Download Emergency Radiology

Emergency Radiology
ER001-EB-X
Ultrasound Evaluation of the Symptomatic Popliteal Fossa: It's Not All Baker's Cysts
All Day Room: ER Community, Learning Center
Participants
Peter M. Ghobrial, MD, Chardon, OH (Presenter) Nothing to Disclose
Richard L. Barger JR, MD, Painesville, OH (Abstract Co-Author) Nothing to Disclose
Ravi Guttikonda, MD, Cleveland, OH (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The popliteal fossa is a common site of pain and other symptoms for patients prompting evaluation. Ultrasound (US) is very often
used to begin, and frequently complete imaging evaluation of symptomatology at this location. After viewing this presentation the
learner will accomplish the following:1. Review constituent anatomy of the popliteal fossa.
2. Discuss a concise US scanning protocol for popliteal fossa evaluation, with emphasis on normal sonographic anatomy.
3. Review the differential diagnosis of various causes of popliteal fossa symptoms through an US case based approach, with
multimodality correlation in some instances.
TABLE OF CONTENTS/OUTLINE
Introduction
Anatomy of the Popliteal Fossa
Ultrasound Protocol for Popliteal Fossa Evaluation
The "Normal" Popliteal Fossa at Ultrasound
Ultrasound Diagnosis of the "Baker's Cyst"
Case Based Review of Causes of Popliteal Fossa "Lump" and "Pain"
Conclusion
References
ER003-EB-X
Pitfalls in Pediatric Musculoskeletal Imaging: Normal Variants Causing Problems for the Radiologist in the
Pediatric Emergency Department
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Matthew Hermann, MD, Ann Arbor, MI (Presenter) Nothing to Disclose
Jessica R. Leschied, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose
Suzanne T. Chong, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose
Peter J. Strouse, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Following review of this educational exhibit, the learner will:1. Recognize the more common osseous variants in the pediatric
cervical spine and extremities that can cause difficulty in radiographic interpretation.
2. Identify some of the accessory centers of ossification in the foot and ankle that should not be confused for fractures.
3. Understand the variable appearance of centers of ossification in the pediatric extremities.
4. Contrast normal variants with actual pathology using case examples.
TABLE OF CONTENTS/OUTLINE
A. Background and relevance in the pediatric emergency departmentB. Cases and review of imaging findings (examples of what will
be shown):Skull: normal and accessory suturesC-spine: Pseudosubluxation of the cervical spinePelvis: Ischiopubic synchondrosis;
os acetabuli; superior pubic ramus developmental variantExtremities:- Physiologic Periosteal reaction of the infant- Irregularity of
the distal femoral epiphysis- Bipartite patella/dorsal defect of the patella- Irregularity of the distal femoral metaphysis/cortical
desmoid- Accessory ossicles of the foot and ankle- Fifth metatarsal apophysis- Bifid great toe phalangeal epiphysisDifferentiation of
normal metaphyseal development from child abuse fracturesC. Normal variants vs. actual pathologyD. Conclusion
ER005-EB-X
Abdominal Vascular Emergencies (AVE): How to Improve Diagnosis using DECT
All Day Room: ER Community, Learning Center
Participants
Khalid W. Shaqdan, MD, Boston, MA (Presenter) Nothing to Disclose
Anushri Parakh, MBBS, MD, Basel, Switzerland (Abstract Co-Author) Consultant, Bayer AG
Laura L. Avery, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
George R. Oliveira, MD, East Boston, MA (Abstract Co-Author) Nothing to Disclose
Avinash R. Kambadakone, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Dushyant V. Sahani, MD, Boston, MA (Abstract Co-Author) Research support, General Electric Company; Medical Advisory Board,
Allena Pharmaceuticals, Inc
TEACHING POINTS
Abdominal vascular emergencies are challenging clinical pathologies with high mortality. Imaging patients for AVE is continually
increasing, with CT as the preferred modality. Dual-energy CT (DECT) offers material-specific reconstructions, monoenergetic
imaging, and increasing CNR reducing iodine utilization and radiation exposure while improving lesion detection.
TABLE OF CONTENTS/OUTLINE
Introduction Clincal aspects of AVE and management CT protocols Aorta CTA CTV Mesenteric bowel ischemia DE data acquisition,
image processing, and reconstruction VNC Monoenergetic images Case based review of vascular pathologies Rupture and impending
rupture of AAA Celiac artery dissection Acute mesenteric ischemia Rupture of visceral aneurysms Portal vein and IVC thrombosis
DECT workflow Limitations Conclusion
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Dushyant V. Sahani, MD - 2012 Honored Educator
Dushyant V. Sahani, MD - 2015 Honored Educator
Dushyant V. Sahani, MD - 2016 Honored Educator
Laura L. Avery, MD - 2016 Honored Educator
ER006-EB-X
Imaging of Penetrating Trauma to the Brain
All Day Room: ER Community, Learning Center
Participants
Ajay K. Singh, MD, Boston, MA (Presenter) Nothing to Disclose
Mona T. Vakil, MD, Los Angeles, CA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. CT is helpful in deciding definitive surgical management in patients who necessitated surgery after CT. 2. CT, MR and CT
angiography are key imaging modalities that are frequently used to determine the course of the foreign object and the extent of
brain tissue injury as well as to rule out vascular injury. 3. Early surgical exploration by a multidisciplinary team approach is
essential to attain good recovery and a favorable outcome.
TABLE OF CONTENTS/OUTLINE
Self-inflicted trauma is the more common mechanism
Types: High velocity & low-velocity trauma
Mortality from isolated intracranial injury = approx 41%
Imaging: CT with and without CT angiography Imaging provides information on entrance and exit wounds, missile track & secondary
changes CT angiography has limited overall sensitivity in detecting arterial injuries but is accurate in identifying traumatic
intracranial aneurysm.Pathophysiology: Biometry reveals destruction zone of 3.6 cm around the permanent track (temporary
cavity). Axonal injury present at sites remote from the permanent cavity
Complications: Local wound infection Meningitis Brain abscess Cerebrospinal fluid leaks Aneurysm and bleeding
HydrocephalusTreatment: Removal of a penetrating foreign object with direct visualization and after preparations for vascular
control.
ER007-EB-X
Imaging of Necrotising Fasciitis
All Day Room: ER Community, Learning Center
Participants
Ajay K. Singh, MD, Boston, MA (Presenter) Nothing to Disclose
Sergey Kochkine, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Necrotising fasciitis is rapidly progressive, often fatal infection of soft-tissue fascia deep to the skin and superficial to the
muscles.2. The diagnostic feature on CT is the presence of soft tissue gas and deep fascial crescenteric fluid collections.
TABLE OF CONTENTS/OUTLINE
Necrotising fasciitis is rapidly progressive, often fatal infection of soft-tissue fascia deep to the skin and superficial to the
muscles.Epidemiology More common in immunocompromised patients (HIV, DM etc.).Pathology Most common type: polymicrobial
infection Single organism (most commonly group A streptococci) LocationExtremities, perineum, and truncal areas most commonly
involved Radiographic features Soft-tissue thickening from cellulitis Gas in the soft tissues Asymmetrical fascial thickening
associated with fat stranding Edema extending into the inter-muscular septa Thickening of superficial and/or deep fascial layers
Abscess MRI: Modality of choice for detailed evaluation of soft tissue infectionTreatment and prognosis Fasciotomy with
debridement
ER100-ED-X
Leaking Ureter: Why Do We Struggle to Detect Ureteral Injuries on Multimodality Imaging?
All Day Room: ER Community, Learning Center
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Presenter) Nothing to Disclose
Christine O. Menias, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose
David Dreizin, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Sanjeev Bhalla, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
Man Hon, MD, Forest Hills, NY (Abstract Co-Author) Nothing to Disclose
Andres O'Brien, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To illustrate critical imaging findings in blunt and penetrating traumatic and iatrogenic ureteral injuries. To discuss the advantages
and disadvantages of different imaging modalities for the diagnosis of ureteral injuries. To review the clinical and imaging literature
on ureteral injuries, with an emphasis on potential pitfalls, and missed injuries.
TABLE OF CONTENTS/OUTLINE
Traumatic ureteral injuries are rare and can be easily overlooked by the radiologist due to multiple concomitant injuries, the absence
of delayed images, and the non-specific clinical presentation. The majority of non-iatrogenic cases are caused by gunshot wounds.
Blunt ureteral injuries are very uncommon, but can be encountered in severe multitrauma patients. Iatrogenic injuries can occur
during gynecologic, bowel and vascular surgery. The role of MDCT, IVP and retrograde pyelography will be explored and
demonstrated. Potential pitfalls in imaging evaluation, including specific features of incomplete ureteral transection, will be
highlighted. Differential diagnosis and management options with an emphasis on interventional radiology will be discussed. This
exhibit offers an opportunity to review the imaging appearance of traumatic and iatrogenic ureteral injuries and emphasizes the role
of radiologist in the detection and management of these life-threatening entities.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Christine O. Menias, MD - 2013 Honored Educator
Christine O. Menias, MD - 2014 Honored Educator
Christine O. Menias, MD - 2015 Honored Educator
Christine O. Menias, MD - 2016 Honored Educator
Sanjeev Bhalla, MD - 2014 Honored Educator
Sanjeev Bhalla, MD - 2016 Honored Educator
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
ER102-ED-X
Gallbladder: What's New in Gallbladder Imaging with Emphasis on Dual Energy CT
All Day Room: ER Community, Learning Center
Awards
Identified for RadioGraphics
Participants
Jennifer W. Uyeda, MD, Boston, MA (Presenter) Nothing to Disclose
Ian Richardson, BS, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
TEACHING POINTS
Common gallbladder pathologies can be evaluated on varioius imaging modalities including US, CT, MRI, HIDA, and PET.Application of
DECT post-processing can aid in diagnosis of various gallbladder pathologies including cholelithiasis, acute cholecystitis, and
carcinoma and potentially decrease the need for subsequent imaging.
TABLE OF CONTENTS/OUTLINE
Review pathophysiology of gallstones and other pathologies Review of imaging findings of gallstones and various pathologies on
multiple modalities including US, CT, MR, HIDA, and PET. Illustrate the potential applications of dual energy CT post-processing
utilizing creation of iodine maps, virtual noncontrast, and virtual monoenergetic images Ability to make noncalcified gallstones visible
with virtual monochromatic images Improve detection of acute cholecystitis on CT with iodine maps Differentiate stones from
carcinoma Future directions and summary
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
ER103-ED-X
Missed Acute Appendicitis on MDCT and MRI: Legal Ramifications, Challenges, and Avoidance Strategies
All Day Room: ER Community, Learning Center
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Presenter) Nothing to Disclose
Eitan Sosner, BA, Stony Brook, NY (Abstract Co-Author) Nothing to Disclose
Abraham H. Dachman, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose
Victoria Chernyak, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To discuss the legal ramifications of the missed or incorrect imaging diagnosis of acute appendicitis (AA) by radiologists, which is
highly relevant to the current practice of emergency radiologyTo illustrate common misinterpretations in the diagnosis of AA on
MDCT and MRI examinations, based on lessons learned from Morbidity & Mortality Rounds.
TABLE OF CONTENTS/OUTLINE
The failure to diagnose AA is the third most common incorrect gastrointestinal diagnosis resulting in medical malpractice allegations.
The medical-legal aspects of missed and/or delayed diagnosis of AA will be reviewed. The misinterpretation of imaging examinations
in patients with suspected appendicitis may be caused by suboptimal technique, failure to review a portion of the examination,
satisfaction of search error, and the misinterpretation of imaging findings. This exhibit will review optimised MDCT and MRI protocols
for the detection of AA. MDCT and MR imaging findings of the following challenging presentations of AA will be also illustrated: tip
appendicitis; stump appendicitis; peri-appendicits; and appendicitis on non-enhanced MDCT. This exhibit offers an opportunity to
review common mistakes in diagnosis of the AA on MDCT and MRI, to review the imaging, clinical, and legal literature on this
specific topic, and also suggests strategies to avoid potential misinterpretations.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
ER104-ED-X
Orbital Hemorrhage: Can You Localize the Blood?
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Jeanne Amuta, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose
Meir H. Scheinfeld, MD, PhD, Bronx, NY (Presenter) Nothing to Disclose
TEACHING POINTS
To understand the anatomy of the orbit and globe.To correctly localize hemorrhage within the orbit and globe.To appreciate the
significance of hemorrhage within different locations of the orbit and globe and what are the typical treatments for these
conditions.
TABLE OF CONTENTS/OUTLINE
Orbital anatomy will be illustrated and reviewedCases of orbital hemorrhage will be presented and discussed, including:Hemorrhage
within the globe: Retinal hemorrhage Choroidal hemorrhage Vitreous hemorrhage Anterior chamber hemorrhage
(hyphema)Hemorrhage anterior to globe: Preseptal hematoma Subconjunctival hemorrhageHemorrhage posterior to the globe:
Retrobulbar hemorrhage Retrobulbar hematoma Hemorrhage into the optic nerve sheath Hemorrhage into an extra-occular muscle
ER105-ED-X
Pelvic CT Angiography in Trauma: 10 Year's of Experience at a Level I Trauma Center
All Day Room: ER Community, Learning Center
Participants
Shahnaz Rahman, MD, Boston, MA (Presenter) Nothing to Disclose
Arthur Baghdanian, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Armonde Baghdanian, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Alessandra J. Sax, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jorge A. Soto, MD, Boston, MA (Abstract Co-Author) Royalties, Reed Elsevier
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Pelvic CT angiography may be employed in the trauma setting to evaluate for vascular injuries.2. Understand the utility of
arterial, portal venous, and delayed phase imaging in characterizing traumatic vascular injuries. 3. Discuss protocol considerations
for incorporation of arterial phase imaging in patients who sustain pelvic trauma.
TABLE OF CONTENTS/OUTLINE
1. Illustrate and discuss various CT findings of traumatic vascular injury using arterial, portal venous phase and delayed phase
imaging.2. Understand the utility of arterial, portal venous, and delayed phase imaging in characterizing traumatic vascular injuries.
3. Discuss protocol considerations for incorporation of arterial phase imaging in patients who sustain pelvic trauma.4. Illustrate
pelvic anatomy using 3D models.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jorge A. Soto, MD - 2013 Honored Educator
Jorge A. Soto, MD - 2014 Honored Educator
Jorge A. Soto, MD - 2015 Honored Educator
ER106-ED-X
What an On Call Radiology Resident Needs to Know About MR Imaging in Spinal Trauma
All Day Room: ER Community, Learning Center
Participants
Yogesh Kumar, MD, Bridgeport, CT (Presenter) Nothing to Disclose
Gerard J. Muro, MD, Southport, CT (Abstract Co-Author) Nothing to Disclose
Joshua M. Sapire, MD, Bridgeport, CT (Abstract Co-Author) Nothing to Disclose
Kusum Hooda, MBBS, Stratford, CT (Abstract Co-Author) Nothing to Disclose
Francisco J. Lazaga, MD, Bridgeport , CT (Abstract Co-Author) Nothing to Disclose
Francisco E. Valles, MD, Bridgeport, CT (Abstract Co-Author) Nothing to Disclose
Daichi Hayashi, MBBS, PhD, Bridgeport, CT (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. To discuss the indications of magnetic resonance imaging (MRI) in spinal trauma. 2. To review the normal anatomy and various
MR sequences for adequate evaluation of spinal trauma. 3. To discuss the MRI findings of ligamentous and spinal cord injuries. 4. To
explain the role of MRI in evaluating stable versus unstable spinal injuries and predicting prognosis in spinal cord injury. 5. To
discuss vascular injuries and their complications, extra medullary collections such as epidural hematoma, subdural hematoma and
CSF leaks.6. To review the role of MRI in differentiating benign versus malignant vertebral fractures, and acute versus chronic
compression fractures . 7. To review various pitfalls in MRI in spinal trauma.
TABLE OF CONTENTS/OUTLINE
Normal MRI appearances of spinal ligamentous structures.Mechanisms of Spinal TraumaWhen to suspect ligamentous and cord
injuries based on CT findings?Review of imaging findingsSample cases- Various ligament tears. Spinal cord contusions-hemorrhagic
and non hemorrhagic. Traumatic disc herniation, vascular injuries and extradural/subdural hematoma. Benign versus malignant
vertebral fractures. Acute versus chronic compression fractures. Various artifacts and pitfalls in spinal MRI in trauma.
ER107-ED-X
Acute Abdominal Diseases on CT and MRI; The Underlying Etiology of Lumber Pain
All Day Room: ER Community, Learning Center
Participants
SHOTA TAKEHARA, Okinawa, Japan (Presenter) Nothing to Disclose
Masahiro Okada, MD, Nishihara-Cho, Japan (Abstract Co-Author) Nothing to Disclose
Yuko Iraha, Nishihara-cho, Japan (Abstract Co-Author) Nothing to Disclose
Kimei Azama, Nishihara City, Japan (Abstract Co-Author) Nothing to Disclose
Yuka Morita, MD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Sadayuki Murayama, MD, PhD, Nishihara-Cho, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation
TEACHING POINTS
Gastric ulcer, duodenal ulcer, acute cholecystitis, acute pancreatitis, pancreatic necrosis, pyelonephritis, renal cell carcionoma and
pancreas cancer etc, which show lumber pain, are reviewed by typical and/or atypical images on CT and MRI.For these acute
abdominal diseases, points to bear in mind are shown in this exhibit.
TABLE OF CONTENTS/OUTLINE
Contents1. General education of acute abdominal diseases with lumber pain.2. CT and MR applications for these abdominal
diseases.3. Technical developments for abdominal CT and MR. 4. Quizzes of CT and MR images for acute abdominal diseases with
lumber pain.Gastric ulcerDuodenal ulcerUreteral stoneAcute cholecystitisAcute pancreatitisPancreatic necrosisPyelonephritisRenal
cell carcionomaPancreas cancerGallbladder cancerIschemic colitis These general review and quizzes are provided for every radiology
resident/ fellow.
ER108-ED-X
New Trends in the Management of Acute Diverticulitis: Imaging Findings and Implications
All Day Room: ER Community, Learning Center
Participants
Marina C. Bernal Fernandez, MD, Boston, MA (Presenter) Nothing to Disclose
David D. Bates, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Cecilia Ponchiardi, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Joshua Teich, Boston, MA (Abstract Co-Author) Nothing to Disclose
Michael von Plato, Boston, MA (Abstract Co-Author) Nothing to Disclose
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Chaitan Narsule, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Avneesh Gupta, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Detail the recent changes in the surgical management of patients with acute diverticulitis2. Review CT imaging features of
diverticulitis that can help guide management3. Discuss the clinical implications of the Hinchey classification as well as the
complications of diverticulitis
TABLE OF CONTENTS/OUTLINE
Epidemiology of Acute Diverticulitis Pathophysiology of Acute Diverticulitis Current Trends and Recent Literature on the Changing
Surgical Management of Acute Diverticulitis Imaging Features of Acute Diverticulitis on CT -- Hinchey Classification -Complications and Fistulas -- Pathologic Correlation Images Summary
ER109-ED-X
Whole Body CT Protocol for Trauma: Review of Arm Positioning with Emphasis on Image Quality and
Radiation Dose
All Day Room: ER Community, Learning Center
Participants
Alessandro A. Lemos, MD, Milan, Italy (Presenter) Nothing to Disclose
Roberto Brambilla, PhD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Vincent R. Tatco, MD, Quezon City, Philippines (Abstract Co-Author) Nothing to Disclose
Maria C. Firetto, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Lucrezia Marica Gentile, l'Aquila, Italy (Abstract Co-Author) Nothing to Disclose
Cristiano Sorge, RT, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Pietro R. Biondetti, MD, Milano, Italy (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:1. To review arm positioning at whole-body CT protocol for trauma. 2. To review the influence of
different arm positioning techniques on image quality and radiation dose.3. To learn optimal strategies to minimize beam-hardening
artefacts and to reduce radiation dose in patients unable to abduct both or a single arm over the head.
TABLE OF CONTENTS/OUTLINE
Arm positioning techniques.-Standard arm positioning with overhead abduction of both arms (modified swimmer's position)-Alongside
the abdomen in foam sponge ramps (astronaut's position)-On a pillow ventrally (traveler's position).-Only one arm abducted over
the head (swimmer's position).Effect on image quality and radiation dose-Summary -The modified swimmer's position is the standard
technique to scan polytrauma patients when both arms can be fully abducted over the head.-The traveler's position is the most
appropriate technique to reduce beam hardening artefacts when both arms cannot be moved up. However, the radiation dose is
higher than that of standard swimmer's position.-We selectively employed swimmer's position to reduce beam hardening artifacts at
the base of neck and thoracic inlet. -The astronaut's position should be employed selectively when standard (arms up) CT cannot
be performed (i.e.shoulder fractures).
ER110-ED-X
Chasing the Dragon: America's Opiate Epidemic and the Emergency Radiologist
All Day Room: ER Community, Learning Center
Awards
Identified for RadioGraphics
Participants
David D. Bates, MD, Boston, MA (Presenter) Nothing to Disclose
Katherine M. Gallagher, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jennifer W. Uyeda, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Akira M. Murakami, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Bindu Setty, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Mariza O. Clement, MD, East Meadow, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. To recognize key emergency radiology findings by system in patients with opiate use2. To review the pathophysiology of various
opiate related conditions that are seen in emergency radiology3. To familiarize the audience with a multimodality imaging approach
to opiate related emergency conditions
TABLE OF CONTENTS/OUTLINE
Epidemiology of opiate abusePathophysiology of opioid related conditionsReview of imaging findings, Pitfalls and Sample Cases-Neuro (including hypoxic brain death, embolic stroke, mycotic aneurysm, heroin leukoencephalopathy)-- Chest (including cardiac
valve vegetations, septic embolic, pulmonary artery pseudoaneurysms)-- Gastrointestinal/Genitourinary (including intra-abdominal
abscesses, septic emboli to solid viscera)-- Musculoskeletal (including rhabdomyalysis, septic joint, osteomyelitis, bacterial
tenosynovitis of the hands on ultrasound)Summary
ER111-ED-X
Acute Presentations of Colorectal Carcinomas: What Radiologists Need To Know
All Day Room: ER Community, Learning Center
Participants
Manickam Subramanian, MBBS, FRCR, Singapore, Singapore (Presenter) Nothing to Disclose
Kabilan Chokkapan, MBBS, MD, chennai, India (Abstract Co-Author) Nothing to Disclose
Ashish Chawla, MD, MBBS, Singapore, Singapore (Abstract Co-Author) Nothing to Disclose
Jagadish Narayana Shenoy, Singapore, Singapore (Abstract Co-Author) Nothing to Disclose
Dinesh D. Chinchure, FRCR, Singapore, Singapore (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To briefly review various acute presentations of colorectal carcinomas. To briefly describe the vital role of computed tomography
in the evaluation of acute presentations of colorectal carcinomas. To present in an interactive manner a series of acute
presentations of colorectal carcinomas. To briefly review the diagnostic clues that will help radiologists to make an accurate
diagnosis.
TABLE OF CONTENTS/OUTLINE
The cases will be presented in an interactive manner. Key diagnostic points will be highlighted in the discussion of each case. The
list of acute presentations of colorectal carcinoma cases includes:Intestinal obstructionPerforation and peritonitisAcute appendicitis
and small bowel obstructionAbscessDiverticulitisColovesical fistulaIntussusceptionBleeding due to vascular invasion/erosion.
ER113-ED-X
Pediatric Non Accidental Head Trauma: Role of MRI and What a Radiologist Should Know ?
All Day Room: ER Community, Learning Center
Participants
Amin Kathan, MD, Chicago, IL (Presenter) Nothing to Disclose
Dheeraj Reddy Gopireddy, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose
Oluwaseun O. Babalola, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose
Osbert O. Egiebor, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose
Alexander Ree, MD, Oak Park, IL (Abstract Co-Author) Nothing to Disclose
Corinne E. Atty, DO, Chicago, IL (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Trauma is the most common cause of death in childhood, and non accidental head trauma is the most common cause of traumatic
death and morbidity in infants younger than 1 year. In this electronic exhibit we demonstrate key MRI imaging features indicative of
brain trauma in this pediatric population.Emphasis is also laid on key imaging sequences, common pitfalls and differential diagnosis as
well.
TABLE OF CONTENTS/OUTLINE
MRI imaging detected nearly four times as many intraparenchymal lesions (43%) as compared with CT imaging (11%). Cases of
abusive head trauma in young children five years of age and younger has more than doubled, from 13.7 to 28.9 per 100,000 in last
few years.3 times as many intraparencheymal lesions were detected by MRI (44%) compared to CT (15%) Key focus areas include
: Skull fracturesSubdural and epidural hematomasHemorrhagic contusionDiffuse axonal injury
ER114-ED-X
Radiology Reflexes: When Recommending Another Study is Required for a Complete Diagnosis
All Day Room: ER Community, Learning Center
Awards
Cum Laude
Participants
Meir H. Scheinfeld, MD, PhD, Bronx, NY (Presenter) Nothing to Disclose
Robert J. Dym, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose
Mike Spektor, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To identify emergency musculoskeletal imaging cases where a finding in a specific area requires additional imaging to complete the
diagnosisTo identify emergency thoracic, abdominal and pelvic imaging cases where a finding in a specific area requires additional
imaging to complete the diagnosisTo identify emergency neurological imaging cases where a finding in a specific area requires
additional imaging to complete the diagnosis
TABLE OF CONTENTS/OUTLINE
Using a quiz format, for each item, the imaging scenario will be presented and the viewer will be asked to choose the next
appropriate test to complete the diagnosis:Musculoskeletal Isolated medial or posterior malleolus fracture Isolated greater
trochanter fracture Calcaneal fracture(s) Pediatric bucket handle/corner fracture Hypertrophic osteoarthropathy Subtrochanteric
femoral fractureTorso Peripheral wedge shaped pulmonary opacity on non-contrast CT imaging Young male with lung masses
Isolated right varicocele Hyperenhancement of Segment IV of the liverNeurological Spinal lesion(s) on MRI Stroke in multiple
vascular territories Stroke in two separate vascular territories High medial temporal lobe T2 weighted signal on MRI
ER115-ED-X
More than Appendicitis: Imaging and Differential Diagnosis of Acute Right Lower Quadrant Pain
All Day Room: ER Community, Learning Center
Participants
Christopher J. Steel, MD, Travis AFB, CA (Abstract Co-Author) Nothing to Disclose
Trevor A. Thompson, MD, Columbus, OH (Abstract Co-Author) Nothing to Disclose
Dell P. Dunn, MD, Newton, MA (Abstract Co-Author) Nothing to Disclose
Valerie Hostetler, MD, Travis AFB, CA (Presenter) Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:
1. To review the ACR appropriateness criteria of imaging for right lower quadrant pain in different patient populations.
2. Discuss utility of intravenous, oral, and rectal contrast in imaging for acute abdominal pain.
3. Case review of abdominal and pelvic disease that often result in acute right lower quadrant pain.
TABLE OF CONTENTS/OUTLINE
Introduction
ACR appropriateness criteria of imaging for right lower quadrant pain in different patient populations
Use of intravenous, oral, and rectal contrast in imaging for acute abdominal pain
Comprehensive case review of abdominal and pelvic disease resulting in acute right lower quadrant pain
-Bowel
-Omentum/Mesentery
-Urinary
-Uterine/Ovarian
-Vascular
-Musculoskeletal
Summary
ER116-ED-X
Urinary Bladder Injury: Pearls and Pitfalls
All Day Room: ER Community, Learning Center
Participants
Krystal Archer-Arroyo, MD, Baltimore, MD (Presenter) Nothing to Disclose
Robin B. Levenson, MD, Newton, MA (Abstract Co-Author) Nothing to Disclose
Stuart E. Mirvis, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Review the types of bladder injury and associated findings on cystography, computed tomography (CT) and CT cystography.2.
Discuss the most appropriate imaging technique(s) to assess for urinary bladder injury.3. Demonstrate potential pitfalls in urinary
bladder injury evaluation to help avoid misdiagnosis.
TABLE OF CONTENTS/OUTLINE
I. Introduction II. AnatomyA. MaleB. Female III. Mechanisms of injuryA. BluntB. PenetratingC. Spontaneous IV. Classification
Systems A.American Association for the Surgery of Trauma (AAST)-Organ Injury Scale B. Societe Internationale D'Urologie V.
Imaging evaluation:A. CystographyB. Computed Tomography C. CT cystography VI. Types of Injury, including imaging findings and
treatment/managementA. ContusionB. Interstitial injuryC. Intraperitoneal ruptureD. Extraperitoneal rupture
i. Simple ii.
ComplexE. CombinedVII. Pitfalls, including but not limited to:A. Intraluminal blood clot in the bladder obscuring bladder injuryB.
Penetrating pelvic trauma with rectal injury mimicking bladder injuryC. Arterial bleed mimic VIII. Summary IX. References
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Stuart E. Mirvis, MD - 2015 Honored Educator
ER117-ED-X
Update and Review of Dual-Energy CT Clinical Applications of the Urolithiasis
All Day Room: ER Community, Learning Center
FDA
Discussions may include off-label uses.
Participants
Xiaohu Li, MD, Hefei, China (Presenter) Nothing to Disclose
Yongqiang Yu, MD, Hefei, China (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
• Review DECT technique and discuss clinically specific renal protocols
• Apply various DECT imaging displays and advance post-processing techniques to differentiate urinary stone composition and use Ultra-low-dose to find urinary stone
TABLE OF CONTENTS/OUTLINE
Dual energy implies at two different kV(80KV,140KV) levels simultaneously., which allows characterizing the imaged tissue or material.Imaging review of DECT protocols used to characterize different urinary stone composition: v
UA stone. with high accuracy. Urinary calculi can be effectively evaluated at Ultra-lowdose with use of lower tube voltages and the adaptive statistical iterative reconstruction algorithm not only in vitro but also in vivo.DECT provides diverse, easily utilized series that aid in more accurate characterization of diffe
ER118-ED-X
The Use of Split Bolus Single Pass Whole Body CT in the Severely Injured Trauma Patient
All Day Room: ER Community, Learning Center
Participants
Vincent Leung, MBCHB, Stoke-On-Trent, United Kingdom (Presenter) Nothing to Disclose
Sahithi Nishtala, MBBS, Stoke On Trent, United Kingdom (Abstract Co-Author) Nothing to Disclose
Hefin Jones, FRCR, Birmingham, United Kingdom (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Split bolus contrast CT provides angiographic and venous phase imaging with a single pass of the CT gantry. Following this exhibit
the learner should: Have the technical knowledge to implement a split bolus protocol. Understand the advantages and
disadvantages of split bolus CT compared to traditional multi-pass trauma CT Begin to recognise the appearance of solid organ and
vascular injury on split bolus CT
TABLE OF CONTENTS/OUTLINE
Physiology behind a split bolus CT protocol Technical requirements for split bolus CT An example split bolus CT protocol: Contrast
regime and timing Advantages of split bolus CT Disadvantages of split bolus CT Sample trauma cases performed with split bolus CT
including normal appearances, solid organ injury and vascular injury
ER119-ED-X
Hip Dislocations in the Emergency Department: What the Orthopedic Surgeon Needs to Know
All Day Room: ER Community, Learning Center
Awards
Cum Laude
Participants
Jacob C. Mandell, MD, Waltham, MA (Presenter) Nothing to Disclose
Richard A. Marshall, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Michael Weaver, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Mitchell A. Harris, PhD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
Bharti Khurana, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To understand the anatomy of the hip joint and how the mechanism of hip dislocation leads to certain patterns of osseous and soft
tissue injury. To understand the types of hip fracture dislocations, associated injuries, and sequelae. To describe key imaging
findings that the surgeon needs to know upon initial presentation and in the post-reduction setting.
TABLE OF CONTENTS/OUTLINE
Review the relevant anatomy of the hip joint using illustrations and radiological images. Demonstrate the different types of hip
dislocations, associated injuries, and complications on various imaging modalities. Describe and illustrate the classification systems
of hip fracture dislocation most commonly used by orthopedic surgeons, in a simplified manner. Describe key imaging findings that
the orthopedic surgeon needs to know to properly manage a hip dislocation upon its initial presentation and on post reduction
imaging. Review the imaging findings of dislocated hip arthroplasty.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Bharti Khurana, MD - 2014 Honored Educator
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
ER120-ED-X
Imaging Overlap in Inflammatory and Neoplastic Abdominopelvic Conditions in the Emergency Setting
All Day Room: ER Community, Learning Center
Participants
Tarek N. Hanna, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Gayatri Joshi, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Jacqueline Junn, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Tadeusz Ciszak, MD, Atlanta, GA (Presenter) Nothing to Disclose
Keith D. Herr, MD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose
Jamlik-Omari Johnson, MD, Atlanta, GA (Abstract Co-Author) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University
Press
TEACHING POINTS
1. Review emergent abdominopelvic inflammatory or infectious conditions that have imaging overlap with neoplasm.
2. Recognize morphologic patterns and imaging features favoring neoplasm versus infection/inflammation.
3. Be comfortable with the spectrum of imaging overlap, understanding that certain cases will be equivocal. Review management of
these equivocal cases.
4. Learn appropriate imaging follow-up for both neoplastic and inflammatory/infectious conditions.
TABLE OF CONTENTS/OUTLINE
Emergent abdominopelvic inflammatory or infectious conditions, which have overlapping imaging features with neoplasm will be
presented in tandem, with an emphasis on imaging features favoring one condition or the other. These conditions include
esophagitis/esophageal cancer, gastritis/gastric adenocarcinoma, colitis/colon cancer, appendicitis/mucinous tumor or carcinoid,
pancreatitis/pancreatic adenocarcinoma, cholecystitis/gallbladder carcinoma, cholangitis/cholangiocarcinoma, hepatitis/infiltrative
hepatocellular carcinoma, focal pyelonephritis/renal cell carcinoma or renal lymphoma, ureteritis/transitional cell carcinoma,
cystitis/transitional cell carcinoma, mesenteric fat stranding/infiltrative lymphoma or peritoneal carcinomatosis, and
aortitis/lymphoma. Additionally, appropriate imaging follow-up will be addressed for further elucidation of these conditions.
ER121-ED-X
Volleyball Injuries: Musculoskeletal Trauma of the Extremities and the Spine
All Day Room: ER Community, Learning Center
Participants
Daichi Hayashi, MBBS, PhD, Bridgeport, CT (Presenter) Nothing to Disclose
Akira M. Murakami, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ali Guermazi, MD, PhD, Boston, MA (Abstract Co-Author) President, Boston Imaging Core Lab, LLC Research Consultant, Merck KgaA
Research Consultant, Sanofi-Aventis Group Research Consultant, TissueGene, Inc Research Consultant, OrthoTrophic Research
Consultant, AstraZeneca PLC
Frank W. Roemer, MD, Boston, MA (Abstract Co-Author) Chief Medical Officer, Boston Imaging Core Lab LLC; Research Director,
Boston Imaging Core Lab LLC; Shareholder, Boston Imaging Core Lab LLC; ;
Yogesh Kumar, MD, Bridgeport, CT (Abstract Co-Author) Nothing to Disclose
Michel D. Crema, MD, Boston, MA (Abstract Co-Author) Shareholder, Boston Imaging Core Lab, LLC
TEACHING POINTS
To describe acute trauma and chronic overuse injuries in volleyball players at their most common sites and to discuss the available
imaging methods for diagnosis and detailed assessment focusing on therapeutic relevance To illustrate and discuss the mechanisms
of injuries in volleyball players
TABLE OF CONTENTS/OUTLINE
1. Epidemiology of volleyball injuries
2. Pictorial review of characteristic injuries in volleyball players, including the following pathologies and mechanism of injury:Lower
extremities: Ankle – inversion sprain, talofibular ligament tear, calcaneofibular ligament tear Knee – jumper’s knee, anterior cruciate
ligament tear, medial collateral ligament tearUpper extremities: Shoulder – internal and external impingement resulting in rotator
cuff injury, labral tear and muscle denervation Hand – tear of collateral ligaments at the interphalangeal joints of fingers, Mallet
fingerBack and spine: spondylolysis, stress-related bone marrow edema of pars interarticularis, paravertebral muscle strainInjuries in
youth and children: tibial tuberosity apophysitis3. Role of multimodality imaging for treatment decisions and conclusion
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Ali Guermazi, MD, PhD - 2012 Honored Educator
ER122-ED-X
A Hazard at Home? Facilitating the Safe Imaging of Repatriated Patients with Confirmed Ebola Virus Disease
All Day Room: ER Community, Learning Center
Participants
Josephine E. Bretherton, MA, MBBS, London, United Kingdom (Presenter) Nothing to Disclose
Gary Cross, MBBCHIR, London, United Kingdom (Abstract Co-Author) Nothing to Disclose
Fiona Lam, MBBS, London, United Kingdom (Abstract Co-Author) Nothing to Disclose
Carla Papagiorcopulo, MD, London, United Kingdom (Abstract Co-Author) Nothing to Disclose
Dylan R. Tsukagoshi, MBBS, London, United Kingdom (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
By viewing this exhibit, the reader will be able to:1. Gain insight into the standard operating protocol developed in our institution for
the safe diagnostic imaging of contagious patients on our High Level Isolation Unit, specifically with regard to X-ray and ultrasound
imaging of patients with confirmed Ebola Virus Disease.2. Consider the technical limitations and challenges of performing imaging
investigations on this patient cohort.3. Share the lessons learned when the protocol was exercised, and the plans we made to
prepare for a wider outbreak.
TABLE OF CONTENTS/OUTLINE
1. Background: Ebola Virus Disease in Africa and the international response2. The High Level Isolation Unit at our institution:
history, description, photographs and floorplan3. Role of imaging in patients with confirmed Ebola Virus Disease4. Scope for imaging
of patients with confirmed Ebola Virus Disease5. Outline of departmental protocol created in anticipation of the first patient's arrival
(X-ray and limited ultrasound)6. Lessons learned from the first admission and subsequent development of protocol for portable
ultrasound imaging7. Planning for increased numbers of patients in isolation (overflow unit) and for cases no longer considered
infectious
ER123-ED-X
Twist and Shout: A Resident's Guide to Recognizing Volvulus and Torsion in Organs across the Body
All Day Room: ER Community, Learning Center
Participants
Heather Schultz, MD, Santa Barbara, CA (Presenter) Nothing to Disclose
Maximilian Cho, MD, Santa Barbara, CA (Abstract Co-Author) Nothing to Disclose
Tara A. Bloom, MD, Santa Barbara, CA (Abstract Co-Author) Nothing to Disclose
Bernard Chow, MD, Santa Barbara, CA (Abstract Co-Author) Nothing to Disclose
Christopher D. Kuzminski, MD, Charlottesville, VA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Torsion consists of a structure twisting on a pedicle around its axis. This serious condition can lead to vascular constriction within a
twisted pedicle and result in visceral ischemia. The gastrointestinal tract is a well-recognized site of volvulus. Abnormally long or lax
peritoneal attachments can predispose organs to hypermobility and eventual twisting. Ovarian and testicular anatomy similarly
prediposes these organs to torsion. Although less frequent, torsion can occur in other organs, including the heart and lungs. Since
clinical presentations of torsion may be nonspecific, imaging often plays a crucial role in diagnosis and management. Knowledge of
specific imaging findings for both common and rare forms of torsion is critical for diagnosis and guides timely intervention.
TABLE OF CONTENTS/OUTLINE
This exhibit will provide a thorough review of intra-abdominal volvulus and torsion as well discuss less common extra-abdominal
correlates. The incidence, risk factors, pathophysiology, imaging findings, complications and management will be presented in a
case-based format. Unique institutional examples include volvulus of the stomach, gallbladder, cecum and sigmoid colon, as well
as cases of ovarian, testicular and lobar lung torsion. Additionally, examples of cardiac, splenic and renal torsion will be presented
to supplement our institution's cases.
ER124-ED-X
Beyond Appendicitis: Ultrasound Findings of Acute Bowel Pathology
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Jihee Choe, MD, Boston, MA (Presenter) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aya Michaels, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Asha Sarma, MD, Jamaica Plain, MA (Abstract Co-Author) Nothing to Disclose
Urvi P. Fulwadhva, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
TEACHING POINTS
1) Bowel pathology is a common unexpected finding on routine pelvic and abdomen ultrasound; therefore, familiarity with
characteristic ultrasound features of bowel pathologies is essential. 2) Graded compression scan technique is an important
component of ultrasound evaluation of the bowel and can significantly improve the ability to identify bowel pathology. 3) Real time
sonographic assessment of wall thickening and bowel motility provides important clues to underlying bowel pathology.
TABLE OF CONTENTS/OUTLINE
1) Basic ultrasound scan technique for bowel evaluation.2) Anatomic review of the ultrasound appearance of normal small and large
bowel.3) Case based review of the ultrasound features of acute bowel abnormalities including appendicitis, enteritis, colitis, bowel
obstruction, ileus, and bowel ischemia.4) Common mimics and diagnostic pitfalls in ultrasound evaluation of the bowel.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
ER125-ED-X
It's a Bleeder! Traumatic Intracranial Hemorrhage and Associated Complications
All Day Room: ER Community, Learning Center
Participants
Neha Gowali, MD, Morristown, NJ (Presenter) Nothing to Disclose
Elana B. Smith, MD, Denver, CO (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1.
2.
3.
Recognize the types of traumatic intracranial hemorrhage.
Review the complications associated with traumatic intracranial hemorrhage.
Discuss imaging pitfalls that may be misinterpreted as intracranial hemorrhage.
TABLE OF CONTENTS/OUTLINE
I. Introduction
II. Types of Hemorrhage
A. Epidural Hematoma – Arterial and Venous
B. Subdural Hematoma
C. Subarachnoid hemorrhage
D. Intraventricular Hemorrhage
E. Parenchymal hemorrhage/contusion
F. Diffuse Axonal Injury
III. Special Cases
A. Penetrating Trauma
B. Non-accidental Trauma
IV. Pitfalls/Mimics of hemorrhage
A. Pseudosubarachnoid hemorrhage
B. Failure of FLAIR suppression
C. Contrast staining
D. Calcifications
V. Complications
A. Herniation Patterns
1. Uncal
2. Descending Transtentorial
3. Ascending Transtentorial
4. Subfalcine
5. External
6. Cerebellar Tonsillar
B. Secondary Hemorrhage
C. Infarct
D. Encephalomalacia/Gliosis
VI. Summary
ER126-ED-X
Small Object, Big Trouble: Dangerous Foreign Body in Adults
All Day Room: ER Community, Learning Center
Participants
Wei Wang, Beijing, China (Presenter) Nothing to Disclose
Xiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to Disclose
Xiaoyu Hu, Beijing, China (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Discuss the role of CT in the diagnosis and evaluation of complications for foreign body in adults. Describe the characteristics of
foreign bodies that may cause trouble in adults. Recognize the critical situations that may require aggressive treatment.
TABLE OF CONTENTS/OUTLINE
□Predisposed patients & Clinical history□Types of foreign bodies in adults–Common types–The trouble ones□Imaging approach –Plain
film & CT–The importance of CT •Existence, location, characteristics, complications •Fast and accurate □More cautions, prefer CT–
Special shape –Special composition –Special location –Special history □Treatment
ER127-ED-X
Imaging Diagnosis of Various Appendiceal Disease: Beyond Acute Appendicitis
All Day Room: ER Community, Learning Center
Participants
Akitoshi Inoue, MD, Shiga, Japan (Presenter) Nothing to Disclose
Shinichi Ota, MD,PhD, Otsu, Japan (Abstract Co-Author) Nothing to Disclose
Akira Furukawa, MD, PhD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Takayasu Iwai, Omihachiman, Japan (Abstract Co-Author) Nothing to Disclose
Ryo Kuwahara, MD, Kyoto, Japan (Abstract Co-Author) Nothing to Disclose
Shigetaka Sato, MD, Otsu, Japan (Abstract Co-Author) Nothing to Disclose
Kenji Furuichi, Osaka, Japan (Abstract Co-Author) Nothing to Disclose
Michio Yamasaki, MD, Ritto, Japan (Abstract Co-Author) Nothing to Disclose
Norihisa Nitta, MD, Kyoto, Japan (Abstract Co-Author) Nothing to Disclose
Kiyoshi Murata, MD, Otsu, Japan (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Various pathologic conditions including inflammatory processes may arise in the appendix. Besides, other diseases required to be
distinguished from acute appendicitis may also arise in and around the appendix. Radiologist should be familiar with the modalities
and pathophysiology of the appendceal disease.The aims of this presentation include the following:1) To describe anatomy of the
appendix and imaging modalities for appendiceal disease2) To review many variations and differential diagnoses of acute
appendicitis3) To describe other diseases of the appendix besides appendicitis
TABLE OF CONTENTS/OUTLINE
1, Anatomy, variation, and anomaly of the appendix2, Imaging modalities for diagnosis of appendicitis3, Acute Appendicitis 3-1,
Cause 3-2, Severity 3-3, Complications 3-3, Treatment 3-4, Atypical appendicitis 3-5, Differential diagnosis4, Beyond
appendicitis 4-1, Appendiceal diverticulum
Diverticulitis, acute appendicitis with diverticulum 4-2, Intussusception
Caused
by acute appendicitis, adenocarcinoma 4-3, Neoplasms
Benign: appendiceal neuromak, endometriosis
Malignant: carcinoid,
mucinous cyst adenoma, adenocarcinoma, lymphoma 4-4, Miscellaneous
Small bowel obstruction due to adhesive appendix5,
Summary
ER128-ED-X
Cross-Sectional Imaging Spectrum of Uterine and Fallopian Tube Emergencies
All Day Room: ER Community, Learning Center
Participants
Ameya J. Baxi, MBBS, DMRD, San Antonio, TX (Presenter) Nothing to Disclose
Vijayanadh Ojili, MD, San Antonio, TX (Abstract Co-Author) Nothing to Disclose
Dhanashree Rajderkar, MD, Gainesville, FL (Abstract Co-Author) Nothing to Disclose
Arpit M. Nagar, MBBS, Columbus, OH (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. To describe the imaging manifestations of uterine and fallopian tube emergencies and discuss the clinical implications of specific
imaging findings.2. To discuss the role of imaging and image-guided interventions in the management of these patients.
TABLE OF CONTENTS/OUTLINE
1. Introduction, etiopathogenesis and clinical presentation of uterine and fallopian tube emergencies.2. Role of cross-sectional
imaging modalities (particularly MDCT)3. Imaging spectrum of uterine and fallopian tube emergencies.
A. Uterus (gas gangrene
of the uterus, prolapsing fibroid, red degeneration of fibroids, uterine perforation from a wide variety of causes etc.)
B. Fallopian
tube (tubal torsion, tubo-ovarian abscess, ruptured tubal ectopic etc.)
C. Miscellaneous (uterine AVM, uterine artery
aneurysm/pseudoaneurysm, uterine rupture with abscess, fistulas etc.)
ER129-ED-X
Ultrasound of Right Upper Quadrant Abdominal Pain: The Gallbladder is Not Always to Blame!
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Identified for RadioGraphics
Participants
Gayatri Joshi, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Kevin A. Crawford, MD, Chattanooga, TN (Presenter) Nothing to Disclose
Tarek N. Hanna, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Keith D. Herr, MD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose
Kathryn A. Robinson, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
Nirvikar Dahiya, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Review the causes of right upper quadrant pain using an organ-system approach Illustrate the sonographic appearance of select
pathologies from each organ-system with multimodality imaging correlates Discuss the pathophysiology and management of these
entities as relevant to the radiologist
TABLE OF CONTENTS/OUTLINE
Though acute cholecystitis is the most common diagnosable cause for right upper quadrant (RUQ) pain presenting in the Emergency
Department, over 1/3 of these patients have RUQ pain attributable to other causes. This exhibit is a systematic organbased review of etiologies for RUQ pain in a case-based format. The cases shown will demonstrate gallbladder/biliary, pancreatic,
hepatic, gastrointestinal, renal, adrenal, vascular, and thoracic etiologies for RUQ pain. As ultrasound (US) is the modality of choice
for evaluation of RUQ abdominal pain in the Emergency setting, each entity will be illustrated with initial sonographic appearance
followed by multimodality imaging correlates and a short discussion of pathophysiology and management of these entities as
relevant to the radiologist.
