white arrow) from the false lumen (black arrow). A small amount of intramural hematoma is seen at the level of the lower descending thoracic aorta. (M) Axial image shows atherosclerosis (arrow) of the aorta with a large noncalcied plaque along the left lateral aspect. There is likely a component of thrombus associated with the plaque, given the signicant asymmetry. Less severe disease can also be noted in the ascending aorta, including a small amount of calcied plaque (black arrow). (N) Axial image shows a penetrating ulcer (arrow) extending into the wall of the descending aorta. (O) Axial image at the level of the aortic arch shows extensive soft tissue thickening (arrows) surrounding the opacied aortic lumen. This is the typical appearance of aortitis which is Takayasu aoritis in this patient.

Approach to reading the extracardiac portion of the examination


Soft tissue windows (CT settings: center 50 and width 350)
Lymph nodes Given the limited eld of view of cardiac CT, the primary lymph nodes to evaluate are located in the mediastinum and hilum. Two important features to consider when a lymph node is identied are density and size. The size of a lymph node is important. For CT studies, the lymph node short-axis size that raises concern is R1 cm. Once the lymph node reaches 1 cm in short-axis dimension, it is considered enlarged and may be pathologic (Fig. 3).4 The lymph node could be reactive to an infectious/inammatory process or, more importantly, secondary to neoplasm. If the enlarged lymph node is likely reactive with secondary signs of infection such as

pneumonia, then the likely benign nature of the lymph node can be suggested. If the lymph node is enlarged without secondary ndings to suggest the underlying cause, then neoplasm must be considered and follow-up and/or biopsy should be pursued. Lymph nodes with high density often contain calcication and reect a benign process. For example, if there is central or diffuse calcication, the lymph node is likely secondary to a benign process such as prior tuberculosis, sarcoidosis, silicosis, or histoplasmosis (Fig. 3A). Although a peripheral egg-shell pattern of calcication is most likely secondary to silicosis, this pattern can sometimes be seen with longstanding sarcoidosis. Not all calcied lymph nodes are benign; thus, the pattern of calcication is important. Specically, if the calcication within a lymph node is small and eccentric in location, then the lymph node cannot be dismissed as benign (Fig. 3B). The size and other features of the lymph node must be evaluated to determine whether there is concern for neoplasm. Consultation with a radiologist is recommended. Lymph nodes with low density

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Journal of Cardiovascular Computed Tomography, Vol 6, No 4, July/August 2012 the aortic diameter increases and then decreases again, this indicates ectasia or aneurysm, depending on the measured diameter. Examination of the aorta for dissection or intramural hematoma is also important, especially when the study is obtained in the setting of acute chest pain (Fig. 5K-L). If there is clinical concern for dissection or intramural hematoma, a noncontrast study should be performed rst to evaluate for hyperdense acute blood within the wall of the aorta and/or the presence of a thrombosed lumen. Another common aortic disease is atherosclerosis (Fig. 5M), usually seen as a combination of calcied and noncalcied (low-density) plaque along the periphery of the aorta. In areas with a large amount of plaque, a thrombus can form and potentially embolize peripherally. Penetrating ulcers can also develop in the setting of atherosclerotic disease (Fig. 5N). This process occurs when an atherosclerotic plaque ulcerates, disrupts the intima, and extends into the media of the aortic wall. Penetrating ulcer, especially at the level of the mid descending thoracic aorta, can result in intramural hematoma or even aortic dissection. Aortitis is less common than atherosclerotic disease, but it should be considered when ndings of diffuse wall thickening, stenosis, occlusion, or even dilatation of the aorta are present. Takayasu arteritis is the most common aortitis and typically show wall thickening at the aortic arch along with stenosis at the descending thoracic or abdominal aorta (Fig. 5O). Solid organs of the upper abdomen Usually only a limited portion of the upper abdomen is visualized on a cardiac CT. Portions of the liver, spleen, adrenal glands, and bowel are often included within the eld of view. The superior aspect of the kidneys and pancreas may also be visualized. Most important during evaluation of the upper abdomen is exclusion of a solidorgan mass lesion (Fig. 6A). Liver and renal cysts are common benign lesions encountered when evaluating the upper abdomen (Fig. 6B-C). Cysts appear as smooth, round, low-density lesions. The Hounseld unit of a cyst should be near zero, indicating the presence of water-like uid. The hemangioma is another common benign lesion found in the liver. Hepatic hemangioma is a highly vascular lesion showing a characteristic early peripheral nodular pattern of enhancement, often termed peripheral puddling (Fig. 6D). Adrenal disease is also relatively common, especially the adrenal adenoma. This diagnosis can be made when an adrenal nodule is of low attenuation, measuring ,10 HU (Fig. 6E). Such a low Hounseld value is usually only seen on a noncontrast study, and the adrenal adenoma can show variable enhancement (4050 HU) on a contrast-enhanced examination. It is important to realize that the evaluation of the solid abdominal organs can be limited because of the early phase of contrast present during the cardiac scan.

