Welcome to brand new Ask the Fish. Post your questions in different boards to get in touch with CTisus team & Dr. Elliot K. Fishman!
Our old Ask the Fish forum can be still viewed as an archive at https://ctisus.com/redesign-askfish/index.html.
We encourage all the users to register in this new forum to get answers to their questions since the posts in old forum will no longer be reviewed!
Thank you for visiting & looking forward to your feedback!

Recent Posts

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Case Studies / Re: Looking for a second opinion
« Last post by tunnellight on Today at 03:22:36 am »
Just checking if you received my email. It should come from [email protected]...
CT Scan Protocols / Re: Contraindications to Oral Contrast (omnipaque)
« Last post by Elliot K. Fishman, MD on January 20, 2019, 01:19:25 pm »
I would not worry in the scenario you mentioned. The comment I make is that if someone is so sensitive to iodinated contrast that I would take the path of least residence and use s barium based product.
CT Scan Protocols / Contraindications to Oral Contrast (omnipaque)
« Last post by freshfaust on January 20, 2019, 12:37:35 pm »
Hello Dr. Fishman,

I have a questions concerning oral omnipaque for positive bowel opacification: in your iOS-CONTRAST-App you mention that only very small amounts are absorbed, thus you do not obtain consent; in patients with a history of allergic reactions to omnipaque you would rather use barium, however.

Would you have any concerns using omnipaque in a patient with hyperthyroidism? What about patients planning to undergo radioactive iodine therapy for thyroid cancer?

Thank you so much for your contributions to our field - they are truly transformative!

Kind regards,

CT Scan Protocols / Re: IV size for CTP
« Last post by Elliot K. Fishman, MD on January 18, 2019, 08:12:40 pm »
A 20 will work but an 18G is ideal. A solution is to use the BD Nexiva catheter. These at 20g can handle 10cc/sec contrast so it will solve your problem.
here is some info
Journal Club / CT derived FFR: "The Game Changer?" revisited.
« Last post by Lilly Kauffman on January 18, 2019, 12:07:26 pm »
CT derived FFR: "The Game Changer?" revisited.

J Cardiovasc Comput Tomogr. 2018 Nov - Dec;12(6):447-449. doi: 10.1016/j.jcct.2018.08.006.
Hecht HS1.


The practice of cardiology has been revolutionized by the emergence of coronary computed tomographic angiography (CTA) as a major addition to the armamentarium for the evaluation of coronary artery disease. In an extraordinarily short time span, the CTA literature has been populated with studies documenting accuracy superior to the most commonly utilized functional testing modalities of treadmill testing, stress echocardiography (SE) and SPECT myocardial perfusion imaging (MPI) for the identification of invasive coronary angiographic (ICA) stenoses >50%.1, 2, 3 Recognizing that ICA stenosis correlates inadequately with invasive fractional flow reserve (IFFR) and is not the appropriate gold standard, CTA has also been correlated with IFFR, with similar superiority in sensitivity to the standard modalities but lower specificity. The less often utilized and more expensive positron emission tomography (PET) and magnetic resonance imaging (MRI) stress testing have sensitivities similar to CTA but superior specificities.4, 5, 6, 7

In addition, studies have documented the better prognostic value of CTA compared to SE and MPI,8 as well as superior outcomes in chest pain patients without established CAD randomized to CTA versus the standard modalities,9, 10, 11, 12 despite the relatively poor specificity using the IFFR gold standard. The reasons for the low specificity of CTA are multiple: Firstly, as with ICA, there is an imperfect correlation of percent stenosis with IFFR. Secondly, the classification by intention to diagnose of heavily calcified or motion artifact degraded segments as “positive” will decrease specificity. Thirdly, visual overestimation of % DS on CTA is undoubtedly as common as it is in invasive angiography.

DOI: https://doi.org/10.1016/j.jcct.2018.08.006


What are your thoughts?  Comments?
CT Scan Protocols / IV size for CTP
« Last post by lbraikov22 on January 18, 2019, 11:13:54 am »
What is the iv size you are using for CTA Brain Perfusion?
Do you use a 20g if an 18g is unattainable?

We currently request 18g antecubital iv from our Neuro ICU, however, they often complain that they can not obtain an 18g and want us to do it with a 20G, we have done it in the past but we find the scans not as good and often at 5cc/sec the iv blows.

Thank you
Case Studies / Re: Looking for a second opinion
« Last post by Elliot K. Fishman, MD on January 17, 2019, 03:28:19 pm »
happy to look at the images.
my email is [email protected]
CT Scan Protocols / Re: TAVR protocol
« Last post by Elliot K. Fishman, MD on January 17, 2019, 03:27:11 pm »
you must gate the chest like a cardiac CT for a TAVR study. If you do not you have motion and the measurement for the TAVR will be incorrect.
Case Studies / Looking for a second opinion
« Last post by tunnellight on January 17, 2019, 04:12:46 am »
Hi Dr. Fishman,

My wife was diagnosed with urogenital tuberculosis in August 2018 and she has been taking TB drugs since then. Recently, she has had some recurring symptoms (cystitis: hematuria, dysuria, nocturia, urgency, frequency) and the doctors cannot determine the cause or willing to change the TB therapy, which is under WHO supervision. We have been to many local urologists who keep sending us to gynecologists, who in their turn send us back to urologists. We live in Uzbekistan. I'm trying to get my wife diagnosed and treated correctly as we have doubts about the diagnosis and treatment regimen done so far. I've been reading/watching about her disease on the Internet, where I came across your YT video on hematuria. Can you help us or know someone who could? She did CT urography scan in August 2018. I would be glad to share the link with you privately if you can take a look.


Journal Club / Imaging of acute ischemic stroke
« Last post by Lilly Kauffman on January 16, 2019, 02:55:45 pm »
Imaging of acute ischemic stroke

Rudkin S1, Cerejo R2, Tayal A2, Goldberg MF3.


For decades, imaging has been a critical component of the diagnostic evaluation and management of patients suspected of acute ischemic stroke (AIS). With each new advance in the treatment of AIS, the role of imaging has expanded in scope, sophistication, and importance in selecting patients who stand to benefit from potential therapies. Although the field of stroke imaging has been evolving for many years, there have been several major recent changes. Most notably, in late 2017, the window for treatment expanded to 24 h from onset of stroke symptoms in selected patients. Furthermore, for those patients in expanded time windows, guidelines issued in early 2018 now recommend the use of “advanced” imaging techniques in the acute setting, including CT perfusion and MRI, to guide therapeutic decision-making. With these and other changes, the emergency radiologist must be prepared to handle a growing volume and complexity of AIS imaging. This article reviews the various imaging modalities and techniques employed in the imaging of AIS patients, with an emphasis on recommendations from recent randomized controlled trials and national consensus guidelines.

DOI: https://doi.org/10.1007/s10140-018-1623-x


What are your thoughts?  Comments?
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