ER130-ED-X
Is That A Fracture? Differentiating Spine Fractures From Their Mimics
All Day Room: ER Community, Learning Center
Participants
Thomas F. Flood, MD, PhD, Aurora, CO (Abstract Co-Author) Nothing to Disclose
Elana B. Smith, MD, Denver, CO (Presenter) Nothing to Disclose
TEACHING POINTS
1. Demonstrate developmental variants and disease processes that can simulate spine fractures.
2. Recognize imaging artifacts that may simulate spine fractures and how they can be distinguished from fractures.
3. Review the pathogenesis/technical factors that result in these spine fracture mimics.
TABLE OF CONTENTS/OUTLINE
Spine fracture mimics will be directly compared and contrasted to similar appearing fractures. The information will be presented in
quiz format. Cases will include:
I. Normal Variants
A. Os odontoidium and os terminale
B. Butterfly vertebrae
C. Limbus body
D. Neural arch clefts
E. Unfused apophysis
F. Venous channels
G. Physiologic wedging
H. Trapezoidal L5 vertebral body
I. Transverse foramen defect
II. Pathologic Processes
A. Schmorl node
B. Osteophytes
C. Scheuerman’s disease
D. Kyphosis
E. Spondylolysis
III. Technical
A. Mach lines
B. Motion artifact
C. Beam hardening artifact
D. Parallax
ER131-ED-X
Detection and Management of FISHBONE Ingestion
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
SHOTA TAKEHARA, Okinawa, Japan (Presenter) Nothing to Disclose
Masahiro Okada, MD, Nishihara-Cho, Japan (Abstract Co-Author) Nothing to Disclose
Maho Tsubakimoto, MD, Nishihara, Japan (Abstract Co-Author) Nothing to Disclose
Tsuneo Yamashiro, MD, Nishihara, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation
Yuko Iraha, Nishihara-cho, Japan (Abstract Co-Author) Nothing to Disclose
Sadayuki Murayama, MD, PhD, Nishihara-Cho, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation
Yurika Agarie, MD, Okinawa, Japan (Abstract Co-Author) Nothing to Disclose
Kimei Azama, Nishihara City, Japan (Abstract Co-Author) Nothing to Disclose
Nanae Tsuchiya, Okinawa, Japan (Abstract Co-Author) Nothing to Disclose
Makoto Takara, Okinawa, Japan (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The purposes of this exhibit are:1. To review the findings of plain X-ray, CT and US in patients with FISHBONE.2. To discuss the
relationship between clinical and image findings in patients with FISHBONE, including emergency (perforation and abscess, etc).3.
To explain the utility of CT for the complications associated with FISHBONE.This review article is provided for every radiology
resident/ fellow.
TABLE OF CONTENTS/OUTLINE
1. Signs and symptoms of FISHBONE; including risk factors of FISHBONE ingestion; acute inflammation type and chronic status
2. CT applications for acute abdominal diseases
3. X-ray, CT and US findings of FISHBONE ingestiona) X-ray; linear calcification, b) CT; linear high density, c) US; linear high echoic
shadow4. When FISHBONE is inserted into different locations, such asa) Pharynx, b) Esophagus, c) Stomach, d) Duodenum, e)
Small intestine, f) Colon, g) Passing from stomach to liver5. Treatment strategy corresponding to the location and symptom of
FISHBONEa) Surgical resection, b) Endoscopic resection c) Laparoscopic resection, d) Abscess drainage, e) Conservative
management6. Perforation from GI tract
7. The utility of the workstation (reconstructed CT images)
8. Pitfalls of FISHBONE imaging
9. Quizzes of CT imaging for acute abdomen
ER132-ED-X
First Trimester Emergencies: What the Radiologist Needs to Know and What the Clinician Wants to Know
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Catherine Phillips, MD, Boston, MA (Presenter) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Elizabeth Ginsburg, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
Bharti Khurana, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. First trimester embryologic development is a stepwise process and knowledge of the findings suspicious for pregnancy failure is
critical.2. Complications of early pregnancy include ectopic implantation, subchorionic hematoma, ectopic implantation, pregnancy
failure, retained productions of conception, and gestational trophoblastic disease.3. To provide meaningful interpretation and
improve the value of image interpretation, radiologists must understand what the ER and OB/GYN physicians need to know to guide
effective treatment of first trimester emergencies.
TABLE OF CONTENTS/OUTLINE
1. The anatomy of the developing embryo including illustrations, ultrasound, and MRI examples.2. Radiologic appearance and
management of early pregnancy complications, including ectopic pregnancy, gestational trophoblastic disease, subchorionic
hematoma, retained products of conception, and pregnancy failure.3. Frequently seen complications of pregnancy associated with
assisted reproductive techniques.4. Imaging appearance of common pitfalls and mimics in imaging early pregnancy, including
trauma, hemorrhagic ovarian cysts, and pre-existing lesions such as pedunculated fibroids.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
Bharti Khurana, MD - 2014 Honored Educator
ER133-ED-X
The Many Faces of Ectopic Pregnancy
All Day Room: ER Community, Learning Center
Participants
Arash Bedayat, MD, Worcester, MA (Presenter) Nothing to Disclose
Byron Y. Chen, MD, Worcester, MA (Abstract Co-Author) Nothing to Disclose
Carolyn S. Dupuis, MD, Worcester, MA (Abstract Co-Author) Nothing to Disclose
William Parkhurst, MD, Jefferson, MA (Abstract Co-Author) Nothing to Disclose
Michael J. Caruso, DO,BS, Worcester, MA (Abstract Co-Author) Nothing to Disclose
Hao S. Lo, MD, Worcester, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Review the typical and atypical imaging findings of ectopic pregnancy.
2. Discuss the imaging pitfalls and clinical complications associated with the diagnosis.
TABLE OF CONTENTS/OUTLINE
Knowledge of the different manifestations of ectopic pregnancy and differentiation of ectopic pregnancy from other causes of first
trimester abdominal pain or bleeding (i.e., intrauterine pregnancy, intrauterine fetal demise and molar pregnancy) is critical in the
emergency setting. Ectopic pregnancy is the most common cause of pregnancy-related mortality in the first trimester. Key imaging
findings and pertinent recommendations to include in the radiology report will be discussed in this educational exhibit.
ER134-ED-X
Secondarily Caused Acute Abdomen: What is the "True" Causative, but Covert Disease in the Patient?
All Day Room: ER Community, Learning Center
Participants
Maho Tsubakimoto, MD, Nishihara, Japan (Presenter) Nothing to Disclose
Tsuneo Yamashiro, MD, Nishihara, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation
Nanae Tsuchiya, Okinawa, Japan (Abstract Co-Author) Nothing to Disclose
Masahiro Okada, MD, Nishihara-Cho, Japan (Abstract Co-Author) Nothing to Disclose
Sadayuki Murayama, MD, PhD, Nishihara-Cho, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation
TEACHING POINTS
Although acute abdomens are very common for radiologists, we rarely encounter acute abdomens secondarily caused by
unexpected, covert diseases in daily practice. The purpose of this exhibit is to introduce these rare acute abdominal conditions with
actual CT images.
TABLE OF CONTENTS/OUTLINE
Classification of the etiology Imaging findings and details of cases from our institutions in a quiz format. Endocrine abnormality
Acute pancreatitis due to parathyroid adenoma Jejunum perforation due to pyloric gastrinoma = Zollinger-Ellison Syndrome
Megacolon with severe constipation in multiple endocrine neoplasia type 2bAutoimmune disease Severe enteritis due to systemic
lupus erythematosus Bilateral adrenal infarction due to antiphospholipid antibody syndrome Intestinal bleeding due to polyarteritis
nodosa Enteritis due to Henoch–Schönlein purpuraInfection Intestinal obstruction by anisakiasis Intestinal strongyloidiasis coinfected with human T-lymphotropic virus type 1Foreign body Liver abscess due to fish bone migration Pelvic actinomycosis due to
an intrauterine device Esophageal perforation by a press-through packOther Renal vein thrombosis due to nephrotic syndrome
Bowel obstruction and liver subcapsular hematoma due to heterotopic endometriosis Bowel obstruction by a gallstone
ER135-ED-X
Diverticulosis Stem-to-Stern: A New Look at an Old Disease with Emphasis on Diagnosis and Treatment of
Complications
All Day Room: ER Community, Learning Center
Participants
Jessica Wen, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Satomi Kawamoto, MD, Laurel, MD (Abstract Co-Author) Nothing to Disclose
Margaret Fynes, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Richard M. Fleming, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Elliot K. Fishman, MD, Baltimore, MD (Abstract Co-Author) Institutional Grant support, Siemens AG; Institutional Grant support,
General Electric Company;
Pamela T. Johnson, MD, Baltimore, MD (Presenter) Consultant, National Decision Support Company
Franco Verde, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Diverticular disease can affect any gastrointestinal segment from esophagus to the distal colon. Radiologists must be cognizant of
potential complications of diverticulosis in each anatomic segment. This exhibit reviews: Pathophysiology of diverticulosis
Classification including rare forms (meckels, appendiceal) CT technique for optimal evaluation CT findings in setting of complications
Management of complications
TABLE OF CONTENTS/OUTLINE
Background Pathophysiology Classification Esophageal Gastric Duodenal Jejunal Meckels Ileocecal Appendiceal Colonic Imaging
Fluoroscopy CT protocols tailored to suspected complications PO and IV contrast for inflammation water soluble PO contrast if
perforation suspected neutral/no PO if GI bleeding optimal timing delay to avoid pseudothrombus of mesenteric veins
MPRs facilitate identification of complications (mesenteric inflammation, hemorrhage)Complications Dysphagia Aspiration Bacterial
overgrowth Obstruction/inflammation Perforation Abscess (subserosal, peritoneal, hepatic) Septic thrombophlebitis Hemorrhage
Bladder/vaginal fistulaTreatment Conservative management Abscess drainage Surgical resection Embolization of active bleeding
Anticoagulation for septic thrombophlebitis
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Pamela T. Johnson, MD - 2016 Honored Educator
Elliot K. Fishman, MD - 2012 Honored Educator
Elliot K. Fishman, MD - 2014 Honored Educator
Elliot K. Fishman, MD - 2016 Honored Educator
ER136-ED-X
No Way Out: Causes of Duodenal and Gastric Outlet Obstruction
All Day Room: ER Community, Learning Center
Awards
Identified for RadioGraphics
Participants
Kris Tantillo, MD, Bronx, NY (Presenter) Nothing to Disclose
Benjamin Taragin, MD, Teaneck, NJ (Abstract Co-Author) Medical Advisory Board, Carestream Health, Inc
Meir H. Scheinfeld, MD, PhD, Bronx, NY (Abstract Co-Author) Nothing to Disclose
Victoria Chernyak, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose
Alla M. Rozenblit, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose
Robert J. Dym, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is to:1. Provide an image rich review of common and uncommon causes of duodenal and gastric outlet
obstruction, providing classic imaging findings when appropriate, which may be encountered in ER setting2. Demonstrate the
overlap in the imaging appearance of many of these conditions on radiography and upper GI series and to show how cross sectional
imaging can be used for further evaluation
TABLE OF CONTENTS/OUTLINE
Outline: Pediatric/Congenital:Including cases such as pyloric stenosis, duodenal atresia, duodenal web/diaphragm, malrotation with
midgut volvulus, annular pancreas, and obstructing duplication cyst
Infectious/inflammatory:Including cases such as
retroperitoneal fibrosis, peptic ulcer disease, Crohns stricture, duodenitis, and pancreatitis
Neoplastic:Including cases such as gastric/duodenal mass, pancreatic mass, and colon mass Mechanical:Including cases such as
Bouveret syndrome, gastric volvulus, gastroparesis, bezoar, SMA syndrome, gastric volvulus, post-traumatic/spontaneous duodenal
hematoma, and iatrogenic/post-surgical
ER137-ED-X
Computed Tomography in Elderly Patients with Acute Abdominal Pain: What Surgeons Need to Know
All Day Room: ER Community, Learning Center
Participants
Lourdes Del Campo, PhD, Madrid, Spain (Presenter) Nothing to Disclose
Elena Ocon, MD, PhD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Pablo Rodriguez Carnero, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Ricardo Rivas Cuadrado, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Paloma Largo Flores, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Ramiro Pedro Campos Rivas, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Jose M. Munoz, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Review the most frequent pathology in elderly patients with abdominal pain in the emergency room.Evaluate the imaging findings in
computed tomography (CT) in common and uncommon abdominal pathology in elderly peopleDiscuss the principal imaging findings
that influences the management and decision-making in these patients.
TABLE OF CONTENTS/OUTLINE
As the population in the world continues to age, it is frequent to find in the emergency room patients older than 80 years old
presenting with acute abdominal pain.The most common diagnosis in this subset of patients includes small and large bowel
obstruction, inflammatory-infectious diseases, bowel ischemia and infarction, vascular related emergency, perforation, neoplasm,
appendicitis and hernias. Our institution attends a great number of patients older than 80 years old suffering abdominal pain in the
emergency department. Abdominopelvic CT is the method of choice used in these patients. This poster shows the typical and
atypical radiological findings to illustrate the most frequent conditions associated with acute abdominal pain, specially emphasizing
on how the clinical or surgical management may be influenced by the imaging. Diagnosis was confirmed with final clinical diagnosis,
surgical intervention and/or follow-up.
ER138-ED-X
IVC Trauma. What are We Missing? A Fresh Look and Proposal for a Comprehensive Location Based IVC
Injury Grading
All Day Room: ER Community, Learning Center
Participants
Razia Rehmani, MD, New York, NY (Presenter) Nothing to Disclose
TEACHING POINTS
What is the current AAST IVC injury grading? How can you improve it?
TABLE OF CONTENTS/OUTLINE
Introduction: IVC injuries although rare are associated with a high mortality rate. Inspite of the recent advances in imaging and
surgical techniques, IVC trauma accounts for 25% of abdominal vascular trauma, of which more than a third of patients expire
before reaching the hospital. About half of the patients who reach hospital expire within 48 hours. AAST qualifies IVC injury as a
grade III or more. Penetrating wounds account for 85-95% of trauma to IVC and blunt abdominal trauma (BAT) accounts for only 310%.Role of Imaging: Key identifers of IVC injury on CECT include (1) irregular contour (2) retroperitoneal hematoma, (3) contrast
extravasation. We propose a more systematic location based approach to grade IVC injuries; Grade 1 (Infrarenal), Grade 2
(Suprarenal/Infrahepatic) & Grade 3 (Suprahepatic/Retrohepatic). Suprarenal injuries usually result from BAT, whereas infrarenal are
more often due to penetrating wounds with a better prognosis. Retrohepatic injuries are associated with other severe injuries and
have a very high mortality rate and are often seen at laparotomy.Summary: Stakes are high when dealing with IVC injuries. A
simplified location based approach such as ours can allow quick assessment and appropriate triage of these critical patients.
ER139-ED-X
Rectal Trauma: Current Concepts in Imaging Diagnosis and Management
All Day Room: ER Community, Learning Center
Participants
Justin Holder, MD, Brooklyn, NY (Presenter) Nothing to Disclose
Patrick J. Hammill, MD, Brooklyn, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Review the anatomy of the rectum and perirectal spaces, including regional arterial supply and venous drainage. Describe and
demonstrate the spectrum of imaging findings seen with rectal injuries. Highlight pitfalls in imaging interpretation. Discuss
management of rectal injuries, including surgical and nonoperative approaches. Demonstrate important imaging findings to guide
trauma management.
TABLE OF CONTENTS/OUTLINE
Injuries to the rectum have become increasingly common with rises in urban violence, and considerable debate exists regarding their
optimal treatment. This exhibit will review the rectal and anal canal anatomy and imaging appearance. A comprehensive spectrum of
injuries found in blunt and penetrating rectal trauma will then be presented in a quiz format, which will include various grading
scales used in clinical practice. The multiple management approaches to rectal injury will be highlighted, and emphasis will be placed
on current controversies in operative and nonoperative practices. After reviewing the exhibit, the participant will be able to identify
the imperative imaging findings that influence management decisions.
ER140-ED-X
High Energy Facial Fractures: Ten Key Points. A Systematic Approach for an Easy Diagnostic and Classification
All Day Room: ER Community, Learning Center
Participants
Luis S. Cueto, MD, PhD, Sevilla, Spain (Presenter) Nothing to Disclose
Daniela D. Martins-Romeo, MD, Seville, Spain (Abstract Co-Author) Nothing to Disclose
Alejandro Garcia de la Oliva, MD, Sevilla, Spain (Abstract Co-Author) Nothing to Disclose
Teresa Ruiz Garcia, MD, PhD, Sevilla, Spain (Abstract Co-Author) Nothing to Disclose
Amparo Rivera, MD, Sevilla, Spain (Abstract Co-Author) Nothing to Disclose
Esther Piriz, Sevilla, Spain (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Know the types of complex fractures of the face. Evaluate the structures affectec specifically in each type. Use of check list for a
correct diagnosis. Exhibition of interactive cases.
TABLE OF CONTENTS/OUTLINE
Review of facial butresses system. Describe the face high energy fractures: Le Fort I, Le Fort II, Le Fort III and N.O.E. Fractures.
Key structures affected in each fracture. CT protocols. The best views for evaluate them. Chek list for a easy, rapid and safe
diagnostic. Synchronous skull and spine involvement. Presentation of cases problem.
ER141-ED-X
Torsion of Wandering Spleen: A Rare Cause of Acute Abdomen
All Day Room: ER Community, Learning Center
Participants
Michele Porcu, MD, Cagliari, Italy (Presenter) Nothing to Disclose
Giovanni M. Argiolas, MD, Monserrato, Italy (Abstract Co-Author) Nothing to Disclose
Giovanna Demurtas, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
Grazia T. Bitti, MD, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
Paolo Siotto, MD, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
Luca Saba, MD, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
Stefano Cossa, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
Stefano Cossa, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Recognise the main radiological features of the torsion of wandering spleen. Distinguish this condition from other causes of acute
abdomen.
TABLE OF CONTENTS/OUTLINE
Acute abdomen is one of the most frequent clinical syndromes in emergency department. The quick recognition of the etiology of
this clinical pattern is of primary importance in order to correctly manage the patient and limit complications.Among the possible
causes of acute abdomen, the torsion of not fixed organs (such as spleen, ovaries, omentum and testes) have always to be
considered.The “wandering spleen” is a very rare condition, due to the absence or accentuated laxity of the spleen suspensory
ligaments, in particular the gastrolienal and the lienorenal. This condition is more frequent in the paediatric and female
population.The torsion of the vascular pedicle of the spleen on its longitudinal axis, with splenic ischemia and the onset of the
acute abdomen syndrome, is one of the possible complications of this condition.
ER142-ED-X
MDCT Review of Intravenous Drug Abuse Complications
All Day Room: ER Community, Learning Center
Participants
Franco Verde, MD, Baltimore, MD (Presenter) Nothing to Disclose
Constantine Burgan, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Elliot K. Fishman, MD, Baltimore, MD (Abstract Co-Author) Institutional Grant support, Siemens AG; Institutional Grant support,
General Electric Company;
TEACHING POINTS
Intravenous drug abuse is becoming an epidemic in the US Multiple complications can occur from simple cellulitis to large open
wounds, vascular injury, and septic emboli. Radiologists must be aware of such complications and imaging findings for optimal
patient care
TABLE OF CONTENTS/OUTLINE
A. Introduction Statistics on IV drug abuse in the US B. Role of imaging Extent of disease Benefits of MPR/3Ds C. Case examples of
Cellulitis without abscess Cellulitis with abscess Cellulitis with ulceration Cellulitis with thrombophlebitis Chronic wounds Deep
extension of abscess Arterial pseudoaneurysm Retained needles Septic emboli D. Management of complications
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Elliot K. Fishman, MD - 2012 Honored Educator
Elliot K. Fishman, MD - 2014 Honored Educator
Elliot K. Fishman, MD - 2016 Honored Educator
ER143-ED-X
A Tale of Two Ovaries: Cross-Sectional Imaging Spectrum of Ovarian Emergencies
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Ameya J. Baxi, MBBS, DMRD, San Antonio, TX (Presenter) Nothing to Disclose
Arpit M. Nagar, MBBS, Columbus, OH (Abstract Co-Author) Nothing to Disclose
Dhanashree Rajderkar, MD, Gainesville, FL (Abstract Co-Author) Nothing to Disclose
Vijayanadh Ojili, MD, San Antonio, TX (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. To describe the imaging manifestations of ovarian emergencies and discuss the clinical implications of specific imaging findings.2.
To discuss the role of imaging and image-guided interventions in the management of these patients.3. To highlight the usefulness
of imaging in evaluating the rare systemic manifestations such as Anti-NMDA encephalitis, thyrotoxicosis, pulmonary embolism,
congestive heart failure etc. which are associated with specific ovarian disorders.
TABLE OF CONTENTS/OUTLINE
Introduction, etiopathogenesis and clinical presentation of ovarian emergencies.Role of cross-sectional imaging modalities
(particularly MDCT)Imaging spectrum of ovarian emergencies.
Torsion (torsion of an otherwise normal ovary, teratoma, cysts and
cystic neoplasm)
Infections (oophoritis, tubo-ovarian abscess)
Rupture (ruptured ovarian cyst with hemoperitoneum, ruptured
teratoma with hemorrhage and chemical peritonitis, etc.
Oncologic emergencies (peritoneal carcinomatosis with small bowel
obstruction, hydronephrosis from mass effect etc.)
Miscellaneous (ovarian vein thrombosis, gonadal AVM, ovarian
hyperstimulation syndrome, Anti-NMDA receptor encephalitis due to ovarian teratoma)
ER144-ED-X
Is There Osteo? Magnetic Resonance Imaging (MRI) of the Neuropathic Foot for Suspected Osteomyelitis in
the Emergency Department (ED)
All Day Room: ER Community, Learning Center
Participants
Rosan Patel, MD, Ann Arbor, MI (Presenter) Nothing to Disclose
Adam Wright, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose
Corrie M. Yablon, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose
Jon A. Jacobson, MD, Ann Arbor, MI (Abstract Co-Author) Consultant, BioClinica, Inc; Royalties, Reed Elsevier; ; ;
Suzanne T. Chong, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Review the pathophysiology of osteomyelitis in the setting of neuropathic feet, implications for clinical management, and the
recommended imaging tests for suspected osteomyelitis per ACR Appropriateness Criteria.2. Discuss MRI evaluation of the
neuropathic foot for suspected osteomyelitis including key imaging findings, protocol optimized for streamlined interpretation in the
ED, and potential imaging pitfalls.3. Reinforce the understanding of these concepts through the use of interactive, illustrative
cases.
TABLE OF CONTENTS/OUTLINE
Cases from a quaternary care, academic teaching hospital with a Level 1 trauma center were reviewed for this exhibit. In patients
who present to the ED with foot pain and skin ulcer in the setting of a neuropathic foot, the diagnosis of osteomyelitis can be
clinically challenging. Initial radiographs are limited in sensitivity and MRI is often ordered to provide a more definitive diagnosis. We
will discuss our MRI protocol for foot osteomyelitis streamlined for expedited interpretation through the ED, present cases to
illustrate the spectrum of disease from reactive edema in neuropathic foot to frank osteomyelitis, and highlight imaging pitfalls for
radiologists to avoid. Cases will be presented to reinforce and challenge the reader's understanding of this topic.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jon A. Jacobson, MD - 2012 Honored Educator
ER145-ED-X
Renal 911 - Renal Emergencies
All Day Room: ER Community, Learning Center
Awards
Identified for RadioGraphics
Participants
Soumya Maddula, MD, New Hyde Park, NY (Presenter) Nothing to Disclose
John J. Hines JR, MD, New Hyde Park, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To become aware of various disease processes that can present as acute renal emergencies, including neoplastic, vascular,
infectious, iatrogenic, and obstructive causesTo become familiar with CT imaging findings of acute renal emergencies, and to
develop accurate and reasonably specific diagnosis for such findings.To improve knowledge of proper CT protocol for various
suspected renal diseases, including appropriate use of non IV-enhanced, arterial, nephrographic and urographic phases.
TABLE OF CONTENTS/OUTLINE
Review of CT protocol for various renal diseasesReview of Imaging findings/ Mimics Neoplasm
a.Hemorrhagic cysts
b. Hemorrhagic angiomyolipoma
c. Hemorrhagic Renal Cell Carcinoma
2. Infection
a.
Xanthogranulomatous pyelonephritis
b. Renal abscess
c. Emphysematous pyelonephritis
d. Fungus
ball in collecting system
3. Obstruction (unusual causes)
a. Steinstrasse
b. Congenital causes- UPJ
obstruction, retrocaval ureter
c. Retroperitoneal micrometastases
4. Iatrogenic
a. Post surgical
bleeding
b. Urinoma
c. Pseudoaneurysm
5. Vascular
a. Spontaneous and post-surgical
infarction
b. Renal artery aneurysm
d. Renal Artery DissectionSummary
ER146-ED-X
Imaging Pitfalls in Pelvic Trauma
All Day Room: ER Community, Learning Center
Participants
Carson A. Kisner, MD, Shreveport, LA (Presenter) Nothing to Disclose
Guillermo P. Sangster, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
Simon Long, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
Justin W. Skweres, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
Luis M. De Alba Padilla, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
Alberto A. Simoncini, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Purpose/aim:Pelvic trauma injuries can range from benign to life threatening. Pelvic injuries are often associated with significant
bleeding, concomitant internal injuries, and high mortality. In this setting, the role of the sonographic FAST scan and pelvic
radiograph is suboptimal and commonly obscures severe internal injuries. Multidetector Computed Tomography (MDCT) plays an
essential role in diagnosing and characterizing pelvic trauma. Adequate knowledge of typical and atypical MDCT imaging patterns is
essential for a prompt and correct diagnosis to avoid diagnostic pitfalls and unnecessary surgical interventions. This educational
review aims to highlight the limitations of evaluating pelvic injuries in isolation. Learning objectives: Emphasize the limitations in
determining the extent of pelvic injuries if radiographs or sonography are used in isolation. Demonstrate the importance of active
distention of the urinary bladder when evaluating urinary tract injuries. Highlight MDCT‘s role as the modality of choice for
detection, characterization and pre-operative planning in hemodynamically stable patients with pelvic injuries.
TABLE OF CONTENTS/OUTLINE
Content organization: Skeletal Pelvic Injury Secondary injuries Genitourinary Gastrointestinal Vascular
ER147-ED-X
Taking Run-off CT Angiography to TASC - Acute Vascular Pathology and the Role of Imaging for the
Emergency Radiologist
All Day Room: ER Community, Learning Center
Participants
Yaseen Oweis, MD, MBA, Saint Louis, MO (Presenter) Nothing to Disclose
Zachary J. Viets, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
Yuntong Ma, St. Louis, MO (Abstract Co-Author) Nothing to Disclose
Anup S. Shetty, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Review abdominopelvic and lower extremity vascular anatomy CT Protocols and techniques for specific indications in the emergency
department TASC classification and its role in triaging the acute vascular emergency Review case examples of traumatic and nontraumatic vascular diseases in the acute setting
TABLE OF CONTENTS/OUTLINE
Role of imaging in acute vascular pathology in the Emergency Department Review of abdominopelvic and lower extremity vascular
anatomy CT Protocols Arterial/Venous/Delayed series Out-running bolus and other pitfalls Review of TASC II Classification - TransAtlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease Clinical cases of emergent peripheral
vascular conditions Traumatic Iatrogenic Accidental Peripheral vascular disease ‘Typical’ peripheral vascular disease Stenosis
Occlusion Embolic Vasculitis Bypass grafts Thrombosis Infection Aneurysm Summary and take-home points
ER148-ED-X
Cross-Sectional Musculoskeletal Imaging in the Emergent Setting: Indications and Common Cases
All Day Room: ER Community, Learning Center
Participants
Talentshia Vethanayagamony, MD, Bolingbrook, IL (Presenter) Nothing to Disclose
Suraj Chandrasekar, MD, MS, Hoffman Estates, IL (Abstract Co-Author) Nothing to Disclose
Rina Patel, MD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. To highlight the importance and utility of further imaging evaluation with cross sectional imaging including CT, MRI, and
ultrasound in specific emergency room situations.2. To understand indications for cross sectional imaging in the emergent setting3.
To understand CT and MR features of commonly encountered emergent MSK cases including commonly encountered mimics
TABLE OF CONTENTS/OUTLINE
Commonly encountered Scenarios in the Emergency Room1. Fracturesa. Pelvis
- Discuss ACR recommendations for secondary imaging to detect occult fractures in the sacrum, hip, etc.
- Examples of occult fracturesb. Knee
- ACR recommendation for secondary imaging and examples of cases
- tibial plateau fracture.c. Ankle2. Infectiona. septic joint
- ACR recommendation for further evaluation
- US and MRIb. Osteomyelitis
- ACR recommendation
- MRI3. Miscellaneous/Mimicsa. Tendon injury
- Hamstring strain/tear on MRI presenting as hip pain
- US diagnosis of triceps tear after fallb. HADD/CPPD
- Mimicking infection/septic joint
ER149-ED-X
Myonecrosis: The Obscurity of Rhabdomyolysis
All Day Room: ER Community, Learning Center
Participants
Simon Long, MD, Shreveport, LA (Presenter) Nothing to Disclose
Jared R. Garrett, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
Alberto A. Simoncini, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
Guy T. Alexander, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
Gabriel H. Aguilar, MD, Buenos Aires, Argentina (Abstract Co-Author) Speaker, sanofi-aventis Group; Speaker, AbbVie Inc
Guillermo P. Sangster, MD, Shreveport, LA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
PURPOSE/AIMThis educational exhibit identifies the spectrum of findings associated with different imaging modalities in
rhabdomyolysis including radiography, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and bone
scintigraphy.TEACHING POINTS Recognize the different modality-based imaging patterns in patients with rhabdomyolysis. Review
radiologic, clinical, and laboratory findings of potential rhabdomyolysis mimics.
TABLE OF CONTENTS/OUTLINE
CONTENT ORGANIZATIONRhabdomyolysis has traditionally been a clinical diagnosis with healthcare providers utilizing historical
context, physical exam, and laboratory data to arrive at a diagnosis. However, there are a plethora of imaging findings which can
support a presumptive diagnosis while ruling out differentials. This exhibit seeks to review imaging findings associated with
rhabdomyolysis using different modalities including radiographs, US, CT, MRI, and bone scintigraphy.
ER150-ED-X
Leg Veins Ultrasound and Pulmonary Artery CT Angiography for Deep Vein Thrombosis and Pulmonary
Embolism Rule Out. When and How to Perform. When Not to Perform. What to Expect
All Day Room: ER Community, Learning Center
Participants
Demosthenes D. Cokkinos, MD, Athens, Greece (Presenter) Speaker, Bracco Group
Eleni Antypa, Athens, Greece (Abstract Co-Author) Nothing to Disclose
Sofia Tsolaki, Athens, Greece (Abstract Co-Author) Nothing to Disclose
Eleni Lazaridou, Athens, Greece (Abstract Co-Author) Nothing to Disclose
Anastasia Anagnostopoulou, Athens, Greece (Abstract Co-Author) Nothing to Disclose
Ploutarhos A Piperopoulos, MD, PhD, Athens, Greece (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To outline imaging guidelines for performing emergency ultrasound (US) of leg veins for deep vein thrombosis (DVT) rule out and CT
pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE). To study the place of these imaging modalities
in appropriateness criteria after performing pre-test probability evaluation of Wells Score and D-dimer blood count.
TABLE OF CONTENTS/OUTLINE
Different chapters of the presentation include: Description of pre-test probability evaluation of Wells Score and D-dimer blood count
according to guidelines before performing leg veins US and CTPA. Indications, technique description, findings, limitations, diagnostic
value and pitfalls of leg veins US for DVT detection and CTPA technique for PE detection. Examples of clinical scenarios in which
these imaging modalities are not indicated. Imaging examples of DVT and PE are presented and findings are explained. The
questions of difficulty in performing US below the knee and reporting subsegmental branches PE are assessed. Dose reduction
techniques for CTPA are also discussed.
ER151-ED-X
Acetabular Fractures: A Radiologic Review in Multiple Modalities Utilizing a Novel Teaching Approach with 3Dprinted Models
All Day Room: ER Community, Learning Center
Participants
Scott Honowitz, MD, San Jose, CA (Presenter) Nothing to Disclose
Ryan Chao, MD, San Jose, CA (Abstract Co-Author) Nothing to Disclose
Jeffrey Tseng, MD, Menlo Park, CA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Important cause of morbidity and mortality following trauma. Two classification schemes include the more widely used JudetLetournel system and the modern CT-based Harris-Coupe system. Teaching this complex subject may be aided by the use of 3Dprinted models.
TABLE OF CONTENTS/OUTLINE
Normal acetabular anatomy. Fracture patterns in two classification systems with imaging pearls for both radiography and CT.
Clinical significance of the fracture classifications. 3D-Printed models for educational purposes: Graphic comparisons of different
acetabular fracture patterns in multiple modalities including radiography, CT 2D images, CT 3D reformations, and 3D printed models.
If platform space is available at the RNSA exhibit, actual 3D-printed models will be displayed for inspection and manipulation by
attendees.
ER152-ED-X
Nontraumatic Perforation in the Gastrointestinal Tract: CT Diagnosis and Its Differentiation
All Day Room: ER Community, Learning Center
Participants
Nam Kyung Lee, MD, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Jeongmyeong Kim, MD, Pusan, Korea, Republic Of (Presenter) Nothing to Disclose
Suk Kim, MD, Pusan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Ga Jin Han, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Sang Jeong Ahn, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Tae Un Kim, MD, Yangsan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To describe the CT features of various pathologic conditions causing gastointestinal perforation beyound trauma. To discuss
the characteristic CT features to differentiate malignant from benign causes in the gastointestinal perforation. To differentiate
gastrointestinal perforation requiring emergency surgery from balanced penumoperitoneum.
TABLE OF CONTENTS/OUTLINE
IntroductionVarious conditions causing nontrauamtic GI tract perforation1. Neoplastic conditions Adenocarcinoma GIST Metastasis
Lymphoma Appendiceal neoplasm2. Nonneoplastic condition Peptic ulcer Strangulation: Volvulus Diverticulosis Diverticultis, colon
Meckel’s diverticulum Appendicitis Stercoral perforation Inflammation Balanced penumoperitoneum3. MicellaneousConclusion
ER153-ED-X
Buckle Fracture of the Proximal Tibia Associated with Trampoline Use in Children
All Day Room: ER Community, Learning Center
Participants
Saurabh Gupta, MD, Philadephia, PA (Presenter) Nothing to Disclose
Victor M. Ho-Fung, MD, Philadelphia, PA (Abstract Co-Author) Nothing to Disclose
Sayed Ali, MD, Aston, PA (Abstract Co-Author) Nothing to Disclose
Summer L. Kaplan, MD, MS, Philadelphia, PA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Recognize subtle buckle fractures of the proximal tibia associated with trampoline and inflatable bouncer use in young children.2.
Be aware that young children may not localize pain to the site of fracture and the radiologist may suggest imaging the proximal tibia
in patients with trampoline related injury to the lower extremity.3. Reassure clinician of good outcomes associated with healing of
these fractures.
TABLE OF CONTENTS/OUTLINE
1. Demographics of trampoline use and injury2. Patient presentation3. Mechanisms: a. Hyperextension b. Bouncing with others,
especially larger person4. Sample cases and mimics5. Treatment and prognosis6. Future directions and summary
ER154-ED-X
Stop Blaming the Gallbladder! Imaging of the Unlikely Suspects of Right Upper Quadrant Pain
All Day Room: ER Community, Learning Center
Participants
Refky Nicola, DO, MSc, Worcester, MA (Presenter) Nothing to Disclose
Adib R. Karam, MD, Worcester, MA (Abstract Co-Author) Nothing to Disclose
Mariam Moshiri, MD, Seattle, WA (Abstract Co-Author) Consultant, Reed Elsevier; Author, Reed Elsevier;
Puneet Bhargava, MD, Shoreline, WA (Abstract Co-Author) Editor, Reed Elsevier
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Mariano Scaglione, MD, Castel Volturno, Italy (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Discuss the advantages and disadvantages of US, CT and MRI for the evaluation of patient with acute right upper quadrant (RUQ)
pain
Review imaging pitfalls in a patient with RUQ pain
Illustrate causes of right upper quadrant pain when the gallbladder is normal.
Discuss the role of point of care ultrasound in the emergency department.
TABLE OF CONTENTS/OUTLINE
US mimics of acute cholecystitis will be reviewed
Sonographic findings of the following non traumatic emergencies will be illustrated and reviewed: perforated duodenal ulcer, acute
pancreatitis, portal vein thrombosis, tumor thrombus, ruptured hepatocellular carcinoma, acute hepatitis, giant cavernous
hemangioma, hepatic steatosis, choledocholithiasis, gallbladder carcinoma, emphysematous cholecystitis, gangrenous cholecystitis,
adenomyomatosis
Imaging pitfalls, differential diagnosis and management options will be discussed...... .
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
Mariam Moshiri, MD - 2013 Honored Educator
Mariam Moshiri, MD - 2015 Honored Educator
Puneet Bhargava, MD - 2015 Honored Educator
ER155-ED-X
Potpourri of Emergency Radiology Abdominopelvic Cases: A Quiz for the Aces
All Day Room: ER Community, Learning Center
Participants
Carlos Francisco M. da Silva, MD, Setubal, Portugal (Presenter) Nothing to Disclose
Pedro M. Alves, MD, Lisboa, Portugal (Abstract Co-Author) Nothing to Disclose
Hugo A. Rio Tinto, MD, Lisbon, Portugal (Abstract Co-Author) Nothing to Disclose
Joao R. Inacio, MD, Ottawa, ON (Abstract Co-Author) Nothing to Disclose
Ana N. Monica, MD, Oeiras, Portugal (Abstract Co-Author) Nothing to Disclose
Jorge Brito, MD, Portimao, Portugal (Abstract Co-Author) Nothing to Disclose
Maria Teresa F. Guerra, Setubal, Portugal (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The gamut of acute abdominopelvic pathology encountered in everyday practice can be varied and rare.The purpose of this exhibit
is to expose radiologists to a series of challenging and rare cases in order to help improve the radiologist’s awareness and diagnostic
accuracy.
TABLE OF CONTENTS/OUTLINE
The cases will be presented in a quiz format.Key differential diagnostic points will be highlighted in the discussion of each case.The
list of cases includes:
• Interparietal type of inguinal hernia
• Small-bowel obstruction due to Meckel's Diverticulum
• Cholecystitis presenting in a woman with agenesis of the right hepatic lobe
• Situs inversus totalis
• Intestinal nonrotation
• Cecal volvulus
• Wandering Spleen
• Omental Infarct
ER156-ED-X
Internal Hernias: Imaging Features and Complications
All Day Room: ER Community, Learning Center
Participants
Bella P. Desai, MD, Houston, TX (Presenter) Nothing to Disclose
Latifa L. Sanhaji, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit1. Review normal anatomy and congenital or acquired defects of the abdominal cavity2. Discuss clinical
and imaging presentation of internal hernias3. Explain appropriate intervention for complications related to internal hernias
TABLE OF CONTENTS/OUTLINE
1. Normal anatomy of the abdominal cavity2. Congenital and acquired defects of the abdominal cavity 3. Imaging features of
internal hernias - paraduodenal, foramen of Winslow, transmesenteric, pericecal, bowel anastomoses 4. Imaging of complications of
internal hernias 5. Summary
ER157-ED-X
It's a Soft Call: Diagnosable Soft Tissue Injury by CT in Setting of Osseous Trauma
All Day Room: ER Community, Learning Center
Participants
Matthew L. Uriell, MD, Atlanta, GA (Presenter) Nothing to Disclose
Philip K. Wong, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Yara Younan, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Ty K. Subhawong, MD, Miami, FL (Abstract Co-Author) Nothing to Disclose
Monica B. Umpierrez, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Walter A. Carpenter, MD, PhD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Adam D. Singer, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
In the setting of trauma, CT is often used to assess degree of osseous injury and for surgical planning. While CT is accurate in the
characterization of osseous injuries, soft tissue damage can often also be detected, however may be overlooked. Early detection of
soft tissue injury by CT could serve to change management of these patients. MRI anatomy is relevant to CT anatomy and should
be considered when interpreting CT soft tissue windows.
TABLE OF CONTENTS/OUTLINE
Introduction to Soft Tissue Injury: muscle, tendon, ligament, meniscus, nerve, vessel, skin Importance of Soft Tissue Injury for
Surgical Planning, Prognosis, and Rehabilitation Case Examples Tendon/ligament/meniscus tears and avulsions Tendon entrapment
Nerve injury Vascular injury Skin/soft tissue (degloving) and coverage issues
ER158-ED-X
Dual Energy CT Characterization of Adnexal Lesions in the Emergency Department
All Day Room: ER Community, Learning Center
Participants
Michael T. Caton, MD, Boston, MA (Presenter) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jennifer W. Uyeda, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Urvi P. Fulwadhva, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
TEACHING POINTS
1. Adnexal lesions are common in patients presenting to the emergency room, both as the cause of symptoms and as incidental
findings on pelvic CT performed for other reasons.2. Dual Energy CT (DECT) can aid assessment of common adnexal lesions.3. DECT
analysis of adnexal pathology may augment pelvic ultrasound and in some cases, obviate the need for further imaging studies.
TABLE OF CONTENTS/OUTLINE
1. DECT overview: review relevant aspects of DECT technology including three material decomposition for creation of iodine maps
and virtual noncontrast images, and highlight technical and workflow challenges.2. Case-based review of DECT characterization of
adnexal lesions commonly encountered in the Emergency Department including ovarian torsion, tubo-ovarian abscess, and common
benign and malignant adnexal masses.3. Future directions: expanding the role of DECT to increase diagnostic accuracy, reduce
follow-up imaging, and improve radiology workflow.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
ER161-ED-X
Acute Abdomen Due to Hemorrhagic Liver Lesions
All Day Room: ER Community, Learning Center
Participants
Elsa Camuera Gonzalez, Bilbao, Spain (Presenter) Nothing to Disclose
Jenny Catalina Correa Zapata, Barakaldo, Spain (Abstract Co-Author) Nothing to Disclose
Itziar Tavera Bahillo, Barakaldo, Spain (Abstract Co-Author) Nothing to Disclose
Leticia Mugica, Barakaldo, Spain (Abstract Co-Author) Nothing to Disclose
Ana Rosa Gil Martin, Bilbao, Spain (Abstract Co-Author) Nothing to Disclose
Ricardo Ituarte Uriarte, Barakaldo, Spain (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is: To review the hemorrhagic liver lesions and their imaging findings. To recognize the importance of CT
in the diagnosis of acute hemoperitoneum. To show different types of embolization procedures.The major teaching points are: The
first diagnosis in patients with cirrhosis and hemorrhagic liver lesion will be a HCC. Young woman using long-term oral contraceptives
with subcapsular hematoma may have an adenoma.
TABLE OF CONTENTS/OUTLINE
Spontaneous liver bleeding is an uncommon entity that usually occurs in a pathological liver. Hepatic hemorrhage, in absence of
trauma or anticoagulant therapy, has been linked to anatomical lesions. The most common non-traumatic causes are hepatocellular
carcinoma and adenoma. Other hemorrhagic liver lesions are metastasis, focal nodular hyperplasia or haemangiomas. This condition
is potentially lethal. Patients present to emergency room with abdominal pain and hemodynamic instability.CT is the most useful
technique to determine the cause and the site of bleeding. In addition, it allows for realizing a vascular map. The immediate
therapy is selective arterial embolization. This procedure can produce haemostasis in hemodynamically
unstable patients.Radiologists play a crucial role in the diagnosis and immediate management of hemorrhagic liver lesions.
ER162-ED-X
Application of Dual Energy CT for Abdominal Emergency
All Day Room: ER Community, Learning Center
Participants
Ryosuke Abe, Tokyo, Japan (Presenter) Nothing to Disclose
Takehiko Gokan, MD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Yuichi Nakai, tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Naruki Mizobuchi, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Keita Yamana, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Masanori Hirose, MD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To review the technology of dual energy CT including a variety of image reconstruction and postprocessing techniquesTo discuss
the advantages and disadvantages of dual energy CT for the emergency abdominal radiologyTo learn how to use the advantages of
dual energy CT for the emergency abdominal radiology
TABLE OF CONTENTS/OUTLINE
1 Technology of dual energy CT2 Case presentation to show advantages of dual energy CT for the emergency abdominal
radiology.All cases were performed with 3rd generation dual energy CT. Iodine map image can show ischemic status due to torsion
of intestine, ovarian mass etc.Monoenergy low KeV image can reduced contrast dose, salvage suboptimal studies because of
enhanced vascular visualization.Artifact reduction with monoenergy high KeV imageRadiation reduction with virtual noncontrast
imageVirtual noncalcium image in the evaluation of bone marrow edema due to acute vertebral compression fracture3 . Case
presentation to demonstrate disadvantages of dual energy CT.Suboptimal scan time of DECT etc.
ER163-ED-X
MDCT of Duodenal Emergencies: Utility of 2D MPRs and 3D Rendering for Challenging but Critical Diagnoses
All Day Room: ER Community, Learning Center
Awards
Identified for RadioGraphics
Participants
Mikhael Polotsky, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Margaret Fynes, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Elliot K. Fishman, MD, Baltimore, MD (Abstract Co-Author) Institutional Grant support, Siemens AG; Institutional Grant support,
General Electric Company;
Pamela T. Johnson, MD, Baltimore, MD (Presenter) Consultant, National Decision Support Company
TEACHING POINTS
Emergency department patients with upper abdominal pain are often imaged with MDCT to evaluate for pancreatic, biliary, gastric
or duodenal pathology. Acute, critical duodenal pathology may be overlooked if the radiologist is not knowledgable about the range
of potential pathology and does not include the duodenum in their search pattern, using both axial and multiplanar MDCT
interpretation. This exhibit reviews: Spectrum of acute, emergent pathology that can arise from the duodenum MDCT findings with
emphasis on importance of supplementing axial with coronal and sagittal views Importance of inspecting the duodenum for accurate
diagnoses
TABLE OF CONTENTS/OUTLINE
IntroductionMDCT technique IV contrast trend toward PO water for oral contrast in ED patients narrow reconstruction sections for
high quality MPRs and 3D renderingPathology and MDCT findings severe duodenitis perforation perforated duodenal ulcer (contained
and free perforation) following ERCP traumatic perforation due to stab wound duodenal hemorrage from GDA pseudoaneurysm
duodenal diverticulitis duodenal hematoma duodenal obstruction
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Pamela T. Johnson, MD - 2016 Honored Educator
Elliot K. Fishman, MD - 2012 Honored Educator
Elliot K. Fishman, MD - 2014 Honored Educator
Elliot K. Fishman, MD - 2016 Honored Educator
ER164-ED-X
Imaging of Acetablar Fractures: From Wreck to Rehab
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Nicholas M. Beckmann, MD, Houston, TX (Presenter) Nothing to Disclose
TEACHING POINTS
1. Follow the imaging course of trauma patients with pelvic fractures from initial presentation through pelvic fracture fixation.2.