often contain fat. If there is a large fatty hilum in the lymph node, ndings are consistent with a benign lymph node, even if it is enlarged by size criteria (Fig. 3C). Thyroid The thyroid gland is not routinely included within the eld of view during cardiac CT imaging. In the case of coronary artery bypass graft and evaluation for graft patency, however, more superior images are obtained, and the thyroid may be visualized. Heterogeneous enhancement of the thyroid may indicate the presence of a thyroid nodule (Fig. 4A). Concern for thyroid nodule can be mentioned, and dedicated thyroid ultrasound scanning can be recommended for further evaluation. A thyroid gland that is diffusely enlarged and heterogeneous may indicate thyroid goiter. A large thyroid goiter can extend into the mediastinum, displacing the trachea and great vessels (Fig. 4B). Thyroid goiter is most common in elderly women. Characteristic ndings of thyroid goiter usually do not require additional imaging evaluation. Great vessels The pulmonary artery is often included within the eld of view in a coronary CT study. The most important feature to evaluate for the pulmonary artery is the size. The diameter of the main pulmonary artery should not be .3 cm. If the diameter is .3 cm, this nding should be mentioned (Fig. 5A). Dilatation of the main pulmonary artery can be an indicator of pulmonary artery hypertension, especially in patients with concurrent lung disease, such as emphysema. Right ventricular dilatation is a secondary sign of pulmonary hypertension, and the combination of pulmonary artery and right ventricular dilatation should highly suggest the diagnosis. The remainder of the great vessels will not routinely be included in coronary CT but may be included as part of other cardiac CT studies. A few vascular anomalies are important to recognize, especially for cardiovascular disease. These anomalies include a persistent left superior vena cava (SVC) and partial anomalous pulmonary venous return (PAPVR). A persistent left SVC typically empties into the coronary sinus (Fig. 5B-D) but can also drain into other locations, such as a cardiac chamber. A left SVC can be seen in combination with a right SVC or can be present as the only SVC. Left upper lobe PAPVR is important to distinguish from a left SVC (Fig. 5E-G). In left-sided PAPVR, the left upper lobe pulmonary vein drains into the left innominate vein. PAPVR can also be seen on the right, usually with a right upper lobe pulmonary vein draining into a right SVC (Fig. 5H-I). The diameter of the aorta should be measured to exclude the presence of aortic aneurysm (Fig. 5J). The aortic size is best measured in true cross-section, and the normal ascending aorta should not exceed 4 cm in diameter. The aorta should taper in caliber from the sinotubular junction to the diaphragm. If there is any area where

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Figure 6 (A) Axial image of the upper abdomen included as part of a coronary CT angiogram. A 1-cm hypervascular lesion is seen in the right hepatic lobe (arrow). The differential diagnosis would include small hemangioma, arterioportal shunting, and other diseases. In a patient with cirrhosis, ndings would raise concern for hepatocellular carcinoma. (B) Axial images show low-density lesions (arrows) in the liver which are round with smooth margins. The large 2 lesions measure close to 0 HU units, conrming they are benign cysts. (C) A similar lesion (arrow) is noted in the kidney, also consistent with a benign cyst. (D) Axial image shows a large centrally low-density lesion (arrow) with areas at the periphery (black arrow) which are bright, consistent with peripheral puddling, which is an enhancement pattern diagnostic of hemangiomas. (E) Axial image shows a low-density lesion in the left adrenal gland which is round with smooth borders. The lesion measures 4 HU, consistent with a benign adrenal adenoma. The abundant fat within the adenoma accounts for the low Hounseld measurement. (F) Axial image shows an enlarged common bile duct (arrow) as it passes through the head of the pancreas. The patient has had prior cholecystectomy as indicated by the surgical clips (black arrow). The common bile duct can measure up to 1.0 cm after cholecystectomy, consistent with postoperative change. (G) Additional image shows intrahepatic biliary dilatation in a patient with metastatic disease. Note is made of a metastatic lesion in the left lobe of the liver (arrow) and surrounding ascites (black arrow). (H) Axial image shows bilateral hydronephrosis (black arrows), more marked on the right than on the left. The patient had retroperitoneal lymphadenopathy, resulting in ureteral obstruction and thus hydronephrosis.

