Presentation
Atypical chest pain. Myocardial perfusion scintigraphy was negative but unable to exclude balanced 3-vessel CAD.
Patient Data
Technique
patient premedication: beta blocker and nitrates
acquisition method: step and shoot (prospective acquisition)
contrast injection protocol: triphasic injection
image reconstruction with no edge correction
Findings
normal coronary origins and proximal courses
right coronary arterial dominance
Plaque burden:
calcium score (according to Agatson, not shown): 0
aortic wall calcification in the descending aorta
Right coronary artery (RCA): (gives rise to posterior descending artery)
no plaques or stenoses in the proximal, middle and distal segments
posterior descending artery (PDA): no plaques or stenosis
Left main (LM): inconspicuous
Left anterior descending artery (LAD): (one diagonal branch)
no plaques or stenoses in the proximal, middle and distal segments
no plaques or stenoses of the diagonal branch (D1)
Ramus intermedius: thin, no plaques or stenoses
Circumflex artery (CX): (strong obtuse marginal branch, thin lateral segment with posterolateral branches)
no plaques or stenoses in the main epicardial vessel
no plaques or stenosis of the obtuse marginal (OM) and posterolateral branches
Impression
normal coronary CT angiogram
no evidence of coronary stenosis or plaques - CAD-RADS 0
Exam courtesy: Silva Sölle & Yvonne Kirchner-Bock (radiographers)
MonoE 40
MonoE40 images are virtual monochromatic images synthesized at a level of 40 keV
the study here shows reconstructions in the standard reconstruction algorithm and with a sharp reconstruction algorithm (XCD) both displayed with a window setting C:800 W:2000
the sharp reconstruction algorithm XCD offers increased spatial resolution at the expense of more image noise
Conventional + MonoE 40 overlay
conventional images, reconstructed with a standard soft tissue filter and supplemented with a color-coded MonoE 40 overlay ranging from -200 to 1000 (C:400 W:1200)
Iodine no water + virtual non-contrast overlay
iodine no water images obtained by subtracting water from contrast-enhanced images with a color-coded virtual non-contrast overlay (VNC) ranging from -200 to 400 (C:100 W:600)
this setting can be nicely used to illustrate calcium
Z-effective
the effective atomic number Zeff calculated by dual-energy analysis
Case Discussion
A case of a normal coronary CTA with different dual-energy maps for viewing.
The absence of any luminal stenosis and plaques is consistent with a CAD-RADS 0 category. The patient was reassured and requires no further investigation for coronary artery disease 1.
The monoenergetic images reconstructed at a level of 40 keV are close to the iodine K-edge and can be used to increase iodine contrast attenuation 2,3.
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