Along course of following patient discuss: Controversies in pelvic fracture imaging Accurately reporting acetabular fractures using
Judet-Letournel classification Important CT findings beyond fracture pattern classification Indications for non-operative vs
operative managment
TABLE OF CONTENTS/OUTLINE
Intro/Statistics on pelvic and acetabular fx Initial presentation of patient with pelvic trauma What to look for on AP pelvis xray Are
AP xrays needed if pelvis CT is done? (literature review) Acetabular fracture is identified on CT How to describe the fracture
(Judet-Letournel classification) Associated findings to look for on CT Acetabular articular impaction Femoral head fx Morel-Lavallee
lesion Intra-articular fragments Extravasation Pre-operative planning Is surgery even needed? (outcomes discussion) Percutaneous
fixation vs open reduction-internal fixation Pre-operative imaging: Have 3D CT reformatted images obviated need for AP pelvis and
Judet views? (literature review) Post-operative hardware assessment Are xray adequate or should CT be performed? (literature
review) New technology: intra-operative CT
ER165-ED-X
Spectrum of Abdominal Aortic Emergencies: MDCT Appearance
All Day Room: ER Community, Learning Center
Participants
Nagaramesh Chinapuvvula, MBBS, Houston, TX (Presenter) Nothing to Disclose
David A. Spak, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
Suresh Cheekatla, MBBS, Houston, TX (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. To review the MDCT appearance of abdominal aortic emergencies, both traumatic and non traumatic2. To discuss the
MDCT protocol that needs to be adopted for evaluating the abdominal aorta in the acute setting
TABLE OF CONTENTS/OUTLINE
a. MDCT signs and appearance of traumatic and non traumatic abdominal aortic emergencies which include1. Abdominal aortic
aneurysm/rupture2. Aortic dissection, non traumatic3. Intramural hematoma4. Acute aortic thrombus5. Penetrating atherosclerotic
ulcer6. Traumatic aortic injury7. Endoleaksb. MDCT protocol for evaluating the abdominal aorta in the emergency setting
ER167-ED-X
Panscan CT Techniques for Patients with High-energy Injuries
All Day Room: ER Community, Learning Center
Participants
Keishi Ogura, RT, PhD, Sapporo, Japan (Presenter) Nothing to Disclose
Kei Miyata, MD, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Syogo Misumi, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Junpei Suzuki, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Taiki Chono, RT, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Masaki Abukawa, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Yoshiya Oohashi, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Kenta Yoshikawa, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Syunpei Katoh, Sapporo, Japan (Abstract Co-Author) Nothing to Disclose
Masamitsu Hatakenaka, MD, PhD, Sapporo, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation;
TEACHING POINTS
This exhibit will:Demonstrate the necessity of panscan computed tomography (CT) for patients with high-energy injuries.
Demonstrate optimized scan protocols for high diagnostic performance using reduced radiation dose.Present the impact of using
panscan CT with increased sensitivityDescribe the methods for using clinical data to create three-dimensional (3D) images in
patients with high-energy injuries.
TABLE OF CONTENTS/OUTLINE
This exhibit is designed to highlight important issues and considerations during imaging of patients with high-energy
injuries.Necessities for panscan CT:High accuracy for a wide range of injuriesHigh rates of detectionRapid application.Optimal scan
conditions:Demonstrate the optimal scanning protocols to maintain high diagnostic performance with minimized radiation
dose.Determine the optimal timing for panscan CT and administration of contrast agents.Present methods for reducing image noise
and artifacts using iterative reconstruction.Benefits of using 3D images for high diagnostic accuracy in high-energy injury
cases:Immediate determination of the presence and extent of active bleeding.Provision of a map of injured vessels to determine the
appropriate therapeutic strategy.Improved understanding of the complex fractures.
ER168-ED-X
Reporting More Than Just Emergent Findings - Role of Detailed Abdominal and Pelvic Imaging in Oncologic
Emergencies
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Alexa O. Levey, MD, Atlanta, GA (Presenter) Nothing to Disclose
Peter A. Harri, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Pardeep K. Mittal, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Lauren F. Alexander, MD, Atlanta, GA (Abstract Co-Author) Spouse, Stockholder, Abbott Laboratories; Spouse, Stockholder, AbbVie
Inc; Spouse, Stockholder, General Electric Company
Courtney A. Coursey Moreno, MD, Suwanee, GA (Abstract Co-Author) Nothing to Disclose
Frank H. Miller, MD, Chicago, IL (Abstract Co-Author) Research Grant, Siemens AG
Bobby T. Kalb, MD, Tucson, AZ (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Review the types of diagnoses that present emergently to radiologists on cross sectional imaging secondary to malignancies.
2. Describe the important details and subtle findings of the malignancy that go beyond reporting the presenting diagnosis and can
speed up oncologic treatment.
3. Discuss the impact of accurate initial diagnosis of a malignancy, characterization, and early description, on clinical management
and reducing repeat imaging.
TABLE OF CONTENTS/OUTLINE
1. Review common primary and secondary abdominal and pelvic malignancies that cause morbidity requiring emergent imaging.
2. Review important findings of the underlying malignancies that should be discussed to expedite oncologic treatment.
a. The hepatic system: masses causing intrapertioneal hemorrhage.
b. The pancreaticobiliary system: cholangiocarinoma and pancreatic cancer causing jaundice and right upper
quadrant pain.
c. The gastrointestinal tract: colorectal adenocaricoma and ovarian cancer causing bowel obstruction.
d. The genitourinary tract: renal cell carcinoma and urothelial cell carcinoma causing hematuria and cervical
cancer
causing urinary obstruction.
3. Discuss the impact of accurate pre-surgical evaluation and staging on management and treatment options.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Courtney A. Coursey Moreno, MD - 2016 Honored Educator
Pardeep K. Mittal, MD - 2016 Honored Educator
Frank H. Miller, MD - 2012 Honored Educator
Frank H. Miller, MD - 2014 Honored Educator
ER169-ED-X
Posterior Reversible Encephalopathy Syndrome: What's in a Name? Catch Subtle Signals!
All Day Room: ER Community, Learning Center
Participants
Madhav Hegde, MD, Bangalore, India (Presenter) Nothing to Disclose
Anuradha Rao, Bangalore, India (Abstract Co-Author) Nothing to Disclose
Sharath Kumar G.G, MBBS,MD, Bangalore, India (Abstract Co-Author) Nothing to Disclose
Balakrishna P. Shetty, MBBS, Bangalore, India (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1.To understand that PRES is not a single diagnostic entity,but is an inclusive term for “similar” imaging appearance in various
clinical scenarios in emergency room2.To acquiant radiologists the typical and atypical imaging features in PRES3.To highlight the
importance of identifying this entity distinctly in its subtle forms from other imitators in confusing clinical scenarios,thus preventing
delay in patient care4.To stress on the 'non posterior' and 'irreversible' components masked in its name
TABLE OF CONTENTS/OUTLINE
1.Common clinical associations with typical clinical presentations.2. Pathogenesis.3.Usual imaging features,highlighting on
reversibility.4.Unusual,atypical imaging features,various patterns on imaging including holohemisphereic, superior frontal sulcus
pattern,dominant parieto-occipital pattern,assymetric/partial expressions.5.Imaging appearance on CT,MR,MRA and
DWI.6.Complications of PRES-hemorrhage and infarction.7.Imaging Mimics : PML, infectious encephalitis, acute disseminated
encephalomyelitis, cerebral venous sinus thrombosis,ischemic stroke; In isolated brain stem variety-pontine infarct,osmotic
demyelination,brainstem encephalitis as mimics.8.Clinical mimics of PRES-seizures of various causes, migraine.9.Mimics in
hemorrhagic variety-ADEM.
ER170-ED-X
A Race Against the Clock: Imaging of Life Threatening Cardiovascular Emergencies
All Day Room: ER Community, Learning Center
Participants
Malay Bhatt, MD, Royal Oak, MI (Presenter) Nothing to Disclose
Nick Sousaris, MD, Rootstown, OH (Abstract Co-Author) Nothing to Disclose
Sayf A. Al-Katib, MD, Royal Oak, MI (Abstract Co-Author) Nothing to Disclose
Syed Zafar H. Jafri, MD, Royal Oak, MI (Abstract Co-Author) Nothing to Disclose
Kostaki G. Bis, MD, Bloomfield Hills, MI (Abstract Co-Author) Nothing to Disclose
Hanh V. Nghiem, MD, Royal Oak, MI (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Advanced imaging studies are continuing to become more quickly accessible. This trend has increased the demand for timely and
accurate interpretations by the radiologist. The purpose of this exhibit is: To display a myriad of cases to alert the radiologist to a
variety of common and uncommon life threatening cardiovascular emergencies. To review the pertinent imaging findings of each
diagnosis and highlight the key elements to consider in one’s diagnostic search pattern.
TABLE OF CONTENTS/OUTLINE
A multitude of cases will be displayed with subsequent case discussions that provide pertinent imaging findings and review key
diagnostic and differential considerations. Cardiovascular Emergencies Cardiac Cardiac tamponade Ventricular pseudoaneurysm
Coronary artery anomalies LIMA graft pseudoaneurysm Thoracic Massive pulmonary embolism Aortic dissection Traumatic aortic
pseudoaneurysm Aorto-esophageal fistula Abdominal Aortic aneurysm rupture Aortoenteric fistula Mycotic aneurysm Portal vein
thrombosis with bowel ischemia SMA thrombus Mesenteric vascular traumatic injury Pelvic Pelvic hemorrhage due to various
traumatic vascular injuries
ER171-ED-X
Wooden Foreign Bodies in the Gastro-intestinal Tract: A Challenge for the Radiologist
All Day Room: ER Community, Learning Center
Participants
Michele Porcu, MD, Cagliari, Italy (Presenter) Nothing to Disclose
Giovanni M. Argiolas, MD, Monserrato, Italy (Abstract Co-Author) Nothing to Disclose
Federica Schirru, MD, Nurri, Italy (Abstract Co-Author) Nothing to Disclose
Paolo Siotto, MD, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
Jasjit S. Suri, Pocatello, ID (Abstract Co-Author) Nothing to Disclose
Luca Saba, MD, Cagliari, Italy (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
To review the main direct and undirect findings of the presence of a ingested wooden foreign body along the gastro-intestinal tract
To expose the complication that can origin from the presence of wooden foreign bodies along the gastro-intestinal tract.
TABLE OF CONTENTS/OUTLINE
The ingestion of foreign bodies, accidental or not, is a frequent cause of admission to the emergency department, especially in the
paediatric population.
In case of the presence of a foreign body in the gastro-intestinal tract the radiologist has to work
with the other members of the clinical team in order to promptly recognise the causes of disease, to detect the foreign body and to
avoid or limit complications (in particular perforations, occlusions or sub-occlusions and haemorrhages).
The wooden
objects (in particular those with sharp ends, such as toothpicks), represent a challenge for the Radiologist because of
its composition; in fact it is not as much radiopaque as other objects, and its detection with conventional radiology or computed
tomography can be very difficult.
In this job we expose a case report of a man who came in our emergency department
with a two days story of acute abdomen following the accidentally ingestion of a toothpick.
ER173-ED-X
Thinking Outside the Myocardium: Imaging Review of Non-cardiac, Non-traumatic Causes of Acute Chest Pain
All Day Room: ER Community, Learning Center
Awards
Certificate of Merit
Participants
Junichi Tsuchiya, MD, Tokyo, Japan (Presenter) Nothing to Disclose
Yasuyuki Kurihara, MD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Ryo Miyazawa, MD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Masaki Matsusako, MD, PhD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Jay Starkey, MD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
(1)
To teach the differential diagnoses of acute chest pain in the emergency room in cases of non-cardiac, non-traumatic
causes.(2)
To teach relevant anatomy and pathophysiology.
TABLE OF CONTENTS/OUTLINE
I.
Review of anatomy on chest radiograph, CT, and MRI, including: great vessels, mediastinum, pleura, pericardium,
esophagus, and spinal cord.II.
The cases will be presented in a quiz format. Review of pathophysiology and images as
unknowns in cases where the patient presents with acute chest pain and without history of trauma to the Emergency Dept. Cases
include:-Pulmonary Pulmonary embolism Idiopathic pneumomediastinum Pneumothorax-Aorta Aortic dissection Aortic
rupture-Pericardium Pericarditis-Esophagus Idiopathic esophageal rupture; Boerhaave syndrome Esophageal Anisakis-Spine
Spinal epidural hematoma-Mediastinum Benign matured teratoma Malignant lymphoma
ER174-ED-X
Traumatic Retroperitoneal Hemorrhage: MDCT Evaluation and Importance of Zonal Anatomy for Management
All Day Room: ER Community, Learning Center
Participants
Nagaramesh Chinapuvvula, MBBS, Houston, TX (Presenter) Nothing to Disclose
Suresh Cheekatla, MBBS, Houston, TX (Abstract Co-Author) Nothing to Disclose
O. C. West, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. To discuss the zonal anatomy of the retroperitoneum ( Zones I,II,III) on MDCT which is critically important to the surgeon for
management.2. To familiarize the viewer the appearance of retroperitonel hemorrhage on MDCT and elaborate the common sources
of hemorrhage in the trauma setting.3. To emphasize the importance of including the location of retroperitonel hemorrhage ( Zone
I,II,III) in the CT report, especially when no obvious contributing source can be identified in the trauma patient .5. To give an
insight into how retroperitoneal hemorrhage is managed.
TABLE OF CONTENTS/OUTLINE
1. Zone 1 ( central ) retroperitoneal hemorrhage: MDCT appearance of major vascular injuries including abdominal aorta and IVC
injuries with or without active vascular extravasation; pancreatico duodenal injuries which are major contributors to central
retroperitoneal hemorrhage2. Zone 2 ( lateral) retroperitoneal hemorrhage: MDCT appearance of renal, adrenal and proximal ureteral
injuries contributing to lateral retroperitoneal hemorrhage3. Zone 3 ( pelvic) retroperitoneal hemorrhage: MDCT appearance of iliac
vascular injuires, pelvic fractures contributing to pelvic retroperitoneal hemorrhage4. Management of retroperitoneal hemorrhage
ER175-ED-X
Multimodality Imaging of Non-Aortic Cardiothoracic Trauma
All Day Room: ER Community, Learning Center
Participants
Sachin S. Saboo, MD, FRCR, Dallas, TX (Presenter) Nothing to Disclose
Kirk G. Jordan, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose
Kiran Batra, MD, Coppell, TX (Abstract Co-Author) Nothing to Disclose
Prabhakar Rajiah, MD, FRCR, Dallas, TX (Abstract Co-Author) Institutional Research Grant, Koninklijke Philips NV; Speaker, Koninklijke
Philips NV
Asha Kandathil, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose
Suhny Abbara, MD, Dallas, TX (Abstract Co-Author) Author, Reed Elsevier; Editor, Reed Elsevier; Institutional research agreement,
Koninklijke Philips NV; Institutional research agreement, Siemens AG
Jacqueline T. Caire, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose
Devri L. Weakley, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose
Ashish R. Khandelwal, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Prashant Nagpal, MBBS, Iowa, IA (Abstract Co-Author) Nothing to Disclose
Michael J. Landay, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Describe plain radiographic and CT features of various manifestations of non-aortic injury in the chest associated with blunt,
penetrating, and barotrauma
Review classical radiographic signs associated with thoracic injury
Radiologist and clinicians should be able to recognize imaging findings of trauma in acute and chronic settings involving airway,
parenchyma, mediastinum, diaphragm, and chest wall that may require further imaging and/or surgical or interventional
management.
TABLE OF CONTENTS/OUTLINE
Trauma associated visits to the Emergency Room: High-speed motor vehicles Blunt trauma related to fall Penetrating trauma
BarotraumaNon-aortic traumatic chest injury: Mediastinal: Pericardial, Myocardial, Esophageal Vascular: Systemic and Pulmonary
arterial Lungs and Airways:Hemorrhage/Contusions, Lacerations, Bronchopleural Fistula,Pulmonary Interstitial Emphysema
Diaphragmatic:Rupture, Paralysis Chest wall:Flail Chest, Lung Hernia, FracturesRadiographic Signs Deep sulcus Double Diaphragm
Mediastinal shift Contiguous Diaphragm Thymic Sail Ring around the Artery Fallen Lung Dependent Viscera Collar
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Suhny Abbara, MD - 2014 Honored Educator
Prabhakar Rajiah, MD, FRCR - 2014 Honored Educator
ER176-ED-X
Gynecological Emergencies: Pictorial Review
All Day Room: ER Community, Learning Center
FDA
Discussions may include off-label uses.
Awards
Certificate of Merit
Participants
Catarina A. Silva, MD, Senhora da Hora, Portugal (Presenter) Nothing to Disclose
Ines Sarmento, Matosinhos, Portugal (Abstract Co-Author) Nothing to Disclose
Joao C. Pinto, Matosinhos, Portugal (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is: Provide concise imaging review of gynecological emergencies, focusing on the cross sectional
techniques (MDCT and MRI) Learn to recognize the differential diagnosis Know how to optimize imaging protocols, based on personal
experience, in order to assure the correct diagnosis.
TABLE OF CONTENTS/OUTLINE
Anatomy of the female internal genitalia Gyn emergencies: how to optimize the protocols MDCT MRI Common Gyn emergencies:
Cross sectional Imaging findings with pathological correlation Ovarian/adnexal torsion Ruptured hemorrhagic cyst Tubo-ovarian
abscess/PID Ectopic pregnancy Uncommon Gyn emergencies: Cross sectional Imaging Findings with pathological correlation Infected
uterine tumor Uterine rupture Bleeding uterine tumor /AVN Acute teratoma complications Diferential diagnosis Acute appendicitis
Diverticular perforation Diverticulitis Ureterolithiasis Cystitis Spontaneous iliopsoas haematoma GI invasive/perforated tumor
Summary
ER177-ED-X
The Fart and The Furious: A Pictorial Review of the Mild and the Severe Intestinal Disorders an ER Radiologist
Should Master
All Day Room: ER Community, Learning Center
Participants
Natalia Romero, MD, Hospitalet De Llobregat, Spain (Presenter) Nothing to Disclose
Lara Farras Roca, MD, Barcelona, Spain (Abstract Co-Author) Nothing to Disclose
Ivan Carrion, MD, Hospital de Llobregat, Spain (Abstract Co-Author) Nothing to Disclose
Camilo Pineda Ibarra, MD, Barcelona, Spain (Abstract Co-Author) Nothing to Disclose
Teresa Martinez Fernandez, Lhospitalet De Llobregat, Spain (Abstract Co-Author) Nothing to Disclose
Eugenia De Lama Salvador, MD, Barcelona, Spain (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
- To describe the main clinical presentation of acute intestinal conditions most frequently seen in the ER department.- To review
the typical radiological findings of each entity and potential imaging pitfalls.- To identify benign conditions that present with similar
symptoms as potentially severe conditions.- To provide useful tools and appropiated CT protocols for each scenario.
TABLE OF CONTENTS/OUTLINE
There are several scenarios in the ER with potentially fast and fatal course (rigid wooden abdomen, lower tract occlusion,
hypovolemic shock…) which push us to establish an immediate diagnosis. Most of the time, however, we will find benign disease as
the cause (enteritis, constipation, Ogilvie's, ), which will be properly studied at a later time.However, there are some other entities
we should take into account and should be included as a possible differential diagnosis as we face an acute abdomen, such as:Inflammatory conditions: diverticulitis, intestinal inflamatory disease, pseudomembranous colitis- Lower tract occlusion: secondary
to tumor cause, bezoar or foreign body.- Acute rectal bleeding; intestinal or extrinsecal (aortic fistulae)- Colonic volvulus, internal
hernias.- Ischaemic conditions with associated pneumatosis.We aim to help provide a fast and accurate diagnosis in a timesensitive environment
ER179-ED-X
Role of Dual Energy CT in Pancreatic Disease: A Pictorial Review
All Day Room: ER Community, Learning Center
Participants
Elizabeth George, MD, Boston, MA (Presenter) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jennifer W. Uyeda, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Urvi P. Fulwadhva, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
TEACHING POINTS
1. Dual energy CT acquisition enables the creation of iodine maps, virtual noncontrast, and virtual monoenergetic images from a
single post-contrast acquisition.
2. Pancreatic pathologies offer a particular challenge in abdominal CT due to the subtlety of critical imaging findings. The use of
dual energy CT can improve characterization of pancreatic diseases, including adenocarcinoma, cystic lesions, and pancreatitis.
3. Application of dual energy CT post-processing can potentially aid early and accurate diagnosis of pancreatic pathologies, while
avoiding the need for additional imaging phases or modalities.
TABLE OF CONTENTS/OUTLINE
1. Review of the relevant physics and principles of dual energy CT.
2. Current applications of dual energy CT for various pancreatic pathologies.A. Case based review of the use of iodine maps, virtual
non-contrast, and virtual monoenergetic images in the identification and characterization of focal pancreatic lesions, such as
adenocarcinoma, cystic lesions, and other neoplasms such as neuroendocrine tumors. Correlation with other imaging modalities and
potential reduction in follow-up imaging will be discussed.
B. Review of potential applications of dual energy technology in pancreatitis, including early detection of necrosis and vascular
complications, and characterization of pancreatic/peripancreatic collections.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
ER180-ED-X
Abdominal Emergencies in Patients with Undiagnosed Tumor: A Diagnostic Dilemma
All Day Room: ER Community, Learning Center
Participants
Sandra M. Ramirez, MD, Medellin, Colombia (Presenter) Nothing to Disclose
Vanessa Garcia, Medellin, Colombia (Abstract Co-Author) Nothing to Disclose
Claudia P. Huertas, MD, Medellin, Colombia (Abstract Co-Author) Nothing to Disclose
Viviana Marcela Palacio Castano, Medellin, Colombia (Abstract Co-Author) Nothing to Disclose
Tatiana Suarez, MD, Medellin, Colombia (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
Acute complications caused by abdominal malignancies in patients with undiagnosed tumor are potentially fatal
conditions.Complications represent a diagnostic dilema in the ER and some of them include hemorrhagic cholecystitis in gallbladder
carcinoma, hemoperitoneum secondary to rupture of HCC, bleeding from adrenocortical carcinoma, urinoma due to ureter
obstruction from nodal lymphoma, bladder outlet obstruction due to prostatic sarcoma, bowel obstruction due to invaginated
lymphoma in the ileocecal valve, abdominal abscess due to rupture of cholangiocarcinoma, acute abdominal pain due to renal artery
thrombosis by renal cell carcinoma, acute pancreatitis due to pancreatic adenocarcinoma, acute abdominal pain due to appendiceal
neuroendocrine, among others. The purpose of this exhibit is: - To identify the CT imaging appearances of acute and potentially
fatal complications caused by abdominal malignancies in patients with undiagnosed tumor as differential diagnosis from classic acute
abdomen etiologies.- To discuss clinical scenarios that may lead to the development of abdominal emergencies secondary to
abdominal neoplasms.
TABLE OF CONTENTS/OUTLINE
- Tumors presenting with abdominal bleeding- Obstructive conditions secondary to neoplasms- Tumors presenting as perforated
hollow viscus- Tumors presenting with acute abdominal pain
ED004-SU
Emergency Radiology Sunday Case of the Day
Sunday, Nov. 27 7:00AM - 11:59PM Room: Case of Day, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Presenter) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
David Dreizin, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Manickam Kumaravel, MD, FRCR, Houston, TX (Abstract Co-Author) Nothing to Disclose
Constantine A. Raptis, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
David D. Bates, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Thomas Battey, Timonium, MD (Abstract Co-Author) Nothing to Disclose
Nicholas M. Beckmann, MD, Houston, TX (Program Committee Staff) Nothing to Disclose
TEACHING POINTS
1) Recognize key imaging findings on multimodality imaging of emergency/trauma patients. 2) Develop differential diagnosis based on
the clinical information and imaging findings. 3) Recommend appropriate management including image-guided interventions.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
SSA06
Emergency Radiology (Utilization and Practice Management)
Sunday, Nov. 27 10:45AM - 12:15PM Room: N226
CT
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Karen S. Lee, MD, Boston, MA (Moderator) Nothing to Disclose
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Moderator) Nothing to Disclose
Sub-Events
SSA06-01
Accuracy of Outside Radiologists' Reports of Computed Tomography Exams of Emergently
Transferred Patients
Sunday, Nov. 27 10:45AM - 10:55AM Room: N226
Participants
Jeffrey D. Robinson, MD, MBA, Seattle, WA (Presenter) Consultant, HealthHelp, LLC; President, Cleareview, Inc;
Ken F. Linnau, MD, MS, Seattle, WA (Abstract Co-Author) Royalties, Cambridge University Press; Speaker, Siemens AG
Daniel S. Hippe, MS, Seattle, WA (Abstract Co-Author) Research Grant, Koninklijke Philips NV; Research Grant, General Electric
Company
Kellie L. Sheehan, Seattle, WA (Abstract Co-Author) Nothing to Disclose
Joel A. Gross, MD, MS, Seattle, WA (Abstract Co-Author) Nothing to Disclose
PURPOSE
Determine the concordance rate of CT interpretations of emergently transferred patients to a Level 1 trauma center.
METHOD AND MATERIALS
The IRB determined this retrospective study to be exempt after reviewing the study protocol. Outside CT scans of all adult patients
transferred to the Emergency Department of a Level 1 trauma center from May 9, 2015 to June 9, 2015 were retrospectively
reviewed. Patients were categorized as trauma or non-trauma transfers. The original imaging report was compared to the reviewer’s
findings, and categorized as concordant or discordant. Discordant findings were rated as minor, moderate or major. Major
discordances were defined as having the potential to impact clinical management. Rates of each type of discordance and 95%
confidence intervals (CIs) were calculated per transfer and per exam.
RESULTS
628 CT scans from 327 transfers were reviewed. There were 213 (65%) trauma transfers and 114 (35%) non-trauma transfers,
corresponding to 490 trauma-related exams and 138 non-trauma exams. Of the 327 total transfers, there were 119 (36%, 95% CI:
31-42%) with any discordance and 56 (17%, 95% CI: 13-22%) with at least one major discordance. These major discordances
were identified in 49 (23%, 95% CI: 18-29%) of the 213 trauma transfers and 7 (6.1%, 95% CI: 2.7-13%) of the non-trauma
transfers (p<0.001 for the difference). On a per exam basis, 59 of 628 (9.4%) total exams had a major discordance. Among the
trauma-related exams and non-trauma exams there were 51 (10%) and 8 (5.8%) major discordances, respectively. The rates of
major, moderate and minor discordances are further summarized in the Figure.
CONCLUSION
We identified major interpretive discrepancies in the CT scans of 17% of patients emergently transferred to a Level 1 trauma
center. Trauma transfer patients were significantly more likely to have a major discordance than non-trauma transfer patients.
CLINICAL RELEVANCE/APPLICATION
Routine over-reading of pre-transfer CT scans may be justified due to the substantial likelihood of a major discordance in
interpretation that may impact the clinical management of patients.
SSA06-02
Repeated CT Scans in Trauma Transfers: An Analysis of Indications, Radiation Dose Exposure, and
Costs
Sunday, Nov. 27 10:55AM - 11:05AM Room: N226
Participants
Ricarda M. Hinzpeter, MD, Zurich, Switzerland (Presenter) Nothing to Disclose
Kai Sprengel, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
Hatem Alkadhi, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
PURPOSE
To identify the number of CT scans repeated in acute trauma patients receiving imaging before being referred to a trauma center,
to define indications, and to assess radiation doses and costs of repeated CT.
METHOD AND MATERIALS
This retrospective study included all adult trauma patients transferred from other hospitals to a Level-I trauma center during 2014.
Indications for repeated CT scans were categorized into: inadequate CT image data transfer, poor image quality, repetition of head
CT after head injury together with completion to whole-body CT (WBCT), and follow-up of injury known from previous CT. Radiation
doses from repeated CT were determined; costs were calculated using.
RESULTS
Within one year, 85/298 (28.5%) trauma patients were transferred from another hospital because of severe head injury (n=45,
52.9%) and major body trauma (n=23; 27.1%) not manageable in the referring hospital, repatriation from a foreign country (n=14;
16.5%), and no ICU-capacity (n=3; 3.5%). Of these 85 patients, 74 (87.1%) had repeated CT in our center because of inadequate
CT data transfer (n=29; 39.2%), repetition of head CT with completion to WBCT (n=24; 32.4%), and follow-up of known injury
(n=21; 28.4%). None occurred because of poor image quality. Cumulative DLP and annual costs of potential preventable, repeated
CT (inadequate data transfer) was 631mSv (81’304mGy*cm) and 40’192$, respectively.The mean time from trauma to admission to
our center was significantly shorter in patients without repeated CT (median 1.5 ± 3 hours) as compared to those with repeated CT
(median 3.0 ± 19 hours, p<0.001).
CONCLUSION
A considerable number of transferred trauma patients undergo potentially preventable, repeated CT, adding radiation dose to
patients and costs to the health care system.
CLINICAL RELEVANCE/APPLICATION
Repetition of CT in trauma patients occurs relatively often and mainly is caused by inadequate image data transfer.
SSA06-03
Prospective Implementation of a Triage System to Prioritize Review and Finalization of Preliminary
Reports with Emergent Findings
Sunday, Nov. 27 11:05AM - 11:15AM Room: N226
Awards
Student Travel Stipend Award
Participants
Hriday Shah, MD, San Francisco, CA (Presenter) Nothing to Disclose
Stanley Lee, San Francisco, CA (Abstract Co-Author) Nothing to Disclose
Joseph Mesterhazy, BS, San Francisco, CA (Abstract Co-Author) Nothing to Disclose
Eric C. Ehman, MD, Pacifica, CA (Abstract Co-Author) Nothing to Disclose
Javier Villanueva-Meyer, MD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose
Soonmee Cha, MD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose
Jason F. Talbott, MD, PhD, San Francisco, CA (Abstract Co-Author) Data Safety Monitoring Board, StemCells, Inc
PURPOSE
In an academic center, expedient finalization of radiology reports with emergent findings is challenging but clinically critical. We
prospectively investigated the efficacy of a PACS-based system that allows trainees taking independent call to rapidly prioritize
attending review and finalization of preliminary reports with critical findings.
METHOD AND MATERIALS
On-call trainees triaged studies using a PACS-based system based on their impression of study acuity. "Prelim 1" was defined as
studies with emergent radiologic findings, "Prelim 2" as studies with subacute or no concerning findings, and "Prelim 3" as outpatient
studies with non-urgent findings. Triage status and final dictation times were queried for consecutive CT preliminary reports from
weeknights between July 1, 2015 and March 23, 2016. Discrepancies between preliminary and final reports were scored as major or
minor by a board-certified radiologist. Dictation times between triage statuses were compared using ANOVA testing. The proportion
of reports finalized before 12pm and discrepancy rates were compared by triage status using Fisher's exact test.
RESULTS
A total of 6597 studies were initially interpreted by trainees on call over 9 months. Of these, 2671 (40.4%) were triaged as Prelim
1, 3427 (51.9%) as Prelim 2, 199 (3.0%) as Prelim 3, and 300 (4.5%) were not triaged. Prelim 1 studies were finalized earlier than
the remainder of the studies (p<0.01). The average final dictation time was 9:50am for Prelim 1 studies, 10:23am for Prelim 2
studies, and 10:38am for Prelim 3 studies. The percentage of studies dictated before 12 pm was also significantly different by
triage status: 93% for Prelim 1, 87% for Prelim 2 and 83% for Prelim 3 (p<0.01). Major discrepancies occurred in 1% of Prelim 1
studies compared to 0.5% of Prelim 2 studies (p=0.24).
CONCLUSION
We successfully implemented a triage system at a large academic center to expedite attending review and finalization of preliminary
reports ruling acute findings. Our data shows that this triage system is effective in prioritizing finalization of high-priority studies
with acute clinical implications.
CLINICAL RELEVANCE/APPLICATION
At teaching institutions, finalization of preliminary reports can be triaged based on acuity of findings to improve patient care. Our
triage method is easy to implement and generalizable to other academic institutions.
SSA06-04
Impact of Insurance Status on Obtaining Recommended Imaging Follow-Up of Incidental Pulmonary
Nodules Identified in the Emergency Department
Sunday, Nov. 27 11:15AM - 11:25AM Room: N226
Participants
Michael S. Kelleher Jr, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose
Lauren Sapienza, New Haven, CT (Abstract Co-Author) Nothing to Disclose
Howard P. Forman, MD, New Haven, CT (Presenter) Nothing to Disclose
PURPOSE
Communication of imaging follow-up recommendations is essential for optimal patient care. Despite effective communication, many
patients do not receive recommended follow-up. We sought to determine if patient insurance status impacts the percentage of
patients who successfully complete recommended imaging follow-up in the emergency department setting
METHOD AND MATERIALS
Our institution’s IRB deemed this study a QI project. During the month of February 2016, a retrospective chart review identified
patients who presented to our ED during the year 2014 who were found to have 4-8mm incidental pulmonary nodules. Patients with
a history of pulmonary nodules or malignancy were excluded, as were those who died during the recommended follow-up period. We
then determined if follow-up imaging was performed. Patient demographics, including insurance status were recorded. We then
contacted the primary care providers for patients who did not undergo imaging follow-up in our healthcare system to determine if
the provider was aware of follow-up and if it had been performed at an outside facility. Descriptive statistics were then calculated
and p values were determined using a Fisher’s exact test.
RESULTS
87 patients met study criteria. 27 patients were excluded with the most common reason being death during the follow-up period
(11/27). Average patient age was 62.6 years (range 36-91 years). 21% (21/87) of patients received follow-up imaging. A
significantly higher percentage of patients with private insurance received follow-up compared to those on Medicare (p=0.02) as
well as compared to those on Medicaid or uninsured (p=0.02). Of patients who did not receive imaging follow-up within our health
care system, 11% had imaging follow-up performed at an outside facility, 11% did not show up for follow-up imaging, and in 78% of
patients the primary care provider was not aware of the need for follow-up.
CONCLUSION
A minority of our emergency department patients obtain recommended lung nodule follow-up. Of those who do, the majority have
private insurance. These findings suggest that reporting and communicating is not enough and that additional strategies must be
implemented in order to “close the loop.”
CLINICAL RELEVANCE/APPLICATION
We have found that despite appropriately communicating critical results, the "loop" is infrequently closed for emergency department
patients found to have incidental pulmonary nodules.
SSA06-05
Assessing the Gap in First or Senior Female Authorship in the Journal Emergency Radiology: Trends
Over a 20-year Period
Sunday, Nov. 27 11:25AM - 11:35AM Room: N226
Awards
Student Travel Stipend Award
Participants
Kristopher McKenzie, MD, Pontiac, MI (Presenter) Nothing to Disclose
Milita Ramonas, MD, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
To examine trends in female first and senior (listed last) authors in the journal Emergency Radiology, from January 1994 to
December 2014.
METHOD AND MATERIALS
Two researchers retrospectively reviewed a total of 1617 articles in the journal Emergency Radiology. Original articles, case
reports, review articles, and pictorial essays were included. However, articles including letters, acknowledgements,
communications, commentaries, editorials, status reports, book reviews, technical notes, annual meeting reports, proceedings,
point counterpoints, clinical quizzes, challenge cases, and abstract reviews were all excluded. Special editions or supplementary
issues were also excluded from analysis. Author’s gender was categorized as male or female using the knowledge of basic names
that are commonly associated with gender (such as Anna for female and John for male). For less common names, a Google search
was performed with the author’s names. The first 30 search listings were examined to determine the gender of the author. If the
gender was still uncertain, the author was excluded. Comparative statistical tests were performed using a commercially available
statistical package (SPSS).
RESULTS
Out of a total of 1617 articles reviewed, there were 1420 articles fulfilling the inclusion criteria. There were a total of 1420 first
authors and 1295 senior authors.125 were solo authors. We were able to confidently determine the gender of 96% of first authors
(1368 of 1420), and 96% of last authors (1246 of 1295). Overall, female authors constituted 20% of first authors (290 of 1420),
and 14% of last authors (180 of 1295). The increase in female first authors throughout the last 20 years was non-significant, from
17.5% in 1994 to 20.9% in 2014 (P = 0.514). However, there was significant increase in female last authors, from 12.9% in 1994,
to 21.3% in 2014 (P= 0.026).
CONCLUSION
Over last 20 years, there has been statistically significant upward linear trend of female senior authorship in the journal Emergency
Radiology, and a non-statistically significant increase in female first authorship.
CLINICAL RELEVANCE/APPLICATION
Despite an increase in female authors in the Emergency Radiology journal over last two decades, the authorship remains low and
female participation should be encouraged.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
SSA06-06
Inadequate Clinical Information in Emergency Radiology Consultations-Does it Really Affect the Error
Rate or is it Merely a Bugbear?
Sunday, Nov. 27 11:35AM - 11:45AM Room: N226
Participants
Anjali Agrawal, MD, Delhi, India (Presenter) Nothing to Disclose
Arjun Kalyanpur, MD, Bangalore, India (Abstract Co-Author) CEO, Teleradiology Solutions Pvt Ltd
PURPOSE
The frustration of receiving inadequate clinical information during a referral is well known to any practicing radiologist. We sought to
determine if there was any correlation between the quality of clinical information and the types of errors in our emergency
teleradiology practice.
METHOD AND MATERIALS
We maintain a record of cases sent for quality assurance (QA) review by our client radiology practices. These comprise less than
1% of all cases and are scored as per ACR RADPEER guidelines, ranging from 1 (no error) to 4 (obvious miss), further denoted as “a”
(clinically insignificant) or “b” (clinically significant). In 831 cases flagged for QA review, we additionally scored the quality of clinical
information – category 1 (inadequate), 2 (adequate), 3 (detailed), for the study type ordered, and without knowledge of the
missed findings or the QA grade. Similarly, we also scored 304 cases where no QA was flagged. Chi-square tests and regression
models were used to determine the associations between quality of clinical information and radiologic error.
RESULTS
Surprisingly, detailed histories (Category 3) were less frequent in the cases without QA than those with QA or error (p < 0.01).
There was no significant influence of clinical information score upon QA category. More history did not reduce the rates of obvious
errors or any errors. Stronger effects were seen for the type of study, with MR studies being significantly associated with increased
rates of clinically significant (ACR “b”) errors (p=0.008). The level of clinical information was not associated with any reduction in
the proportion of significant error (ACR2b, 3b, 4b), when compared to no error.
CONCLUSION
It is likely that experienced radiologists do not require much clinical information to reach an accurate radiological diagnosis in the
emergent setting with a relatively well defined mix of cases. Whether this is also true for radiologists-in-training or those in the
early years of practice needs to be tested.
CLINICAL RELEVANCE/APPLICATION
Perceived inadequate clinical information by radiologists does not translate to increased rates of radiologic error, at least in an
emergency radiology setting with experienced radiologists.
SSA06-07
Emergency Radiology Resident Interpretation in an Era of 24-7 Radiology Attending Coverage and
Supervision
Sunday, Nov. 27 11:45AM - 11:55AM Room: N226
Awards
Student Travel Stipend Award
Participants
Siavash Behbahani, MD, Mineola, NY (Presenter) Nothing to Disclose
A. Orlando Ortiz, MD, MBA, Mineola, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
To assess the impact of 24-7 in-house radiology attending coverage on radiology resident performance
METHOD AND MATERIALS
We retrospectively reviewed radiology resident reports on emergent diagnostic radiology procedures over an 11 month period. The
emergent studies included plain radiographs and cross sectional examinations (US, CT and MRI). All reports where assessed for
accuracy in terms of missed findings as compared to the final attending reading. Missed findings were identified using emergency
room call back forms. The missed findings were categorized as minor or major depending on whether or not the finding impacted on
subsequent patient management. A radiology attending and resident reviewed each missed finding in order to determine, by
consensus, the significance of the missed finding. Resident performance was also stratified by year of training. These data were
compared to a metanalysis of historical resident performance as gleamed from the radiology literature.
RESULTS
During 11 months, a total number of 29,636 studies were preliminary interpreted by 17 radiology residents on call under 24/7
supervision of an in-house radiology attending. The resident-faculty discrepancy rate for radiographs is 0.8% vs. 1.4% (based on
literature). For cross-sectional studies the rates were: CT 0.5% vs. 2.4%, US 0.1% vs. 0.6%, MR 1.1% vs. 3.7%, based on
literature, respectively. With respect to plain radiographs the most common area for discrepant findings was chest radiography. The
rate of minor and major discrepancy substantially decreased by increasing resident year of training
CONCLUSION
Radiology resident on-call performance, with respect to diagnostic radiology interpretations, improves with the presence of 24-7 inhouse radiology attending coverage. In-house radiology attending coverage and supervision ultimately improves patient care,
emergency room management/discharge time, and appropriateness of management.
CLINICAL RELEVANCE/APPLICATION
In a new era of the provision of real-time radiology services, a concern has arisen regarding the educational experience and
performance of radiology residents who take call in programs where an in-house radiology attending is available. Our results show a
favorable impact on resident performance based on a reduction of missed findings.
SSA06-08
Criteria-based Direct Access to Polytrauma Whole-body CT in the Emergency Department Leads to a
Dramatic Fall in Use of Plain Radiographs Prior to Whole-body CT at a Major Trauma Centre
Sunday, Nov. 27 11:55AM - 12:05PM Room: N226
Awards
Student Travel Stipend Award
Participants
Nikola Tomanovic, MBBS, Brighton, United Kingdom (Presenter) Nothing to Disclose
Ahmed Daghir, MRCP, FRCR, Oxford, United Kingdom (Abstract Co-Author) Nothing to Disclose
PURPOSE
A set of criteria for direct Emergency Department access to polytrauma whole-body CT were introduced in 2013 to help guide
clinical decision making and speed up patient imaging in the Emergency Department.This study aims to determine whether the use
of criteria based patient selection protocols affects the numbers of plain radiographs performed prior to CT acquisition.
METHOD AND MATERIALS
A retrospective sample of 60 polytrauma whole-body CT scans, performed over a two month period, at a major trauma centre was
analysed in 2012, 2014 and 2015.Criteria-based direct Emergency Department access to polytrauma whole-body CT scans was
introduced over 2013 at our hospital, with criteria modified from the patient inclusion criteria for the REACT-2 trial. When the
criteria are met the patient proceeds directly to CT without prior discussion with a radiologist.The proportion of patients undergoing
a plain radiograph examination of the chest or pelvis prior to CT was compared before (2012) and after (2014 and 2015)
introduction of these criteria.
RESULTS
In 2012, prior to the implementation of the direct ED access to CT protocol, 73% of polytrauma patients (44/60) had a plain chest
radiograph and 60% (36/60) had a plain pelvic radiograph prior to CT.Following protocol implementation, however, these numbers
reduced drastically. In 2014, 37% of polytrauma patients (22/60) had a plain chest radiograph and 25% (15/60) had a plain pelvic
radiograph prior to CT.In 2015, no patients (0/60) had a plain chest radiograph and only 2% (1/60) had a plain pelvic radiograph
prior to CT.None of the plain pelvic and chest radiographs in this study yielded any results that were not also noted on the
subsequent CT.
CONCLUSION
Our results show that a criteria-based direct access to CT protocol in the Emergency Department is associated with a dramatic
decrease in the use of plain chest and pelvic radiographs prior to whole-body CT. As expected our data also confirm that there
were no additional findings shown on plain film over CT.
CLINICAL RELEVANCE/APPLICATION
The introduction of a “direct access to CT” protocol is associated with a dramatic reduction in the use of plain radiographs before
CT. This implies that faster access to CT removes the need for plain radiographs to direct urgent intervention for life-threatening
injuries.
SSA06-09
National Trends in Imaging Suspected Appendicitis: Current Status
Sunday, Nov. 27 12:05PM - 12:15PM Room: N226
Awards
Student Travel Stipend Award
Participants
Victoria F. Tan, MD, Hamilton, ON (Presenter) Nothing to Disclose
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
To assess the current trends in the imaging of suspected appendicitis in adult patients presenting to emergency departments of
academic medical centers across our country.
METHOD AND MATERIALS
A questionnaire was sent electronically to all 17 academic centers in our country to be completed by Emergency Radiology Section
Chiefs. The questionnaires were sent over a period of 3 months staring on October 1, 2015. The survey and analysis of the
resulting data was approved by the IRB at our institution.
RESULTS
Fifteen centers (88%) responded to the questionnaire. Eleven respondents (73%) used IV contrast - enhanced CT as the imaging
modality of choice in imaging of all patients with suspected appendicitis. Twelve respondents (80%) use ultrasound as the initial
modality of choice in imaging pregnant patients with suspected appendicitis. Ten respondents (67%) use ultrasound as the modality
of choice in patients younger than 40 years of age. When CT is used, 80% use non-focused CT of the abdomen and pelvis, and
47% of centers routinely use oral contrast. Twelve centers (80%) have ultrasound available 24 hours/7 days a week. At twelve
centers (80%), the ultrasound examinations are performed by trained ultrasound technologists. Ten centers (67%) have MRI
available 24/7. All fifteen centers (100%) use non-enhanced MRI. However, MRI is used as first modality for the imaging of pregnant
patients in only three centers (20%) and as first modality for the imaging of patient younger than 40 years in only one center (7%).
CONCLUSION
There is heterogeneity in the imaging practice and protocols for patients with suspected appendicitis at our country, which varies
depending on patient demographics, resource availability and institutional protocols.
CLINICAL RELEVANCE/APPLICATION
Imaging trends should be considered to develop a national imaging algorithm to permit standardization across our country.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
ERS-SUA
Emergency Radiology Sunday Poster Discussions
Sunday, Nov. 27 12:30PM - 1:00PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Moderator) Nothing to Disclose
Karen S. Lee, MD, Boston, MA (Moderator) Nothing to Disclose
Sub-Events
ER200-SDSUA1
Trauma - Attenuation of Abdominal and Pelvic Structures on Computed Tomography in the Setting of
Shock
Station #1
Awards
Student Travel Stipend Award
Participants
Michael Wasserman, MD, Boston, MA (Presenter) Nothing to Disclose
Michael J. Hsu, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Venkata Satyam, Boston, MA (Abstract Co-Author) Nothing to Disclose
Tina Shiang, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jennifer Xiao, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Deepan Paul, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ahmed Y. El-Araby, MD , West Warwick, RI (Abstract Co-Author) Nothing to Disclose
Vaeman Chintamaneni, Boston, MA (Abstract Co-Author) Nothing to Disclose
Robert Burns, Boston, MA (Abstract Co-Author) Nothing to Disclose
Arthur Baghdanian, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jorge A. Soto, MD, Boston, MA (Abstract Co-Author) Royalties, Reed Elsevier
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
Hypotension is an important marker of a patient’s clinical condition in the setting of trauma. Contrast-enhanced computed
tomography of the abdomen and pelvis (CTAP) is an invaluable tool in evaluating blunt or penetrating trauma. The purpose of this
study is to investigate the effects of hypotension on the enhancement of a patient’s abdominopelvic structures in the setting of
trauma.
METHOD AND MATERIALS
This HIPAA-compliant, retrospective study performed at our urban academic teaching hospital was approved by the Institutional
Review Board (IRB); informed consent was waived.A database of patients, aged 18 and older, receiving CTAP in the setting of blunt
or penetrating trauma during 2014 was assembled using our hospital’s EMR. Two cohorts were selected. One cohort comprised of
individuals who were hypotensive with a systolic blood pressure of less than 90 on initial presentation to the Emergency Department
(ED). The second cohort was comprised of individuals with normal vital signs and lab values on initial presentation to the ED, and
without any clinically significant findings on CTAP.Attenuation of the patient’s abdominal and pelvic vascular structures and solid
organs were measured in Hounsfield Units (HU). Measurements were obtained in the arterial and portal venous phases. 14
hypotensive individuals were evaluated. Mann Whitney U-tests were used in data analysis.