Other common abdominal disorders include biliary ductal dilatation (Fig. 6F-G) and hydronephrosis. Although biliary ductal dilatation can be a normal nding in patients after cholecystectomy, this nding can also herald the presence of an obstructing distal biliary tract stone or pancreatic head mass. Hydronephrosis presents as dilatation of the pylocalyceal system (Fig. 6H). This nding is most commonly because of an obstructing renal or ureteral calculus

but on rare occasions can be caused by an abdominal or pelvic mass that compresses the distal ureter. Stomach and bowel Hiatal hernia is the most common nding when evaluating the stomach and bowel (Fig. 7A). A hiatal hernia is present when there is stomach, identied by the characteristic rugal fold pattern, located above the level of the gastroesophageal

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Figure 7 (A) A portion of the stomach is located above the diaphragm, posterior to the heart and anterior to the spine and descending thoracic aorta. The stomach can be denitively identied by its characteristic rugal fold pattern and air content. These ndings are consistent with a moderate-sized hiatal hernia. (B) Single axial noncontrast CT image shows multiple air-lled outpouchings (arrow) along the margin of the transverse colon, consistent with colonic diverticulosis.

junction. Colonic diverticulosis is also a common nding (Fig. 7B). Colonic diverticuli are small air-lled outpouchings along the wall of the colon. Most other disease of the stomach and bowel is beyond the scope of this review. Peritoneal cavity When evaluating the peritoneal cavity, the 2 most important ndings are pneumoperitoneum (free air) and ascites. Sometimes it can be helpful to use lung window settings to view the peritoneal cavity and evaluate for free air. Unless massive in quantity, free air will usually present as small bubbles that are non-dependent in location, such as anterior to the diaphragm and along the inferior surface of the liver (Fig. 8A-B). Ascites is usually visualized as an amorphous collection of hypodense uid that collects in the dependent portions of the peritoneal cavity, often around the liver, gall bladder, and/or spleen (Fig. 8C). Uncomplicated ascites should measure ,20 HU. Ascitic uid with attenuation .20 HU should raise concern for blood or bowel contents within the uid.

Subcutaneous tissue Subcutaneous tissues included in the eld of view may show subcutaneous nodules, sebaceous cysts, and other more concerning lesions, such as melanoma (Fig. 9). Injection granulomas may also be visualized as soft tissue nodular densities with associated calcication present in the subcutaneous tissues. These injection granulomas form at sites of repeated subcutaneous injections.

Lung windows (CT settings: center 2500 and width 1800)


Lung parenchyma In the evaluation of the lung parenchyma, disease can be separated into 2 main categories: diseases that make the lung more lucent (black) and diseases that make the lung more dense (white). Processes that make the lung more lucent result from parenchymal destruction, such as emphysema, cystic lung disease, or air trapping.

Figure 8 (A) Axial image (lung window) shows a crescent-shaped collection of free air anterior to the liver (arrow), separated from the lung parenchyma by the diaphragm. (B) The sagittal image nicely shows the anatomic location of pneumoperitoneum (arrow), anterior to the liver and below the diaphragm. (C) Axial image (soft tissue window) shows ascites (arrow) throughout the upper abdomen, primarily located along the borders of the liver and spleen. The liver is small and shows a micronodular contour, and the nding of ascites is not unexpected in this patient with hepatic cirrhosis.

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Figure 9 Axial image shows two soft tissue density nodules (arrows) located within the posterior chest wall subcutaneous tissues. In this patient with a history of melanoma, these soft tissue nodules are highly concerning for subcutaneous metastases. A left para-aortic lymph node and left lower lobe nodule are also noted, consistent with metastatic disease.

