Standardizing how incidental findings are reported to physicians who order a CT cervico-cerebral angiography (CTCCA) examination may help prevent those of clinical significance from being overlooked or ignored, say Irish radiologists who are making this recommendation in the August 2015 issue of the European Journal of Radiology.
Matthew Thomas Crockett, MD, of Mater Misercordiae University Hospital in Dublin and colleagues studied the prevalence, clinical significance and management of extravascular incidental findings detected on CTCCA. CTCCA is the imaging exam of choice to assess acute ischemic stroke, cervicocerebral vascular anomalies, steno-occlusive carotid arterial disease, vascular trauma, and vasculitis. CTCCA also assesses nonvascular structures of the head, neck and upper thorax. Its imaging range enables radiologist to identify incidental findings not related to vascular issues in the lung apices, the thyroid gland, soft tissues and osseous structures of the neck. Some of these incidental findings may aid in the early diagnosis and treatment of potentially curable diseases.
The radiologists conducted a retrospective review of all CTCCA reports prepared over a three-year period by 19 consultant radiologists starting in November 2009. In addition to the hospital’s electronic medical records (EMR) system, they used the National Integrated Imaging Management System (NIMIS) a nationwide PACS covering most hospitals in Ireland to capture external patient follow-up treatment. They classified incidental findings based upon an adaptation of the CT colonography reporting and data system (C-RADS). Incidental findings were rated as one of four extra-vascular categories (normal, low, intermediate and high clinical significance).
A total of 302 patients underwent CTCCA studies. Of these exams, 69% were ordered to assess suspected acute ischaemic stroke. The mean age of the 171 male and 131 patients was 61 years, with a range of 16 to 95 years. One hundred fifty-one incidental extravascular findings were detected in 131 patients.
Of the 302 patients, 8.2% had incidental findings of high clinical significance such as pneumothorax or a highly suspicious lesion. A total of 17% of the incidental findings were classified as being of high clinical significance. More than 80% of these were suspicious lesions that required further follow up, and four of the 21 lesions identified proved to be malignant. A total of 5.6% of the patients had incidental findings of intermediate clinical significance (11% of the total reported), such as an indeterminate thyroid nodule.
Of the 26 patients with high clinical significance incidental findings, the researchers determined that five did not undergo appropriate follow-up. These included three patients who had pulmonary nodules identified and two patients with suspicious thyroid lesions. The researchers were not able to determine why there was no follow-up. However, they speculated that because of the inconsistency in the way incidental findings were reported, they may have been overlooked by the referring physician(s) receiving the report or their significance was not properly understood.
Because of this, the researchers recommend that a defined classification system for the categorization of extravascular incidental findings in a CTCCA examination be adopted. “This would aid both radiologists in recording incidental findings and referring physicians in interpret significance of such findings, thus improving appropriateness of patient follow-up and management,” they concluded.
Standardization recommended for CTCCA reporting of incidental clinical findings . Appl Radiol.