RESULTS
In the arterial phase, scanned at 30 seconds, hypotensive individuals demonstrated statistically significant increased attenuation of
the aorta, portal vein and renal medulla compared to normotensive individuals. In the portal venous phase, scanned at 70 seconds,
hypotensive individuals had significantly decreased attenuation of the renal cortex, spleen, pancreas and liver compared to
normotensive individuals.
CONCLUSION
In the setting of trauma, hypotensive individuals have significant differences in perfusion compared to normotensive individuals, as
evidenced by increases in attenuation of the aorta, portal vein and renal medulla in the arterial phase and decreases in attenuation
of the renal cortex, spleen, pancreas and liver in the portal venous phase.
CLINICAL RELEVANCE/APPLICATION
In the setting of trauma, hypotensive individuals have significant differences in perfusion compared to normotensive individuals,
which are demonstrated on CTAP. Awareness of these differences may assist in triaging patients and predicting clinical outcomes.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jorge A. Soto, MD - 2013 Honored Educator
Jorge A. Soto, MD - 2014 Honored Educator
Jorge A. Soto, MD - 2015 Honored Educator
ER201-SDSUA2
Emergency Ultrasound for Acute Appendicitis: Technical Factors that Influence Follow-up Radiation in
Pediatric Patient Populations with Suspected Appendicitis
Station #2
Awards
Student Travel Stipend Award
Participants
Joshua Ewell, DO, Norwalk, CT (Presenter) Nothing to Disclose
Alicia DeRobertis, MD, Norwalk, CT (Abstract Co-Author) Nothing to Disclose
Ichiro Ikuta, MD, MMedSc, Norwalk, CT (Abstract Co-Author) Nothing to Disclose
Steven M. Bernstein, MD, Weston, CT (Abstract Co-Author) Nothing to Disclose
PURPOSE
The purpose of this study is to optimize technical skills to support successful identification of normal and pathologic appendices and
to identify technical factors that contribute to non-diagnostic US, with subsequent CT radiation exposure in pediatric patients.
METHOD AND MATERIALS
All exams were performed by trained radiology residents (RR) or ultrasound technicians (UT). PACS query criteria: date: 01/0112/31/2015; modality: US; procedure: Appendix. 266 studies met criteria. Data-points: performed by RR or UT;
time imaging; visualization/non-visualization; subsequent CT and MRI; ave radiation exposure from subsequent imaging; surgical and
pathologic concordance; patient demographics. The primary endpoint of the study is to establish exam optimization/best-practice
guidelines for diagnostic identification of the appendix during sonographic evaluation. Secondary endpoints include minimizing
radiation dose to pediatric patients and pre-empting more costly follow-up MRI imaging.
RESULTS
Preliminary results (17/266) are provided. Sensitivity (visualized) US = 24%. Specificity (surgically proven) = 50%. Ave time
scanning 8 min (vis/non-vis). RR = average of 12 min scanning. UT = average of 5.9 min scanning. RR were twice as likely to
identify the appendix (33% of the time versus UT 18%). 6/17 US were followed by CT, with 1 surgically proven appendicitis. Total
ave effective dose = 2.8 mSv. 11/17 had no followup imaging, with unrelated discharge diagnoses. The remaining 4 were discharged
with diagnoses of abdominal pain NOS. 6/17 were followed by CT. 1 went to surgery with surgical and pathologic concordance. The
remaining 5 CTs demonstrated normal appendices on CT. The only abnormal appendix in this group was correctly identified on US.
CONCLUSION
RR are better at identifying the appendix, suggesting multi-modality correlation and anatomic knowledge may improve success. Low
suspicion (screening) ultrasounds from the ED were never positive. Average dose to patients = 2.84 mSv, with 1/6 CT positive for
acute appendicitis.
CLINICAL RELEVANCE/APPLICATION
Preliminary data suggests use of US as a screening tool for nonspecific abdominal pain in the ED is frequent and inappropriate. UT
exams may benefit from anatomic review and landmark identification. Further analysis should identify additional factors that
contribute to visualization and non-visualization of the appendix and the associated effective radiation doses of subsequent
imaging.
ER203-SDSUA4
National Trends in Imaging Suspected Appendicitis: Current Status
Station #4
Participants
Victoria F. Tan, MD, Hamilton, ON (Presenter) Nothing to Disclose
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
To assess the current trends in the imaging of suspected appendicitis in adult patients presenting to emergency departments of
academic medical centers across our country.
METHOD AND MATERIALS
A questionnaire was sent electronically to all 17 academic centers in our country to be completed by Emergency Radiology Section
Chiefs. The questionnaires were sent over a period of 3 months staring on October 1, 2015. The survey and analysis of the
resulting data was approved by the IRB at our institution.
RESULTS
Fifteen centers (88%) responded to the questionnaire. Eleven respondents (73%) used IV contrast - enhanced CT as the imaging
modality of choice in imaging of all patients with suspected appendicitis. Twelve respondents (80%) use ultrasound as the initial
modality of choice in imaging pregnant patients with suspected appendicitis. Ten respondents (67%) use ultrasound as the modality
of choice in patients younger than 40 years of age. When CT is used, 80% use non-focused CT of the abdomen and pelvis, and
47% of centers routinely use oral contrast. Twelve centers (80%) have ultrasound available 24 hours/7 days a week. At twelve
centers (80%), the ultrasound examinations are performed by trained ultrasound technologists. Ten centers (67%) have MRI
available 24/7. All fifteen centers (100%) use non-enhanced MRI. However, MRI is used as first modality for the imaging of pregnant
patients in only three centers (20%) and as first modality for the imaging of patient younger than 40 years in only one center (7%).
CONCLUSION
There is heterogeneity in the imaging practice and protocols for patients with suspected appendicitis at our country, which varies
depending on patient demographics, resource availability and institutional protocols.
CLINICAL RELEVANCE/APPLICATION
Imaging trends should be considered to develop a national imaging algorithm to permit standardization across our country.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
ER101-EDSUA5
Dual Energy CT for Abdominal and Pelvic Trauma: A Pictorial Review
Station #5
Awards
Certificate of Merit
Identified for RadioGraphics
Participants
Jeremy R. Wortman, MD, Boston, MA (Presenter) Nothing to Disclose
Jennifer W. Uyeda, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Urvi P. Fulwadhva, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
TEACHING POINTS
1) Dual energy CT enables a number of applications that can be useful in assessing patients with abdominal and pelvic trauma,
including creation of iodine overlay and virtual non-contrast (VNC) images, evaluation of bone marrow edema, and creation of
virtual monoenergetic images to accentuate differential enhancement or to reduce metal artifact. 2) Dual energy post-processing in
trauma patients can be particularly useful in assessment of active contrast extravasation as well as evaluation of decreased
enhancement of abdominal and pelvic viscera, which can be crucial in appropriate management of patients with abdominal and
pelvic trauma. 3) Routine dual energy CT imaging and post-processing can be performed in trauma patients in the Emergency
Department setting, and can be incorporated into clinical workflow.
TABLE OF CONTENTS/OUTLINE
1) Applications of dual energy CT to patients with abdominal and pelvic trauma: review the variety of post-processing applications
available with dual energy CT, and how these can benefit assessment of trauma patients2) Case based review of dual energy CT
findings in trauma patients3) Future directions and summary
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
ERS-SUB
Emergency Radiology Sunday Poster Discussions
Sunday, Nov. 27 1:00PM - 1:30PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
FDA
Discussions may include off-label uses.
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Moderator) Nothing to Disclose
Karen S. Lee, MD, Boston, MA (Moderator) Nothing to Disclose
Sub-Events
ER205-SDSUB2
An Unusual Complication of a Common Finding: Acute Epiploic Appendagitis within Abdominal Wall
Hernias - Frequency and Subtypes
Station #2
Awards
Student Travel Stipend Award
Participants
Renata R. Almeida, boston, MA (Presenter) Nothing to Disclose
Mohammad Mansouri, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ajay K. Singh, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Bernardo C. Bizzo, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Michael H. Lev, MD, Boston, MA (Abstract Co-Author) Consulant, General Electric Company; Institutional Research Support, General
Electric Company; Stockholder, General Electric Company; Consultant, MedyMatch Technology, Ltd; Consultant, Takeda
Pharmaceutical Company Limited; Consultant, D-Pharm Ltd
PURPOSE
Acute Epiploic Appendagitis (AEA) as a complication of abdominal wall hernias is poorly studied in the literature. Our aim was to
assess the prevalence of AEA within abdominal wall hernias, stratified by hernia subtype.
METHOD AND MATERIALS
This was an IRB approved HIPAA-compliant retrospective study. Our medical data base was searched for Computed Tomography
(CT) cases of abdominal wall hernias occurring between 2003 and 2015, to assess the prevalence of AEA within hernia sacs.
Imaging findings on CT were analyzed in the positive cases. Medical records were searched for clinical features and treatment.
RESULTS
Among 4352 abdominal wall hernias from 4069 patients, 44% (1952/4352) were inguinal, 4.1% (185/4352) Spigelian, 1.5%
(64/4352) femoral and 49.4% (2151/4352) ventral hernias. Nine patients had AEA within hernia sacs (Mean age: 70.7 years; 66.7%
males). The prevalence of AEA was 0.2% (9/4352) within all abdominal wall hernias, 2.2% within Spigelian (4/185), 0.25% (5/1952)
within inguinal, and 0% within femoral and ventral hernias. 77.8% (7/9) of the patients had previous history of anterior abdominal
wall surgery. Imaging features included fat stranding (88.9%;8/9), central dot (44.5%;4/9), two inflamed epiploic appendages
(33.3%;3/9) and fluid inside the hernia sac (33.3%;3/9). In 66.7% (6/9) only the inflamed appendage was herniated. All the cases
presented with local pain. Hernia sacs were incarcerated in 4 cases; strangulated in 1 case, and non-palpable in 4 cases. Hernia
treatment was conservative in 55.5% (5/9) and surgical in 44.5% (4/9).
CONCLUSION
AEA within hernia sacs is rare. This complication is exceedingly unlikely (0%) among ventral or femoral hernias, very unusual in
inguinal hernias (0.25%), and most likely to occur within Spigelian hernias (2.2%). Patients were most commonly elderly males with
a history of previous abdominal wall surgery.
CLINICAL RELEVANCE/APPLICATION
Emergency radiologists should be aware that AEA as a complication of abdominal wall hernia is very rare, but when it does occur is
most likely within Spigelian hernias.
ER206-SDSUB3
Performance of an Ultrasound-First ED Consensus Imaging Algorithm for Suspected Acute
Appendicitis Above and Below an Alvarado Score of 3
Station #3
Participants
Urvi P. Fulwadhva, MD, Boston, MA (Presenter) Nothing to Disclose
Sarah Frasure, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Wendy B. Landman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Amy Hildreth, Boston, MA (Abstract Co-Author) Nothing to Disclose
Naomi Schimizu, Boston, MA (Abstract Co-Author) Nothing to Disclose
Micheal Stone, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
PURPOSE
We recently implemented an US-first consensus-imaging algorithm for suspected acute appendicitis in non-obese patients younger
We recently implemented an US-first consensus-imaging algorithm for suspected acute appendicitis in non-obese patients younger
than 40 years old. The purpose of this study was to evaluate algorithm performance stratified by Alvarado scores above and below
a threshold of 3.
METHOD AND MATERIALS
Methods and Materials:This HIPAA compliant, IRB approved retrospective study included 277 consecutive ER patients who
underwent appendix ultrasound from May 2015 to Feb 2016 based on a new interdepartmental US-first consensus algorithm with CT
following inconclusive US. The Alvarado score for all patients was calculated, and patients stratified into scores 3. The patients
were then divided based on results of US (normal appendix, appendix not seen no secondary, equivocal US and acute appendicitis).
Sensitivity and specificity was calculated.
RESULTS
Of 111 patients with Alvarado =/<3, US reported a normal appendix in 4, appendix not seen in 92, equivocal findings in 13, and
suspected appendicitis in 2. 53 (47.7%) proceeded to CT, 2 (1.8%) to the OR, and none ultimately proved to have appendicitis. 17
(15.3%) had alternative diagnoses explaining symptoms by US, 13 (24%) by CT. The specificity is 98% with NPV of 100%.Of 165
patients with Alvarado >3, US reported a normal appendix in 3, appendix not seen in 99, equivocal findings in 41, and suspected
appendicitis in 22. 101 (60%) proceeded to CT, 49 (29%) to the OR, and 44 had pathology proven appendicitis. 27 (16%) had
alternative diagnoses explaining symptoms by US, 23 (22%) by CT. Sensitivity and specificity is 44% and 98% with NPV of 82%.
CONCLUSION
Ultrasound has a higher negative predictive value and should be used as a first tool for evaluation of non-obese young patients
with suspected appendicitis with Alvarado score less than 3. Percentage of patients with alternative diagnosis on either CT or US
was similar between the two groups.
CLINICAL RELEVANCE/APPLICATION
Appendix US has higher negative predictive value and should be used as first tool for evaluation of non-obese young patients age
less than 40 years with Alvarado score less than 3.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
ER207-SDSUB4
Inadequate Clinical Information in Emergency Radiology Consultations - Does It Really Affect the
Error Rate or Is It Merely a Bugbear?
Station #4
Participants
Anjali Agrawal, MD, Delhi, India (Presenter) Nothing to Disclose
Arjun Kalyanpur, MD, Bangalore, India (Abstract Co-Author) CEO, Teleradiology Solutions Pvt Ltd
PURPOSE
The frustration of receiving inadequate clinical information during a referral is well known to any practicing radiologist. We sought to
determine if there was any correlation between the quality of clinical information and the types of errors in our emergency
teleradiology practice.
METHOD AND MATERIALS
We maintain a record of cases sent for quality assurance (QA) review by our client radiology practices. These comprise less than
1% of all cases and are scored as per ACR RADPEER guidelines, ranging from 1 (no error) to 4 (obvious miss), further denoted as “a”
(clinically insignificant) or “b” (clinically significant). In 831 cases flagged for QA review, we additionally scored the quality of clinical
information – category 1 (inadequate), 2 (adequate), 3 (detailed), for the study type ordered, and without knowledge of the
missed findings or the QA grade. Similarly, we also scored 304 cases where no QA was flagged. Chi-square tests and regression
models were used to determine the associations between quality of clinical information and radiologic error.
RESULTS
Surprisingly, detailed histories (Category 3) were less frequent in the cases without QA than those with QA or error (p < 0.01).
There was no significant influence of clinical information score upon QA category. More history did not reduce the rates of obvious
errors or any errors. Stronger effects were seen for the type of study, with MR studies being significantly associated with increased
rates of clinically significant (ACR “b”) errors (p=0.008). The level of clinical information was not associated with any reduction in
the proportion of significant error (ACR2b, 3b, 4b), when compared to no error.
CONCLUSION
It is likely that experienced radiologists do not require much clinical information to reach an accurate radiological diagnosis in the
emergent setting with a relatively well defined mix of cases. Whether this is also true for radiologists-in-training or those in the
early years of practice needs to be tested.
CLINICAL RELEVANCE/APPLICATION
Perceived inadequate clinical information by radiologists does not translate to increased rates of radiologic error, at least in an
emergency radiology setting with experienced radiologists.
ER112-EDSUB5
Imaging of the Perineum in the Emergency Setting: A Pictorial Review
Station #5
Awards
Certificate of Merit
Identified for RadioGraphics
Participants
Jihee Choe, MD, Boston, MA (Presenter) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
Bharti Khurana, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jennifer W. Uyeda, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1) The perineal area can be easily overlooked by radiologists as pathologies are relatively infrequent and potentially complicated. 2)
The anatomy of the perineum is complex. It is important for radiologists to be familiar with relevant anatomy of the perineum for
accurate identification of origin and extent of the disease. 3) Various imaging modalities can be used to evaluate the perineum;
however, CT is most commonly utilized in the acute setting. The widespread availability and rapid acquisition afforded by CT allows
for the evaluation of acute perineal pathologies such as traumatic injury, infectious/inflammatory process, neoplastic process, and
foreign body.
TABLE OF CONTENTS/OUTLINE
1) Review anatomy of the perineum 2) Discuss role of the imaging modalities in evaluating the perineum3) Illustrate characteristic
imaging features of common traumatic perineal injuries encountered in the emergency setting 4) Demonstrate various cases and
imaging features of nontraumatic pathologies including infectious/inflammatory processes, neoplasms, and foreign bodies
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
Bharti Khurana, MD - 2014 Honored Educator
RC108
Emergency Neuroradiology (An Interactive Session)
Sunday, Nov. 27 2:00PM - 3:30PM Room: N227B
NR
CT
MR
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Sub-Events
RC108A
Non-traumatic Subarachnoid Hemorrhage
Participants
Diego B. Nunez JR, MD, MPH, Boston, MA (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Analyze the various causes, patterns of distribution and imaging features of non-traumatic subarachnoid hemorrhage. 2) Identify
the different diagnostic pitfalls encountered in the initial assessment of patients with suspected subarachnoid hemorrhage. 3)
Assess the contribution of additional imaging (CTA, MR, DSA) as integral part of the admitting evaluation of patients with
subarachnoid hemorrhage.
ABSTRACT
RC108B
CT and MRI of Neck Infections
Participants
Wayne S. Kubal, MD, Tucson, AZ (Presenter) Stockholder, Stryker Corporation; Stockholder, Sarepta Therapeutics Inc;
Stockholder, CVS Health Corporation; Stockholder, Gilead Sciences, Inc; Author, Reed Elsevier; Editor, Reed Elsevier
LEARNING OBJECTIVES
1) To diagnose neck infection on CT and MR. 2) To characterize the nature and the location of the infection. 3) To appreciate the
complications that may result from the infection.
ABSTRACT
Active Handout:Wayne Scott Kubal
http://abstract.rsna.org/uploads/2016/16000635/ACTIVE Handout for Course RC108B.pdf
RC108C
CT and MRI of Spine Infections
Participants
A. Orlando Ortiz, MD, MBA, Mineola, NY (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Review the epidemiology and pathophysiology of spine infection. 2) Focus on making the diagnosis of infectious spondylitis
utilizing: Clinical findings, Imaging findings, Biopsy. 3) Distinguish infectious spondylitis from other radiographic mimics.
RC131
Interventional Stroke Treatment: Practical Techniques and Protocols (An Interactive Session)
Sunday, Nov. 27 2:00PM - 3:30PM Room: S103AB
ER
NR
IR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Joshua A. Hirsch, MD, Boston, MA (Moderator) Consultant, Medtronic plc; Data Safety Monitoring Board, Johnson & Johnson;
LEARNING OBJECTIVES
1) Describe the diagnostic evaluation and decision making algorithms leading to urgent endovascular treatment of acute stroke. 2)
Review endovascular techniques for the treatment of acute stroke from microcatheter set up to intraarterial thrombolysis to
mechanical thrombectomy. 3) Discuss case examples of endovascular treatment including patient selection, technique, and pitfalls.
ABSTRACT
Rapid advances in the evaluation, selection, treatment and management of the acute stroke patient necessitates an ongoing
educational event highlighing the newest information, techniques and strategies for obtaining the best outcomes for our patients.
In this session, all of these topics will be covered in a practical "how to" and case based approach which is designed to help the
practitioner implement best practices. The course is useful for those performing imaging, treatment or both. Analysis of the latest
ongoing trials, devices and techniques will be presented. Endovascular tips and tricks will be discussed, as well as pitfalls in the
treatment of these patients.
Sub-Events
RC131A
Devices and Data that Support IA Treatment as the Standard of Care for Ischemic Stroke
Participants
Allan L. Brook, MD, Bronx, NY (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC131B
Optimizing Patient Selection with Imaging
Participants
Ramon G. Gonzalez, MD, PhD, Boston, MA (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the essential ischemic stroke physiology parameters that are essential in selecting patients for endovascular
treatment of a large vessel occlusion. 2) Be familiar with the imaging methods that can measure ischemic stroke physiology
parameters and their relative accuracy. 3) Use the best available evidence, recognize the optimal imaging approach to select
patients with acute ischemic stroke for endovascular treatment.
RC131C
Minimally Invasive Surgery for ICH - The Next Frontier
Participants
David J. Fiorella, MD, PhD, Stony Brook, NY (Presenter) Institutional research support, Siemens, AG; Institutional research support,
Terumo Corporation; Institutional research support, Sequent Medical, Inc; Consultant, Medtronic plc; Consultant, Penumbra, Inc;
Consultant, Sequent Medical, Inc; Consultant, Johnson & Johnson; Stockholder, Vascular Simulations LLC; Consultant, Vascular
Simulations LLC; Owner, TDC Technologies; Owner, CVSL; Royalties, Johnson & Johnson; ; ;
LEARNING OBJECTIVES
1) Understand the essential ischemic stroke physiology parameters that are essential in selecting patients for endovascular
treatment of a large vessel occlusion. 2) Be familiar with the imaging methods that can measure ischemic stroke physiology
parameters and their relative accuracy. 3) Use the best available evidence, recognize the optimal imaging approach to select
patients with acute ischemic stroke for endovascular treatment.
ABSTRACT
Properly selected patients with acute ischemic stroke caused by large vessel occlusion (LVO) may be effectively and safely
treated endovascularly with modern thrombectomy devices. We have developed a high-precision imaging tool for selecting such
patients. It is an experience and evidence-based clinical triage tool that uses advanced imaging to identify INDIVIDUAL patients
most likely to benefit from endovascular stroke therapy. It was based on over a decade of using advanced imaging (CT, CTA, CT
perfusion, DWI, MR perfusion) in acute stroke patients and a critical review of the literature and has been validated in clinical trials.
The approach focuses on answering the following key questions using modern imaging:
1. Is there a hemorrhage? Noncontrast
CT
2. Is there an occlusion of the distal ICA and/or proximal MCA? CTA
3. Is irreversible brain injury below a specific threshold (e.g. <70ml)? DWI Perfusion imaging is not employed unless patients
cannot undergo MRI, or they do not meet the criteria for intervention. Investigations to understand the reasons for the
unsuitability of perfusion CT to substitute for DWI have revealed theoretical and practical shortcomings of CTP. A major problem is
the low signal-to-noise (SNR) ratio of CT perfusion that results in a poor contrast-to-noise (CNR) ratio in severely ischemic brain.
In a comparison between DWI and CTP in over 50 consecutive patients with LVA, Schaefer, et al. showed that the mean CNR of
DWI was >4 while it was <1 for CTP derived CBF. The poor CNR results in large measurement error: using Bland-Altman analyses it
was found that the 95% confidence interval was ~+/- 50 ml for ischemic lesion volume measurements in individual patients.
The Cleveland Clinic adopted a nearly identical algorithm and their results were published. They reported that after the new
algorithm was adopted, there was a ~50% reduction in mortality and a ~3-fold increase in good outcomes, despite a ~50%
decrease in the number of procedures. A recent prospective observational trial at the MGH using stentrievers and this imaging
approach demonstrated >50% favorable outcomes (mRS 0-2) that is similar to recent randomized clinical trials. However, only 3
patients were evaluated for every patient that was treated, a screening to treatment ratio that is much lower than in recently
published clinical trials.1. Gonzalez RG, Copen WA, Schaefer PW, Lev MH, Pomerantz SR, Rapalino O, et al. The Massachusetts
General Hospital acute stroke imaging algorithm: an experience and evidence based approach. Journal of neurointerventional
surgery. 2013;5 Suppl 1:i7-12.
2. Wisco D, Uchino K, Saqqur M, Gebel JM, Aoki J, Alam S, et al. Addition of hyperacute MRI AIDS in patient selection, decreasing
the use of endovascular stroke therapy. Stroke; a journal of cerebral circulation. 2014;45(2):467-72.
3. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet.
1986 Feb 8;1(8476):307-10.4.
Schaefer PW, Souza L, Kamalian S, Hirsch JA, Yoo AJ, Kamalian S, Gonzalez RG, Lev MH. Limited
reliability of computed tomographic perfusion acute infarct volume measurements compared with diffusion-weighted imaging in
anterior circulation stroke. Stroke. 2015 Feb;46(2):419-24.
ED004-MO
Emergency Radiology Monday Case of the Day
Monday, Nov. 28 7:00AM - 11:59PM Room: Case of Day, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Presenter) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
David Dreizin, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Manickam Kumaravel, MD, FRCR, Houston, TX (Abstract Co-Author) Nothing to Disclose
Constantine A. Raptis, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
David D. Bates, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Thomas Battey, Timonium, MD (Abstract Co-Author) Nothing to Disclose
Nicholas M. Beckmann, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
Matt H. Kwon, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Aderonke Ramos, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1) Recognize key imaging findings on multimodality imaging of emergency/trauma patients. 2) Develop differential diagnosis based on
the clinical information and imaging findings. 3) Recommend appropriate management including image-guided interventions.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
RC205
Neuroradiology Series: Stroke
Monday, Nov. 28 8:30AM - 12:00PM Room: N227B
NR
ER
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 4.00
FDA
Discussions may include off-label uses.
Participants
Ajay Gupta, MD, New York, NY (Moderator) Consultant, Biomedical Systems;
Howard A. Rowley, MD, Madison, WI, ([email protected] ​ ​ ) (Moderator) Research Consultant, Bracco Group Research
Consultant, Guerbet SA Research Consultant, General Electric Company Consultant, F. Hoffmann-La Roche Ltd Consultant, W.L.
Gore & Associates, Inc Consultant, Lundbeck Group
Sub-Events
RC205-01
Stroke Systems of Care and Implications for the Radiologist
Monday, Nov. 28 8:30AM - 9:00AM Room: N227B
Participants
Edward C. Jauch, MD, MS, Charleston, SC (Presenter) Research Support, F. Hoffmann-La Roche Ltd; Research Support, Ischemia
Technologies; Research Support, Medtronic plc; Research Support, Stryker Corporation; Research Support, Penumbra, Inc;
Research Support, NoNO, Inc; Research Support, ZZ Biotech, LLC; ;
RC205-02
Prediction of Treatment Response to IV Thrombolysis in Acute Ischemic Stroke Patients using CT
Perfusion-Based Wavelet-Transformed Angiography
Monday, Nov. 28 9:00AM - 9:10AM Room: N227B
Participants
Wolfgang G. Kunz, MD, Munich, Germany (Abstract Co-Author) Nothing to Disclose
Matthias Fabritius, Munich, Germany (Abstract Co-Author) Nothing to Disclose
Lukas Havla, Munich, Germany (Abstract Co-Author) Nothing to Disclose
Birgit B. Ertl-Wagner, MD, Munich, Germany (Abstract Co-Author) Board Member, Koninklijke Philips NV; Board Member, Bracco
Group; Board Member, Springer Science+Business Media; Consultant, MMI Munich Medical International GmbH; Consultant,
Koninklijke Philips NV; Consultant, Springer Science+Business Media; Consultant, Thieme Medical Publishers, Inc; Consultant, Bracco
Group; Institutional Research Grant, Eli Lilly and Company; Institutional Research Grant, F. Hoffmann-La Roche Ltd; Institutional
Research Grant, Guerbet SA; Institutional Research Grant, Merck KGaA; Institutional Research Grant, Bayer AG; Institutional
Research Grant, Novartis AG; Speaker, Siemens AG; Author, Springer Science+Business Media; Author, Thieme Medical Publishers,
Inc; Author, Bracco Group; Royalties, Springer Science+Business Media; Royalties, Thieme Medical Publishers, Inc; Stockholder,
Siemens AG; Travel support, Siemens AG;
Wieland H. Sommer, MD, Munich, Germany (Abstract Co-Author) Founder, QMedify GmbH
Kolja M. Thierfelder, MD,MSc, Munich, Germany (Presenter) Nothing to Disclose
Maximilian F. Reiser, MD, Munich, Germany (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate the predictive value of vessel occlusions that were only detected using CT perfusion-based wavelet-transformed
angiography (waveletCTA) on morphologically determined response to IV thrombolysis.
METHOD AND MATERIALS
In this IRB-approved study, patients out of a retrospective cohort of 929 consecutive subjects who had undergone multiparametric
CT including whole-brain CT perfusion due to suspected ischemic stroke were included. Inclusion criteria were: (1) significant
cerebral blood flow (CBF) deficit, (2) no evidence of single phase CTA (spCTA) occlusion, and (3) acute ischemic non-watershed
infarction as confirmed by follow-up imaging. waveletCTA defines angiographic signal by best fitting of time-attenuation curves to a
generic contrast bolus curve in each voxel as described before. Two blinded and experienced readers analyzed the waveletCTA
images with respect to presence and location of vessel occlusions. Morphologic outcome was defined as relative final infarction
volume using the ratio (final infarction volume) / (CBF deficit volume), of which smaller values were considered favorable.
Multivariate linear regression analyses were performed to identify independent associations.
RESULTS
Seventy-six patients (mean age 71.6 years, SD 12.7) fulfilled the inclusion criteria. Among all 76 patients with unremarkable spCTA,
39 (51.3%) patients showed an occlusion on waveletCTA (vascular territories: MCA 34, PCA 2, ACA 1, SCA 2). Patient subgroups
receiving IV thrombolysis (IVT) (N=39) or supportive care (SC) (N=37) showed no statistically significant difference in age, sex,
time from symptom onset, early infarction signs, CTP mismatch, waveletCTA-detected occlusions or NIHSS on admission (all
p>0.05). In patients treated with IVT, linear regression analysis showed that the presence of a waveletCTA-detected occlusion
was an independent predictor of a favorable morphologic outcome (beta=-0.524; p=0.015), while it failed to predict morphologic
outcome in patients receiving SC (beta=0.046; p=0.812).
CONCLUSION
The presence of an spCTA occult vessel occlusion detected using waveletCTA is an independent predictor of a favorable response
to IVT in terms of a smaller relative final infarction volume.
CLINICAL RELEVANCE/APPLICATION
waveletCTA has the potential to contribute to decision making in acute stroke as occlusions that are detected with this technique
waveletCTA has the potential to contribute to decision making in acute stroke as occlusions that are detected with this technique
(but not on spCTA) seem to predict a more favorable response to IVT.
RC205-03
Cost-Utility Analysis of MR Selection with DWI for Thrombectomy in Proximal Large Vessel Occlusion
Stroke
Monday, Nov. 28 9:10AM - 9:20AM Room: N227B
Awards
Student Travel Stipend Award
Participants
Brian C. Cristiano, MD, Loma Linda, CA (Presenter) Nothing to Disclose
Rajeev Nowrangi, MD,MPH, Loma Linda, CA (Abstract Co-Author) Nothing to Disclose
Udo Oyoyo, Loma Linda, CA (Abstract Co-Author) Nothing to Disclose
Matthew D. Pond, MD, Loma Linda, CA (Abstract Co-Author) Nothing to Disclose
Somnath Basu, MD, Toluca Lake, CA (Abstract Co-Author) Nothing to Disclose
J. Paul Jacobson, MD, Loma Linda, CA (Abstract Co-Author) Shareholder, Genelux Corporation
PURPOSE
Mechanical thrombectomy improves outcomes for patients with proximal large vessel occlusion (LVO) stroke. Treatment selection
strategies however remain poorly defined. At our institution we have observed favorable results among patients with small
presenting DWI core volume regardless of time from onset. Here we leveraged data from an institutional stroke database to model
the cost and effectiveness of a time-independent, MR-driven treatment selection strategy compared with the present standard of
care, which emphasizes time from onset and excludes late candidates.
METHOD AND MATERIALS
A decision-analysis model was constructed using outcomes, probabilities and cost data from published sources and an institutional
stroke database. Willingness to pay (WTP) was set at $50k/QALY. Two selection strategies were modeled: (1) treat all early LVO
patients if reasonable to achieve access within 6 hours of onset (standard of care), (2) treat all LVO patients with small
presentation core infarct (≤50 mL diffusion restriction on MRI), regardless of time from onset. Probabilistic and one-way sensitivity
analyses were performed.
RESULTS
Using a US cost structure, MR screening dominates the standard-of-care, with improved QALYs (0.42 v. 0.40) and reduced costs
($33,800 v. $35,410). In a probabilistic sensitivity analysis, MR screening was more cost-effective in 99% of simulations. In a
separate Monte Carlo simulation using a UK cost environment, MR screening was more cost-effective 89% of the time.
CONCLUSION
A time-independent, MR-driven treatment selection strategy is more cost effective than the current standard of care, which
emphasizes time from symptom onset as the major criterion for selection.
CLINICAL RELEVANCE/APPLICATION
Improved outcomes and reduced costs may be achievable in proximal LVO stroke by selecting patients for thrombectomy based on
presenting DWI infarct volume rather than time from onset.
RC205-04
Machine Learning in the Detection of Brain Infarct on Computed Tomography
Monday, Nov. 28 9:20AM - 9:30AM Room: N227B
Awards
Student Travel Stipend Award
Participants
Ashley Knight-Greenfield, MD, New York, NY (Presenter) Nothing to Disclose
Lohendran Baskaran, New York, NY (Abstract Co-Author) Nothing to Disclose
Praneil Patel, MD, Philadelphia, PA (Abstract Co-Author) Nothing to Disclose
Tong Zhang, Piscataway, NJ (Abstract Co-Author) Nothing to Disclose
Peng Sun, Piscataway, NJ (Abstract Co-Author) Nothing to Disclose
Qi Chang, Piscataway, NJ (Abstract Co-Author) Nothing to Disclose
Hooman Kamel, MD, New York, NY (Abstract Co-Author) Speaker, F. Hoffmann-La Roche Ltd
Ajay Gupta, MD, New York, NY (Abstract Co-Author) Consultant, Biomedical Systems;
James K. Min, MD, New York, NY (Abstract Co-Author) Speakers Bureau, General Electric Company Advisory Board, General Electric
Company Stockholder, General Electric Company Consultant, Koninklijke Philips NV
PURPOSE
To utilize a deep learning technique in which a computer is trained and tested in the detection of infarct on computed tomography
(CT).
METHOD AND MATERIALS
56 head CT scans from an IRB-approved institutional stroke database were selected at random and uploaded to an annotation
system. A total of 1482 axial CT slices were annotated by a single radiologist. Brain centerline was drawn, and brain area and
infarct area were manually traced on CT slices. Categories of annotation included presence of infarct, chronicity of infarct, type of
infarct (ischemic/hemorrhagic), and sidedness of infarct. CT slices from 47 scans were utilized as a training set, while slices from 9
scans were used as a test set. In order to train the computer, 60 x 60 pixel sections, or patches, were utilized with a 10 pixel
stride for a total of 1.8 million training patches and 360,000 test patches. Patches were input into a max-pooling convolutional
neural network, a type of deep learning architecture, for the purposes of training and testing the computer. Sensitivity, specificity,
and receiver operating characteristic (ROC) analysis for pixel accuracy was performed on the test set. Heat maps were generated
by the computer denoting possibility of infarct.
RESULTS
387 (31%) slices were positive for infarct in the training set, 223 (58%) of which were acute, while 76 (30%) slices were positive in
the test set, 35 (46%) of which were acute. Increased accuracy for infarct detection by the computer was observed on sequential
testing cycles. Sensitivity for infarct detection in the test set was 76.6%, with specificity of 90.25%. ROC analysis revealed area
under the curve of 0.93.
CONCLUSION
We demonstrated that a deep learning technique can be used as a tool to train computers in infarct detection, with ultimate selflearning capability. With future optimization of this learning process, we hope to develop a highly accurate assistive tool for
radiologists in the detection of infarct.
CLINICAL RELEVANCE/APPLICATION
Early stages of brain infarction can oftentimes be difficult to detect with computed tomography, and thus an assistive tool, such as
a computer, would be of use to radiologists.
RC205-05
A Simplified Alberta Stroke Program Early CT Score (sASPECTS) for Prognostication and Treatment
Triage of Anterior Circulation Acute Ischemic Stroke
Monday, Nov. 28 9:30AM - 9:40AM Room: N227B
Participants
Seyedmehdi Payabvash, MD, San Francisco, CA (Presenter) Nothing to Disclose
Siamak Noorbaloochi, Minneapolis, MN (Abstract Co-Author) Nothing to Disclose
Adnan I. Qureshi, MD, Minneapolis, MN (Abstract Co-Author) Nothing to Disclose
PURPOSE
To develop a predictive tool based on the topology of early ischemic changes on the admission noncontrast CT scan of anterior
circulation ischemic stroke.
METHOD AND MATERIALS
The study cohort was derived from the ALIAS (Albumin in Acute Stroke) multicenter trials. Patients with admission noncontrast CT
scan and anterior circulation stroke were included. Two expert readers graded ischemic change on admission CT scan using the
Alberta Stroke Program Early CT Score (ASPECTS). A stepwise penalized logistic regression determined those components of the
ASPECTS on admission scans that were independent predictors of favorable outcome – defined by 3-month modified Rankin Scale
(mRs) score ≤2. Follow-up 24-hour CT/MRI scans were reviewed for evidence of intracranial hemorrhage (ICH).
RESULTS
A total of 1115 patients were included. The ischemic changes of the caudate, lentiform nucleus, insula, and M5 components of
ASPECTS on admission CT scan were independent predictors of favorable outcome based on stepwise penalized logistic regression.
A 0-to-4 point simplified ASPECTS (sASPECTS) was developed including these components. There was no significant difference
between the ASPECTS and sASPECTS in prediction of clinical outcome (p=0.738). Among patients with sASPECTS≥1, the rate of
favorable outcome was higher in patients with IV thrombolytic therapy (501/837, 59.9%) versus those without treatment (91/183,
49.7%, p=0.013); whereas, among patients with sASPECTS of 0, IV thrombolysis was not associated with improved clinical
outcome. Moreover, patients with sASPECTS of 0 were more likely to develop symptomatic ICH (odds ratio=2.62, 95% confidence
interval: 1.49–4.62), compared to those with sASPECTS≥1 (p=0.004).
CONCLUSION
In anterior circulation stroke patients, topographic assessment of acute ischemic changes in the caudate, lentiform nucleus, insula,
and M5 (as part of sASPECTS) can predict clinical outcome as accurately as the ASPECTS. Moreover, sASPECTS may identify those
patients with favorable outcome associated with thrombolytic therapy, and those who are at risk of developing symptomatic ICH.
CLINICAL RELEVANCE/APPLICATION
A semi-quantitative assessment of central MCA territory early ischemic changes can assist stroke treatment triage by identifying
patients who may benefit from IV tPA therapy and those at risk of developing symptomatic ICH.
RC205-06
One Year Out from the 2015 Trials- Where does Endovascular Treatment Stand?
Monday, Nov. 28 9:40AM - 10:10AM Room: N227B
Participants
Philip M. Meyers, MD, New York, NY (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) The participant will appreciate the significance of recent endovascular stroke trials demonstrating safety and efficacy of
mechanical thromboectomy for treatment of acute large artery ischemic stroke. 2) The participant will understand the context in
which additional NIH stroke trials address outstanding questions about endovascular treatment of acute ischemic stroke in a
broader patient population.
ABSTRACT
Stroke remains a leading cause of adult death and disability throughout the world. During the last two years, a series of
randomized, controlled trials comparing mechanical thrombo-embolectomy plus medical therapy to medical therapy alone have
demonstrated superior clinical outcomes with rapid revascularization using catheter-based techniques. In carefully selected
patients, the odds of recovery are better. These studies show benefit most often when treatment is performed as quickly as
possible and within 6 hours of stroke onset. For a variety of reasons, many stroke victims – perhaps even a majority – present
outside of the conventional time window. With imaging to assess directly or indirectly for cerebral viability, identification of
additional treatment candidates is possible. This is an important goal of the next set of ischemic stroke trials.
LEARNING OBJECTIVES
1) The participant will appreciate the significance of recent endovascular stroke trials demonstrating safety and efficacy of
mechanical thromboectomy for treatment of acute large artery ischemic stroke. 2) The participant will understand the context in
which additional NIH stroke trials address outstanding questions about endovascular treatment of acute ischemic stroke in a
broader patient population.
ABSTRACT
Stroke remains a leading cause of adult death and disability throughout the world. During the last two years, a series of
randomized, controlled trials comparing mechanical thrombo-embolectomy plus medical therapy to medical therapy alone have
demonstrated superior clinical outcomes with rapid revascularization using catheter-based techniques. In carefully selected
patients, the odds of recovery are relatively good. These studies show benefit most often when treatment is performed as quickly
as possible and within 6 hours of stroke onset. For a variety of reasons, many stroke victims – perhaps even a majority – present
outside of the conventional time window. With imaging to assess directly or indirectly for cerebral viability, identification of
additional treatment candidates is possible. This is an important goal of the next set of ischemic stroke trials.
RC205-07
Excluded Patients from the 2015 Trials: The Silent Majority
Monday, Nov. 28 10:20AM - 10:50AM Room: N227B
Participants
Achala S. Vagal, MD, Cincinnati, OH, ([email protected] ​ ) (Presenter) Research Grant, F. Hoffmann-La Roche AG
LEARNING OBJECTIVES
1) Recognize the imaging features of patients who were included in the 2015 endovascular trial. 2) Discuss which groups of patients
were excluded from the 2015 trials. 3) Discuss the current evidence and future research directions in these excluded subgroups.
ABSTRACT
RC205-08
Acute Reperfusion without Recanalization: Assesment of Collaterals Using Perfusion-Weight MRI
Monday, Nov. 28 10:50AM - 11:00AM Room: N227B
Participants
Leila Chamard, BRON, France (Presenter) Nothing to Disclose
Nikolaos Makris, BRON, France (Abstract Co-Author) Nothing to Disclose
Tae-Hee Cho, MD, Bron, France (Abstract Co-Author) Nothing to Disclose
Marc Hermier, MD, PhD, Lyon, France (Abstract Co-Author) Nothing to Disclose
Roxana R. Ameli, Bron, France (Abstract Co-Author) Nothing to Disclose
Guy Louis-Tisserand, MD, Bron Cedex, France (Abstract Co-Author) Nothing to Disclose
Norbert Nighoghossian, MD, PHD, Lyon, France (Abstract Co-Author) Nothing to Disclose
Yves Berthezene, MD, PhD, Bron, France (Abstract Co-Author) Nothing to Disclose
PURPOSE
Acute reperfusion despite persistent vessel occlusion can occur in about 30% of patients. Retrograde reperfusion through
leptomeningeal collaterals may explain this phenomenom. The present study evaluated relationship between colaterals and
reperfusion and clinical outcome in acute stroke.
METHOD AND MATERIALS
From a multicenter prospective database (I-KNOW), 46 patients with MR-angiography-visible occlusion and in whom both
reperfusion and recanalization were assessed within 6 hours of symptoms onset where identified. Maps of collateral flow at arterial,
capillary and late veinous phases were automatically generated from dynamic susceptibility-contrast perfusion images through
inter-frame registration, baseline signal substraction and temporal summation, and graded according to the American Society of
Interventional and Therapeutic Neuroradiology system. Flow direction (anterograde vs retrograde) was visually assessed from the
dynamic images. The acute evolution of collateral grades was evaluated against the reperfusion and recanalization status.
RESULTS
Acute reperfusion was associated with better collateral grades at baseline (OR: 36.02; 95% CI: 8.5-207.7; p<0.001). Among
patients without recanalization, collateral grades significantly improved between admission and acute follow-up in reperfused
patients (OR: 4.57; 95% CI: 1.1-22.7; p=0.048), but not in those without reperfusion (OR: 1.34; 95% CI: 0.4-4.5; p=0.623). Acute
reperfusion was associated with favourable clinical outcome, regardless of flow direction.
CONCLUSION
Acute reperfusion without recanalization is related to a significant improvement of retrograde collateral flow.
CLINICAL RELEVANCE/APPLICATION
Collateral status is usefull for management in patient with acute stroke
RC205-10
MR Perfusion to Determine the Status of Collaterals in Patients with Acute Ischemic Stroke: Look
Beyond Perfusion Time-Maps
Monday, Nov. 28 11:10AM - 11:20AM Room: N227B
Participants
Kambiz Nael, MD, New York, NY (Presenter) Research Consultant, Olea Medical
James R. Knitter, BS, Tucson, AZ (Abstract Co-Author) Nothing to Disclose
Amish H. Doshi, MD, New York, NY (Abstract Co-Author) Nothing to Disclose
J. Mocco, MD, Nashville, TN (Abstract Co-Author) Nothing to Disclose
Reade Deleacy, MD, New York, NY (Abstract Co-Author) Nothing to Disclose
Joshua Bederson, MD, New York, NY (Abstract Co-Author) Nothing to Disclose
Thomas P. Naidich, MD, New York, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
MR perfusion time-maps show delayed perfusion but are unable to differentiate antegrade from collateral flow if used alone. Using a
multiparametric approach, we aimed to identify perfusion parameter/s that can represent the extent of collaterals in comparison to
angiographic findings in patients with acute ischemic stroke (AIS).
METHOD AND MATERIALS
AIS patients with anterior circulation proximal occlusion who had baseline MR perfusion and cerebral angiography were evaluated.
MR perfusion data were processed using Bayesian method to generate arterial tissue delay (ATD) maps at thresholds of 2, 6
seconds. The volume of delayed perfusion (Vol-ATD2sec), critical hypoperfusion (Vol-ATD6sec), and hypoperfusion (Vol-ATD 2sec6sec) in addition to corresponding values of rCBV and rCBF were calculated using volume-of-interest (VOI) analysis. Collateral
status was dichotomized to poor (ASITN/SIR 0-2) or good (ASITN/SIR 3–4) using baseline cerebral angiography. Statistical analysis
was performed using multivariate logistic regression and receiver operating characteristic (ROC) analysis.
RESULTS
In 37 patients included, 20 (54%) had good collaterals using cerebral angiography. After controlling for age, baseline NIHSS and
infarct volume, multivariate logistic regression analysis identified rCBV (p=0.001) and hypoperfused volume (Vol-ATD 2sec-6sec)
(p=0.01), but not rCBF (p=0.08), Vol-ATD 2sec (p=0.3) or Vol-ATD 6sec (p=0.07), as independent predictors of good collaterals.
For rCBV, ROC analysis showed the greatest AUC (0.89) at the threshold > 2.1 with sensitivity/specificity of 85%/90%. For Vol-ATD
2sec-6sec, ROC analysis showed the greatest AUC (0.78) at a threshold > 51 ml with sensitivity/specificity of 70%/82%.
Hypoperfused tissue volume (Vol-ATD 2sec-6sec) multiplied by its rCBV, termed hypoperfused tissue collateral index, remained an
independent predictor of good collaterals, with improved diagnostic accuracy over each measure alone (AUC: 0.96 at a threshold >
90, sensitivity/specificity of 91%/100%).
CONCLUSION
Hypoperfused tissue collateral index defined as hypoperfused volume (Vol-ATD 2sec-6sec) x rCBV is a new perfusion index with
diagnostic accuracy of 96% compared to angiographic findings to predict status of collaterals.
CLINICAL RELEVANCE/APPLICATION
In patients with AIS, evaluation of collateral flow using baseline imaging can have therapeutic and prognostic implications.
RC205-12
Don't Fall for These Stroke Mimics
Monday, Nov. 28 11:30AM - 12:00PM Room: N227B
Participants
Pamela W. Schaefer, MD, Boston, MA (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize the key neuroimaging characteristics of acute ischemic stroke and common stroke mimics. 2) Use pertinent imaging
features and key clinical factors to differentiate acute ischemic stroke from stroke mimics. 3) Discuss the utility of various imaging
techniques to distinguish stroke mimics from acute ischemic stroke.