Emphysema is usually related to smoking and is commonly present in the same patient population that is undergoing evaluation for coronary artery disease. Emphysema is the result of parenchymal destruction and presents as small or large holes within the lung (Fig. 10A). These holes within the lung parenchyma do not have discernible walls, a key nding in the distinction between emphysema and cystic lung disease. When areas of lung destruction are large, bullae may form. These bullae may be located at the lung apices, which are not often included within the eld of view on a cardiac study. Holes in the lung parenchyma that show denable walls are usually secondary to cystic lung disease (Fig. 10B), such as Langerhans cell histiocytosis (eosinophilic granuloma) or lymphangioleiomyomatosis. If cystic lung disease is suspected, consider consultation with a radiology expert. Many diseases result in increased opacity within the lung parenchyma. Ground-glass opacities are common and are characterized by hazy increased attenuation of the lung with preserved visualization of the bronchial and vascular margins (Fig. 10C). These ground-glass opacities are often nonspecic in appearance, and a denitive diagnosis usually cannot be made. Infectious and inammatory processes are the most common cause for ground-glass attenuation; however, adenocarcinoma in situ (commonly referred to as bronchioloalveolar cell carcinoma) can have an identical imaging appearance. Therefore, it is important to recommend follow-up imaging for ground-glass opacities to evaluate for resolution or stability. A focal ground-glass nodular opacity that is increasing in size and/or density over time should raise concern for

malignancy, and further investigation with biopsy may be appropriate. Consolidation is characterized by a more conuent area of increased density within the lung parenchyma (Fig. 10D). Although pneumonia is the most common cause, the accumulation of pus, blood, water, or cells (tumor) within the air spaces of the lung can result in consolidation. If clinical symptoms of pneumonia are absent (ie, fever or leukocytosis), other processes such malignancy must be considered. Solid lung nodules are one of the most common incidental ndings in cardiac CT (Fig. 10E-F). This statement is especially true in geographic areas where endemic fungal infections are common, such as the Ohio River Valley and dessert regions of the Southwest. Lung nodules must be followed by imaging to evaluate for interval growth or other signs of malignancy. The Fleischner Society has published guidelines for follow-up imaging of incidental pulmonary nodules.12 Similar to lymph nodes, the presence of calcication with a lung nodule is often an indicator of a benign process. The thin-section images obtained for cardiac imaging are useful when looking for nodule calcication; however, as with lymph nodes, the pattern of calcication is critical. Nodules with central or diffuse calcication are considered benign (Fig. 10G-H). The presence of eccentric calcication is more worrisome and does not conrm a benign cause (Fig. 10I-J); follow-up imaging or further evaluation is necessary. Unfortunately, without follow-up imaging, it is impossible to determine whether a small noncalcied nodule is benign or an early lung cancer. A lung mass is distinguished from a lung nodule by a size R 3 cm. The presence of a lung mass is obviously a much more worrisome nding, and primary lung cancer or metastatic disease must be considered (Fig. 10K). Short-term follow-up imaging for a lung mass or nodule . 1 cm in diameter is usually not appropriate. Sometimes positron emission tomography/CT may be valuable; however, oftentimes biopsy is necessary for denitive diagnosis. Pleural effusion The pathology of the pleural space can range from simple transudative effusion of pulmonary edema to complex empyema. Simple pleural effusion should measure ,20 HU, layer dependently within the chest, and show a meniscus conguration (Fig. 11A). Loculated pleural effusion can occur when pockets of uid form, often in nondependent locations within the pleural space. Pleural uid of high density (.20 HU) may represent hemothorax or empyema. Other characteristics of empyema include loculation, pleural thickening, and the presence of small bubbles of air within the pleural uid collection (Fig. 11B-C). Intravenous contrast can help distinguish among pleural uid, pleural thickening, and atelectatic lung. After contrast administration, pleural uid will often remain low density, thickened pleura will show mild enhancement, and atelectatic lung will brightly enhance.

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Figure 10 (A) Axial image (lung window) shows replacement of the normal lung parenchyma by multiple holes without discernible borders. The appearance is characteristic of emphysema. (B) Axial image also shows multiple holes within the lung parenchyma. In contrast to the case of emphysema in panel A, the cysts in this example show thin but denable walls, consistent with cystic lung disease. In this 34-year-old woman with progressive dyspnea, the diagnosis is lymphangioleiomyomatosis. (C) Coned down axial image (lung window) shows a small ground-glass opacity (arrow) in the left lower lobe. Although this opacity could be secondary to a focal infectious or inammatory process, in this case the diagnosis was bronchioloalveolar cell carcinoma. The presence of a focal ground-glass opacity should prompt short-term imaging follow-up or further diagnostic workup. (D) Axial image (lung window) shows a focal area of consolidation in the left lower lobe. In this 28-year-old man with fever and cough, ndings are consistent with pneumonia. In an older patient with consolidation, follow-up imaging after treatment to ensure complete resolution is recommended to exclude neoplasm. (E) This image (lung window) shows a small nodule (arrow) in the lingula. (F) This image (soft tissue window) shows the same nodule (arrow) and conrms the absence of any calcication. This subcentimeter incidental nodule is indeterminate in cause, and follow-up recommendations are based on the Fleischner Society guidelines. (G) This image (lung window) shows a small nodule (arrow) in the left upper lobe. The center of the nodule appears denser. (H) This image (soft tissue window) conrms the presence of a high-density calcication in the center of the nodule (arrow). This appearance is classic for a benign calcied granuloma, and no follow-up imaging is necessary. Axial (I) and sagittal (J) images (lung window) show a nodule (arrow) in the right upper lobe. This nodule contains a small focus of calcication, located in an eccentric position along the inferior margin of the nodule. In contrast to the large central calcication shown in panels I and J, the small eccentric focus of calcication in this example is not enough to conrm a benign cause. This partially calcied nodule remains indeterminate, and short-term imaging follow-up or further evaluation is recommended. (K) Cardiac CT was performed for evaluation of the pulmonary vein anatomy before pulmonary vein ablation. Axial image (lung window) shows a 5-cm mass in the right upper lobe. This mass shows spiculated borders and some adjacent ground-glass opacication. The appearance is a concern for primary lung cancer, and pathologic studies from percutaneous biopsy conrmed adenocarcinoma.

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Figure 12 Axial image (lung window) shows a small left pneumothorax. Air appears as pure black within the pleural space. There is a thin pleural line (arrow) separating the air within the pleural space from the lung parenchyma.

Pneumothorax Pneumothorax is a relatively easy diagnosis to make and should be looked for on every examination. Pneumothorax is characterized by the presence of low-density air within the pleural space. Often there is a sharp pleural line, indicating the boundary between the lung parenchyma and the adjacent pleural air (Fig. 12).

Bone windows (CT settings: center 500 and width 2000)


Lytic or sclerotic lesions When evaluating the bones, it is important to look for focal lesions of abnormal increased (sclerotic) or decreased (lytic) density. Metastatic lesions can be either sclerotic or lytic, depending on the cause of the primary malignancy. These focal lesions must be distinguished from the process of degenerative disc disease, which is commonly seen in the spine. Degenerative changes are often more diffuse, characterized by osteophyte formation and intervertebral disk space narrowing (Fig. 13A-B). Although bony metastatic disease can be diffuse and widespread, most lesions are more focal in nature and tend to preserve the disk spaces (Fig. 13C). Fractures Rib fractures (Fig. 14) and vertebral compression fractures can be incidental ndings discovered on a cardiac CT. Most of these fractures will be chronic rather than acute ndings. Chronic rib fractures are characterized by
Figure 11 (A) Axial image (lung window) shows bilateral pleural effusions. The effusions are layering dependently within the posterior pleural spaces. This image also shows mild interlobular septal thickening and subtle bilateral ground-glass opacities. The constellation of ndings in this case is most consistent with pulmonary edema. (B) Axial image (soft tissue window) shows a right pleural collection. There is thickening and enhancement of

both the visceral and parietal pleura layers (arrows). This nding is known as the split pleura sign and is suggestive of empyema. (C) Axial image (lung window) also shows a right pleural collection. This collection contains multiple small pockets of air, raising the concern for empyema. Sometimes recent instrumentation, such as recent thoracentesis, can produce a similar appearance.

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Figure 14 (A) Axial image (bone window) shows angulation and cortical disruption of a left-sided rib (arrow). Findings are consistent with rib fracture. In this case, there is little callus formation, and the fracture age may be acute to subacute. (B) This image shows sclerotic change at the site of the right rib fracture (arrow). This is an old rib fracture that has had incomplete healing.

irregular contour and sclerotic change with or without visualization of the actual fracture line. Callus formation is often seen during the subacute phase. An acute rib fracture may show a sharp fracture margin and frank angulation. Vertebral compression fractures are best visualized on the sagittal images as vertebral body height loss.