ABSTRACT
This talk will discuss the key imaging features of common stroke mimics and how to distinguish them from acute ischemic stroke.
Entities resembling acute ischemic stroke due to restricted diffusion - such as seizures, tranisent global amnesia, hypoglyycemia,
central pontine myelinolysis and other metaqboilc disorders, methotrexate and other drug toxicities, diffuse axonal injury, some
metastases, fat emboli, demyelinative lesions, some products of hemorrhage, and some infections - will be discussed. Entities
resembling subacute stroke with vasogenic edema and elevated diffusion - such as venous thrombosis, hyperperfusion syndrome,
and PRES - will be presented. Entities with gyrifrom enhancement resembling subacute stroke - such as some neoplasms, infectious
processes and inflammatory processes - will be discussed.
RC208
Emergency Radiology Series: Current Imaging of the Acute Abdomen
Monday, Nov. 28 8:30AM - 12:00PM Room: S102AB
GI
CT
MR
ER
AMA PRA Category 1 Credits ™: 3.50
ARRT Category A+ Credits: 4.00
FDA
Discussions may include off-label uses.
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON, ([email protected]) (Moderator) Nothing to Disclose
Zachary S. Delproposto, MD, Ann Arbor, MI (Moderator) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Moderator) Nothing to Disclose
LEARNING OBJECTIVES
1) To discuss common and uncommon causes of acute abdomen relevant to emergency imagers.
ABSTRACT
Sub-Events
RC208-01
CT of Gastroduodenal Ulcers and Related Disorders
Monday, Nov. 28 8:30AM - 9:00AM Room: S102AB
Participants
Perry J. Pickhardt, MD, Madison, WI, ([email protected] ​ ​ ) (Presenter) Co-founder, VirtuoCTC, LLC; Stockholder, Cellectar
Biosciences, Inc; Stockholder, SHINE Medical Technologies, Inc; Research Grant, Koninklijke Philips NV
LEARNING OBJECTIVES
1) Comprehend the underestimated role of CT in diagnosing gastroduodenal ulcer disase. 2) Analyze the CT findings of
gastroduodenal ulcers, related conditions, and differential diagnosis. 3) Apply these CT features into daily clinical practice to affect
patient outcomes.
ABSTRACT
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Perry J. Pickhardt, MD - 2014 Honored Educator
RC208-02
Diagnosing Gastric Band Slippage in the Emergency Department: Performance of 4 Imaging Signs on
Both Radiography and Computed Tomography
Monday, Nov. 28 9:00AM - 9:10AM Room: S102AB
Participants
Michael S. Furman, MD, Providence, RI (Presenter) Nothing to Disclose
David W. Swenson, MD, Brooklyn, CT (Abstract Co-Author) Nothing to Disclose
Kevin J. Chang, MD, Sharon, MA (Abstract Co-Author) Nothing to Disclose
David J. Grand, MD, Providence, RI (Abstract Co-Author) Nothing to Disclose
Albert A. Scappaticci, MD, Providence, RI (Abstract Co-Author) Nothing to Disclose
Grayson L. Baird, PhD, Providence, RI (Abstract Co-Author) Nothing to Disclose
Anna Ellermeier, MD, Seattle, WA (Abstract Co-Author) Nothing to Disclose
PURPOSE
Gastric band slippage occurs in up to 30% of gastric band patients. We previously reported the performance of 4 signs (2 old, and 2
new) of slippage on barium swallow exams. This study now evaluates the applicability of these signs to plain radiographs and CT
studies performed in the emergency department.
METHOD AND MATERIALS
We identified 45 gastric band patients who underwent radiography and/or CT in the emergency department from 1/1/2008 –
12/31/2014. Of these patients, 13 were surgically diagnosed with band slippage, while 32 were discharged and returned to standard
clinical follow-up without evidence of slippage. Three board-certified radiologists retrospectively reviewed all imaging studies while
blinded to patient symptoms and clinical outcomes. The following signs were assessed: (1) abnormally increased phi angle (>58º),
(2) inferior displacement of the superolateral gastric band margin from the diaphragm by >2.4 cm, (3) presence of an “O Sign”, and
(4) presence of an air-fluid level above the gastric band. Sensitivity, specificity, and interobserver agreement (Cohen’s Kappa
statistic) were calculated for each sign.
RESULTS
For a phi angle >58º, sensitivity and specificity for gastric band slippage were 100% and 81%, respectively, on CT (k=0.93), but
73% and 75% on radiography (k=0.94). For inferior displacement by >2.4 cm, sensitivity and specificity were 89% and 100% on CT
(k=0.98), while 100% and 98% on radiography (k=0.92). For presence of an “O sign”, sensitivity and specificity were 13% and
100% on CT (k=0.04), while 30% and 94% on radiography (k=0.64). For presence of an air-fluid level above the gastric band,
sensitivity and specificity for slippage were 83% and 99% on CT (k=0.92), while 90% and 100% on radiography (k=0.95).
CONCLUSION
Both inferior gastric band displacement by >2.4 cm from the diaphragm, and the presence of an air-fluid level above the gastric
band, are highly reproducible signs of band slippage in the emergency department, and can be identified on both radiography and
CT.
CLINICAL RELEVANCE/APPLICATION
Signs of gastric band slippage that were recently defined on barium swallow studies can be effectively applied to simple radiography
and CT, thus improving efficiency of diagnosis in the emergency department.
RC208-03
Epiploic Appendagitis is Associated with Peritoneal Inflammation and Visceral Obesity
Monday, Nov. 28 9:10AM - 9:20AM Room: S102AB
Participants
James P. Nugent, Vancouver, BC (Presenter) Nothing to Disclose
Hugue A. Ouellette, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
D. P. O'Leary, PhD, Limerick, Ireland (Abstract Co-Author) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
PURPOSE
The location, size and coexisting local inflammatory findings in acute epiploic appendagitis have not been reported outside of
isolated case reports. The association between EA and increased body mass index is controversial and disputed in the radiological
and surgical literature. Our aim is to investigate if abdominal adipose volume (AAV), visceral adipose area (VAA) and subcutaneous
adipose area (SAA) quantified by CT scans is higher in EA patients than matched controls. We also report the location, size and
frequency of coexisting local inflammatory findings in a series of patients with acute epiploic appendagitis.
METHOD AND MATERIALS
Consecutive patients with an imaging diagnosis of EA scanned between January 2009 and June 2014 were selected for inclusion (n
= 100). 100 consecutive patients imaged with abdominal CT for non-EA related acute abdominal pain were selected as controls.
OsiriX v.5.5.2 (Pixmeo, Geneva, Switzerland) was used to retrospectively quantify abdominal adipose tissue volume and crosssectional area using Hounsfield unit threshold based semi-automated segmentation between -50 HU and -180 HU. The site, size and
severity of inflammation of the involved appendage was also recorded.
RESULTS
EA had a male sex predilection, with 67% of EA versus 41% of acute abdominal cases (p = 0.0002). EA patients had 34% greater
AAV, 197% greater VAA, and 135% greater SAA than the control subjects (p < 0.0001). The inflamed appendage was found in the
sigmoid colon in 49% of cases, descending colon in 23% and right colon in 19%. Peritoneal thickening was a frequently reported
associated sign of inflammation found in 76% of cases. Bowel wall thickening was common (47%) and diverticulosis co-existed
incidentally in 28% of cases.
CONCLUSION
VAA was almost 200% larger in patients with EA as compared with control subjects. Peritoneal thickening was a frequently reported
associated sign of inflammation found in 76% of cases. Inflammation of the parietal peritoneum may contribute to the clinical
presentation with acute pain.
CLINICAL RELEVANCE/APPLICATION
The association between EA and increased body mass index is controversial and disputed in radiological and surgical literature. Our
study finds that visceral adipose area is almost 200% higher in EA.
RC208-04
CT and MRI of Biliary Tract Emergencies
Monday, Nov. 28 9:20AM - 9:50AM Room: S102AB
Participants
Jorge A. Soto, MD, Boston, MA, ([email protected] ​ ) (Presenter) Royalties, Reed Elsevier
LEARNING OBJECTIVES
1) Understand the clinical situations where CT or MR are appropriate alternatives to US for the diagnosis of acute conditions
affecting the biliary tract. 2) Recognize the CT and MR findings that allow the specific diagnosis of common acute diseases of the
biliary tract. 3) Be aware of potential imaging pitfalls that can lead to missed diagnoses or misinterpretations of CT or MR
examinations in the setting of suspected acute biliary disease.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jorge A. Soto, MD - 2013 Honored Educator
Jorge A. Soto, MD - 2014 Honored Educator
Jorge A. Soto, MD - 2015 Honored Educator
RC208-05
Abdominal Ultrasound for Identifying Cholecystitis after Pain Medication Administration
Monday, Nov. 28 9:50AM - 10:00AM Room: S102AB
Awards
Student Travel Stipend Award
Participants
Joel P. Thompson, MD, Rochester, NY (Presenter) Nothing to Disclose
Jason G. Birnbaum, MD, Rochester, NY (Abstract Co-Author) Nothing to Disclose
Timothy M. Baran, PhD, Rochester, NY (Abstract Co-Author) Research Consultant, Zenalux Biomedical Inc
Vikram S. Dogra, MD, Rochester, NY (Abstract Co-Author) Editor, Wolters Kluwer nv ;
PURPOSE
The Murphy sign is reported to have the highest likelihood ratio and specificity for the diagnosis of acute cholecystitis with or
without the presence of gallstones. However, many patients receive pain medication prior to ultrasound (US) examination, limiting
the ability to elicit a Murphy sign. We sought to identify US signs of cholecystitis in patients after pain medication administration.
METHOD AND MATERIALS
IRB-approved retrospective review of adult emergency department and inpatients with right upper quadrant pain who received an
US within 2 hours of receiving pain medication. Cholescintigraphy (HIDA) performed within 48 hours of the US served as the gold
standard to identify patients with and without cholecystitis. Patients post cholecystectomy were excluded. US exams were
reviewed for the presence of gallstones, gallbladder distention, wall thickening, sludge, wall hyperemia, and pericholecystic fluid.
Gallbladder length and width was measured on a single sagittal image and were used to calculate gallbladder volume.57 patients
met inclusion criteria; 6 patients with hepatitis or choledocholithiasis were excluded. US findings compared between 16/51 patients
with normal HIDA and 35/51 with positive HIDA.
RESULTS
Stones in the gallbladder neck were highly associated with cholecystitis (40% vs 6% of controls, p=0.002), particularly when
stones were immobile (29% vs 0%, p=0.001). Increased gallbladder distention and lumen width were associated with cholecystitis
(67 mL3 vs 34 mL3, p=0.002; width 34 mm vs 27 mm, p=0.014). Lumen width >31 mm had a sensitivity of 60% and specificity of
88% for cholecystitis. Gallbladder sludge was also associated with cholecystitis (54% vs 25%, p=0.045). The presence of
gallstones, gallbladder wall thickening, and wall hyperemia were not significantly associated with cholecystitis. No US findings
significantly differentiated acute from chronic cholecystitis.
CONCLUSION
US can reliably identify cholecystitis even when a Murphy's sign cannot be elicited in patients medicated for pain. Immobile
gallbladder neck stones, sludge, gallbladder distention, and gallbladder lumen width >31mm are highly associated with cholecystitis.
CLINICAL RELEVANCE/APPLICATION
US can reliably identify cholecystitis even when a Murphy's sign cannot be elicited in patients medicated for pain, potentially
decreasing time to diagnosis and treatment.
RC208-06
Seeing is Believing: Visualization of Radiolucent Gallstones on Dual-Energy CT
Monday, Nov. 28 10:00AM - 10:10AM Room: S102AB
Participants
Tim O'Connell, MD, Meng, Vancouver, BC (Presenter) President, Resolve Radiologic Ltd Speake, Siemens AG
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
Faisal Khosa, FFR(RCSI), FRCPC, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Mohammed F. Mohammed, MBBS, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Luck J. Louis, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
PURPOSE
Gallstone disease affects 10-15% of the population, and is a frequent cause of presentation to the ER for abdominal pain.
Unfortunately, up to 80% of gallstones are radiolucent, making their diagnosis on x-ray or CT very difficult, and requiring an
ultrasound or MRI for diagnosis. In this study, we hypothesized that radiolucent calculi not visible on standard CT could be
diagnosed using dual-energy CT with post processing using a virtual noncalcium (VNC) technique.
METHOD AND MATERIALS
40 dual-energy CT scans in unique patients without evidence of cholelithiasis were obtained, in 20 patients with cholelithiasis and
20 without as proven on a recent ultrasound. CT scans were performed on a dual-tube, dual-energy multidetector CT scanner
(either a Siemens Definition Flash or Force). Post processing was performed with Siemens Syngo.Via software using VNC with a
threshold set at 0 HU, and these images were reviewed alongside the standard blended-energy greyscale images. Three reviewers
(two staff and one fellow), all with abdominal radiology fellowships, reviewed all 40 cases in a blinded and randomized fashion, and
scored whether cholelithiasis was present or absent, along with a confidence rating (0-10).
RESULTS
Of the 20 cases with radiolucent cholelithiasis, 15 were identified correctly by all readers. Of the 20 cases without cholelithiasis, 19
were identified correctly by all readers. Across all readers, diagnostic performance (95% CI) was: Sensitivity 85% (72.9-92.5%),
Specificity 98.3% (89.8-99.9%), PPV 98.1%(88.4-99.8%), NPV 86.8% (75.8%-93.4%). Average reader confidence was 9.6/10. If
only cases with calculi > 5mm are included, performance improves to: Sensitivity 91.1% (79.6-96.7%), Specificity 98.1% (88.899.9%), PPV 98.1% (88.4-99.9%), NPV 91.3% (80.3-96.8%).
CONCLUSION
We have demonstrated that dual-energy CT can be used to diagnose cholelithiasis in cases of radiolucent calculi. It is suggested
that sensitivity may be better in cases where calculi are larger. Limitations of this study include the small sample size, and a lack of
post-surgical correlation for calculus type. Future study will expand the sample size, include ex-vivo calculus evaluation, and also
evaluate for cases of choledocholithiasis.
CLINICAL RELEVANCE/APPLICATION
Diagnosing cholelithiasis at CT will reduce costs of US and MRI usage and will help patients through diagnosis of biliary colic and
may improve diagnostic accuracy for cholecystitis.
RC208-07
Imaging of Bowel Obstruction
Monday, Nov. 28 10:10AM - 10:40AM Room: S102AB
Participants
Vincent M. Mellnick, MD, Saint Louis, MO (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Utilize CT to identify and characterize bowel obstruction and to correlate these findings with plain film and fluoroscopy. 2)
Identify patients for whom MRI would be a reasonable alternative diagnostic imaging choice when radiation dose is a primary
concern. 3) Compare the underlying causes and imaging findings of bowel obstruction, including common causes such as adhesions,
malignancy, and hernias, emphasizing the differences in epidemiology between small and large bowel obstruction. 4) Assist referring
clinicians in identifying the cause and severity of bowel obstruction, including cases complicated by or at risk for ischemia, to guide
operative versus nonoperative management.
ABSTRACT
Bowel obstruction is a common cause for abdominal pain in emergency department patients. A timely diagnosis is critical – when
left untreated, bowel obstruction can lead to vascular compromise and potentially necrosis and perforation. CT has become the
diagnostic mainstay for evaluating bowel obstruction, and is typically preferred over plain film and fluoroscopy due to its superior
performance in identifying an underlying cause as well as patients who have or are at risk for intestinal ischemia. In young
patients, particularly those with chronic bowel obstruction and/or who are pregnant, MRI can be a reasonable alternative imaging
exam choice, however. Causes of bowel obstruction vary based on anatomic location, but broadly include adhesions, tumors, and
hernias. These common causes as well as more rare diagnoses will be discussed in this case-based review.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Vincent M. Mellnick, MD - 2016 Honored Educator
RC208-08
New Trends in the Management of Acute Diverticulitis: Predicting Outcomes with MDCT and Clinical
Parameters
Monday, Nov. 28 10:40AM - 10:50AM Room: S102AB
Awards
Student Travel Stipend Award
Participants
David D. Bates, MD, Boston, MA (Presenter) Nothing to Disclose
Marina C. Bernal Fernandez, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Cecilia Ponchiardi, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Michael von Plato, Boston, MA (Abstract Co-Author) Nothing to Disclose
Joshua Teich, Boston, MA (Abstract Co-Author) Nothing to Disclose
Chaitan Narsule, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Avneesh Gupta, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
To determine whether MDCT imaging features and clinical findings can predict outcomes in patients with acute diverticulitis in the
Emergency Department (ED).
METHOD AND MATERIALS
This retrospective study was IRB approved; informed consent was waived. All adult patients (>18 years old) diagnosed with acute
diverticulitis in the ED via contrast-enhanced abdominopelvic MDCT from 1/1/2015-12/31/2015 were included. 169 patients met
inclusion criteria (males n=69, female n=100, mean age 54.7 years, range 23-90 years). The CT studies were blind reviewed by an
abdominal radiologist for the presence of bowel wall thickening, inflamed diverticulum, pericolonic inflammation, pericolonic fluid
collection, free fluid, free air or fistula. A Hinchey classification was also determined. Clinical data was acquired via medical chart
review. Clinical parameters and CT imaging findings were compared with the clinical outcomes. Statistical analysis was performed
using Fisher's exact test and Student's t-test.
RESULTS
Statistically significant imaging features on MDCT for patients requiring surgical management at any point during the study period
included the presence of a pericolonic fluid collection (p = 0.0011), a Hinchey classification of 1b or greater (p = 0.0002) and the
presence of a colonic fistula (p = 0.0007). There was no significant difference for the presence of bowel wall thickening, an
inflamed diverticulum, pericolonic inflammation, free fluid, or free air. No laboratory values or vital sign parameters were significantly
different.
CONCLUSION
Imaging features demonstrating a significant association with the need for surgery when compared with diverticulitis patients who
were successfully managed non-operatively include the presence of a pericolonic collection, a colonic fistula, or a Hinchey
classification of 1b or higher. In addition, increased hospital length of stay was associated with the need for surgical management.
CLINICAL RELEVANCE/APPLICATION
In light of a trend in surgical management away from colonic resection, CT imaging and clinical parameters may predict which
patients will require operative management in acute diverticulitis.
RC208-09
Inter-Reader Agreement of CT Features of Acute Mesenteric Ischemia
Monday, Nov. 28 10:50AM - 11:00AM Room: S102AB
Participants
Pauline Copin, MD, Clichy, France (Presenter) Nothing to Disclose
Maxime Ronot, MD, Clichy, France (Abstract Co-Author) Nothing to Disclose
Matthieu Lagadec, MD, Clichy, France (Abstract Co-Author) Nothing to Disclose
Julie Benzimra, Paris, France (Abstract Co-Author) Nothing to Disclose
Anne Kerbaol, Paris, France (Abstract Co-Author) Nothing to Disclose
Magaly Zappa, MD, Clichy, France (Abstract Co-Author) Nothing to Disclose
Valerie Vilgrain, MD, Clichy, France (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate the inter-reader agreement of CT features of acute mesenteric ischemia (AMI)
METHOD AND MATERIALS
This study was approved by the IRB and informed consents were waived. Between 2006 and 2014, all patients admitted in our
institution with the diagnosis of acute mesenteric ischemia were included. CT scans were retrospectively reviewed by two
abdominal radiologists. Inter-observer agreement of imaging features of vascular insufficiency, bowel ischemia, and complication
was assessed with the percentage of agreement and the kappa statistics.
RESULTS
The final population included 109 patients (57 men, 52%, mean age 50 years [17-83]), including 42% initially managed in our
institution. AMI was occlusive in 102 patients (94%), including 72 (66%), 30 (28%), and 10 (9%) patients with an arterial, venous,
and combined cause of AMI. respectively. The median time delay between symptoms onset and CT scan acquisition was 1 day, and
71% were performed during the first 48-hours. CT protocol included unenhanced images in 77 (71%) patients, arterial phase images
in 73 (67%) patients, and oral contrast media ingestion in 11 (10%) patients. The image quality was rated as excellent for the
majority of the patients (65% for reader 1 and 75% for reader 2). Inter-observer agreement was highly variable (k=0.25-0.98).
Decreased/absent bowel wall enhancement showed moderate inter-observer agreement (k=0.52), but rose to excellent (k=0.82) in
the 47 patients (43%) with both unenhanced and arterial phase images, no oral contrast medium, and excellent image quality
("optimal" CT protocol). It was also improved in patients with serum lactate level >2mmol/L and when CT scan was performed during
the first 24-hours after the symptoms onset. Inter-observer agreement for thickened wall (k = 0.56 vs. k = 0.61), and bowel loop
dilatation (k = 0.63 vs. k = 0.65) were not improved in patients with an optimal CT protocol, but that for the small bowel feces sign
was significantly higher (k = 0.65 vs. k = 0.44).
CONCLUSION
Most imaging features of AMI show moderate to substantial inter-reader agreement. An optimal CT protocol acquisition leads to an
improved inter-observer agreement of imaging features of AMI, especially for the decreased/absent bowel wall enhancement.
CLINICAL RELEVANCE/APPLICATION
An optimal CT scan protocol acquisition should be performed to improved inter-observer agreement of imaging features of AMI, and
better identify patients with bowel necrosis.
RC208-10
MRI of Acute Right Lower Quadrant Pain
Monday, Nov. 28 11:00AM - 11:30AM Room: S102AB
Participants
Jennifer W. Uyeda, MD, Boston, MA, ([email protected]​ ​ ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) To review the current utilization of MR imaging in acute right lower quadrant pain in the emergency setting. 2) To describe
potential pitfalls in interpretation of MR in acute right lower quadrant pain. 3) To illustrate cases of various etiologies for acute right
lower quadrant pain and their imaging manifestations on MR imaging.
ABSTRACT
RC208-11
Magnetic Resonance Imaging of Pregnant Appendicitis: Sensitivity, Specificity and Inter-reader
Reliability
Monday, Nov. 28 11:30AM - 11:40AM Room: S102AB
Participants
Richard Tsai, MD, Saint Louis, MO (Presenter) Nothing to Disclose
Joseph W. Owen, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
Vincent M. Mellnick, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
Constantine A. Raptis, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
Kathryn J. Fowler, MD, Chesterfield, MO (Abstract Co-Author) Nothing to Disclose
PURPOSE
The literature on MR imaging of suspected appendicitis in pregnancy demonstrates a low negative predictive value which may be
the result of a low incidence of disease. Despite this low reported negative predictive value, the MR diagnosis of appendicitis is not
binary, with findings such as free fluid and increased appendiceal diameter alone lacking specificity and frequently producing an
indeterminate result. A retrospective review was performed of all cases of suspected appendicitis in pregnancy imaged with MR to
assess the rate of acute appendicitis after an indeterminate interpretation.
METHOD AND MATERIALS
A retrospective chart review of MR interpretations for pregnant patients with suspected appendicitis presenting to the emergency
room was performed from 1/1/2003 to 4/1/2015. MR interpretations that were not read as unequivocally positive or negative were
categorized as "indeterminate" for appendicitis. Patient outcomes were categorized as "acute appendicitis," "no acute
appendicitis," and "other appendiceal pathology”. Reference standard was surgical pathology and clinical outcomes.
RESULTS
There were 240 cases of abdominal MR performed in pregnant women for suspected appendicitis at our institution with 13 cases of
acute appendicitis. 206 cases were interpreted as negative with 1 false negative. 19 cases were interpreted as positive, 12 had
acute appendicitis, 3 had non acute appendiceal pathology, 3 had a normal appendix, and 1 patient was observed and released
without antibiotics (7 false positives). 15 cases were interpreted as indeterminate (e.g. upper limits of normal appendix with
adjacent free fluid or dilated appendix but no free fluid or stranding), 4 patients went to surgery and 8 patients were admitted for
observation, no patient had acute appendicitis and 1 patient who was observed was a new presentation of Crohn disease which
was included in the differential.
CONCLUSION
MR imaging of appendicitis has a low negative predictive value, likely due to the low prevalence, and a high rate of indeterminate
interpretations. Equivocal findings of appendicitis including adjacent free fluid and “upper limits of normal appendix” should not be
managed surgically, but may warrant admission for observation.
CLINICAL RELEVANCE/APPLICATION
MR imaging of pregnant appendicitis can help triage patients to those that may be managed conservatively, surgically, or may
provide an alternative diagnosis.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Vincent M. Mellnick, MD - 2016 Honored Educator
RC208-12
Anatomic Reasons for Failure to Visualize the Appendix with Graded Compression Sonography:
Insights from Concurrent CT
Monday, Nov. 28 11:40AM - 11:50AM Room: S102AB
Awards
Trainee Research Prize - Resident
Participants
Wilson Lin, MD, Redwood City, CA (Presenter) Nothing to Disclose
Angela Trinh, MD, Palo Alto, CA (Abstract Co-Author) Nothing to Disclose
Eric W. Olcott, MD, Palo Alto, CA (Abstract Co-Author) Nothing to Disclose
R. Brooke Jeffrey Jr, MD, Stanford, CA (Abstract Co-Author) Nothing to Disclose
PURPOSE
To identify anatomic reasons from CT for non-visualization of the appendix on graded compression sonography (GCS)
METHOD AND MATERIALS
A searchable database retrospectively yielded 197 consecutive patients with suspected appendicitis, enrolled over 22 months, who
met inclusion criteria including: 1) appendiceal GCS was the initial imaging examination, performed in typical fashion at 8-15 MHz, 2)
appendix was not visualized on GCS, and 3) appendix was visualized on CT performed within 48 hours after sonography. The
following were evaluated on post-sonography CT, defining appendix position as that of the appendiceal tip: depth from the skin
surface, position above or below the iliac crest, and axial location in one of four quadrants centered on the ileocecal valve,
designated anteromedial (AMQ), posteromedial (PMQ), posterolateral (PLQ), and anterolateral (ALQ). Statistical evaluations with
Stata 14.1 software employed the two-sided multinomial test to evaluate appendiceal distribution among quadrants collectively,
and the exact binomial test to evaluate appendiceal distribution in quadrants specifically and to determine 95% confidence intervals
(CI).
RESULTS
The depth of the appendix from the skin surface ranged 7 to 163 mm (mean 78.9 mm, 95% CI 75.1 - 82.7 mm) overall, and 94 to
163 mm in the deepest quartile of appendices. Of the 197 patients, 39 (19.8%, 95% CI 14.4-26.1%) had appendices lying above
the iliac crest. Frequencies of the appendix found in the ALQ, PMQ, PLQ, and AMQ were 18 (9.1%), 123 (62.4%), 43 (21.8%), and
13 (6.6%), respectively, with highly significant non-uniformity among the quadrants collectively (P < 0.0001) favoring the PMQ
specifically (P < 0.0001).
CONCLUSION
Appendices not visualized on sonography are significantly likely to lie in the PMQ, at a depth of 94-163 mm in 25% of patients and
above the iliac crest in 19.8% of patients. Because these regions are not typically scanned in GCS, additional scanning for the
nonvisualized appendix is indicated specifically through the PMQ, above the iliac crest, and with atypically low frequency (e.g., 6
MHz or less) sufficient to reach 9-16 cm in depth.
CLINICAL RELEVANCE/APPLICATION
When the appendix is not initially visualized on sonography, further specific scanning should be performed posteromedially to the
ileocecal valve as well as above the iliac crest, and with sufficiently low frequency (i.e. 6 MHz or less) to interrogate 9-16 cm from
the skin surface.
RC208-13
Are Spectral Doppler Waveforms Useful to Diagnose Acute Appendicitis?
Monday, Nov. 28 11:50AM - 12:00PM Room: S102AB
Participants
Lewis Shin, MD, Stanford, CA (Presenter) Nothing to Disclose
Eric W. Olcott, MD, Palo Alto, CA (Abstract Co-Author) Nothing to Disclose
Gerald Berry, MD, Stanford, CA (Abstract Co-Author) Nothing to Disclose
R. Brooke Jeffrey Jr, MD, Stanford, CA (Abstract Co-Author) Nothing to Disclose
PURPOSE
To test the hypothesis that appendiceal spectral Doppler waveforms distinguish patients with and without acute appendicitis.
METHOD AND MATERIALS
With IRB approval and HIPAA compliance, sonograms performed for suspected appendicitis in 337 consecutive patients over 5
months were retrospectively blindly reviewed. Of the 155 (46%) patients in whom the appendix was visualized, spectral Doppler
tracings with peak systolic velocities (PSV) and resistive indices (RI) were successfully acquired in 95 (61%). These 95 patients
were categorized as appendicitis-positive [A(+)] by histopathologic examination after appendectomy or by CT confirmation of
appendicitis, or as appendicitis-negative [A(-)] when 6-week post-sonography clinical chart review demonstrated no further
evidence of appendicitis. Data were compared and confidence intervals (CI) obtained with Stata 14.1 software utilizing the 2-tailed
T test for means and the exact binomial test for proportions.
RESULTS
The 95 patients with spectral Doppler tracings included 74 children (age <19 years) and 21 adults (ages 1-56 years, mean 13.3
years), with 54 males and 41 females, of whom 56 were A(-) and 39 were A(+).The mean PSV for A(-) and A(+) subjects were
7.1cm/s (95% CI 6.4-7.8 cm/s) and 19.2cm/s (95% CI 7.1-21.2 cm/s), respectively (P<0.0001). The mean RI for A(-) and A(+)
subjects were 0.49 (95% CI 0.47-0.52) and 0.68 (95% CI 0.64-0.73), respectively (P<0.0001).Utilizing PSV >10 cm/s as abnormal,
sensitivity and specificity for appendicitis were 87.2% (95% CI 72.6-95.7%) and 94.6% (95% CI 85.1-98.9%), respectively. Utilizing
RI >0.60 as abnormal, sensitivity and specificity were 69.2% (95% CI 52.4-83.0%) and 89.3% (95% CI 78.1-96.0%), respectively.
Utilizing both PSV >10cm/s and RI >0.60 as abnormal, sensitivity and specificity were 64.1% (95% CI 47.2-78.8%) and 96.4% (95%
CI 87.7-99.6%), respectively.
CONCLUSION
Patients with appendicitis exhibit significantly higher PSV and RI than patients without appendicitis, and are distinguishable with
high specificity utilizing PSV >10cm/s and RI >0.60 as diagnostic criteria.
CLINICAL RELEVANCE/APPLICATION
Spectral Doppler interrogation appears potentially useful for distinguishing patients with appendicitis from those without
appendicitis, providing a high level of specificity utilizing straightforward criteria based on PSV and RI.
ERS-MOA
Emergency Radiology Monday Poster Discussions
Monday, Nov. 28 12:15PM - 12:45PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Ferco H. Berger, MD, Toronto, ON (Moderator) Nothing to Disclose
Sub-Events
ER208-SDMOA1
Multi Detector CT Angiography (CTA): Influence of Its Findings in Therapeutic Decision-making in
Patients with Acute Lower Gastrointestinal Bleeding in the Emergency Service
Station #1
Participants
Alfonso Martin Diaz, BMedSc, San Sebastian De Los Reyes, Spain (Presenter) Nothing to Disclose
Lucia Fernandez Rodriguez, BMBS, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Lorena F. Rodriguez-Gijon, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Milagros Marti De Gracia, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Alberto Borobia, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Aurea Diez Tascon, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Jose Maria Artigas, Zaragoza, Spain (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate the influence of multidetector CTA findings in therapeutic management of patients with ALIB.
METHOD AND MATERIALS
Retrospective observational study that includes patients with ALIB signs in the Emergency Service of a tertiary Hospital, from
October 2009 to October 2013. Adults with rectal bleeding/ hematochezia (anorectal source excluded) or patients with melena and
negative upper endoscopy are included. A triphasic CT examination was performed.Studied variables: demographics, nature, source
and etiology of bleeding, and therapeutic procedure.Descriptive results are expressed as absolute frequencies and percentages.
Univariate analysis (chi-square and student-T, or their non parametric equivalent) was performed to evaluate differences in
variables between patients with and without active bleeding. Statistic software IBM SPSS Statistic v.20 was used.This study has
been approved by Etical Comitee of Clinical Investigation from La Paz Universitary Hospital.
RESULTS
In this period of time 173 CTA were performed in patients with ALIB signs. 30 of them were excluded because of insufficient
information. Final analysis was made over 143 patients (68 women; 75 men), mean age 72,6 years (SD 19,6). CTA indicated
bleeding lesion in 121 patients (84,6%) and showed active bleeding in 48 (33,6%), 43 arterial and 5 venous source.32 patients
(66,7%) from the group with active bleeding required immediate therapeutic procedure (8 angiography, 17 endoscopy and 7
surgery) versus 5,3% in patients without demonstrated active bleeding(p<0,001).
CONCLUSION
Presence of active bleeding on CTA is an independent factor in the therapeutic decision-making.
CLINICAL RELEVANCE/APPLICATION
CT angiography has become the image modality of chice for the management of patients with acute lower gastrointestinal bleeding
in Emergency Service.
ER209-SDMOA2
Variability in Emergency Department Utilization of Lumbar spine MRI for Evaluation of Low Back Pain:
How Much Inappropriate Imaging is Being Done, and for What Reasons
Station #2
Participants
Travis Smith, BS,MS, Hershey, PA (Presenter) Nothing to Disclose
Michael A. Bruno, MD, Hershey, PA (Abstract Co-Author) Nothing to Disclose
Timothy J. Mosher, MD, Hershey, PA (Abstract Co-Author) Research Consultant, Medical Metrics, Inc Stockholder, Johnson &
Johnson
PURPOSE
Managing the appropriate use of advanced medical imaging is both an essential element and a significant challenge for radiologists
seeking to optimizing value in imaging. The high value for patients of appropriately utilized imaging services is readily apparent;
however no value is added when imaging is chosen inappropriately. Determining appropriate uses of Magnetic Resonance Imaging
(MRI) for evaluation of patients with low back pain is under review by several agencies, based on evidence of comparative
effectiveness and as an opportunity to increase value of clinical care. The National Quality Forum (NQF) currently has two quality
measures under consideration addressing imaging of patients with low back pain; NQF measure number 0052 "Use of Imaging
Studies for Low Back Pain”, and NQF measure number 0514 MRI Lumbar Spine for Low Back Pain.
METHOD AND MATERIALS
A total of 233 MRI examinations of the lumbar spine were performed on patients seen in our ED in CY 2014, of which 63 were
requested for evaluation of low back pain and another 76 were listed as “other.” We scored these studies via a detailed manual
audit of the EMR in order to assess the level of appropriate utilization based on the National Quality Forum (QPS) Measure 0514.
Secondarily, we have attempted to identify factors that drive inappropriate ED utilization of lumbar spine MRI for patients with low
back pain, testing the hypotheses that (1) there is inappropriate use of the ED specifically for the purpose of circumventing
outpatient MRI utilization controls and (2) that there is significant self-referral of patients to ED in order to expedite their care, i.e.,
to “jump the queue.”
RESULTS
Of the 233 examinations, 41 (17.6%) were considered to be inappropriate based on our standard. A significant fraction of these
appear to represent misuse of the Emergency Department either to circumvent outpatient utilization controls or to expedite a
scheduled outpatient study .
CONCLUSION
While most utilization of MRI in the Emergency Setting was appropriate, a significant fraction of patients appear to be misusing the
ED to circumvent utilization controls or wait times for routine outpatient care.
CLINICAL RELEVANCE/APPLICATION
This study is clinically relevant in that it evaluates the use of evidence-based medicine vs. other factors in the utilization of
advanced medical imaging in the ED setting.
ER210-SDMOA3
Very Affordable Immersion Pump for Post Mortem CT Angiography in Forensic Pathology: First 10
Cases. The Results Were Comparable, In That No Notable Differences Remained
Station #3
Participants
Wolf Schweitzer, MD, Zuerich, Switzerland (Presenter) Nothing to Disclose
Patricia M. Flach, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
Michael J. Thali, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
Dominic Gascho, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
Stamatios Stamou, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
PURPOSE
About ten years after the usage of roller pumps for post mortem CT angiography was introduced into forensic pathology, it remains
an open question why that relatively expensive pump mechanism (costing around 1000 USD for a used old heart lung machine to 80
000 USD for dedicated top of the line post mortem equipment) is actually necessary for post mortem CT angiography
(PMCTA).Roller pumps make sense for non-Newtonian fluids like blood, where also mechanical hemolysis is a factor. In PMCTA,
however watery or oily liquid is pumped into the vascular system of a body.After we established in a feasibility study that a simple
immersion pump (priced around 15-20 USD) can be calibrated to obtain a linear voltage - flowrate relationship for the contrast
agent solution used, and that vascular filling compared to a roller pump is basically the same, we present the results of the first ten
cases in this talk.
METHOD AND MATERIALS
Cantonal ethics review board waived responsibility (retrospective anonymized data usage).10 cases from forensic pathology
caseload were selected where PMCT angiography (PMCTA) was seen as relevant to the case. 10 control cases examined with a
conventional heart lung machine roller pump were used as comparison. Both arterial and venous sides were filled from a femoral
access.Immersion pump: a Barwig model 0444 pump (max. 10L/min) was used (required PMCTA flow rate 0,2 - 0,8L/min).Roller
pump: Stoeckert Shiley heart lung machine (max. 10L/min) was employed.PMCT / PMCTA: Dual source / energy CT scanner
(Somatom Flash Definition, Siemens, Germany) was used (100 kVp tube voltage, automatic dose modulation).
RESULTS
Vascular filling was compared related to large vessels, coronary arteries, neck and head arteries, extremity arteries and on the
same level, veins. Figure (IP: immersion pump: HLM: heart lung machine).
CONCLUSION
With a very low fraction of the cost, forensic pathology may be supplemented with high quality PMCTA when using a cheap
immersion pump.
CLINICAL RELEVANCE/APPLICATION
To be able to perform a post mortem CT angiography with very affordable equipment means that a parametrized method can be
validated and employed in far more institutes than when very expensive equipment is used.
ER211-SDMOA4
Absent Secondary Signs of Appendicitis When the Appendix is Not Visualized
Station #4
Participants
Vivek Patel, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose
Aditi Vyas, MD, Norwalk, CT (Abstract Co-Author) Nothing to Disclose
Saad Hussain, MD, New Haven, CT (Presenter) Nothing to Disclose
Mahan Mathur, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Mike Spektor, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose
PURPOSE
The purpose of this study is to determine the negative predictive value (NPV) of the sonographic secondary signs of appendicitis
when the appendix is not visualized. The secondary signs of appendicitis seen on ultrasound (US) include free fluid, hyperemia,
lymphadenopathy, and phlegmon formation.
METHOD AND MATERIALS
A retrospective review was completed looking for ultrasound images and reports that did not visualize the appendix in its entirety
and also specifically stated that no secondary signs of appendicitis were visualized. The review spans 2013-2015. 130 studies were
found meeting the inclusion criteria.
RESULTS
Of the 130 total studies, 95 did not have imaging follow up or surgery for appendicitis. Either the ultrasound revealed an alternate
diagnosis (example: mesenteric adenitis) or the patient was discharged with an alternate clinical diagnosis (example: constipation).
35 studies had follow up imaging with CT (31), MRI (2) or US (2). Of the 31 follow up CTs, 4 did not visualize the appendix (and the
patients were discharged) and the remaining 27 revealed normal appendices. The 2 MRI examinations showed normal appendices
and the patients were discharged. One repeat ultrasound was negative and the patient was discharged. The other repeat
ultrasound was positive and the patient was taken to surgery and had pathology proven appendicitis.The negative predictive value
for absent secondary signs of appendicitis when the appendix is not visualized is 97%. CT, MRI, and repeat US that visualized a
negative appendix were considered true negatives.
CONCLUSION
When the appendix is not visualized clinicians are often left to make a decision on whether or not to subject the patient (often
pediatric) to ionizing radiation (CT), a lengthy MRI or a repeat US. It is important that radiologists and technologists look for the
secondary signs of appendicitis when the appendix is not visualized. The radiologist should specifically mention the lack of
secondary signs when appropriate. Based on the findings of this study, such a statement carries a high NPV. Armed with such
information, the clinicians will be better suited in making the difficult decision in regards to further imaging or intervention.
CLINICAL RELEVANCE/APPLICATION
Secondary signs of appendicitis carry a high negative predictive value and should be evaluated for when the appendix is not
visualized on ultrasound.
ER212-SDMOA5
Epiploic Appendagitis is Associated with Peritoneal Inflammation and Visceral Obesity
Station #5
Participants
James P. Nugent, Vancouver, BC (Presenter) Nothing to Disclose
Hugue A. Ouellette, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
D. P. O'Leary, PhD, Limerick, Ireland (Abstract Co-Author) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
PURPOSE
The location, size and coexisting local inflammatory findings in acute epiploic appendagitis have not been reported outside of
isolated case reports. The association between EA and increased body mass index is controversial and disputed in the radiological
and surgical literature. Our aim is to investigate if abdominal adipose volume (AAV), visceral adipose area (VAA) and subcutaneous
adipose area (SAA) quantified by CT scans is higher in EA patients than matched controls. We also report the location, size and
frequency of coexisting local inflammatory findings in a series of patients with acute epiploic appendagitis.
METHOD AND MATERIALS
Consecutive patients with an imaging diagnosis of EA scanned between January 2009 and June 2014 were selected for inclusion (n
= 100). 100 consecutive patients imaged with abdominal CT for non-EA related acute abdominal pain were selected as controls.
OsiriX v.5.5.2 (Pixmeo, Geneva, Switzerland) was used to retrospectively quantify abdominal adipose tissue volume and crosssectional area using Hounsfield unit threshold based semi-automated segmentation between -50 HU and -180 HU. The site, size and
severity of inflammation of the involved appendage was also recorded.
RESULTS
EA had a male sex predilection, with 67% of EA versus 41% of acute abdominal cases (p = 0.0002). EA patients had 34% greater
AAV, 197% greater VAA, and 135% greater SAA than the control subjects (p < 0.0001). The inflamed appendage was found in the
sigmoid colon in 49% of cases, descending colon in 23% and right colon in 19%. Peritoneal thickening was a frequently reported
associated sign of inflammation found in 76% of cases. Bowel wall thickening was common (47%) and diverticulosis co-existed
incidentally in 28% of cases.
CONCLUSION
VAA was almost 200% larger in patients with EA as compared with control subjects. Peritoneal thickening was a frequently reported
associated sign of inflammation found in 76% of cases. Inflammation of the parietal peritoneum may contribute to the clinical
presentation with acute pain.
CLINICAL RELEVANCE/APPLICATION
The association between EA and increased body mass index is controversial and disputed in radiological and surgical literature. Our
study finds that visceral adipose area is almost 200% higher in EA.
ER166-EDMOA6
MDCT of Midfacial Fractures: Classification Systems, Principles of Reduction, and Common
Complications
Station #6
Awards
Certificate of Merit
Identified for RadioGraphics
Participants
David Dreizin, MD, Baltimore, MD (Presenter) Nothing to Disclose
Silviu Diaconu, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Uttam Bodanapally, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Arthur Nam, MD, MS, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Felipe Munera, MD, Miami, FL (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
After completing this exhibit, viewers will be able to…
1. Understand the dependent nature of midfacial fractures and importance of sagittal buttresses for restoring facial projection.2.
Explain why Le Fort fracture level is the most important aspect of these fractures to plastic and reconstructive surgeons.
3. Describe common fracture classifications of the palatoalveolar, naso-orbito-ethmoid, zygomatic (malar), and orbital regions, and
how they influence operative decision making.4. Deduce the surgeon’s reasoning for operative approach, mandibulo-maxillary
fixation, choice of plate-fixation points, use of bone grafting, trans-nasal canthal wiring and other techniques based on postoperative MDCT.
TABLE OF CONTENTS/OUTLINE
Beyond buttresses: “stability” in midface fractures. Know your sutures. Palatoalveolar fractures: classifactions Le Fort fractures:
Le Fort I/II/III - review/limitations. Level is key. coexisting ZMC and NOE fractures. Orbital fractures: herniated fat, orbital volume,
and enophthalmos; Blow in and blow out; Defect size mattersNOE fractures: NOE I/II/III; Know your anatomy; post-op findingsZMC
fractures: Grading ZMCs- the zygomaticosphenoid suture; How many plates are enough? A note on zygomatic archLooking to the
future: 3D printing and intra-operative CBCT
Lunch & Learn: Transitioning to DR, Clinical and Financial Benefits Beyond Preventing Reimbursement
Penalties: Supported by Fujifilm (invite-only)
Monday, Nov. 28 12:30PM - 1:30PM Room: S403B
Participants
PARTICIPANTS
Jerry Thomas, MS, FAAPM, DABR, CHP, DABSNM Wichita, KS
William Tobin BS, Tyler, TX
PROGRAM INFORMATION
This course does not offer CME credit.
ERS-MOB
Emergency Radiology Monday Poster Discussions
Monday, Nov. 28 12:45PM - 1:15PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Ferco H. Berger, MD, Toronto, ON (Moderator) Nothing to Disclose
Sub-Events
ER213-SDMOB1
Clinical Parameters Predict Subsequent Traumatic Hepatic and Splenic Injury Identified on Computed
Tomography
Station #1
Participants
Michael J. Hsu, MD, Boston, MA (Presenter) Nothing to Disclose
Michael Wasserman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jennifer Xiao, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Venkata Satyam, Boston, MA (Abstract Co-Author) Nothing to Disclose
Tina Shiang, Boston, MA (Abstract Co-Author) Nothing to Disclose
Deepan Paul, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ahmed Y. El-Araby, MD , West Warwick, RI (Abstract Co-Author) Nothing to Disclose
Vaeman Chintamaneni, Boston, MA (Abstract Co-Author) Nothing to Disclose
Robert Burns, Boston, MA (Abstract Co-Author) Nothing to Disclose
Arthur Baghdanian, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jorge A. Soto, MD, Boston, MA (Abstract Co-Author) Royalties, Reed Elsevier
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
The purpose of this study was to examine commonly collected clinical parameters in the trauma patient, and to determine which
parameters predict subsequent traumatic injury to the liver and spleen as identified on computed tomography (CT).
METHOD AND MATERIALS
This HIPAA-compliant, retrospective study performed at our urban academic teaching hospital was approved by the Institutional
Review Board (IRB); informed consent was waived.All adult patients presenting over a two-year period with hepatic or splenic
trauma as evidenced by CT imaging were enrolled (n=49). A control group of 50 patients presenting with trauma but with negative
CT findings was included for comparison. Admission clinical parameters such as heart rate (HR) and blood pressure (BP) as well the
admission lab values hematocrit (Hct), lactate, blood urea nitrogen (BUN) and creatinine (Cr) were collected for each
patient. Subsequently, the differences in these clinical parameters between the two groups were analyzed using a t-test with pvalue of <0.05 considered statistically significant.
RESULTS
The mean Hct was 39.5 for females and 43.4 for males in the control group and 35.0 for females and 40.6 for males in the
hepatosplenic injury group. Hematocrit was significantly lower in the hepatosplenic injury group (p = 0.003 for females and p =
0.006 for males).Mean lactate was 1.72 and 3.28 for the control and hepatosplenic injury groups, respectively. While lactate was
abnormally elevated for both groups, the hepatosplenic injury group demonstrated a significantly greater degree of lactate elevation
(p = 0.0001).Heart rate and blood pressure were similar between the two groups with no statistically significant differences
identified.Additional laboratory values which were analyzed, including BUN and Cr, were not predictive of hepatosplenic injury as no
statistically significant differences were identified.
CONCLUSION
The admission clinical parameters of HCT and lactate are predictive of traumatic hepatic and splenic injury identified on CT imaging.
Awareness of the potential utility of these clinical parameters may assist in triage and CT protocol considerations during the initial
patient evaluation in the trauma setting.
CLINICAL RELEVANCE/APPLICATION
Identifying clinical parameters that predict hepatosplenic injury on CT alerts physicians to possible hepatosplenic injury, which may
help CT protocol decision-making and support earlier CT imaging.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jorge A. Soto, MD - 2013 Honored Educator
Jorge A. Soto, MD - 2014 Honored Educator
Jorge A. Soto, MD - 2015 Honored Educator
ER214-SDMOB2
Evaluating the Predictive Value of Risk Factors for Retroperitoneal Hemorrhage
Station #2
Participants
Ahmed Fadl, MD, Mineola, NY (Presenter) Nothing to Disclose
Rishi Chopra, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Abieyuwa Eweka, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Amanjit S. Baadh, MD, New York, NY (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Jason C. Hoffmann, MD, Mineola, NY (Abstract Co-Author) Consultant, Merit Medical Systems, Inc; Speakers Bureau, Merit Medical
Systems, Inc
Sameer Mittal, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
Retroperitoneal bleed (RPB) is an uncommon and potentially life threatening condition, often requiring a high index of suspicion to
diagnose correctly. Concern for RPB is often raised given physical examination findings and pertinent laboratory values. Noncontrast computed tomography (CT) has proven to be a fast and accurate means to emergently assess these patients. We
retrospectively evaluated specific risk factors in a series of patients and determined their predictive values in developing RPB when
correlating with CT findings, with the goal of determining which factors are important to consider when determining if emergent
imaging is warranted.
METHOD AND MATERIALS
A single institutional retrospective analysis of 1,000 consecutive patients who underwent a non-contrast CT of the abdomen and
pelvis to evaluate specifically for RPB was conducted. Patients were selected from a database of CT imaging requests (June 2008June 2011). Values including vital signs, recent invasive procedures, coagulation panel, hematologic status, and anticoagulant use
were documented. Corresponding CT imaging at the time of evaluation was analyzed by two board-certified radiologists for the
presence of a retropertioneal bleed. Findings were subsequently compared between the RPB and non-RPB cohorts.
RESULTS
Of the 1,000 patients meeting inclusion criteria, 29 were found to have CT confirmed RPB. A randomly selected equal size cohort
with CT confirmed studies negative for RPB was gathered for comparison. Analysis demonstrated that the CT confirmed RPB
patients had a statistically significant low mean arterial pressure (MAP), with average MAP 76 mmHg versus 86 mmHg in control
group (p=0.0008). Recent invasive procedure was also found to have significance, with 24 of 29 in the RPB group having recent
invasive procedures, compared to 3 of 29 in the control group (p=0.0068). Drop in hemoglobin/hematocrit, coagulation panel, and
anticoagulant use were not found to have statistical significance.
CONCLUSION
Although uncommon, RPB warrants a high index of suspicion and prompt evaluation due to associated morbidity and mortality. Low
mean arterial pressure and recent invasive procedure have predictive value in determining which patients should be emergently
imaged.
CLINICAL RELEVANCE/APPLICATION
Low mean arterial pressure and history of a recent invasive procedure have predictive value in deciding whether emergent imaging
is appropriate to evaluate for RPB.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
ER215-SDMOB3
The Combination of SWI and DTI in Diagnosing Different Severity's Traumatic Brain Injury
Station #3
Participants
Chengru Song, Zhengzhou, China (Presenter) Nothing to Disclose
Jingliang Cheng, MD,PhD, Zhengzhou, China (Abstract Co-Author) Nothing to Disclose
Yong Zhang, DO, Zhengzhou, China (Abstract Co-Author) Nothing to Disclose
PURPOSE
To explore the diagnostic value of SWI and DTI on different severity's traumatic brain injury(TBI).
METHOD AND MATERIALS
Totally 60 TBI patients (including 20 mild TBI patients, 20 moderate TBI patients and 20 severe TBI patients) and 20 health
volunteer underwent SWI, DTI and conventional MRI examination. The numbers of involving regions, numbers and areas of
hemorrhagic lesions detected by SWI, and FA values of 37 brain regions (including knee, body, splenium of corpus callosum,
cingulate bundle, et al.) were compared between each two groups. The correlation analysis between GCS scores and the number of
involving regions, number of hemorrhagic lesions, areas of hemorrhagic lesions detected by SWI, and FA values of each region were
performed.
RESULTS
The differences of involving regions' number, lesions' number, lesion's areas detected by SWI between each two groups were
statistically significant (P<0.05). Severe TBI group got the maximum number of involving regions, lesions, and the largest areas.
Followed by moderate group and mild group. Among the 37 regions, totally 30 regions differ in FA values between the four
groups (P<0.05). And among these 30 regions, 18 regions' FA values, for example corpus callosum region, gradually reduce as the
severity of TBI aggravate. The GCS scores are highly negatively correlated with the number of involving regions, number of lesions,
areas of lesions detected by SWI, but are positively correlated with 30 regions' FA values. The descending order of relevance is
hemorrhagic lesions’ areas(r=-0.932), lesions' number(r=-0.911), involving regions' number(r=-0.900), FA values of right
cingulum(r=0.872), right anterior limb of internal capsule(r=0.801), left cingulum (r=0.787), the splenium of corpus
callosum(r=0.775), the body of corpus callosum (r=0.765), et al.
CONCLUSION
The clinical applications of SWI and DTI is valuable in diagnosing different severity's TBI.
CLINICAL RELEVANCE/APPLICATION
SWI and DTI can be applied in the diagnosis of different severity's TBI.
ER216-SDMOB4
Reducing the Use of CT Angiography in Low Risk Patients with Suspected Pulmonary Embolism via
Implementation of Decision Points in the Emergency Room Setting
Station #4
Awards
Student Travel Stipend Award
Participants
Andrew J. Cantos, MD, East Meadow, NY (Presenter) Nothing to Disclose
Michael Drabkin, MD, East Meadow, NY (Abstract Co-Author) Nothing to Disclose
Harold Hunt, MD, East Meadow, NY (Abstract Co-Author) Nothing to Disclose
Alexander Martynov, MD, East Meadow, NY (Abstract Co-Author) Nothing to Disclose
Eli Q. Harris, BA, East Meadow, NY (Abstract Co-Author) Nothing to Disclose
Victor J. Scarmato, MD, East Meadow, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
To reduce waste in spending, radiation exposure to patients and Radiology Department resources by using accepted criteria and
obtaining D-dimers in order to minimize ordering of CT angiography (CTA) for exclusion of pulmonary embolus.
METHOD AND MATERIALS
Following IRB approval, we reviewed 697 consecutive patients who had CTA to exclude PE over an 18-month period. We set out to
determine whether the appropriate decision points were being used. We systematically documented patients’ presenting symptoms,
demographic information, comorbidities and the results of their hospital workup. Risk categories were assigned, including
consideration of the Wells Criteria.
RESULTS
Of the 697 patients reviewed, 319 were considered low risk for PE using Well’s criteria. D-dimer was ordered in only 89 of these low
risk patients. Overall, 16 of 319 CTAs were positive (5.0%) in the low risk patient group. Of the 89 patients in whom D-dimer was
performed, 24 had a negative D-dimer (<0.5 µg/mL), all of which yielded negative CTA. Of the 65 patients with positive D-dimers, 5
demonstrated PE on CTA (avg. D-dimer = 7.23 µg/mL). Of 230 patients in whom a CTA was performed without D-dimer being
ordered, 11 were found to have CT findings suspicious for PE (4.8%).
CONCLUSION
Data suggests that we are underutilizing D-dimer, and not effectively using that D-dimer value when it is obtained; for both of
these reasons CTAs are not being ordered efficiently. This is evidenced by the low rate of positive CTAs in our selected patient
group, (5.0%) and high number needed to treat (20). By being more discerning in pursuing CTA to evaluate for PE, we can reduce
costs ($27 per D-dimer versus $2,104 per CTA) and patient radiation exposure (7 mSv per CTA), while also allowing our radiologists
more time to focus on more strongly indicated studies. We have since proposed to the ED that all patients meeting “low-risk
criteria” have a D-dimer. We have begun collecting prospective data on patients in whom PE is considered; documenting Wells
score, D-dimer and CTA results.
CLINICAL RELEVANCE/APPLICATION
Excessive ordering of CTA to “rule out” PE results in increased costs, and patient radiation exposure, as well as taking up the time
of our radiologists.
ER217-SDMOB5
The Utility of Early CT of Patients with a First Attack of Acute Pancreatitis in Emergency Department
Station #5
Participants
So Hyun Park, MD, Incheon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Seung Joon Choi, Incheon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Young Sup Shim, MD, Incheon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Sungjin Yoon, Incheon, Korea, Republic Of (Presenter) Nothing to Disclose
PURPOSE
Contrast-enhanced computed tomography (CT) is considered a diagnostic tool of acute pancreatitis (AP) and ideal time is after 72
hours from onset of symptoms. However, in the emergency department (ED), CT has been used in the early stage of AP recently.
This study is to investigate whether early CT affects clinical management of AP.
METHOD AND MATERIALS
Of 116 consecutive adults of AP with a first attack in the ED between March 2015 and March 2016, 56 patients (56/116, 48.3%) of
AP (M:F, 34:22; 50.3 ±15.6) underwent CT in the ED within 48 hours from onset of symptoms. CT images were retrospectively
evaluated for the stage of AP and assessment of complications. Urgent clinical management including endoscopic retrograde
cholangiopancreatitis (ERCP), percutaneous drainage (PCD) or percutaneous transhepatic biliary drainage (PTBD) within 24 hours
after early CT was assessed in AP patients.
RESULTS
Of 56 patients, four patients showed acute necrotizing pancreatitis (3 patients in peripancreatic tissue only, 1 in both pancreas and
peripancreatic tissue) and 52 patients had acute interstital pancreatitis. Alcohol abuse (25/56, 44.6%) and biliary obstruction or
cholangitis (20/56, 35.7%) were the most common causes of AP. Of 20 biliary pancreatitis, 11 received urgent therapeutic ERCP
(mean time interval between CT and ERCP, 11.4 ± 5.4). Of 11 patients, 5 received stone removal from the common bile duct (CBD)
and endoscopic sphincterotomy (EST), 2 received interposition of biliary stent, 2 underwent EST, 1 underwent removal of
pancreatic ductal stones, and 1 underwent CBD stone removal.
CONCLUSION
In conclusion, early CT is useful when a patient suspected of acute biliary pancreatitis and could be applied in clinical management
of AP.
CLINICAL RELEVANCE/APPLICATION
Early CT may be useful in diagnosis and management of suspicious acute biliary pancreatitis.
ER172-EDMOB6
CT Evaluation of Suspected Small Bowel Obstruction and Its Etiology. The Role of CT/CTA with
Multiplanar and 3D Imaging in Diagnosis, Determining Cause, Identifying Complications and Guiding
Patient Management: An Interactive Quiz
Station #6
Participants
Christopher R. Bailey, MD, Baltimore, MD (Presenter) Nothing to Disclose
Pamela T. Johnson, MD, Baltimore, MD (Abstract Co-Author) Consultant, National Decision Support Company
Elliot K. Fishman, MD, Baltimore, MD (Abstract Co-Author) Institutional Grant support, Siemens AG; Institutional Grant support,
General Electric Company;
TEACHING POINTS
MDCT has become the primary imaging modality for patients with small bowel obstruction. Evidence in the literature underscores the
importance of multiplanar evaluation to optimally interpret these studies.Following review of the exhibit the user will understand the
role MPR/3D imaging in detection and differential diagnosis of small bowel obstruction recognizethe various CT appearances of small
bowel obstruction learn how specific CT findings help define the cause of small bowel obstruction be cognizant of CT findings that
define the urgency of surgical management
TABLE OF CONTENTS/OUTLINE
Critical CT findings for each diagnosis are emphasized and the importance ofhigh value interpretations to guidemanagement of these
patients.Case studies (10) in quiz formatwith specific diagnosis include: SBO due to adhesions from prior surgery SBO following
robotic prostatectomy andport site hernia incarcerated inguinal hernia internal hernia with midgut volvulus SBO secondary to
volvulus with SMA and SMV occlusion as well as bowel infarction obstruction due to intussuception of a primary small bowel tumor
obstruction due to intussuception of a metastatic tumor to the small bowel obstruction due to stricture from Crohn's disease SBO
due to radiation enteritis SBO due to gallstone ileus
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Elliot K. Fishman, MD - 2012 Honored Educator
Elliot K. Fishman, MD - 2014 Honored Educator
Elliot K. Fishman, MD - 2016 Honored Educator
Pamela T. Johnson, MD - 2016 Honored Educator
SSE06
Emergency Radiology (Thoracoabdominal Emergencies)
Monday, Nov. 28 3:00PM - 4:00PM Room: N227B
GI
GU
CT
ER
AMA PRA Category 1 Credit ™: 1.00
ARRT Category A+ Credit: 1.00
Participants
Jamlik-Omari Johnson, MD, Atlanta, GA (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University Press
Stephan W. Anderson, MD, Boston, MA (Moderator) Nothing to Disclose
Sub-Events
SSE06-01
Absent Secondary Signs of Appendicitis When the Appendix is Not Visualized
Monday, Nov. 28 3:00PM - 3:10PM Room: N227B
Awards
Student Travel Stipend Award
Participants
Saad Hussain, MD, New Haven, CT (Presenter) Nothing to Disclose
Vivek Patel, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose
Aditi Vyas, MD, Norwalk, CT (Abstract Co-Author) Nothing to Disclose
Mahan Mathur, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Mike Spektor, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose
PURPOSE
The purpose of this study is to determine the negative predictive value (NPV) of the sonographic secondary signs of appendicitis
when the appendix is not visualized. The secondary signs of appendicitis seen on ultrasound (US) include free fluid, hyperemia,
lymphadenopathy, and phlegmon formation.
METHOD AND MATERIALS
A retrospective review was completed looking for ultrasound images and reports that did not visualize the appendix in its entirety
and also specifically stated that no secondary signs of appendicitis were visualized. The review spans 2013-2015. 130 studies were
found meeting the inclusion criteria.
RESULTS
Of the 130 total studies, 95 did not have imaging follow up or surgery for appendicitis. Either the ultrasound revealed an alternate
diagnosis (example: mesenteric adenitis) or the patient was discharged with an alternate clinical diagnosis (example: constipation).
35 studies had follow up imaging with CT (31), MRI (2) or US (2). Of the 31 follow up CTs, 4 did not visualize the appendix (and the
patients were discharged) and the remaining 27 revealed normal appendices. The 2 MRI examinations showed normal appendices
and the patients were discharged. One repeat ultrasound was negative and the patient was discharged. The other repeat
ultrasound was positive and the patient was taken to surgery and had pathology proven appendicitis.The negative predictive value
for absent secondary signs of appendicitis when the appendix is not visualized is 97%. CT, MRI, and repeat US that visualized a
negative appendix were considered true negatives.
CONCLUSION
When the appendix is not visualized clinicians are often left to make a decision on whether or not to subject the patient (often
pediatric) to ionizing radiation (CT), a lengthy MRI or a repeat US. It is important that radiologists and technologists look for the
secondary signs of appendicitis when the appendix is not visualized. The radiologist should specifically mention the lack of
secondary signs when appropriate. Based on the findings of this study, such a statement carries a high NPV. Armed with such
information, the clinicians will be better suited in making the difficult decision in regards to further imaging or intervention.
CLINICAL RELEVANCE/APPLICATION
Secondary signs of appendicitis carry a high negative predictive value and should be evaluated for when the appendix is not
visualized on ultrasound.
SSE06-02
Evaluation of the Diagnostic Value of a Venous Phase in CT Angiography of the Extremities in the
Setting of Trauma
Monday, Nov. 28 3:10PM - 3:20PM Room: N227B
Participants
Zachary Masi, MD, Camden, NJ (Presenter) Nothing to Disclose
Kathryn Gussman, Camden, NJ (Abstract Co-Author) Nothing to Disclose
Joshua Hazelton, DO, Camden, NJ (Abstract Co-Author) Nothing to Disclose
Ron Gefen, MD, Camden, NJ (Abstract Co-Author) Nothing to Disclose
PURPOSE
Patients with traumatic injury to extremities are often evaluated at hospital trauma centers by computed tomography angiography
(CTA) to evaluate for vascular injury, which can utilize arterial and venous phases. The purpose of this study is to assess whether
the venous phase contributes added value to the diagnostic study.
METHOD AND MATERIALS
Institutional IRB approval was obtained. Retrospective analysis of a radiology information system at a level I trauma center
identified adult patients evaluated for injury by upper or lower extremity CTA between September, 2014 and September, 2015 with
both arterial and venous phases. Images were evaluated by a diagnostic radiologist for diagnosis of “no injury”, “arterial injury”,
“venous injury” or “vasospasm”, made by the arterial phase alone, or in conjunction with the venous phase. Statistical analysis
utilized McNemar test and Kappa agreement values (a p value of < 0.05 was considered significant).
RESULTS
There were 157 studies performed on 154 patients, 131 (83%) male and 23 (17%) female (mean age 39). Studies comprised 49
upper and 108 lower extremities. Most common mechanisms of injury were gunshot wound (63), motor vehicle accident (26), and
stab wound (13). There were 99 diagnoses of no injury, 35 arterial injuries, 16 vasospasms, and 7 venous injuries. Four diagnoses
were changed between interpreting the arterial phase alone and both phases together: three venous injuries including one deep
vein thrombosis, and one vasospasm. Only the case of deep vein thrombosis resulted in a change in clinical management. Overall
there was no significant difference in diagnosis between the two methods (p > 0.125). There was high agreement for diagnosis of
no injury (Kappa 0.99), arterial injury (0.96), and vasospasm (0.97), and moderate agreement in diagnosing venous injury (0.59) (p
< 0.001).
CONCLUSION
The venous phase of CTA extremity studies for trauma does not add statistically significant value in diagnosing vascular injury and
can be safely removed from the imaging protocol, thereby decreasing patient scan time and radiation dose.
CLINICAL RELEVANCE/APPLICATION
CT angiography studies of extremities for vascular trauma can be accurately performed with an arterial phase only and do not
require a venous phase.
SSE06-03
Toward an MDCT-based Decision Support Tool for Bleeding Pelvic Fractures using Semi-automated
Volumetric Hematoma Analysis and Probabilistic Modeling: Preliminary Results
Monday, Nov. 28 3:20PM - 3:30PM Room: N227B
Participants
David Dreizin, MD, Baltimore, MD (Presenter) Nothing to Disclose
Nikki Tirada, MD, Brookline, MA (Abstract Co-Author) Nothing to Disclose
Uttam Bodanapally, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Eliot L. Siegel, MD, Baltimore, MD (Abstract Co-Author) Board of Directors, Brightfield Technologies; Board of Directors, McCoy;
Board of Directors, Carestream Health, Inc; Founder, MedPerception, LLC; Founder, Topoderm; Founder, YYESIT, LLC; Medical
Advisory Board, Bayer AG; Medical Advisory Board, Bracco Group; Medical Advisory Board, Carestream Health, Inc; Medical Advisory
Board, Fovia, Inc; Medical Advisory Board, McKesson Corporation; Medical Advisory Board, Merge Healthcare Incorporated; Medical
Advisory Board, Microsoft Corporation; Medical Advisory Board, Koninklijke Philips NV; Medical Advisory Board, Toshiba Corporation;
Research Grant, Anatomical Travelogue, Inc; Research Grant, Anthro Corp; Research Grant, Barco nv; Research Grant, Dell Inc;
Research Grant, Evolved Technologies Corporation; Research Grant, General Electric Company; Research Grant, Herman Miller, Inc;
Research Grant, Intel Corporation; Research Grant, MModal IP LLC; Research Grant, McKesson Corporation; Research Grant, RedRick
Technologies Inc; Research Grant, Steelcase, Inc; Research Grant, Virtual Radiology; Research Grant, XYBIX Systems, Inc;
Research, TeraRecon, Inc ; Researcher, Bracco Group; Researcher, Microsoft Corporation; Speakers Bureau, Bayer AG; Speakers
Bureau, Siemens AG;
Daniel C. Mascarenhas, BS, Cinnaminson, NJ (Abstract Co-Author) Nothing to Disclose
Louis Bivona, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Edward H. Herskovits, MD, PhD, Baltimore, MD (Abstract Co-Author) Consultant, BioClinica, Inc; Shareholder, Galileo CDS, Inc;
PURPOSE
No single CT sign, including intravenous contrast extravasation (ICE), predicts the need for angioembolization with
sufficient accuracy. ICE is only up to 60% sensitive. Active bleeding on angio (AB) is often seen w/o ICE. Pelvic hematoma volumes
are predictive of AB, but have not been validated for point of care use because time consuming slice-by-slice segmentation was
employed. We aimed to developed a multivariate probabilistic model and online calculator incorporating rapid pelvic hematoma
segmentation.
METHOD AND MATERIALS
A retrospective cohort of 116 patients were selected. Inclusion criteria: age > 18, blunt pelvic trauma; arterial phase MDCT prior to
angio. Exclusion criteria: no angio was performed; CT only after angio. Image review: data collected: presence/absence of ICE;
greatest diameter of contrast blush (mm); # vessels with blush; hematoma volumes from seeded region growing segmentation(mL);
fractures of the obturator canal or greater sciatic notch; pubic diastasis; osteopenia; age; gender. Stepwise logistic regression
with forward selection and backward elimination was performed to determine informative variables for AB at angio.
RESULTS
The variable with the strongest correlation with AB was hematoma vol (p<0.001). Age and the greatest diameter of blush were also
explanatory and included in the model. Osteopenia; fractures and diastasis; and # of vessels dropped out during successive forward
selection and backward elimination steps. Logit transformation was performed to derive a probabilistic formula: P=e[(0.027*age)+
(0.004*hematoma vol)+(0.036*diameter largest blush)-3.014]/(1+e[(0.027*age)+(0.004*hematoma vol)+
(0.036*diameter largest blush)-3.014]). A prototype online active bleed calculator was developed- age(yrs) diameter(mm), and
hematoma vol(mL) is entered to determine probability of AB.
CONCLUSION
Prior work using manual segmentation found that hematoma vols<200mL result in 5% likelihood of AB, and vols> 500mL have 45%
likelihood. Our model provides a greater degree of practicality because 1) rapid segmentation can be done at the point of care, and
2) the model is highly granular.For example, an intermediate sized hematoma of 321 mL, even without blush, results in high likelihood
(56%) of AB in an elderly (73yo) victim of blunt trauma.
CLINICAL RELEVANCE/APPLICATION
The proposed model can be used at the point of care to guide trauma/ER radiologists, interventionalists, and trauma surgeons in
The proposed model can be used at the point of care to guide trauma/ER radiologists, interventionalists, and trauma surgeons in
determining the need for angio.
SSE06-04
Colonic Wall Thickening: Can Iodine Quantification Using Dual Source Dual Energy CT Differentiate
Diverticulitis from Adenocarcinoma?
Monday, Nov. 28 3:30PM - 3:40PM Room: N227B
Participants
Kathryn Darras, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Sheldon J. Clark, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Heejun Kang, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Alison C. Harris, MBChB, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Silvia D. Chang, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Mohammed F. Mohammed, MBBS, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Tim O'Connell, MD, Meng, Vancouver, BC (Abstract Co-Author) President, Resolve Radiologic Ltd Speake, Siemens AG
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Presenter) Speaker, Siemens AG
PURPOSE
To evaluate the role of iodine quantification in differentiating colonic diverticulitis from colonic adenocarcinoma.
METHOD AND MATERIALS
Institutional review board approval was obtained, with no informed consent required, for this retrospective analysis. 146
consecutive patients with acute diverticulitis were scanned using a standard protocol on a 128-section dual source, dual energy CT
system (100/140 keV). Patients who did not have follow up colonoscopy, which served as the gold standard, or who received large
volumes of positive oral contrast were excluded. This left 52 patients for analysis, 8 with proven colonic adenocarcinoma and 44
with diverticulitis. Using the virtual non-contrast application, iodine maps and virtual non-contrast datasets were created for all
patients. The coloured iodine maps were superimposed onto the virtual non-contrast images to provide both iodine distribution and
anatomic detail. The iodine concentration was recorded within the thickened bowel wall using a region of interest analysis (mg/ml).
The two groups were compared using two tailed unpaired t tests and the sensitivity and specificity were established.
RESULTS
The average iodine concentration was 1.41±0.56 mg/ml (range 0.2-2.7 mg/ml) in bowel wall thickening due to diverticulitis and
3.15±0.57 mg/ml (range 2.5-4.3 mg/ml) in bowel wall thickening due to adenocarcinoma. This difference was statistically significant
(p < 0.0001). Using a threshold of 2.5 mg/ml, the sensitivity for identifying adenocarcinoma was found to be 100% and the
specificity 95.5%.
CONCLUSION
Using a threshold value of 2.5 mg/ml, dual energy CT iodine quantification was found to have a high sensitivity and specificity for
distinguishing colonic wall thickening due to diverticulitis from thickening due to adenocarcinoma.
CLINICAL RELEVANCE/APPLICATION
Identifying the cause of colonic wall thickening, which is generally regarded as a nonspecific CT finding, will allow for appropriate
patient referral and triage for colonoscopy.
SSE06-05
Evaluation of Pancreatic Injury: Correlation between Pancreas Injury Grade (PIG) Scoring on MDCT
and Clinical Features and other Organ Injuries
Monday, Nov. 28 3:40PM - 3:50PM Room: N227B
Participants
Jung Hyun Noh, MD, Cheonan-si, Korea, Republic Of (Presenter) Nothing to Disclose
Sang Wook Son, MD, Cheon-an, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Mi-Hyun Park, MD, Cheonan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Young-Seok Lee, MD, Cheonan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Keum-Nahn Jee, MD, PhD, Cheonan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
PURPOSE
To assess the correlation of radiological PIG scoring on MDCT and clinical features and other associated organ injuries
retrospectively
METHOD AND MATERIALS
38 patients (mean age = 38.1, male to female ratio = 22 : 16), diagnosed as traumatic pancreatic injury by clinical and initial MDCT
findings, were included from Mar. 2006 to Feb. 2016. Their imaging findings were analyzed about five-scale PIG scoring on MDCT
based on AAST grade by consensus of two radiologists. Clinical records were reviewed about injury type, initial vital sign,
hospitalization period, prognosis and treatment. Associated abdominal MDCT findings were analyzed about other hollow and solid
visceral injury, vascular injury and injuries of other body parts. Evaluation of correlation between radiological PIG scoring on MDCT
and other associated organ injuries, and clinical features was done using statistical analyses by Fisher’s exact test and KruskalWallis test.
RESULTS
Patients with PIG scoring scale from I to V on MDCT included 13, 5, 11, 7, and 2 patients. Among 38 patients, 23 patients (60.5%)
had associated other organ injuries and 4 patients (10.5%) expired early due to unstable vital sign with active arterial bleeding in
liver or abdominal cavity and their PIG scoring was grade I (n=2), grade III (n=1) and grade V (n=1). Their injury types were out
car accident (n=3), in car accident (n=22), fall down (n=2) and blunt trauma (n=11). Patients with high PIG scoring had
characteristics of associated duodenal injury, vascular injury, and treatment choice of operation with statistical significance (p <
0.05). And no statistical significant correlations were between PIG scoring and other associated organ injuries in abdomen except
duodenal and vascular injury, interventional treatment, and other clinical findings of initial vital sign, injury type, hospitalization
period and death rate.
CONCLUSION
Patients with high PIG scoring have the characteristics of associated duodenal and vascular injuries, and treatment choice of
surgery. Associated other organ injuries and mortality cases were not correlated with PIG scoring.
CLINICAL RELEVANCE/APPLICATION
Evaluation of correlation degree between PIG scoring scale and associated every other organ injury and various clinical findings can
be clinically meaningful and these results could be considered as a reference of clinical evaluation of pancreatic injury patient
despite of limitation of number of included patients.
SSE06-06
Focused Abdomino Pelvic CT in Children with Suspected Acute Appendicitis: Assessing Accuracy and
Radiation Dose Reduction by Limiting the Scan Field
Monday, Nov. 28 3:50PM - 4:00PM Room: N227B
Awards
Student Travel Stipend Award
Participants
Andrew Fox, MD, Montreal, QC (Presenter) Nothing to Disclose
Christine Saint-Martin, MD, Montreal, QC (Abstract Co-Author) Nothing to Disclose
PURPOSE
Imaging is widely used in cases of suspected appendicitis with ultrasound the most common first-line modality in pediatric patients.
When sonography is non-diagnostic, a complete abdominopelvic CT is often used as an adjunct to rule in the diagnosis prior to OR.
CT has diagnostic superiority over sonography but the associated radiation is a concern and thus methods to reduce radiation are
of great interest. The concept of Z-axis limitation with combined analysis of accuracy and radiation dose reduction is yet to be
studied in the pediatric population.
METHOD AND MATERIALS
Data was collected from PACS between January 2010-present. The upper limit of the appendix was correlated with the superior
endplate of the corresponding vertebra. Subsequently, an upper limit Z-axis for interpretation was set based on the average
location of the appendix in our series (μ - 2σ), to include >97.5% of the visualized appendices. The studies were then revisited to
assess diagnostic accuracy over this focused range, assessing detection of both primary pathology and incidental findings.
Radiation dose reduction will be calculated using the Radimetrics software suite.
RESULTS
On the initial scans, the appendix was identified in 116/125 patients and not visualized in 9 patients. The average scan range was
438mm. 27 scans were positive for appendicitis and alternate pathology was identified in 17 patients. The average upper limit of
the appendix minus 2 SD corresponded to the L2 vertebra. From L2 caudally, the appendix was completely visualized in 115 scans,
and partially visualized in 1 scan. All of the positive appendicitis cases were diagnosed over the limited scan range. 10 alternate
diagnoses were completely identified, and 2 were partially identified. 5 cases of pulmonary pathology were missed. The average Zaxis Delta was 141mm, corresponding to a 32% reduction in scan field. Radiation dose reduction is being calculated.
CONCLUSION
Focused abdominopelvic CT for appendicitis in the pediatric population reduces the scan range by approximately 32%, while
maintaining 100% diagnostic accuracy for appendicitis (radiation dose reduction pending). Alternate abdominal pathology was either
completely or partially identified over this limited range.
CLINICAL RELEVANCE/APPLICATION
By limiting the scanning range of CTs performed for appendicitis, we are hoping to significantly reduce radiation dose to the patient,
while maintaining diagnostic accuracy.
ED004-TU
Emergency Radiology Tuesday Case of the Day
Tuesday, Nov. 29 7:00AM - 11:59PM Room: Case of Day, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Presenter) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
David Dreizin, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Manickam Kumaravel, MD, FRCR, Houston, TX (Abstract Co-Author) Nothing to Disclose
Constantine A. Raptis, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
David D. Bates, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Thomas Battey, Timonium, MD (Abstract Co-Author) Nothing to Disclose
Nicholas M. Beckmann, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1) Recognize key imaging findings on multimodality imaging of emergency/trauma patients. 2) Develop differential diagnosis based on
the clinical information and imaging findings. 3) Recommend appropriate management including image-guided interventions.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
RC308
Emergency Radiology Series: Imaging of Thoracic and Related Emergencies
Tuesday, Nov. 29 8:30AM - 12:00PM Room: N230B
CH
ER
AMA PRA Category 1 Credits ™: 3.50
ARRT Category A+ Credits: 4.00
Participants
Martin L. Gunn, MBChB, Seattle, WA, ([email protected]) (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge
University Press; Spouse, Consultant, Reed Elsevier; Spouse, Consultant, athenahealth, Inc; ;
Stephen Ledbetter, MD, Boston, MA (Moderator) Nothing to Disclose
Active Handout:Martin Lee David Gunn
http://abstract.rsna.org/uploads/2016/16000652/RC308 Gunn Aortic Injury.pdf
Sub-Events
RC308-01
Esophageal Emergencies
Tuesday, Nov. 29 8:30AM - 9:00AM Room: N230B
Participants
Francis J. Scholz, MD, Burlington, MA, ([email protected] ​ ​ ​ ​ ) (Presenter) Owner, FSpoon Company
LEARNING OBJECTIVES
After this presentation the radiologist will:Understand how to optimally examine for pharyngeal and esophageal trauma using
fluoroscopyRecognize and stage trauma as either A. Mucosal Tear B Intramural Dissection C Transmural Tear
ABSTRACT
Esophageal trauma is common in practice and includes a broad spectrum of clinical and radiologic entities including perforation,
hematoma, and foreign body ingestion that must be recognized promptly in order to reduce morbidity and mortality. Imaging findings
are often subtle or may not be demonstrable by conventional radiography or CT. Recognizing subtle fluoroscopic findings of disease
may avoid additional work up including more invasive endoscopy.Radiologists frequently perform esophageal fluoroscopy for not only
possible spontaneous trauma but also complex post-surgical and endoscopic trauma. In addition, spontaneous or post traumatic
pneumodemiatstinum or air in soft tissues of the neck lead to an urgent request to evaluate for esophageal perforation. This
presentation will provide concise details of our fluoroscopic technique and the findings that permit staging of traumatic insults for
clinical treatment choices, correlated with CT findings. Mucosal tears, intramural dissections, and transmural perforations are
shown. Classic eponymic esophageal traumas - Boerhaave and Mallory Weiss - are discussed and illustrated.
ABSTRACT
Esophageal trauma is common in practice and includes a broad spectrum of clinical and radiologic entities including perforation,
hematoma, and foreign body ingestion that must be recognized promptly in order to reduce morbidity and mortality. Imaging findings
are often subtle or may not be demonstrable by conventional radiography or CT. Recognizing subtle fluoroscopic findings of disease
may avoid additional work up including more invasive endoscopy.Radiologists frequently perform esophageal fluoroscopy for not only
possible spontaneous trauma but also complex post-surgical and endoscopic trauma. In addition, spontaneous or post traumatic
pneumodemiatstinum or air in soft tissues of the neck lead to an urgent request to evaluate for esophageal perforation. This
presentation will provide concise details of our fluoroscopic technique and the findings that permit staging of traumatic insults for
clinical treatment choices, correlated with CT findings. Mucosal tears, intramural dissections, and transmural perforations are
shown. Classic eponymic esophageal traumas - Boerhaave and Mallory Weiss - are discussed and illustrated.
Active Handout:Francis Joseph Scholz
http://abstract.rsna.org/uploads/2016/16000653/rc30801 Esophageal Emergencies DONE 6p.pdf
LEARNING OBJECTIVES
1) Understand presentations of esophageal trauma that warrant prompt fluoroscopic imaging. 2) Know esophageal anatomy and
structure required for fluoroscopic imaging. 3) Use techniques that optimally define esophageal pathology. 4) Diagnose esophageal
trauma, and stage perforations.
ABSTRACT
Esophageal emergencies are common and the radiologist is a key member of the team involved in the diagnosis, staging, and
treatment of many esophageal emergencies. CT and Fluoroscopy remain the principle diagnostic tools in patients with emergent
esophageal symptoms.Introduction to esophageal perforation, fluoroscopy and CT technique, diagnostic findings, and staging
concepts will be discussed and illustrated, including classic diagnoses: Taco Tear, Mallory Weiss, Boerhaave SyndromeSigns and
symptoms of esophageal trauma: odynophagia, pain after endoscopy, neck crepitus, abnormal breath sounds.
PERFORATION ETIOLOGIES:Instrumentation and Surgery
Ingestion/vomiting: Mallory Weiss, Boerhaave, Taco Tear, often alcohol associated
Fragile mucosa: Bullous Dermatoses, Eosinophilic Esophagitis
Radiation Stricture
Caustic agentsTECHNIQUE:If critically ill: CT and/or straight to surgery. If not critically ill and high suspicion, fluoroscopy is the
FIRST BEST TEST for esophageal trauma. It is best suited for finding subtle intramural perforations and for severity
staging.FLUOROSCOPY:Review prior swallow, find prior stricture site
Water-soluble, 90 cc, 4/s AP pharynx; 1/sec AP Esophagus.
If negative: bariumEsophagus: 1/s, upright AP, LAO and prone LPO.Pharynx: 4/s AP, LateralESOPHAGEAL TRAUMA STAGINGMucosal
Intramural
Transmural
Distant tracking, pleural and mediastinal inflammation
RC308-02
Chest Pain CT in the Emergency Department: Watch Out the Myocardium
Tuesday, Nov. 29 9:00AM - 9:10AM Room: N230B
Participants
Kai Higashigaito, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
Ricarda M. Hinzpeter, MD, Zurich, Switzerland (Presenter) Nothing to Disclose
Stephan Baumueller, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
Hatem Alkadhi, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
Fabian Morsbach, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate the frequency and significance of hypodense myocardium (HM) and coronary culprit lesions in chest-pain CT in the
emergency department.
METHOD AND MATERIALS
In this IRB- and ethics committee approved study, ECG-triggered chest-pain CT examinations of 300 consecutive patients (mean
age 59±17 years, 71% male) with acute chest pain referred to our emergency department for DRO (rule-out pulmonary embolism
(PE) and aortic dissection (AD), n=179) and TRO (n=121) between 06/2012 and 11/2015 were retrospectively analyzed. Chest-pain
CT for TRO was performed with s.l. nitroglycerine and without nitroglycerine for DRO. Each myocardial segment was assessed for
the presence of hypodense myocardium (HM). Attenuation of HM was measured and compared to normal myocardium. Coronary
arteries were searched for the presence of culprit lesions and coronary plaques were classified into non-calcified, mixed and
calcified. Presence of positive remodeling was noted. Patient histories were reviewed for the indications of CT, cardiovascular risk
factors, known previous myocardial infarction (MI), and final diagnosis causing acute chest pain.
RESULTS
HM was identified in 27/300 patients (9%): 12/179 in DRO-CT (7%) and 15/121 in TRO-CT (12%). Mean attenuation of HM
(59±40HU) was significantly lower than that of healthy myocardium (112±20HU, p<0.05), with a mean difference of 83±32HU. In
16/27 patients (59%) with HM, the final diagnosis was acute MI, and in the remaining 11/27 patients (41%) previous MI was found
in the patients’ history. DRO-CT identified HM and the corresponding culprit lesion in 6/16 patients (37%) with a final diagnosis of
acute MI. In 13/16 patients (81%), a culprit lesion causing MI was correctly identified and subsequently confirmed with catheter
angiography. Of the identified 13 plaques in culprit lesions, 4 (31%) were non-calcified, 4 (31%) mixed, and 5 (38%) calcified. 9/13
(69%) plaques showed positive remodeling.
CONCLUSION
Hypodense myocardium and the culprit coronary lesion causing acute MI is encountered often in chest-pain CT examinations, even
if only a DRO-CT was performed. This indicates that the myocardium should be analyzed for hypodense regions also if no dedicated
CT of the coronaries and heart was asked for.
CLINICAL RELEVANCE/APPLICATION
Acute MI can be detected in both DRO- and TRO- chest-pain CT examinations and may facilitate the diagnostic workup of acute
chest pain patients.
RC308-03
MDCT of Aortic Dissection
Tuesday, Nov. 29 9:10AM - 9:40AM Room: N230B
Participants
Stephen Ledbetter, MD, Boston, MA, ([email protected]) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
To optimize imaging approach for the ED patient
To review the typical CT imaging findings
To understand the spectrum of disease
RC308-04
Novel CT Predictors of Type A Aortic Dissection
Tuesday, Nov. 29 9:40AM - 9:50AM Room: N230B
Awards
Student Travel Stipend Award
Participants
Nigel R. Munce, MD,PhD, Hamilton, ON (Presenter) Founder, Conavi Medical Inc; Shareholder, Conavi Medical Inc
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Ali Alsagheir, MD, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Forough Farrokhyar, DPhil, PhD, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Dominic Parry, MD, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
PURPOSE
To retrospectively evaluate the clinical relevance of novel MDCT parameters in patients with type A aortic dissection when
compared to a control group having MDCT for the evaluation of thoracic aorta.
METHOD AND MATERIALS
An IRB- approved retrospective review of patients presenting with Type A aortic dissection at our institution (n=51 with available
An IRB- approved retrospective review of patients presenting with Type A aortic dissection at our institution (n=51 with available
MDCT) was conducted from January 2008 - January 2016. MDCT parameters measured were: length of the ascending aorta (AA),
maximal AA diameter, aortic root diameter, the left ventricular outflow tract (LVOT) angle (the angle between an imaginary line
drawn at right angles to the plane of the aortic annulus and a second line representing the transverse plane) and the cardiac apex
(CA) angle (the angle between an imaginary line drawn from left ventricular apex to the mid point of the aortic valve and a second
line representing the transverse plane). Similar measurements were performed in an age and gender matched control group
(n=76). Statistical comparison were made with Student’s t-tests.
RESULTS
51 cases of acute Type A dissection with available MDCT were identified (mean age= 61; M:F= 35:16). Review of 123 urgent CTs
of the complete aorta yielded 76 cases without significant acute aortic pathology or prior thoracic aortic intervention which served
as age and gender matched controls. The mean length of the ascending aorta in the Type A dissection population versus control
group was 12.00 vs 9.27 cm (p < .0001). The maximal aortic diameter was 4.97 vs 3.15 cm (p < .0001) and aortic root diameter
was 4.35 vs 2.89 cm (p<.001). The LVOT and CA angles were both significantly less in the type A dissection group measuring
31.70 vs 44.13 degrees (p< .0001) and 20.44 vs 30.34 degrees (p <.0001), respectively.
CONCLUSION
Our study shows, for the first time to our knowledge, that there is a statistically significant increase in the length of the ascending
aorta in patients with Type A dissection as compared to control group. We also demonstrate that there is a decrease in the angle
of the LVOT and CA angle.
CLINICAL RELEVANCE/APPLICATION
AA length, LVOT angle and CA angle are significantly different in patients with Type A dissection as compared to a control group
and thus may serve as novel predictors for type A aortic dissection.
RC308-05
Morphological Changes between Acute and Chronic Type B Communicating Aortic Dissection on
MDCT: A Retrospective Study
Tuesday, Nov. 29 9:50AM - 10:00AM Room: N230B
Participants
Yumi Imamura, Tokyo, Japan (Presenter) Nothing to Disclose
Satoru Morita, MD, PhD, Shinjuku-ku, Japan (Abstract Co-Author) Nothing to Disclose
Shuji Sakai, MD, Shinjuku-Ku, Japan (Abstract Co-Author) Nothing to Disclose
PURPOSE
No reports have systematically clarified the differences between acute and chronic type B communicating aortic dissection on
computed tomography (CT), though such clarification is sometimes required clinically. Thorough understanding of these differences
from disease onset is important for determining optimal therapeutic methods and accurately estimating the prognosis. The purpose
of this study was to compare the morphological changes between acute and chronic type B communicating aortic dissection on
multidetector row CT (MDCT).
METHOD AND MATERIALS
We analyzed 21 patients with type B communicating aortic dissection who underwent acute-phase contrast-enhanced MDCT. The
flap curvature, flap thickness, long and short diameter of the aorta, and false lumen length were measured at a representative
portion of the descending aorta. The numbers of slices with 5-mm thickness with a fluttering flap, calcification on the flap, and
thrombosis in the false lumen were counted. These findings in the acute and chronic phases before any intervention (median 0 and
181 days after onset) were compared using the Mann–Whitney U test.
RESULTS
The mean flap curvature in the acute phase was significantly larger than in the chronic phase (66.0 ± 18.0 vs. 35.5 ± 30.9 1/m, p
= 0.009). The median number of slices with a fluttering flap in the acute phase was larger than in the chronic phase (10 vs. 1, p =
0.008). The mean ratio of the long to short diameter in the acute phase was relatively lower than in the chronic phase (1.07 ± 0.06
vs. 1.14 ± 0.12, p = 0.073). The mean ratio of the false lumen length to long diameter in the acute phase was significantly lower
than in the chronic phase (0.41 ± 0.10 vs. 0.59 ± 0.16, p < 0.001). No significant differences in the mean flap thickness, median
number of slices with calcification on the flap, and median number of slices with thrombosis in the false lumen were observed (2.4 ±
0.5 vs. 2.7 ± 0.6, p = 0.176; 8 vs. 10, p = 0.651; and 2 vs. 12, p = 0.086).
CONCLUSION
Acute and chronic type B communicating aortic dissection can be differentiated on MDCT. Findings suggestive of acute phase are a
curved flap, flap fluttering, and complete round shape of the descending aorta.
CLINICAL RELEVANCE/APPLICATION
MDCT findings of a curved flap, flap fluttering, and complete round shape of the descending aorta suggest the acute rather than
chronic phase of type B communicating aortic dissection.
RC308-06
Aortic MRA Can Guide ED Management of Suspected Acute Aortic Dissection
Tuesday, Nov. 29 10:00AM - 10:10AM Room: N230B
Participants
Gary X. Wang, MD, PhD, Boston, MA (Presenter) Nothing to Disclose
Sandeep S. Hedgire, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Thang Le, MD, Cambridge, MA (Abstract Co-Author) Nothing to Disclose
Jonathan Sonis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Brian Yun, MD,MBA, Boston, MA (Abstract Co-Author) Nothing to Disclose
Michael H. Lev, MD, Boston, MA (Abstract Co-Author) Consulant, General Electric Company; Institutional Research Support, General
Electric Company; Stockholder, General Electric Company; Consultant, MedyMatch Technology, Ltd; Consultant, Takeda
Pharmaceutical Company Limited; Consultant, D-Pharm Ltd
Ali Raja, MD, MBA, Boston, MA (Abstract Co-Author) Nothing to Disclose
Anand M. Prabhakar, MD, Somerville, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
Though ACR Appropriateness Criteria recommends MRA for suspected acute aortic dissection when CTA is not possible, the
feasibility and utility of this strategy in the ED is unclear. This study examines the indications and outcomes of MRA in suspected
acute aortic dissection evaluation in the ED.
METHOD AND MATERIALS
This study was completed in an urban, academic Level 1 trauma center. An IRB approved retrospective electronic medical record
review identified patients who underwent MRA in the ED for suspected acute thoracic aortic dissection from 2010-2015. Age,
gender, clinical assessment, CTA contraindications, MRA results, clinical outcomes, and times of ED arrival and dismissal, and of
MRA completion were analyzed.
RESULTS
47 patients (mean age 58 years old) underwent MRA: 19 (40%) due to iodinated contrast allergy, 21 (45%) due to renal
insufficiency (eGFR < 30 ml/min/1.73 m² or clinical concern for declining renal function), 2 (4%) due to both, 2 (4%) to spare
ionizing radiation, 2 (4%) for further work-up after CTA, and 1 (2%) due to prior contrast-enhanced CT within 24 hours. Mean ED
arrival to MRA completion time was 381±279 min. 40 studies were fully diagnostic; 7 were limited. Two (4%) patients had acute
dissection on MRA and 45 (96%) had negative exams. 18 (38%) received gadolinium: 14 (78%) had iodinated contrast allergy and
none had renal insufficiency. 29 (62%) patients did not receive gadolinium: 21 (72%) had renal insufficiency and 2 (6%) were on
hemodialysis; 7 (24%) had iodinated contrast allergy. No significant difference exists in ability to achieve a fully diagnostic MRA
with or without gadolinium (p = 0.225, Fisher’s exact test). 16 (34%) of patients were discharged home from the ED; 2 (4%) were
admitted for acute dissection seen on MRA and 29 (62%) for further evaluation after dissection was excluded or to manage an
alternative diagnosis.
CONCLUSION
MRA has a clear role in the evaluation for acute thoracic aortic dissection in the ED, where it can guide management and facilitate
safe discharge to home. Nearly all MRA exams in this study cohort were performed when CTA was not possible, which follows ACR
Appropriateness Criteria and demonstrates its feasibility in the ED.