Figure 13 (A) Sagittal image (bone window) shows endplate sclerosis and osteophyte formation (arrow), consistent with degenerative disk disease. This appearance should be distinguished from

the patchy sclerotic vertebral changes seen with blastic metastatic disease (see panel C). (B) Axial image (bone window) shows the appearance of bulky osteophytes (arrow) in this plane. (C) Sagittal image (bone window) shows patchy sclerosis throughout the bones, including the vertebral bodies, sternum, and manubrium. This appearance is characteristic of blastic metastatic disease, such as in prostate cancer.

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Interpreting extracardiac ndings on coronary CTA

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Conclusion
In summary, a multitude of noncardiac ndings can be present on CTA examinations obtained for coronary artery evaluation. In fact, the high spatial resolution of coronary CT angiography imaging may show more abnormalities and variants than a standard chest CT. Complete evaluation of the examination requires scrutiny of the soft tissues, lung tissues, and bones, both in the chest and adjacent abdomen. It is important to adjust the CT window display settings at various stages of the interpretation process to evaluate all potential extracardiac disease. Although in-depth radiology training would be required to correctly identify and interpret all anomalies, this article serves as an overview and guide to evaluate the extracardiac structures included on a coronary CTA examination. Correct interpretation of extracardiac ndings is critical because a false positive interpretation can lead to unnecessary testing and treatment that can be as harmful as a false negative interpretation. Most importantly, if the cardiac ndings do not explain the patients symptoms, an alternative cause should be specifically sought to appropriately manage the patient.

References
1. Haller S, Kaiser C, Buser P, Bongartz G, Bremerich J: Coronary artery imaging with contrast-enhanced MDCT: extracardiac ndings. AJR Am J Roentgenol. 2006;187:10510. 2. Kirsch J, Araoz PA, Steinberg FB, Fletcher JG, McCollough CH, Williamson EE: Prevalence and signicance of incidental extracardiac ndings at 64-multidetector coronary CTA. J Thorac Imaging. 2007; 22:3304. 3. Lehman SJ, Abbara S, Cury RC, Nagurney JT, Hsu J, Goela A, Schlett CL, Dodd JD, Brady TJ, Bamberg F, Hoffmann U: Signicance of cardiac computed tomography incidental ndings in acute chest pain. Am J Med. 2009;122:5439.

4. Onuma Y, Tanabe K, Nakazawa G, Aoki J, Nakajima H, Ibukuro K, Hara K: Noncardiac ndings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol. 2006;48:4026. 5. American College of Cardiology Foundation Task Force on Expert Consensus Documents, Mark DB, Berman D, Budoff MJ, Carr JJ, Gerber TC, Hecht HS, Hlatky MA, Hodgson JM, Lauer MS, Miller JM, Morin RL, Mukherjee D, Poon M, Rubin GD, Schwartz RS: ACCF/ACR/AHA/NASCI/SAIP/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force. J Am Coll Cardiol. 2010;55:266399. 6. Schragin JG, Weissfeld JL, Edmundowicz D, Strollo DC, Fuhrman CR: Noncardiac ndings on coronary electron-beam computed tomography scanning. J Thorac Imaging. 2004;19:826. 7. Douglas PS, Cerqueria M, Rubin GD, Chin AS: Extracardiac ndings: what is a cardiologist to do? JACC Cardiovasc Imaging. 2008;1: 6827. 8. Sosnouski D, Bonsall RP, Mayer FB, Ravenel JG: Extracardiac ndings at cardiac CT: a practical approach. J Thorac Imaging. 2007; 22:7785. 9. Jacobs JE, Boxt LM, Desjardins B, Fishman EK, Larson PA, Schoepf J: American College of Radiology. ACR practice guideline for the performance and interpretation of cardiac computed tomography (CT). J Am Coll Radiol. 2006;3:67785. 10. Budoff MJ, Achenbach S, Berman DS, Fayad ZA, Poon M, Taylor AJ, Uretsky BF, Williams KA: American Society of Nuclear Cardiology; Society of Atherosclerosis Imaging and Prevention; Society for Cardiovascular Angiography and Interventions; Scoeity of Cardiovascular Computed Tomography: Task force 13: training in advanced cardiovascular imaging (computed tomography) endorsed by the American Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, and Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2008;51: 40914. 11. Budoff MJ, Fischer H, Gopal A: Incidental ndings with cardiac CT evaluation: should we read beyond the heart? Catheter Cardiovasc Interv. 2006;68:96573. 12. MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz EF Jr., Swensen SJ: Fleischner Society: Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237:395400.

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