CLINICAL RELEVANCE/APPLICATION
With increased MRI availability in the ED, MRA can be useful in evaluating suspected acute aortic dissection in ED patients unable
to undergo CTA and can allow for safe discharge to home.
RC308-07
Advanced Imaging of Traumatic Thoracic Aortic Emergencies
Tuesday, Nov. 29 10:10AM - 10:40AM Room: N230B
Participants
Martin L. Gunn, MBChB, Seattle, WA, ([email protected] ​ ​ ​ ) (Presenter) Research Grant, Koninklijke Philips NV; Royalties, Cambridge
University Press; Spouse, Consultant, Reed Elsevier; Spouse, Consultant, athenahealth, Inc; ;
Active Handout:Martin Lee David Gunn
http://abstract.rsna.org/uploads/2016/16000655/ACTIVE RC308 07.pdf
LEARNING OBJECTIVES
1) Review multi-modality imaging findings of traumatic thoracic aortic injuries. 2) Describe the most appropriate use of CT in the
patient at risk of traumatic aortic injury. 3) Explain recent advances in the understanding of blunt aortic injuries, and current
evidence-based management. 4) Identify imaging pitfalls and explain how to differentiate "pseudo-disease" from a true injury.
ABSTRACT
RC308-08
The Incidence and Effect on Mortality of Costochondral Fractures in Blunt Polytrauma Patients- A
Review of 1461 Consecutive Whole Body CT Studies for Trauma
Tuesday, Nov. 29 10:40AM - 10:50AM Room: N230B
Awards
Student Travel Stipend Award
Participants
Mari Nummela, MD, Helsinki, Finland (Presenter) Nothing to Disclose
Frank Bensch, MD, PhD, Helsinki, Finland (Abstract Co-Author) Nothing to Disclose
Seppo K. Koskinen, MD, PhD, Stockholm, Sweden (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate the incidence of costal cartilage fractures (CCfx’s) in blunt polytrauma patients, related injuries, trauma mechanism and
mortality.
METHOD AND MATERIALS
All patients with a history of blunt trauma in a level I trauma center over a period of 36 months were included. All whole body CT
(WBCT) studies were initially double read and retrospectively reviewed by a board certified radiologist blinded to initial reports.
RESULTS
A total of 1461 WBCT studies were found, of which 574 (39%) had thoracic injuries (M 425; 74.0%, mean age 46.6 (range 18-91),
F 149; 26.0%, mean age 48.9 (range 18-97)). Of these, 118 patients (M 101; 85.6%, mean age 48.8 (range 18-84), F 17; 14.4%
mean age 47.4 (range 20-82)) had a total of 225 CCfx’s. The incidence of CCfx’s was 8.1% (118/1461) in all WBCT studies and
20.6% (118/574) in thoracic trauma patients. CCfx’s were categorized as costochondral (101; 44.9%), midchondral (112; 49.8%) or
costosternal (12;5.3%). Costal cartilages of ribs 6 (37/225; 16.4%) and 7 (38/225; 16.9%) were most commonly injured. Multiple
CCfx’s were found in 50% (59/118) and 16/118 patients (13.6%) had bilateral CCfx’s. No correlation between CC calcifications and
fractures was found. However, posttraumatic calcifications were seen adjacent or in the fracture line on follow up CT-studies of 16
patients starting from 21 days after initial trauma. No internal mammary or subclavian artery injuries were detected. Acute
traumatic aortic injury was rare (4/118; 3.4%). Multiple bony rib fx’s occurred in 96 cases of 118 (81.4%) of which 42 cases had
bilateral fx’s. Associated intrathoracic injuries were pneumothorax (76; 64.4%), hemothorax (61; 51.7%), and pulmonary contusions
(62; 52.5%). Intra-abdominal injuries were seen in 29 patients (24.6%). The main trauma mechanisms were MVA (40; 33.9%) and
fall (34; 28.8%). The 30-day mortality of patients with CCfx’s was 7.63% (9/118) in comparison to 4.61% (21/456) of patients with
no CCfx’s (OR 1.71, 95% CI (0.762-3.839)).
CONCLUSION
Costochondral fractures are common in blunt thoracic trauma. CC fx’s are related to high-energy trauma; patients with CCfx’s had a
slightly higher mortality rate than thoracic trauma patients with no CCfx’s.
CLINICAL RELEVANCE/APPLICATION
Costochondral fractures increase rib cage instability and often contribute to the formation of a flail chest. They are usually painful
and may impair respiratory function of chest trauma patients.
RC308-09
Prognostic Value of CT-derived Left Atrial and Left Ventricular Measures in Patients with Acute Chest
Pain
Tuesday, Nov. 29 10:50AM - 11:00AM Room: N230B
Participants
Paul Apfaltrer, MD, Vienna, Austria (Presenter) Nothing to Disclose
Rozemarijn Vliegenthart, MD, PhD, Groningen, Netherlands (Abstract Co-Author) Nothing to Disclose
U. Joseph Schoepf, MD, Charleston, SC (Abstract Co-Author) Research Grant, Astellas Group; Research Grant, Bayer AG; Research
Grant, General Electric Company; Research Grant, Siemens AG; Research support, Bayer AG; Consultant, Guerbet SA; ; ;
John W. Nance JR, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Richard A. Takx, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
The aim of this study was to determine the prognostic value of computed tomography (CT)-derived measures of left ventricular
(LV) and left atrial (LA) geometry and function for future major adverse cardiac events (MACE).
METHOD AND MATERIALS
We retrospectively analyzed data of 225 subjects who had undergone coronary CT angiography (CCTA) using a dual-source CT
system for acute chest pain evaluation between September 2006 and March 2009. LV mass, LV ejection fraction (EF), LV endsystolic volume (ESV) and LV end-diastolic volume (EDV), LA ESV and LA diameter, septal wall thickness and cardiac chamber
diameters were measured. MACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, or late
revascularization. The association between cardiac CT measures and the occurrence of MACE was quantified using Cox proportional
hazard analysis, adjusting for traditional risk factors (age, sex, body mass index, hypertension and Framingham risk score), coronary
calcium score, and obstructive coronary artery disease on CCTA.
RESULTS
225 subjects (mean age±SD, 56.2±11.2; 140 males) were analyzed, of whom 42 (18.7%) experienced a MACE during a median
follow-up of 13 months (range 9-17 months). LA diameter (HR: 1.07, 95% confidence interval [CI] 1.01-1.13 per mm) and LV mass
(HR: 1.05, 95% CI 1.00-1.10 per gram) remained significant prognostic factor of MACE after controlling for Framingham risk score.
LA diameter and LV mass were also found to have prognostic value independent of each other. The other morphologic and
functional cardiac measures were no significant prognostic factors for MACE.
CONCLUSION
CT-derived LA diameter and LV mass are associated with future MACE in patients undergoing evaluation for chest pain, and portend
independent prognostic value beyond traditional risk factors, coronary calcium score, and obstructive coronary artery disease on
CCTA.
CLINICAL RELEVANCE/APPLICATION
The results of the study indicate that CT-derived left atrial diameter and left ventricular mass are prognostic markers of
cardiovascular events in patients with acute chest pain independent of traditional risk factors, coronary calcium score, and
obstructive coronary artery disease on coronary CT angiography.
RC308-10
Multi-modality Imaging of Deep Venous Thrombosis
Tuesday, Nov. 29 11:00AM - 11:30AM Room: N230B
Participants
Douglas S. Katz, MD, Mineola, NY, ([email protected] ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) To review the multi-modality current imaging of deep venous thrombosis (DVT) of the upper and lower extremities. 2) To review
the advantages and disadvantages of the individual modalities for imaging known or suspected DVT in the upper and lower
extremities - ultrasound, CT, MR, and conventional venography. 3) To demonstrate typical and less typical examples of acute as
well as chronic DVT. 4) To review the potential pitfalls in the imaging of DVT.
ABSTRACT
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
RC308-11
A Review of Modified Well's Criteria Score as a Predictor of Lower Limb Venous Thromboembolism
Tuesday, Nov. 29 11:30AM - 11:40AM Room: N230B
Participants
Ronan Waldron, BMBCh, Galway, Ireland (Abstract Co-Author) Nothing to Disclose
Brian M. Moloney, MBBCh, Galway, Ireland (Presenter) Nothing to Disclose
Mary Clare Casey, Co Mayo, Ireland (Abstract Co-Author) Nothing to Disclose
PURPOSE
We aim to assess the use of the Modified Wells Criteria (MWC) score as a determinant for eligibility for Doppler Ultrasound (DUS)
and to determine the diagnostic accuracy of D-Dimers in positively predicting the presence of deep venous thrombosis (DVT)
METHOD AND MATERIALS
All patients who underwent lower limb DUS following suspicion of DVT between November 2012 and September 2014 were
reviewed. Pre-imaging MWC score was recorded and D-Dimer result noted if performed.
RESULTS
A total of 764 patients underwent lower limb DUS. 415(54.3%) of patients involved were female. 10.34% (n=80) of those who
underwent Lower Limb DUS had a positive finding of DVT. 364 patients had a MWC Score of 2, with a positive result in 23(6.32%).
257 patients had a MWC Score of 3, with a positive result in 24 (9.33%). 114 patients had a MWC score of 4, with a positive result
for DVT identified in 21 (18.42%). 29 patients had a MWC score of 5, 9(31.01%) of whom had a DVT. 7 patients had a MWC score
of 6, with a positive result for DVT in 3 (42.85%). The most common presenting symptoms were lower limb oedema (n= 731, 95.7%)
and pain (n=715, 93.6%). D-Dimer was elevated in all cases it was performed (n=564 (73.8%)). A mean elevation of 6.3 times
normal level was recorded with a DVT diagnosed at DUS.
CONCLUSION
Requests for DUS has increased significantly over the past decade in order to provide diagnostic certainty with consequent
significant burden on radiology services. The low positive outcome (10.3%) following DUS, as compared to antiquated international
comparisons of 12-25% supports suggestions of a deluge in reliance on this investigation for a negative diagnosis. Average pre-test
MWC scores suggested the majority of patients were within ‘likely range” for existence of a lower limb DVT, which may suggest a
need to reassess interpretation of the MWC
CLINICAL RELEVANCE/APPLICATION
Venous thromboembolism is a common cause of morbidity and a potentially fatal complication of hospitalization. DVT is the most
common form of venous thrombosis with an estimated incidence of 67 per 100,000 in the general population and a cumulative
lifetime incidence of 2 to 5%. The diagnosis of DVT is initially based on clinical suspicion, clinical examination and the use of the
MWC. DUS is only indicated to confirm the diagnosis of a DVT in a patient with a MWC score of two or greater. A D-Dimer test may
be utilized as an adjunct to an elevated MWC score to support a diagnosis.
RC308-12
Clinical Utility of CT Pulmonary Angiography in the Emergency Department when Providers Override
Evidence-Based Clinical Decision Support
Tuesday, Nov. 29 11:40AM - 11:50AM Room: N230B
Awards
Student Travel Stipend Award
Participants
Zihao Yan, BS, Boston, MA (Presenter) Nothing to Disclose
Ali Raja, MD, MBA, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ivan Ip, MD, MPH, Brookline, MA (Abstract Co-Author) Nothing to Disclose
Joshua Kosowsky, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jeremiah Schuur, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ramin Khorasani, MD, Boston, MA (Abstract Co-Author) Consultant, Medicalis Corp
PURPOSE
Assess frequency of clinically useful diagnoses other than pulmonary embolism (PE) found on CT pulmonary angiography (CTPA) in
emergency department (ED) patients with suspected PE when providers’ imaging request is inconsistent with evidence-based
clinical decision support (CDS).
METHOD AND MATERIALS
This Institutional Review Board-approved study was performed at a tertiary-care, academic medical center ED with approximately
60,000 annual visits. We included all adult patients with suspected PE undergoing CTPA between 1/1/2011-8/31/2013. Each order
was exposed to CDS based on the Wells Criteria. We compared the frequency of clinically useful alternative diagnoses (alternative
diagnoses/ number of CTPAs) when providers overrode CDS alerts (e.g., CTPAs in patients with Well Score (WS) ≤4 with normal or
no–D-dimer) to orders adherent to CDS (CTPAs in patients with WS >4 or WS ≤4 with elevated D-dimer). We defined clinically
useful alternative diagnosis as imaging findings other than PE that could potentially explain the patient’s signs and symptoms (e.g.
shortness of breath) and result in changes in clinical management within 3 months (e.g. thoracentesis 2 days post-CTPA for pleural
effusion not seen on prior X-ray). Incidental findings resulting in changes in clinical management within 3 months (e.g. newly
discovered enlarged mediastinal or hilar lymph nodes resulting in oncology admission) were also included. We hypothesized 20% rate
of alternative diagnoses in the CDS adherent group, and 35% in the non-adherent group, requiring a sample size of 138 CTPAs in
each group to provide 80% power (α = 0.05; two-tailed test). After removing positive PE studies in both groups, 150 CTPAs were
randomly selected from each group. We performed patient chart review to investigate existence of alternative diagnosis. Chisquared test was used for statistical analysis.
RESULTS
Among 2993 CTPA studies, 589 studies were performed against CDS recommendations. The frequency of alternative diagnoses in
the override group was 32% (48/150), compared to 15% (22/150) in the adherent group (p< 0.001).
CONCLUSION
CTPAs performed against the recommendation of evidence-based CDS were more than twice as likely to result in alternative
diagnoses.
CLINICAL RELEVANCE/APPLICATION
CTPA use inconsistent with evidence-based CDS may provide clinical utility in nearly 1/3 of patients, prompting further research to
determine if alternative tests would be more optimal in such patients.
RC308-13
Cardiac and Hemodynamic Effects of Arterial Obstruction in Cancer-related Acute Pulmonary
Embolism
Tuesday, Nov. 29 11:50AM - 12:00PM Room: N230B
Participants
Juana M. Plasencia-Martinez, MD, Murcia, Spain (Presenter) Nothing to Disclose
Alberto Carmona-Bayonas, MD, Murcia, Spain (Abstract Co-Author) Nothing to Disclose
David Calvo-Temprano, MD, Oviedo, Spain (Abstract Co-Author) Nothing to Disclose
Paula Jimenez-Fonseca, MD, Oviedo, Spain (Abstract Co-Author) Nothing to Disclose
PURPOSE
To analyze the impact of acute pulmonary embolism (PE) on right ventricle (RV), and their hemodynamic effects in patients with
cancer.
METHOD AND MATERIALS
303 consecutive patients with symptomatic cancer-related PE were ambispectively enrolled in the multicenter (14 hospitals)
observational EPIPHANY study. All PEs were diagnosed by computed tomography pulmonary angiography. Arterial obstruction
severity was quantified with the Qanadli index (QI). Patients were stratified by PE location as central (trunk, main and/or lobar) or
peripheral (segmentary and/or subsegmentary branches). RV-dysfunction signs were defined as dilated RV (≥39 mm), increased
right-to-left ventricle (RV/LV) diameter ratio (≥1) and abnormal (flattened or inverted) interventricular septum (IVS).
RESULTS
Mean QI scores were higher in subjects with dilated RVs (30.4±21.7 vs. 23.6±18.5, P=0.007) and abnormal IVSs (39.5±20.7 vs.
22.1±18.2, P<0.001). QI measurements correlated with the RL/LV ratio and RV diameter (r=0.39 and 0.28, respectively, P<0.001).
Correlation between QIs and systemic blood pressure (SBP) was weak overall. However, progressively decreased heart adaptive
capacity, as expressed by dilated RVs or abnormal IVSs, QI showed an inverse correlation with SBP that increased gradually (r=0.56, P=0.09; r=-0.998, P<0.001, respectively). Correlations between QI measurements, RV/LV ratios and RV diameters were
stronger in hypotensive subjects (r=0.55 and r=0.64, respectively, P<0.001). In subjects with RV-dysfunction, the QI increased
from normotensive to hypotensive patients (28.7±21.8 vs. 42.1±17.6, P=0.004). All those effects were unrelated with PE location
(central or strictly peripheral).
CONCLUSION
In acute pulmonary embolism, the arterial obstruction index, assessed by Qanadli index, affects the hemodynamic status, but only
when the right-sided heart adaptive capacity fails.
CLINICAL RELEVANCE/APPLICATION
The evaluation of right ventricular dilation by CT pulmonary angiography is more useful than the degree of occlusion of the
pulmonary vasculature in predicting the outcome of cancer-related pulmonary embolism, likely because it evaluates better the
hemodynamic impact of the increased afterload produced by PE on ventricular function, especially in patients with reduced cardiac
contractility
ERS-TUA
Emergency Radiology Tuesday Poster Discussions
Tuesday, Nov. 29 12:15PM - 12:45PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
FDA
Discussions may include off-label uses.
Participants
Jamlik-Omari Johnson, MD, Atlanta, GA (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University Press
Martin L. Gunn, MBChB, Seattle, WA (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University Press;
Spouse, Consultant, Reed Elsevier; Spouse, Consultant, athenahealth, Inc; ;
Sub-Events
ER218-SDTUA1
Potentially Important Unreported Incidental Findings in Urgent Nonenhanced Abdominal CT
Performed for Renal Colic
Station #1
Participants
Elena Belloni, MD, Castel San Giovanni, Italy (Abstract Co-Author) Nothing to Disclose
Paola Scagnelli, Castel san Giovanni, Italy (Abstract Co-Author) Nothing to Disclose
Ilaria Fiorina, Pavia, Italy (Presenter) Travel support, Shenzhen Mindray Bio-Medical Electronics Co, Ltd; Consultant, Esaote SpA;
Consultant, Shenzhen Mindray Bio-Medical Electronics Co, Ltd; Consultant, SuperSonic Imagine; Consultant, Hitachi, Ltd;
Consultant, Toshiba Corporation
PURPOSE
To retrospectively evaluate the prevalence of potentially important unreported incidental findings in consecutive nonenhanced
abdominal CTs performed specifically for renal colic in the urgent setting.
METHOD AND MATERIALS
One radiologist with eight years of experience in CT (two as resident and six as specialist) retrospectively evaluated 156
consecutive nonenhanced abdominal CTs performed specifically for renal colic in 156 patients from the Emergency Department. The
incidental findings, both urinary and extraurinary, were classified as potentially important if they required further imaging and/or
clinical workup. The radiologist was blinded to the potentially important incidental findings highlighted in the finalized reports
performed in the urgent setting, but was aware of the reports of previous radiological examinations, if any. It was evaluated if the
CTs were performed, and the report generated, in the morning shift (hrs 8-14), in the afternoon shift (hrs 14-20) or in the night
shift (hrs 20-8).
RESULTS
The 156 patients in the study were 104 males and 52 females, aged 51 ± 15 years (range 24-89 years). 98 CTs were performed
and reported in the morning shift, 49 in the afternoon shift, 9 in the night shift. In the finalized reports, 19 potentially important
incidental findings in 19 different CTs were highlighted (12.2%), 10 in the morning, 8 in the afternoon and 1 at night. The blinded
retrospective evaluation confirmed all the 19 reported findings and added 24 unreported potentially important incidental findings in
24 different CTs (13 in the morning, 8 in the afternoon, 3 at night) (total of 43 findings in 156 CTs, 27.6%) (p<0.01).
CONCLUSION
A fair amount of potentially important additional findings was present in urgent nonenhanced abdominal CTs performed for renal
colic. Even in the urgent setting, when the radiologist is under pressure, care should be taken to avoid underreporting (that in our
series was particularly frequent in the night shift) and its possible consequences.
CLINICAL RELEVANCE/APPLICATION
CT is a pan-exploratory radiologic technique. For this reason, the radiologist should evaluate every body part included in the fieldof-view, in order to avoid underreporting, even in the urgent setting.
ER220-SDTUA3
Retrospective Study of the Clinical Predictors of a Positive Abdominal Renal CT Scan in Patients
Suspected to Nephro-ureteral Obstruction
Station #3
Awards
Student Travel Stipend Award
Participants
Francisco E. Valles, MD, Bridgeport, CT (Presenter) Nothing to Disclose
Nisarg A. Parikh, MD, MBBS, Bridgeport, CT (Abstract Co-Author) Nothing to Disclose
Yogesh Kumar, MD, Bridgeport, CT (Abstract Co-Author) Nothing to Disclose
Stephen Stein, MD, Westport, CT (Abstract Co-Author) Nothing to Disclose
Scott C. Williams, MD, Westport, CT (Abstract Co-Author) Nothing to Disclose
PURPOSE
Renal CT scans are often used to evaluate patients suspected of having renal colic, which are often negative despite best clinical
judgement. The purpose of this retrospective study is to aid clinicians to more selectively order renal CT scans, thereby minimizing
radiation risk to those with a low likelihood of a positive result.
METHOD AND MATERIALS
A retrospective study of 200 consecutive patients who arrived at a Level I trauma center and subsequently underwent a renal CT
scan. Indications for renal CT scan were analyzed statistically using univariate and multivariate models.
RESULTS
Univariate chi-square tests showed pyuria (OR=2.41; 95% CI; P=0.02) was a predictor of positive renal CT scan. Unilateral flank
pain (OR=2.00; 95% CI; P=0.06) and male sex (OR=1.81; 95% CI; P=0.05) had a tendency towards predicting a positive renal CT
scan. Multivariate logistic regression demonstrated that males with unilateral pain (OR=2.14; 95% CI; P=0.02), males with
hematuria (OR=3.01; 95% CI; P=0.01), and males with pyuria (OR=3.17; 95% CI; P=0.01) were significant predictors of positive
renal CT scan. Males with unilateral flank pain and hematuria (OR=4.09; 95% CI; P=0.002), and males with unilateral flank pain,
pyuria and hematuria (OR=4.52; 95% CI; P=0.01) yielded the highest likelihood of predicting a positive renal CT scan. Women with
non-lateral pain were statistically more likely to have a negative CT scan (P<0.0001).
CONCLUSION
Our data suggests that pyuria is a significant risk factor for a positive renal CT scan in both men and women. Males with unilateral
flank pain, hematuria and/or pyuria have a statistically significant risk for a positive renal CT scan due to nephro-ureteral
obstruction. Conversely, women with non-lateralizing abdominal or back pain have a statistically significant likelihood of negative
renal CT scan.
CLINICAL RELEVANCE/APPLICATION
Clinical predictors for positive renal CT scans would aid clinicians to more selectively order a renal CT scan minimizing radiation risk
to those that have a low likelihood of a positive result.
ER221-SDTUA4
Image Quality and Dose Reduction of CT Pulmonary Angiogram with 100 kVp and Iterative
Reconstruction to Detect Pulmonary Embolism in Emergency Room Patients
Station #4
Awards
Trainee Research Prize - Resident
Participants
Edward Kuoy, MD, Orange, CA (Presenter) Nothing to Disclose
Jeanie C. Zhang, MD, Orange, CA (Abstract Co-Author) Nothing to Disclose
Phillip Reich, MD, Orange, CA (Abstract Co-Author) Nothing to Disclose
Thangavijayan Bosemani, MBBS, MD, Orange, CA (Abstract Co-Author) Nothing to Disclose
Pablo J. Abbona, MD, Orange, CA (Abstract Co-Author) Nothing to Disclose
Mayil S. Krishnam, MBBS, MRCP, Orange, CA (Abstract Co-Author) Nothing to Disclose
PURPOSE
To assess image quality (IQ) and dose savings of CTPA for detecting pulmonary embolism (PE) in patients with 100kVp and iterative
reconstruction(IR) and to compare results with 120kVp and filtered back projection(FBP).
METHOD AND MATERIALS
CTPA performed on 256-slice scanner for 96 consecutive ER patients with suspected PE using 100kVp protocol with adaptive IR
(iDose3) (Group A), and 28 consecutive patients previously imaged for PE with 120kVp and FBP (Group B), stratified by BMI of 25,
were evaluated for dose length product (DLP), volume CT dose index (CTDIv) and effective dose(ED). Arterial contrast density
(Hounsfield Units,HU), contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) of 27 pulmonary artery(PA) segments were
calculated per patient. Two experienced radiologists independently assessed PA segments for IQ, noise, motion artifacts (MA) and
PE.
RESULTS
The median CTDIv in Group A vs B with BMI<25: 6(IQR 5-7) and 10(IQR 9-13) mGy, respectively, and BMI>25: 9(IQR 7-13) and
17(IQR 13-20) mGy, respectively. Median DLP in Group A vs B with BMI<25: 227(IQR 178-283) and 366(IQR 303-486) mGy•cm,
respectively, and BMI>25: 320(IQR 271-448) and 685(IQR 520-824) mGy•cm, respectively. ED in Group A vs B with BMI<25: 3(IQR
2-4) & 5(IQR 4-7) mSv, respectively (40% reduction), and BMI>25: 4(IQR 4-6) & 10(IQR 7-12) mSv, respectively (60% reduction).
CNR and SNR were lower in Group A than B across BMI (p<0.01). Median arterial HU in Group A vs B with BMI<25: 438(IQR 320-519)
& 310(IQR 249-451) HU, respectively, and BMI>25: 359(IQR 301-447) & 285(IQR 230-348) HU, respectively (both p<0.01). Overall
IQ was statistically better in Group A than B with BMI<25, but vice versa for BMI>25 (p<0.01) with good inter-observer agreement
(K>0.6). Minimal subjective noise without affecting diagnostic contents was more in Group A than B across BMI (p<0.01, K>0.6).
There was no difference in MA between groups (p>0.05, moderate K>0.5). Acute segmental and subsegmental PEs (3) and findings
of pulmonary infarcts, nodules and adenopathy were noted in Group A.
CONCLUSION
CTPA with 100kVp and IR results in significant dose reduction and provides improved arterial attenuation with sufficient CNR and
SNR to reliably detect PE in patients with BMI<25.
CLINICAL RELEVANCE/APPLICATION
CTPA with 100kVp and IR can be employed in patients with BMI<25 to achieve significant dose reduction, while also preserving
diagnostic ability for assessment of PE.
ER178-EDTUA6
Blunt Traumatic Vascular Injuries of the Neck in the ED: What the Radiologist Must Know
Station #6
Awards
Identified for RadioGraphics
Participants
Elizabeth George, MD, Boston, MA (Presenter) Nothing to Disclose
Ashish R. Khandelwal, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christopher A. Potter, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
Srinivasan Mukundan, MD, PhD, Boston, MA (Abstract Co-Author) Institutional research support, Siemens AG Institutional research
support, Toshiba Corporation Consultant, Toshiba Corporation
Bharti Khurana, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Diego B. Nunez JR, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1. Blunt trauma to the neck is associated with distinct patterns of vascular injuries. These include intramural hematoma, dissection,
pseudoaneurysm, occlusion, transection and fistula.2. The mechanism of trauma, associated fractures and soft tissue injuries can
be indicative of the likelihood and nature of vascular injury.3. Increased use of screening CTA in high-risk trauma patients has
resulted in increased detection of these injuries. It is essential that radiologists are cognizant of the evidence for the screening
criteria for CTA and understand the imaging features, grading, and management of such vascular injuries.
TABLE OF CONTENTS/OUTLINE
1. Evidence for screening criteria for the initial evaluation of patients with suspected cerebrovascular injury.2. Systematic approach
to CTA interpretation in trauma patients.3. Imaging features of vascular injuries of the neck, including the vertebral and carotid
arterial system and the grades of blunt cerebrovascular injury.4. Review the mechanism of injury by analyzing the
associated fractures and soft tissue injuries. The basic mechanisms, such as shearing from flexion/extension/rotational injury and
direct trauma from fracture fragments will be discussed.5. Describe current management strategies, specifically anticoagulation and
the limited indications for intervention.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
Bharti Khurana, MD - 2014 Honored Educator
ERS-TUB
Emergency Radiology Tuesday Poster Discussions
Tuesday, Nov. 29 12:45PM - 1:15PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Jamlik-Omari Johnson, MD, Atlanta, GA (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University Press
Martin L. Gunn, MBChB, Seattle, WA (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University Press;
Spouse, Consultant, Reed Elsevier; Spouse, Consultant, athenahealth, Inc; ;
Sub-Events
ER223-SDTUB1
Perisiplenic Hematoma Volume Calculation with a New Formula Confirmed with Semi-Automated
Method
Station #1
Participants
Uygar Teomete, MD, Coral Gables, FL (Presenter) Nothing to Disclose
Tuncer Ergin, MD, Ankara, Turkey (Abstract Co-Author) Nothing to Disclose
Ozgur Dandin, MD, Bursa, Turkey (Abstract Co-Author) Nothing to Disclose
Onur Osman, PhD, Istanbul, Turkey (Abstract Co-Author) Nothing to Disclose
Ferhat Cuce, MD, PhD, Van, Turkey (Abstract Co-Author) Nothing to Disclose
Gokalp Tulum, Istanbul, Turkey (Abstract Co-Author) Nothing to Disclose
Adlan Olsun, Istanbul, Turkey (Abstract Co-Author) Nothing to Disclose
PURPOSE
The correct calculation of intraperitoneal hematoma is vital for the management of patients who have trauma. Our aim is to present
a new formula for calculating perisplenic hematoma due to abdominal trauma comparing to the conventional method.
METHOD AND MATERIALS
Data of the patients who had traumatic spleen injuries were evaluated from the database of trauma registry. Randomly selected 25
CT scans from 25 patients with traumatic perisplenic hematomas were studied. We developed a semi-automated system calculating
the perisplenic hematoma volumes in trauma patients utilized as the reference standard. By two radiologists, the calculations were
performed by using conventional formula, trilinear formula, direct method and semiautomatic computer-aided method. Finally, the
results were compared. Total volume (spleen+ hematoma) was provided by using the W1T1L1/2 formula in the conventional
method. The spleen volume was obtained as 0.36(W2T2L2)+28. The total volume was provided as total volume minus spleen
volume. We proposed trilinear approximation functions as total volume=13.96W1-3.20T1-0.44L1-0.067W1T10.13W1L1+0.0417T1L1+9.66x10-4W1T1L1, spleen volume==6.055W2+1.75T2-2.76L2-0.119W2T20.0154W2L2+0.0255T2L2+8.82x10-4W2T2L2. The hematoma volume was provided by the subtracting of spleen volume from total
volume. With direct method, the hematoma volume was calculated as hematoma volume=3.713W1+5.834W20.606T1+0.503T2+1.52L1-4.257L2+0.016W1T1-0.128W2T2
-0.0691W1L1+0.015W2L2+0.006T1L1+0.0326T2L2+5.51 x104W1T1L1-4.89x10-4W2T2L2 where W,T, L are width, thickness and length.All co-efficient were obtained by least squares method
which minimize the error.
RESULTS
The root mean square error of hematoma volume for, the conventional method, trilinear and direct method were 78.54, 67.60 and
24.07 mL, respectively.
CONCLUSION
The volume of perisplenic hematoma calculation was feasible for all cases. Our new formula created with direct method had high
accuracy rate comparing the conventional method. This new formula considered to has an important role in the management of
patients who have perisplenic hematoma due to trauma.
CLINICAL RELEVANCE/APPLICATION
The correct and rapid calculation of perisplenic hematoma volume with our new formula and semiautomatic methods will help to
clinicians by affecting the management and outcome of the patients who have abdominal trauma.
ER224-SDTUB2
Perinephric Fat Stranding on Abdominal CT in Adult Emergency Department Patients: What Are The
Clinical Implications?
Station #2
Participants
Erin N. Gomez, MD, Columbia, MD (Abstract Co-Author) Nothing to Disclose
Susan Lin, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Elliot K. Fishman, MD, Baltimore, MD (Abstract Co-Author) Institutional Grant support, Siemens AG; Institutional Grant support,
General Electric Company;
Linda Regan, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Amit Pahwa, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Pamela T. Johnson, MD, Baltimore, MD (Presenter) Consultant, National Decision Support Company
PURPOSE
Perinephric fat stranding (PFS) is a common finding on abdominal CT. Practitioners have voiced uncertainty regarding the clinical
significance of patients with PFS on CT and whether it is an indicator of urinary tract infection (UTI). The purpose of this study is
to determine the frequency of UTI and define an evidence-based management algorithm for adult emergency department patients
with PFS on CT.
METHOD AND MATERIALS
CT reports of adult patients imaged in the ED were retrospectively searched to identify “perinephric stranding” in the dictated
report. Medical records of 166 subjects imaged between 2013 and 2015 were reviewed for clinical presentation, laboratory and
culture data, CT findings, medical diagnosis and management.Criteria for clinical diagnoses were defined as follows: Uncomplicated
cystitis: asymptomatic pyuria UTI: symptomatic pyuria Pyelonephritis: symptomatic pyuria + fever OR flank pain elevated WBC +
fever + flank pain Statistical analysis was performed using Microsoft Excel and Stata version 14.
RESULTS
Preliminary data includes 93 male and 73 female subjects with average age of 53 years (range 20-88 years).The most common
additional CT finding reported in subjects with PFS was obstructing stone (72/166, 43%). These subjects were removed from
further evaluation. Of the 94 patients without an obstructing stone, 17% (16/94) met criteria for UTI and 12% (11/94) met criteria
for pyelonephritis. Of the 91 patients without an obstructing stone who had urinalysis, 70% (64/91) had pyruia, but 52% (47/91)
had asymptomatic pyuria. Additional analyses of the imaging and clinical findings for the entire cohort of 300 subjects will be used
to generate a management algorithm defining which patients with PFS should be treated for urinary tract infection.
CONCLUSION
Most adult emergency department patients in this cohort with perinephric stranding on abdominal CT had pyuria, but it
was asymptomatic in the majority of cases. Clinical criteria for UTI and pyelonephritis were met in < 30% and should be heavily
weighted in management decision making.
CLINICAL RELEVANCE/APPLICATION
Practitioners and radiologists must recognize that perinephric fat stranding, even in patients with pyuria, does not necessarity
indicate the presence of a clinically significant urinary tract infection. Evidence based management algorithms are warranted to
define which patients require treatment.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Pamela T. Johnson, MD - 2016 Honored Educator
Elliot K. Fishman, MD - 2012 Honored Educator
Elliot K. Fishman, MD - 2014 Honored Educator
Elliot K. Fishman, MD - 2016 Honored Educator
ER225-SDTUB3
Non-contrast MDCT for Ureteral Calculi and Alternative Diagnoses: Yield in Adult Women versus in
Adult Men
Station #3
Awards
Student Travel Stipend Award
Participants
Parisa Fani, MD, Hamilton, ON (Presenter) Nothing to Disclose
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Sandra Monteiro, PhD, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
PURPOSE
To determine the yield of non-contrast CT(NCCT) for the diagnosis of ureteral calculi and alternative diagnoses in adult men versus
adult women presenting with suspected renal colic to the emergency department (ED) of a teaching hospital.
METHOD AND MATERIALS
Our IRB-approved a retrospective review of the non-contrast CT scans of the abdomen and pelvis (APNCCT) performed on adult
patients (18 years and older) presenting to a single emergency department with acute flank pain over a 25-month period. Patients
with known obstructive ureteral calculi, or with known urinary tract infection, malignancy, or trauma, prior to CT, were all excluded.
We compared the prevalence of ureteral calculi and alternative diagnoses between the men and the women, based on review of the
images. P values and Confidence Intervals (CI) were determined using the chi-square test.
RESULTS
One attending radiologist and one radiology resident randomly selected (using a number generator) and reviewed 400 scans from a
total of 1097 APNCCT examinations performed from October 1, 2011, to October 30, 2013, at our institution (representing
approximately 1/3 of the examinations). The mean patient age was 55.2 years, with a range of 19 to 90 years. This included 170
women (mean age 56.8 years), and 230 men (mean age 54.2 years). Ureteral calculi were observed in 42.5% of all patients,
including in 111 men (48%) and 59 women (34.7%). The prevalence of ureteral calculi in men was significantly higher than in
women (p<0.01, Confidence Level of 95%, and CI of 13.3). Alternative diagnoses were demonstrated on APNCCT in 12.5% of
patients, including 23 in men (5.7%) and 27 in women (6.7%). Alternative diagnoses in women included ovarian cyst (n=1), ovarian
torsion (n=1), and degeneration of a uterine fibroid (n=1).There was no statistically significant difference in the overall prevalence
of alternative diagnoses between men and women (p>0.2).
CONCLUSION
Based on our single-institution retrospective review of a subset of adult patients, the likelihood of a ureteral calculus being present
Based on our single-institution retrospective review of a subset of adult patients, the likelihood of a ureteral calculus being present
on APNCCT performed for suspected renal colic was significantly higher in men compared with in women.
CLINICAL RELEVANCE/APPLICATION
APNCCT had a lower yield in women presenting to a single teaching hospital’s ED with suspected renal colic, compared with in men,
although the alternative diagnosis rate was not statistically different.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
ER227-SDTUB5
The Feasibility of Dual Energy Computed Tomography in Cardiac Contusion Imaging
Station #5
Awards
Student Travel Stipend Award
Participants
Recep Sade, MD, Erzurum, Turkey (Presenter) Nothing to Disclose
Mecit Kantarci, MD, PhD, Erzurum, Turkey (Abstract Co-Author) Nothing to Disclose
Hayri Ogul, Erzurum, Turkey (Abstract Co-Author) Nothing to Disclose
Ummugulsum Bayraktutan, Erzurum, Turkey (Abstract Co-Author) Nothing to Disclose
Mustafa Uzkeser, Erzurum, Turkey (Abstract Co-Author) Nothing to Disclose
Sahin Aslan, Erzurum, Turkey (Abstract Co-Author) Nothing to Disclose
Enbiya Aksakal, Erzurum, Turkey (Abstract Co-Author) Nothing to Disclose
Necip Becit, Erzurum, Turkey (Abstract Co-Author) Nothing to Disclose
PURPOSE
The purpose of this study is the evaluation of the efficiency and feasibility of DECT use in the diagnosis of cardiac contusion with
the mildest blunt cardiac injury (BCI)
METHOD AND MATERIALS
From February 2014 to September 2015, a total of 17 consecutive patients (10 men and 7 women; median age 51 years [20-78])
were enrolled in the study. DECT was performed within 48 hours of the trauma and a subsequent control DECT was performed a
little less than one year after the first examination. All examinations were analyzed on iodine map images by two experienced
radiologists. Interobserver agreement was calculated.
RESULTS
The contusion areas were amorphous, with considerable variation in their size, shape, and density. Contusions were primarily
located in the left ventricle’s free wall, the ventricular septum, and the apex, respectively. In 10 patients, contusion areas
disappeared upon control examination. In four patients, the contusion areas decreased but were still present in the control
examination. The interobserver agreements were almost perfect with respect to the presence of cardiac contusion, the anatomic
location of contusions, and the contusion areas (kappa values of 1.0, 1.0, and 0.9, respectively).
CONCLUSION
DECT can show cardiac contusion and can be usable and feasible for the diagnosis and follow-up study in BCIs. DECT is a very
new, user-independent and valuable imaging technique
CLINICAL RELEVANCE/APPLICATION
DECT can show cardiac contusion and can be usable and feasible for the diagnosis and follow-up study in BCIs.
SSJ06
Emergency Radiology (Dual Energy CT)
Tuesday, Nov. 29 3:00PM - 4:00PM Room: N227B
CT
ER
AMA PRA Category 1 Credit ™: 1.00
ARRT Category A+ Credit: 1.00
FDA
Discussions may include off-label uses.
Participants
Martin L. Gunn, MBChB, Seattle, WA (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University Press;
Spouse, Consultant, Reed Elsevier; Spouse, Consultant, athenahealth, Inc; ;
Aaron D. Sodickson, MD, PhD, Boston, MA (Moderator) Research Grant, Siemens AG; Consultant, Bayer AG
Sub-Events
SSJ06-01
Role of a Novel Material Decomposition Algorithm in Detection of Acute Infarction
Tuesday, Nov. 29 3:00PM - 3:10PM Room: N227B
Awards
Student Travel Stipend Award
Participants
Mohammed F. Mohammed, MBBS, Vancouver, BC (Presenter) Nothing to Disclose
Faisal Khosa, FFR(RCSI), FRCPC, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
David J. Ferguson, MBBCh, FRCR, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Reem S. Zakzouk, MD, Riyadh, Saudi Arabia (Abstract Co-Author) Nothing to Disclose
Olivia Marais, BEng, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Tim O'Connell, MD, Meng, Vancouver, BC (Abstract Co-Author) President, Resolve Radiologic Ltd Speake, Siemens AG
Heiko Schmiedeskamp, PhD, Malvern, PA (Abstract Co-Author) Employee, Siemens AG
Bernhard Krauss, PhD, Forchheim, Germany (Abstract Co-Author) Employee, Siemens AG
Michael E. O'Keeffe, MBBCh, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
Axel C. Rohr, MD, Kiel, Germany (Abstract Co-Author) Nothing to Disclose
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
PURPOSE
The role of the non-enhanced CT in the setting of acute stroke has always been that of a quick rule-out tool to exclude
haemorrhage, with low accuracy in detecting acute infarcts and reported accuracy of 61%.DECT with material decomposition (MD)
has shown promise in post post intra-arterial revascularization. We present a novel material decomposition algorithm which improves
detection of acute infarcts on non-enhanced DECT by subtracting grey and white matter, accentuating cytotoxic edema.
METHOD AND MATERIALS
A retrospective study was conducted on consecutive patients that presented to the Emergency Department (ED) at our institution
between January, 2016 and March, 2016, with clinical suspicion of stroke within the last 4 hours and underwent non-enhanced Dual
Energy CT (DECT) of the head (N = 26). Informed consent was waived for this retrospective study. Follow up CT, MRI or catheter
angiography served as the reference standard.DECT images were acquired on a 3rd generation Dual Source DECT scanner at 100 kV
and 150 kV. Material decomposition (MD) images were reconstructed on the Syngo.Via platform, allowing subtraction of Grey Matter
(GM) from White Matter (WM).The images were reviewed by 2 neuroradiology fellowship trained radiologists, blinded to outcomes,
and independently rated concordance of 120 kV images and MD images with the reference standard.
RESULTS
15 of 26(57.7 %) patients presented with confirmed acute infarcts. 120 kV images had a sensitivity, specificity, PPV and NPV of
80% (95% CI = 51.9%-95.7%), 72.7% (95% CI = 39%-94%), 80% (95% CI = 51.9%-95.7%) and 72.73% (95% CI 51.91%-95.67%)
respectively.MD images provided greater sensitivity, specificity, PPV and NPV of 93.33% (95% CI = 68.05%-99.83%), 100% (95%
CI = 71.51%-100%), 100% (95% CI = 76.84%-100%) and 91.67% (95% CI = 61.52%-99.79%) respectively when assessed in
conjunction with the conventional images. MD images improved confidence by 30.77% and were found useful in 85% of studies.
CONCLUSION
Head DECT with MD images reconstructed to subtract GM from WM improve the PPV and NPV of non-enhanced CT in the setting of
acute infarction, up to 100% and 91.67% respectively while boosting confidence by 30.77% when read in conjugation with
conventional 120 kV blended images.
CLINICAL RELEVANCE/APPLICATION
MD images provide a novel tool in assessment of acute stroke on the non-enhanced CT of the head.
SSJ06-02
Advanced Virtual Monoenergetic Imaging in Low-dose Dual-energy Unenhanced Head CT: Evaluation
of Image Quality, Delineation of Intracranial Hemorrhage and Radiation Exposure
Tuesday, Nov. 29 3:10PM - 3:20PM Room: N227B
Participants
Christoph Polkowski, MD, Frankfurt, Germany (Presenter) Nothing to Disclose
Moritz Kaup, Frankfurt, Germany (Abstract Co-Author) Nothing to Disclose
Doris Leithner, MD, Frankfurt am Main, Germany (Abstract Co-Author) Nothing to Disclose
Moritz H. Albrecht, MD, Charleston, SC (Abstract Co-Author) Nothing to Disclose
Julian L. Wichmann, MD, Charleston, SC (Abstract Co-Author) Nothing to Disclose
Claudia Frellesen, Frankfurt, Germany (Abstract Co-Author) Nothing to Disclose
Thomas J. Vogl, MD, PhD, Frankfurt, Germany (Abstract Co-Author) Nothing to Disclose
Jan-Erik Scholtz, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate quantitative image quality parameters of advanced monoenergetic imaging algorithm (VMI+) in low-tube-current dualenergy unenhanced head CT and diagnostic accuracy for the detection of intracranial hemorrhage (ICH) compared to standard 120kVp.
METHOD AND MATERIALS
In this retrospective IRB-approved study with a waiver for written consent, 94 patients underwent unenhanced head CT to detect
or rule out ICH on a third-generation dual-source CT. Standard 120-kVp CT (n=44; CTDIvol, 39.5±0.4mGy) was compared with lowtube-current dual-energy CT (DECT, 80/140-kVp; n=50, CTDIvol, 23.7±2.7mGy) with post-processing VMI+ algorithm. Gray matter
(GM) signal-to-noise ratio (SNR), white matter (WM) SNR, GM-WM contrast-to-noise ratio (CNR), ICH-GM CNR, and posterior fossa
artifact index (PFAI) were calculated. Measurements in VMI+ were performed at energy levels from 40-190-keV with 5-keV
increment. Image series with highest GM-WM CNR and ICH-GM CNR in VMI+ were reconstructed for subjective image analysis. Three
radiologists performed diagnostic evaluation for ICH for both protocols, “gold standard” for ICH evaluation was the medical report.
RESULTS
GM SNR (18.5±3.5 vs. 11.7±1.9) and WM SNR (15.5±2.5 vs. 8.2±1.2) were significantly better at 110-keV VMI+ compared to 120kVp. GM-WM CNR was highest at 40-keV with no significant difference compared to 120-kVp (2.3±0.6 vs 2.2±0.6). ICH-GM CNR
was significantly higher in 140-keV compared to 120-kVp (7.7±3.7 vs. 3.4±2.7, p<0.001). 110-keV VMI+ showed slightly, but not
significantly lower values for ICH-GM CNR compared to 140-keV. PFAI was significantly lower at 110-keV compared to 120-kVp
(2.1±0.3 vs 4.9±0.5HU, p<0.001). All examinations were sufficient for evaluation of ICH in 120-kVp and 110-keV VMI+ with no nondiagnostic cases. 40-keV VMI+ with best values for GM-WM CNR was inadequate for evaluation of ICH non-diagnostic to poor
ratings. Diagnostic accuracy for detection of ICH was excellent in both 110-keV VMI+ (n=14) and 120-kVp (n=11) with no
significant difference and almost perfect interobserver agreement (ICC, 0.88).
CONCLUSION
110-keV VMI+ low-dose dual-energy unenhanced head CT provides increased CNR between ICH and GM with excellent diagnostic
accuracy of ICH while radiation dose is significantly reduced compared to 120-kVp.
CLINICAL RELEVANCE/APPLICATION
110-keV VMI+ allows low-dose unenhanced head dual-energy CT with superior ICH to GM contrast compared to 120-kVp.
SSJ06-03
The Dual Energy Hot Gallbladder and Rim Signs: Evaluation of DECT Iodine Content in Acute
Cholecystitis
Tuesday, Nov. 29 3:20PM - 3:30PM Room: N227B
Participants
Jennifer W. Uyeda, MD, Boston, MA (Presenter) Nothing to Disclose
Tony W. Trinh, MD, Salt Lake City, UT (Abstract Co-Author) Nothing to Disclose
Jeremy R. Wortman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Aaron D. Sodickson, MD, PhD, Boston, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bayer AG
PURPOSE
ED patients often undergo abdominal CT as the initial imaging examination for nonspecific abdominal pain. The purpose of this study
was to assess differences in the dual energy CT (DECT) iodine content of pericholecystic hepatic parenchyma and of the
gallbladder wall in acute cholecystitis compared with controls.
METHOD AND MATERIALS
17 patients (10M, 7F) who underwent cholecystectomy with pathology confirmed acute cholecystitis were included in this IRB
approved, HIPAA compliant study. All patients underwent contrast enhanced DECT on a dual-source 128x2 slice scanner (Siemens
FLASH) with either 80/Sn140 or 100/Sn140 kV pairs depending on patient size. Within 3 mm reconstructed slices, the following
regions of interest (ROI) were placed on iodine overlay images to measure dual energy iodine concentration derived from three
material decomposition: 1 cm2 hepatic parenchyma around the gallbladder fossa, 1 cm2 hepatic parenchyma in a different hepatic
segment, and 5 mm2 on the gallbladder wall. These values were normalized to the iodine concentration in a main portal vein ROI to
calculate a normalized iodine concentration. Measurements were compared to 20 control patients who underwent DECT without
gallbladder pathology. Normalized iodine content in each of the three ROI locations was compared between the two groups using a
t-test.
RESULTS
There was no significant difference between cholecystitis and control patients in normalized iodine content within the hepatic
parenchyma remote from the gallbladder fossa (p=0.72). However, compared with controls, acute cholecystitis patients
demonstrated higher normalized iodine concentration values within the hepatic parenchyma of the gallbladder fossa and within the
gallbladder wall (p<0.001 for both comparisons).
CONCLUSION
DECT can detect increased pericholecystic hepatic parenchymal and gallbladder wall iodine content in patients with acute
cholecystitis. Further work is needed to determine appropriate threshold values of iodine content that may aid in the diagnosis of
acute cholecystitis.
CLINICAL RELEVANCE/APPLICATION
Cholecystitis patients demonstrate increased iodine content within the gallbladder wall and pericholecystic hepatic parenchyma by
Dual Energy CT. This may prove helpful in improving CT diagnosis of acute cholecystitis.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Aaron D. Sodickson, MD, PhD - 2014 Honored Educator
SSJ06-04
Detection of Isodense Gallstones using Monoenergetic Dual Energy CT: Evaluation of Stone Size
Thresholds
Tuesday, Nov. 29 3:30PM - 3:40PM Room: N227B
Awards
Student Travel Stipend Award
Participants
Jun Wang, MD, Vancouver, BC (Presenter) Nothing to Disclose
Yuhao Wu, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Faisal Khosa, FFR(RCSI), FRCPC, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
Tim O'Connell, MD, Meng, Vancouver, BC (Abstract Co-Author) President, Resolve Radiologic Ltd Speake, Siemens AG
Luck J. Louis, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
PURPOSE
To establish the size threshold for identifying previously undetectable isodense gallstones using monoenergeticDual Energy CT
(DECT)
METHOD AND MATERIALS
A retrospective review was performed on 3464 consecutive DECT scans of the abdomen acquired using a dual-source 128-slice
CT (Definition FLASH; Siemens Healthcare, Forcheim, Germany) between the dates January 2013-June 2015. These patients were
cross-referenced using our Picture Archival and Communication System (Impax; Agfa Healthcare, Mortsel, Belgium) to select those
who had undergone an ultrasound of the gallbladder, MRCP or ERCP within six weeks of the DECT scan. Inclusion criteria were
patients who had a DECT scan that did not demonstrate cholelithiasis, but a subsequent investigation (US, MRCP, or ERCP) that did
demonstrate gallstones. Monoenergetic reconstructions were then performed at 40 keV and 190 keV using the DECT raw data from
these patients with gallstone disease that was missed on conventional CT. Overall sensitivity for using monoenergetic
reconstructions to detect isodense gallstones was calculated. Attenuation measurements were made using 1cm2 regions of interest
in the gallbladder as well as the gallstones at 190 kev and 40 kev.
RESULTS
Monoenergetic reconstructions at 40 keV and 190 keV were performed on a total of 31 patients who fit the inclusion criteria and
reviewed for the presence of gallstones. Eight patients had identifiable gallstones. Using a size threshold of <10mm, the sensitivity
of monoenergetic imaging to detect previously missed isodense gallstones was 25.8%. When a threshold size of >10mm was used,
the sensitivity of monoenergetic reconstructions to identify previously missed isodense gallstones increased to 88.9%. ROI
measurements of the gallbladder at 190 keV (mean attenuation 7.77±5.80 HU) were significantly different from gallstone ROI
attenuation (44.9±14.5 HU, p<0.001.). ROI measurements of the gallstones and gallbladder at 40 keV did not differ significantly
(3.70±47.6 HU vs. 23.9±22.5 HU).
CONCLUSION
Monoenergetic dual energy CT acquisitions of the abdomen at 190 keV can identify gallstones that appear iso-dense on
conventional CT with a sensitivity of 88.9% at a size threshold of 10mm.
CLINICAL RELEVANCE/APPLICATION
The use of monoenergetic dual energy CT imaging allows identification of previously undetectable isodense gallstones at a size
threshold of 10mm and improves the sensitivity of CT in the investigation of gallstone disease.
SSJ06-05
Improved Signal and Image Quality at the Cervicothoracic Junction Utilizing Third Generation Dual
Source CT Technology
Tuesday, Nov. 29 3:40PM - 3:50PM Room: N227B
Participants
Sudha R. Muly, MBBS, FRCR, Vancouver, BC (Presenter) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
Luck J. Louis, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Tim O'Connell, MD, Meng, Vancouver, BC (Abstract Co-Author) President, Resolve Radiologic Ltd Speake, Siemens AG
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
Faisal Khosa, FFR(RCSI), FRCPC, Atlanta, GA (Abstract Co-Author) Nothing to Disclose
Nizar Bhulani, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
Heiko Schmiedeskamp, PhD, Malvern, PA (Abstract Co-Author) Employee, Siemens AG
Bernhard Krauss, PhD, Forchheim, Germany (Abstract Co-Author) Employee, Siemens AG
PURPOSE
Evaluation of the cervicothoracic junction is frequently limited by beam hardening and scatter radiation artifacts. Previous studies
have shown the usage of dual energy CT (DECT) to reduce this artifact and improve image quality utilizing Monoenergetic algorithm
(Mono +). The purpose of our study is to determine if the artifacts at the cervicothoracic junction can be further reduced and
image quality can be improved using the third generation dual source CT scanner.
METHOD AND MATERIALS
In this retrospective study, 20 consecutive trauma patients who underwent cervical spine DECT using a third generation dual
source CT scanner (Definition FORCE, Siemens Health care, Germany) between February to April 2016. The DECT data sets (100
and 150 sn kv) were reconstructed using Mono + algorithm at energy levels ranging from 70 to 190 Kev. Attenuation of the spinal
cord at each energy level was compared to the values on the simulated 120kv scan images obtained from the mixed DECT data
sets. Subjective analysis of image quality was conducted on a semi-objective 4 point scoring scheme by 2 radiologists.
RESULTS
Our data demonstrates reduction of noise on the images of 110-130keV range, when compared to the mixed data set images of 120
kvp. We found that the optimal energy level for reduction of artifacts and noise is around 130Kev. The attenuation values of the
spinal cord at C2 and at the cervico-thoracic level are most stable between 110 and 130Kev reconstruction. Semi-quantitative
analysis showed improvement of visualization of the soft tissue structures at 130Kev (p value of 0.002). The diagnostic confidence
of the reader in identifying bone and soft tissue abnormality at the cervico-thoracic junction was significantly increased at the
higher energy levels 130 Kev (p value 0.001 compared to 70 Kev
CONCLUSION
DECT assessment using Mono + algorithm shows significantly reduced artifact at the cervicothoracic junction with increased reader
confidence of assessing structures. Our study demonstrates that reconstruction of images on mono+ at energy levels closer to 130
Kev provide the best image quality with reduced beam hardening artifact reduction and noise levels.
CLINICAL RELEVANCE/APPLICATION
Due to its superior image quality, third generation dual source CT images using Mono + algorithm can provide a significant benefit by
reducing artifact and improving assessment of cervicothoracic junction without increasing the radiation dose.
RC405
Emergency Neuroradiology (An Interactive Session)
Tuesday, Nov. 29 4:30PM - 6:00PM Room: S406B
NR
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
FDA
Discussions may include off-label uses.
Participants
Michael H. Lev, MD, Boston, MA (Moderator) Consulant, General Electric Company; Institutional Research Support, General Electric
Company; Stockholder, General Electric Company; Consultant, MedyMatch Technology, Ltd; Consultant, Takeda Pharmaceutical
Company Limited; Consultant, D-Pharm Ltd
Sub-Events
RC405A
Found Down
Participants
John L. Go, MD, Los Angeles, CA (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Choose the best imaging for each patient. 2) Discuss the Differential Dx for “found down”. 3) Develop a “checklist” for imaging to
identify significant findings. 4) Recognize imaging findings that will acutely change patient management.
ABSTRACT
The "found down" patient is unable to provide a history - and often unable to cooperate for a clinical exam. Up to 1/3 are
mistriaged and require consultation to another service. Common "medical" conditions include: Hypoxia/Hypotension, Subarachnoid
Hemorrhage Hypoglycemia/Hyperglycemia Drugs and Intoxicants Post-ictalCommon "surgical" conditions include: Extraaxial and
Intraaxial Hemorrhage Hydrocephalus Herniation (e.g. from a neoplasm) Large Vessel Occlusion and InfarctionA systematic analysis
using a "checklist" can help identify life-threatening lesions and may be life-saving.
RC405B
Head & Neck Emergencies
Participants
Jenny K. Hoang, MBBS, Durham, NC (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Develop a systematic approach to evaluating patients with head and neck infections. 2) Recognize head and neck emergencies
that result in morbidity and mortality presenting as fever, trauma, difficulty breathing, and bleeding.
RC405C
Emergency Neuroradiology: Don't Miss these Lesions!
Participants
Michael H. Lev, MD, Boston, MA (Presenter) Consulant, General Electric Company; Institutional Research Support, General Electric
Company; Stockholder, General Electric Company; Consultant, MedyMatch Technology, Ltd; Consultant, Takeda Pharmaceutical
Company Limited; Consultant, D-Pharm Ltd
LEARNING OBJECTIVES
1) Summarize the role of imaging in the assessment of acute neurologic emergencies. 2) Apply an evidence based approach to
devise effective and efficient neuroimaging algorithms. 3) Describe technological advances in CT and MRI as they relate to imaging
acute neuro-vascular and traumatic injuries to the brain. 4) Determine imaging predictors in outcome assessment of cerebral
hemorrhage and acute stroke.
ABSTRACT
RC408
Trauma Imaging Pitfalls
Tuesday, Nov. 29 4:30PM - 6:00PM Room: N228
GI
MK
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Sub-Events
RC408A
Abdomen (Solid Organs and Vessels)
Participants
Felipe Munera, MD, Miami, FL, ([email protected]​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1. Identify common pitfalls in interpretation of abdominal trauma CT studies - focus on solid organs and vascular structures. 2.
Optimize CT acquisition techniques to reduce likelihood of missing potentially significant injuries. 3. Develop a search pattern that
includes organs and structures where important lesions are commonly missed. 4. Describe strategies to improve detection of easily
missed injuries
RC408B
Diaphragm
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON, ([email protected] ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) To describe direct and indirect signs of blunt and penetrating diaphragmatic injury. 2) To highlight factors affecting detection of
diaphragmatic injury. 3) To discuss pitfalls in diagnosis of diaphragmatic injury.
ABSTRACT
The traumatic diaphragmatic injury is an uncommon entity. Blunt diaphragmatic injury is undiagnosed at initial presentation in 766%. Penetrating diaphragmatic injury can be occult in 7% of cases. Diaphragmatic injury does not resolve spontaneously and can
cause disastrous complications. The misinterpretation in patients with diaphragmatic injury may be caused by suboptimal technique,
failure to review portion of examination e.g. MPRs, or satisfaction of search error. Potential pitfalls in interpretation include
congenital diaphragmatic hernias and atraumatic defects simulating diaphragmatic injury.
RC408C
Bowel/Pelvis
Participants
Stephan W. Anderson, MD, Boston, MA (Presenter) Nothing to Disclose
RC408D
Extremities
Participants
O. C. West, MD, Houston, TX (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Find upper extremity injuries that are difficult detect on screening radiographs. 2) Employ search patterns that may improve
detection of easily missed injuries.
ABSTRACT
Summary of upper extremity pitfalls: Posterior shoulder dislocation; Supracondylar fracture (anterior humeral line); Monteggia
fracture-dislocation (radio-capitellar line); Proximal radius including vertical head fracture (external oblique view), impacted neck
fracture, flipped radial head fracture-dislocation, Galeazzi fracture-dislocation – beware the lateral radiograph.Imaging joints
requires 3 radiographic projections. The 3rd view varies: Axillary view of shoulder and External oblique of elbow. The wrist needs 4
views: PA, lateral, external oblique and “Scaphoid” view (ulnar deviated PA view).Words to live by: watch for the least obvious of
multiple injuries.
Active Handout:O. Clark West
http://abstract.rsna.org/uploads/2016/16000641/ACTIVE RC408D.pdf
ED004-W E
Emergency Radiology Wednesday Case of the Day
W ednesday, Nov. 30 7:00AM - 11:59PM Room: Case of Day, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Presenter) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
David Dreizin, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Manickam Kumaravel, MD, FRCR, Houston, TX (Abstract Co-Author) Nothing to Disclose
Constantine A. Raptis, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
David D. Bates, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Thomas Battey, Timonium, MD (Abstract Co-Author) Nothing to Disclose
Nicholas M. Beckmann, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
Sanjeev Bhalla, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1) Recognize key imaging findings on multimodality imaging of emergency/trauma patients. 2) Develop differential diagnosis based on
the clinical information and imaging findings. 3) Recommend appropriate management including image-guided interventions.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
RC508
Emergency Radiology Series: Contemporary Topics in Imaging of Trauma
W ednesday, Nov. 30 8:30AM - 12:00PM Room: S405AB
ER
AMA PRA Category 1 Credits ™: 3.50
ARRT Category A+ Credits: 4.00
Participants
Scott D. Steenburg, MD, Zionsville, IN, ([email protected] ​ ​ ) (Moderator) Nothing to Disclose
Clint W. Sliker, MD, Ellicott City, MD (Moderator) Nothing to Disclose
Bharti Khurana, MD, Boston, MA (Moderator) Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the role of radiology in the setting of mass casualty scenarios. 2) Discuss the current role of imaging in the
assessment of liver injuries. 3) Discuss the role of medical imaging in the setting of hip trauma. 4) Discuss the role of CT
angiography for the evaluation of suspected peripheral vascular injuries. 5) Assess and evaluate current trauma radiology research
and it's relevance to clinical practice.
Sub-Events
RC508-01
Disaster/Mass Victim Imaging
W ednesday, Nov. 30 8:30AM - 9:00AM Room: S405AB
Participants
Ferco H. Berger, MD, Toronto, ON, ([email protected]) (Presenter) Nothing to Disclose
Active Handout:Ferco H. Berger
http://abstract.rsna.org/uploads/2016/16000643/RC508 01 MCI - handout.pdf
LEARNING OBJECTIVES
1) Describe the setting of a mass casualty incident. 2) Develop participation of the radiology department in preparation for disaster
management plan activations. 3) Explain why simmulation is crucial and recommend strategies to increase effectiveness of
simulation drills.
ABSTRACT
In the setting of mass casualty incidents (MCI), hospitals need to divert from normal routine to delivering the best possible care to
the largest number of victims. This should be accomplished by activating an established hospital Disaster Management Plan (DMP),
known to all staff through prior training drills.Over the recent decades, imaging has increasingly been used to evaluate critically ill
patients. It can be used as well to increase the accuracy of triaging MCI victims, since over-triage and under-triage can severely
impact resource availability and mortality rates. This presentation emphasizes the importance of including the radiology department
in hospital preparations for an MCI, and highlights factors expected to influence performance during hospital DMP activation
including issues pertinent to effective simulation.
RC508-02
Damage Control Surgery: Significance of CT Imaging in the 24 Hour Window
W ednesday, Nov. 30 9:00AM - 9:10AM Room: S405AB
Awards
Student Travel Stipend Award
Participants
Armonde Baghdanian, MD, Boston, MA (Presenter) Nothing to Disclose
Arthur Baghdanian, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Tina Shiang, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jorge A. Soto, MD, Boston, MA (Abstract Co-Author) Royalties, Reed Elsevier
PURPOSE
To retrospectively investigate the imaging findings, diagnostic accuracy, and clinical significance of CT imaging within 24 hours of
Damage Control Surgery in abdominal trauma.
METHOD AND MATERIALS
This is a retrospective IRB approved and HIPAA compliant study. Informed consent was waived. All patients that sustained
abdominal trauma and underwent immediate damage control surgery upon presentation were included if they had a diagnostic CT
within 24 hours. From 3/2006-8/2013, 49 patients (46 male, 3 female; age range, 17-73 years) met our inclusion criteria. Two
radiologists blinded to original radiology reports retrospectively reviewed CT examinations and recorded acute findings in consensus.
A third investigator compared traumatic injuries from the original radiology reports, retrospective imaging reports, and original
operative notes to determine the incidence of injuries in our patient cohort. A CT examination was categorized as missing a
traumatic injury if the injury was identified on both retrospective imaging review and at surgery. In addition, an exploratory
laparotomy was categorized as missing a traumatic injury if it was diagnosed on retrospective imaging review. Finally, a missed
injury on either CT or surgery was categorized as clinically significant if it necessitated a repeat operation.
RESULTS
The etiology of trauma was blunt in 13/49 (26.5%) and penetrating in 36/49 (73.4%) patients. Overall incidence of injuries in our
patient cohort included: diaphragm 6/49 (12.2%), liver 23/49 (46.9%), spleen 11/49 (22.4%), pancreas 4/49 (8.2%), bowel 38/49
(77.6%), adrenal 4/49 (8.2%), kidney 18/49 (36.7%), ureter 5/49 (10.2%), bladder 4/49 (8.2%), osseous (fracture) 34/49 (69.4%),
and vascular 20/49 (40.8%). Significant CT findings were seen in 17/49 (34.7%) of which 6/17 were secondary to failed surgical
repairs. 8/17 were in surgically explored areas and 9/17 were in unexplored areas. 5/17 radiology reports missed clinically significant
findings found on follow up imaging or surgery.
CONCLUSION
Trauma patients that undergo Damage Control Surgery upon presentation have a broad spectrum of clinically significant injuries
that are not diagnosed at laparotomy and therefore benefit from diagnostic CT imaging in the first 24 hours.
CLINICAL RELEVANCE/APPLICATION
Knowledge of surgical approaches and potential surgical and imaging pitfalls can aid in detection of injuries on MDCT in patients that
undergo Damage Control Surgery.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jorge A. Soto, MD - 2013 Honored Educator
Jorge A. Soto, MD - 2014 Honored Educator
Jorge A. Soto, MD - 2015 Honored Educator
RC508-03
Measuring the Impact of Whole Body Computed Tomography (CT) on Emergency Department (ED)
Lenghth of Stay in Blunt Trauma
W ednesday, Nov. 30 9:10AM - 9:20AM Room: S405AB
Awards
Student Travel Stipend Award
Participants
Jessica Chan, MD, Salt Lake City, UT (Presenter) Nothing to Disclose
Marta E. Heilbrun, MD, Salt Lake City, UT (Abstract Co-Author) Nothing to Disclose
Christopher S. Johnson, Salt Lake City, UT (Abstract Co-Author) Nothing to Disclose
Tom H. Greene, Salt Lake City, UT (Abstract Co-Author) Nothing to Disclose
PURPOSE
Whole-body CT (WBCT) imaging has become commonplace in many emergency departments (ED) in the adult blunt trauma setting,
despite a growing body of research that has found no mortality or hospital length of stay (LOS) benefit for patients who received
WBCT. The purpose of this study was to assess the value that WBCT imaging contributes to ED work flow, in blunt trauma patients
by retrospectively comparing ED LOS between WBCT and selective CT imaging.
METHOD AND MATERIALS
This study is IRB approved. The Institutional Trauma Registry Database was cross-referenced with our radiology information system
database to identify adult patients who sustained blunt trauma between July 2011- June 2013, and received CT imaging. Propensity
score weighting was utilized to achieve balance in baseline covariates, including demographics, hemodynamic stability, Glasgow
coma scale, and socio-economic factors. We generated standardized differences between imaging groups both before and after
propensity-score weighting to assess the effectiveness of our model. A linear regression with log-transformed ED length of stay
was used to assess percent change in the geometric means between imaging strategies.
RESULTS
2,291 patients were identified meeting inclusion criteria, of which 333 (14.5%) underwent WBCT imaging. After propensity score
weighting, the arithmetic mean ED LOS was 55 ± 105 min and 83 ± 56 min for WBCT and selective CT patients respectively. Overall,
there was a 21.2% (95% CI 29.4%, 11.9%) reduction in the geometric mean of ED LOS (in minutes) for those receiving whole-body
scans compared to those receiving selective CT (p<0.001), after propensity score adjustment for baseline covariates. Without
adjustment, we found a 38.7% (95% CI 45.3%, 31.3%) reduction in the geometric mean of ED LOS (in minutes) for those receiving
WBCT compared to those receiving selective CT (p<0.001).
CONCLUSION
WBCT imaging was associated with a statistically and clinically significant reduction in ED LOS for blunt trauma patients.
CLINICAL RELEVANCE/APPLICATION
Our results suggest that WBCT in the blunt trauma setting significantly reduces ED length of stay, thus improving efficiency and
workflow within the ED, and leads to downstream health care cost savings.
RC508-04
The Role of Post Mortem CT in Determining Major Pathological Abnormalities Related to the Cause of
Death with Autopsy Comparison
W ednesday, Nov. 30 9:20AM - 9:30AM Room: S405AB
Participants
Yuichi Sugino, MD, Tsu, Japan (Presenter) Nothing to Disclose
Hajime Sakuma, MD, Tsu, Japan (Abstract Co-Author) Departmental Research Grant, Siemens AG; Departmental Research Grant,
Bayer AG; Departmental Research Grant, Guerbet SA; Departmental Research Grant, DAIICHI SANKYO Group; Departmental
Research Grant, FUJIFILM Holdings Corporation; Departmental Research Grant, Nihon Medi-Physics Co, Ltd
Atsuhiro Nakatsuka, MD, Tsu, Japan (Abstract Co-Author) Nothing to Disclose
PURPOSE
To assess the role of whole-body postmortem CT (PMCT) in determining major pathological abnormalities related to the cause of
death.
METHOD AND MATERIALS
From September 2012 to March 2016 PMCT was performed to investigate the causes of death in 507 cases. Among them, the
causes (e.g. bleeding, massive trauma, major aortic disease) in 241 cases (47.5%, 241/507) were established by PMCT and 94
cases (18.5%, 94/507) underwent autopsy because of unknown cause of death from clinical course. Fifty-five (58.5%, 55/94)
cases were in-hospital death, 17 (18.1%, 17/94) cases were out-of-hospital cardiac arrest (OHCA) and 22 (23.4%, 22/94) patients
were forensic cases. All cases were performed PMCT within 24 hours after death and two board-certified radiologists were
evaluated the detection of cause of death comparing autopsy.
RESULTS
Autopsy diagnosed the cause of death including acute heart failure (n=14, 14.9%, 14/94), malignancy (n=13, 13.8%, 13/94), liver
failure (n=8, 8.5%, 8/94), pneumonia (n=8, 8.5%, 8/94), trauma (n=7, 7.4%, 7/94), infection (n=5, 5.3%, 5/94), GI bleeding (n=4,
4.3%, 4/94), major vascular disease (n=2, 2.1%, 2/94), and others or unknown (n=26, 27.7%, 26/94). PMCT obtained the findings
of the suspected cause of death in 43 cases (45.7%, 43/94) including 27 of 55 (49.1%) in-hospital death cases, 7 of 17 (41.1%)
OHCA cases, and 9 of 22 (40.9%) forensic cases. There were no significant differences between PMCT and autopsy in detection of
the cause of death among in-hospital death cases, OHCA cases, and pre forensic cases. PMCT accurately diagnosed major
pathological abnormalities related to death significantly in pulmonary disorders [odds ratio (OR) = 54.5, P = 0.0016], malignancy
(OR=27.8, P =0.005), liver failure (OR=14.7, P =0.015), and trauma related findings (OR=12.7, P =0.04). There were no significant
differences between PMCT and autopsy in identification of cause of death in acute heart failure, major vascular disease, GI
bleeding, and infection.
CONCLUSION
PMCT could accurately detect the cause of death in pulmonary disorders, malignancies, liver failures, and trauma related findings.
CLINICAL RELEVANCE/APPLICATION
PMCT provides diagnostic information about pulmonary disorders, malignancies, liver failure, and trauma related findings.
RC508-05
Update on Imaging of Hepatic Injuries
W ednesday, Nov. 30 9:30AM - 10:00AM Room: S405AB
Participants
Stuart E. Mirvis, MD, Baltimore, MD (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under the main course title.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Stuart E. Mirvis, MD - 2015 Honored Educator
RC508-06
Emergency CT for Assessment and Management of Splenic Traumatic Injuries in a Level-I Trauma
Center: 10-year Study
W ednesday, Nov. 30 10:00AM - 10:10AM Room: S405AB
Participants
Sergio Margari, MD, Milan, Italy (Presenter) Nothing to Disclose
Diana Artioli, MD, Milano, Italy (Abstract Co-Author) Nothing to Disclose
Ettore Colombo, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Fabrizio Sammartano, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Stefania Cimbanassi, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Osvaldo Chiara, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Angelo Vanzulli, MD, Segrate, Italy (Abstract Co-Author) Travel support, Bracco Group
PURPOSE
Assessing the role of emergency CT in guiding management modality (Operative Management-OM or Non-Operative ManagementNOM) in patients with splenic traumatic injuries.
METHOD AND MATERIALS
We retrospectively analyzed 280 traumatic splenic injuries in 4659 patients, admitted to the emergency room of a Level-I Trauma
Center from October 2002 to December 2013. Based on CT imaging, splenic injuries were classified into 5 degrees from I (the
mildest) to V (the severest), according to the Organ Injury Scale (OIS) of the American Association for the Surgery of Trauma.
Moreover, we considered intraparenchymal (bleed A) or extraparenchymal (bleed B) contrast blush (the active extravasation of the
contrast medium in arterial phase CT scans) as an independent parameter.
RESULTS
We performed 202 CT scans (78 patients were excluded due to hemodynamic instability) and patients were classified on the basis
of OIS degrees (29 OIS I, 46 OIS II, 87 OIS III, 35 OIS IV, 5 OIS V). Moreover, we identified 86 vascular lesions (13
pseudoaneurysms, 34 pseudoaneurysms with blush, 11 bleed A, 7 bleed B, 21 bleed A+B). There were 136 patients treated with OM
(48.57%). Statistically significant predictors of OM were systolic blood pressure <90 mmHg, OIS degrees IV and V, bleed B
(p<0.05). On the other hand, 144 patients underwent NOM (51.43%), all hemodynamically stable or stabilized, and with OIS ≤ III in
94.4%. NOM failed (FNOM) in 23 patients (15.97%): 2 OIS I, 4 OIS II, 16 OIS III, 1 OIS IV. FNOM occurred in 75% of cases within
30 hours from damage, without significant correlation to OIS degree and without increase of death rate. Arterial blush was
predictive of FNOM (p<0.05).
CONCLUSION
Contrast enhanced CT scan is a useful diagnostic tool for the management of splenic traumatic injuries.
CLINICAL RELEVANCE/APPLICATION
CT-imaging permits an accurate assessment of splenic traumatic injuries by identifying parenchymal damage (OIS degrees) and
vascular lesions (mainly arterial blush). CT scan safely influences emergency management of splenic trauma, allowing splenectomy
sparing without any increase in mortality.
RC508-07
Whole-Body Computed Tomography in Trauma Patients: Optimized Patient Positioning Allows a
Significant Shorter Examination Time While Maintaining Image Quality
W ednesday, Nov. 30 10:10AM - 10:20AM Room: S405AB
Participants
Tilman Hickethier, MD, Cologne, Germany (Presenter) Nothing to Disclose
Kamal Mammadov, Cologne, Germany (Abstract Co-Author) Nothing to Disclose
Bettina Baessler, MD, Cologne, Germany (Abstract Co-Author) Nothing to Disclose
David C. Maintz, MD, Koln, Germany (Abstract Co-Author) Nothing to Disclose
De-Hua Chang, Cologne, Germany (Abstract Co-Author) Nothing to Disclose
PURPOSE
Whole-body computed tomography (WBCT) plays a key role in the management of severely injured patients, but still no broad
consensus exists regarding the ideal examination procedure. Hence, we compared examination time and artifact vulnerability of
WBCTs performed either using a conventional or an optimized patient positioning.
METHOD AND MATERIALS
In 200 trauma patients who received a WBCT (with additional head and neck CTA (hnCTA) in 84 patients) the time from initiation of
the scan to completion of the last series was measured. The presence of image artifacts in the most relevant regions was assessed
using a 4-points Likert-scale (1=no artifacts, 2=minor artifacts without relevance, 3=stronger artifacts but maintained diagnostic
image quality (IQ), 4= severe artifacts with non-diagnostic IQ).
In 100 patients (including 41 hnCTAs) the arms were positioned alongside the body for imaging of head and neck, followed by
repositioning of the arms over the head for imaging of the trunk (group “A”). In the other 100 patients (including 43 hnCTAs) the
arms were flexed on a pillow anteriorly to the chest with continuous acquisition of all study regions without need for repositioning
(group “B”).
RESULTS
The total duration of the procedure was significant shorter in “B” than in “A” for patients with hnCTA (6:55±1:54min vs.
10:54±2:04min; p<.001) and without hnCTA (6:46±1:49min vs. 10:19±2:42min; p<.001) resulting in a time saving of 3:59min or
3:33min respectively.
Artifacts in aorta, liver and spleen occurred more commonly in patients from “B”, which resulted in a slight decline in IQ (mean score
for lung 1.07±2.56 “A” vs. 1.02±1.41 “B”, p=0.09; aorta 1.07±2.93 vs. 1.27±4.46, p<.001; liver 1.09±3.21 vs. 1.43±5.55, p<.001;
spleen 1.05±2.19 vs. 1.20±4.49, p<.001). No artifacts were observed in the spine and there was no examination with nondiagnostic IQ.
Random forests and logistic regression analyses showed that the increase in artifacts was not only due to the optimized positioning
itself but also to amendable causes (foreign objects/positioning faults).
CONCLUSION
The continuous acquisition of all study regions by using an optimized positioning protocol for WBCT in trauma patients allows
reducing the examination time by more than 30% while maintaining diagnostic image quality.
CLINICAL RELEVANCE/APPLICATION
A significant reduction in examination time allows a faster diagnosis of severely injured patients and a smoother workflow for the
involved medical employees.
RC508-08
Low-Dose CT with the Adaptive Statistical Iterative Reconstruction (ASIR)-V Technique in Abdominal
Organ Injury Grading: Comparison with Routine-Dose CT with Filtered Back Projection (FBP)
W ednesday, Nov. 30 10:20AM - 10:30AM Room: S405AB
Participants
Nam Kyung Lee, MD, Busan, Korea, Republic Of (Presenter) Nothing to Disclose
Jeongmyeong Kim, MD, Pusan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Suk Kim, MD, Pusan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Seung Hyun Lee, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Ga Jin Han, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
PURPOSE
Whole-body multidetector CT examination has been proposed to evaluate patient who has sustained multisystem trauma. However,
whole-body exposure leads to an increase in radiation dose. Most recently, a novel iterative reconstruction technique, ASIR-V has
potential for significant dose reduction with better image quality than conventional ASIR, at real time speed. Thus, the purpose is
to evaluate American association for the surgery of trauma (AAST) abdominal organ injury grading in low-dose CT with ASIR-V, in
comparsion with routine-dose CT with FBP.
METHOD AND MATERIALS
Eighty-three trauma patients underwent both routine-dose CT using FBP and low-dose CT using ASIR-V in the abdomen. Two
readers reviewed the presence, absence, and the grading of abdominal organ injuries (liver, kidney, spleen or pancreas) using AAST
scales. CT detection rates of abdominal organ injury, and AAST grading were compared between two different CT protocols, using
McNemar test. Additionally, objective image noise was compared between two CT protocols, using paired t-test.
RESULTS
The radiation dose for low-dose CT with ASIR-V was 3.4 mSv, in comparison with 8.8 mSv for routine-dose CT with FBP. Abdominal
organ injury was detected in 33 organs of 21 patients on routine-dose CT with FBP, and 29 organs in 20 patients on low-dose CT
with ASIR-V. The detection rate was not significantly different between two different protocols (p > 0.05). The diagnostic
performance of the AAST grading was also not significantly different between two different protocols (p > 0.05). Image noise was
significantly lower in low-dose CT with 50% ASIR-V than routine-dose CT with FBP (p < 0.001).
CONCLUSION
Low-dose CT with ASIR-V may assess multi-organ abdominal trauma without impairment of image quality, compared to routinedose CT with FBP.
CLINICAL RELEVANCE/APPLICATION
Low-dose CT with ASIR-V can allowed reduction of radiation exposure while maintaining the diagnostic performance in the
evaluation of multi-organ trauma.
RC508-09
Imaging of Hip Trauma
W ednesday, Nov. 30 10:30AM - 11:00AM Room: S405AB
Participants
Bharti Khurana, MD, Boston, MA (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under the main course title.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Bharti Khurana, MD - 2014 Honored Educator
RC508-10
A Pathomorphometric Study of Pelvic Ring Reduction by Binders after Trauma and Effects on
Hemorrhage Control
W ednesday, Nov. 30 11:00AM - 11:10AM Room: S405AB
Participants
David Dreizin, MD, Baltimore, MD (Presenter) Nothing to Disclose
Daniel C. Mascarenhas, BS, Cinnaminson, NJ (Abstract Co-Author) Nothing to Disclose
Jason Nascone, MD, Baltimore, MD (Abstract Co-Author) Royalties, Johnson & Johnson Consultant, Smith & Nephew plc Royalties,
Imaging Diagnostic Systems, Inc
PURPOSE
Clinical markers of hemorrhage and unidimensional plain film measurements are limited for determining benefit from pelvic binders. We
assessed adequacy of reduction in 3 orthogonal planes at CT and effects on segmented pelvic hematoma volumes (HMVs) for 3
major classes of instability
METHOD AND MATERIALS
The CT studies of 56 consecutively selected patients with binders were compared to 53 non-binder controls frequency-matched to
within 15% differences for a given Tile grade determined by an orthopedist (Tile A-stable, B-rotationally unstable, C- rotationally
and vertically unstable). All underwent CT prior to any surgery. CT measurements of pubic symphysis diastasis/offset (PSD) and SI
joint diastasis/offset (SID) were made (mm) in 3 planes (AP/lateral/vertical). Semi-automated region-growing segmentation
(iNtuition) was used to determine pelvic HMVs for each study.
RESULTS
Binders and controls had similar distributions of age, gender, and no significant difference in pelvic AIS or ISS. In Tile A (11 binders;
17 controls), there was no significant difference in morphometric measurements or HMVs, which were 80 mL and 107.2 mL
respectively (p=0.32). In Tile B (rot unstable- 22 binders; 20 controls), AP PSD (1.91 vs 0.59), vert PSD (1.75 vs 1.12), and vert
SID (0.44 vs 0.43) in binders vs controls were not significantly different, but lat PSD, lat SID, and HMVs were lower (6.82 vs 12.6,
p=0.02; 2.45 vs 4.87, p <0.0001; and 160 vs 325 mL respectively, p=0.01) with binders. In Tile C (globally unstable) (21 binders;
16 controls), lat PSD (9.93 vs 10.3) & lat SID (7.72 vs 8.34) were not significantly different. There was substantial vert SID (4.56
vs 5.00, p=0.80) in Tile C, which did not reduce w binders. AP PSD (8.51 vs 1.88, p = 0.03), and vert PSD (8.22 vs 1.95, p <
0.0001) were increased w binders. AP SID (4.96 vs 2.44, p=0.09) increased in binders, approaching significance. Pubic bone
override was only seen in the Tile C binder group (5 patients). HMVs were not decreased w/ binders (269 vs 255 mL, p=0.56)
CONCLUSION
Binders effectively reduce Tile B injuries and decrease hematoma volumes. In Tile C, binders increase distortion and fail to decrease
hematoma volumes.
CLINICAL RELEVANCE/APPLICATION
Binders are thought to lmit hemorrhage by reducing the pelvic ring. We show that this is the case for rotationally unstable injuries,
but binders further distort the globally unstable pelvis, and fail to reduce hemorrhage.in these injuries.
RC508-11
CT Angiography of Peripheral Vascular Imaging
W ednesday, Nov. 30 11:10AM - 11:40AM Room: S405AB
Participants
Scott D. Steenburg, MD, Zionsville, IN, ([email protected] ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Describe optimal CTA imaging protocols and strategies for the evaluation of suspected peripheral vascular injuries. 2) Identify the
various imaging manifestations of peripheral vascular injuries. 3) Recognize limitations and pitfalls in the diagnosis of peripheral
vascular injuries. 4) Recognize when further evaluation with catheter angiography or surgical exploration are required.
ABSTRACT
Peripheral vascular injuries constitute between 40-75% of vascular injuries in civilian trauma centers, and may result from blunt or
penetrating trauma. These injuries place the patient at risk for fatal exsanguination, multi-organ failure from hemorrhagic shock and
limb loss. "Hard" signs of peripheral vascular injuries strongly correlate with the presence of injury, however injuries may still exist
even in the absence of positive clinical findings. Thus, imaging supplementation is an important part of comprehensive patient
evaluation. A multi-modality approach to peripheral vascular injuries will be presented, and reflecting current trends, emphasis will
be placed on evaluation with MDCT angiography. The imaging appearances of the most common types of vascular injuries will be
presented using a case based approach.
RC508-12
Outcome in Renal Trauma: Is it Time to Revise the AAST Renal Injury Scale? A Retrospective Study in
367 Patients
W ednesday, Nov. 30 11:40AM - 11:50AM Room: S405AB
Participants
Anna Luger, Innsbruck, Austria (Presenter) Nothing to Disclose
Bernhard Glodny, MD, Innsbruck, Austria (Abstract Co-Author) Nothing to Disclose
Alexander Loizides, MD, Innsbruck, Austria (Abstract Co-Author) Nothing to Disclose
Johannes Petersen, MD, Innsbruck, Austria (Abstract Co-Author) Nothing to Disclose
Leonhard Gruber, Innsbruck, Austria (Abstract Co-Author) Nothing to Disclose
Peter Rehder, Innsbruck, Austria (Abstract Co-Author) Nothing to Disclose
PURPOSE
The aim of the study was to apply the AAST Renal Injury Scale (AAST RIS) in a large cohort, to show the weakness of the Scaling
System and to find significant parameters for a new classification.
METHOD AND MATERIALS
All renal traumas over the last 10 years were analyzed, including demographics, the Injury Scaling System, accompanying injuries
and radiologic methods. Cross-section of hematomas, infarcts and depth of lacerations were measured. Active bleeding, urinoma,
persisting nephrogramm, congenital abnormalies and all accompanying injuries were documented. We performed regression analysis
in order to predict therapeutic procedures such as angiography and surgery in renal trauma.
RESULTS
A total of 367 patients (61 female) with a mean age of 36.4 ± 19.5 years had blunt renal trauma. In 277 (60%) renal injuries the
AAST Scale was not applicable. The main causes were undefined tissue infarction, persisting nephrogramms, active bleeding and
adjacent renal vessels involved in trauma. Furthermore the AAST Score could not predict outcome, therapy or even length of
hospitalization.Our findings indicate active bleeding as a predictor for angiography and the cross-section dimension of hematoma,
infarction and depth of laceration as predictors for surgery.
CONCLUSION
The AAST Renal Injury Scale does not predict therapeutic procedures and is not applicable in 60 % of injured kidneys. Our findings
indicate the needs to develop of a new Scaling System including significant parameters like active bleeding, cross-section dimension
of hematoma and injuries like persisting nephrogram and adjacent renal vessel bleeding.
CLINICAL RELEVANCE/APPLICATION
The proposed predictors may change the current AAST Classification in order to enhance prognostic power in therapy.
RC508-13
Trends in the Volume of Computed Tomography Imaging in Trauma
W ednesday, Nov. 30 11:50AM - 12:00PM Room: S405AB
Awards
Student Travel Stipend Award
Participants
Michael J. Hsu, MD, Boston, MA (Presenter) Nothing to Disclose
Michael Wasserman, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jennifer Xiao, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Venkata Satyam, Boston, MA (Abstract Co-Author) Nothing to Disclose
Tina Shiang, Boston, MA (Abstract Co-Author) Nothing to Disclose
Deepan Paul, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ahmed Y. El-Araby, MD , West Warwick, RI (Abstract Co-Author) Nothing to Disclose
Vaeman Chintamaneni, Boston, MA (Abstract Co-Author) Nothing to Disclose
Robert Burns, Boston, MA (Abstract Co-Author) Nothing to Disclose
Arthur Baghdanian, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Jorge A. Soto, MD, Boston, MA (Abstract Co-Author) Royalties, Reed Elsevier
Stephan W. Anderson, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
The purpose of this study is to examine seasonal trends in the volume of CT trauma imaging, and to determine what environmental
and circumstantial factors influence the quantity of studies performed.
METHOD AND MATERIALS
This HIPAA-compliant, retrospective study performed at our urban academic teaching hospital was approved by the Institutional
Review Board (IRB); informed consent was waived.The daily volume of trauma CT examinations performed at our urban Level 1
trauma center over a two-year period was collected. Our institution is located in a major city with large seasonal variations in
weather. The effects of the time of day, day of the week, month of the year, as well as weather, on trauma imaging volume was
analyzed.
RESULTS
When analyzed as a function of the time of day, there are hourly variations in volume of trauma CT imaging performed throughout
the day. Uptrends in activity begin at 10 AM and 7 PM. There is a plateau of high volume from 8 PM to 12 AM. There is an
additional peak at 4 AM. The lowest volume of trauma CT imaging is performed from the hours of 5 AM to 9 AM.
When analyzed as a function of the day of the week, the highest volume of trauma CT imaging was performed on Saturday,
followed by Friday and Sunday. There is a gradual downtrend from Monday to Thursday.When analyzed as a function of the month
of the year, there are monthly variations in trauma imaging volumes with an 88% increase in CT trauma imaging during the peak
month of July as compared to the nadir of April.When analyzed as a function of weather, the lowest months of activity coincide
with the winter and there is strong correlation between volume of CT imaging and higher temperatures. There is also an inverse
relationship between snowfall and quantity of trauma CT imaging.
CONCLUSION
There are predictable patterns in trauma CT imaging volume based on the time of day, day of the week and month of the year.
Seasonal variations in temperature, snowfall and sunlight also affect volume. There is particularly high volume in the month of July.
CLINICAL RELEVANCE/APPLICATION
Identifying factors that influence changes in CT imaging volume is important for allocating departmental resources to appropriately
address predictable variations in the amount of trauma imaging performed.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jorge A. Soto, MD - 2013 Honored Educator
Jorge A. Soto, MD - 2014 Honored Educator
Jorge A. Soto, MD - 2015 Honored Educator
RC512
Thoracic Aortic Emergencies (An Interactive Session)
W ednesday, Nov. 30 8:30AM - 10:00AM Room: E353B
VA
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Dominik Fleischmann, MD, Palo Alto, CA (Moderator) Research support, Siemens AG;
Sub-Events
RC512A
The Spectrum of Type A Dissection
Participants
Anne S. Chin, MD, Palo Alto, CA (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Review the pathology, epidemiology, and natural history of acute type A aortic dissection. 2) Describe the imaging strategies for
acute aortic syndromes. 3) Review the recent classification of acute aortic dissection.
4) Illustrate imaging findings of the spectrum of acute type A aortic dissection, with a focus on recognizing subtle CT angiographic
findings related to the lesser known 'Class 3' aortic limited intimal tear or 'limited dissection.'
ABSTRACT
The traditional Stanford classification distinguishes between dissections involving the ascending aorta (Type A) from those that do
not involve the ascending aorta (Type B). Type A aortic dissection is rare, but remains the most lethal of aortic disorders requiring
prompt surgical intervention. The common pathologic denominator in patients with acute dissection is an abnormal aortic media
('cystic medial necrosis') which can be found in genetic/inherited diseases (e.g. Marfan's) but also in patients with severe
hypertension. The CT imaging strategy of suspected acute aortic syndrome should always include (i) non-enhanced images to
assess for intramural hematoma (IMH); when the index of suspicion for aortic dissection is high, also consider (ii) EKG-gating for
motion-free evaluation of the aortic root/ascending aorta, and (iii) including common femoral arteries in the CTA scan range to
assess lesion extent and identify a percutaneous access route. The spectrum of aortic dissection has recently been classified as
the following: Class 1 classic dissection with true and false lumen separated by an intimal flap; Class 2 IMH; Class 3 limited intimal
tear or limited dissection; Class 4 penetrating atherosclerotic ulcer (PAU); and Class 5 iatrogenic/traumatic. A clarification and
modified conceptual classification of aortic dissection will be provided, along with illustrative examples of these aortic lesions.
Particular focus will be given to the lesser known Class 3 'limited dissection' which is described as a subtle and eccentric bulge of
the aortic wall. While it has been reported to elude current imaging techniques, emphasis will be made on recognizing subtle CTA
imaging findings characteristic of this uncommon but important dissection variant.
RC512B
Acute and Chronic Complications of Aortic Dissection
Participants
Anna M. Sailer, MD, MBA, Maastricht, Netherlands, (​ [email protected] ​ ​ ​ ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the natural history and radiological patterns of early and late complications of Type B aortic dissections. 2) Differentiate
the mechanisms of branch ischemia and false lumen dilatation. 3) Assess different treatment strategies for acute and chronic
dissections.
ABSTRACT
RC512C
Traumatic Aortic Injuries
Participants
Savvas Nicolaou, MD, Vancouver, BC (Presenter) Institutional research agreement, Siemens AG
LEARNING OBJECTIVES
1) Discuss the different mechanisms of injuries, pathophysiology, and types of traumatic aortic injuries including aortic dissection,
laceration, transection, pseudoaneurysm and intramural hematoma. 2) Review techniques and advances in imaging including
DECT/Spectral and ultra-high-pitch imaging to optimize imaging of traumatic aortic injuries and the role of gating, MRI, and TEE. 3)
Discuss and demonstrate examples of the grading scheme for traumatic aortic injuries. 4) Demonstrate imaging pitfalls which can
cause misinterpretation of traumatic aortic injuries. 5) Review the appropriate management and treatment options, including open
surgical repair and percutaneous endovascular repair, for the traumatic aortic injuries.
ABSTRACT
ERS-W EA
Emergency Radiology Wednesday Poster Discussions
W ednesday, Nov. 30 12:15PM - 12:45PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Douglas S. Katz, MD, Mineola, NY (Moderator) Nothing to Disclose
Sub-Events
ER228-SDWEA1
Evaluation of Bone Marrow Edema in Thoracolumbar Spinal Trauma: Early Experience with the Third
Generation Dual Source CT Technology in the Acute Setting
Station #1
Participants
Sudha R. Muly, MBBS, FRCR, Vancouver, BC (Presenter) Nothing to Disclose
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
Luck J. Louis, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
PURPOSE
Traumatic bone marrow edema results in small but measurable increase in CT attenuation values due to hemorrhage and increased
interstitial fluid within the bone marrow cavity. To evaluate the sensitivity and specificity of dual energy CT (DECT) in detecting
bone marrow edema (BME) in thoracic and lumbar spine. To identify the pitfalls and common artifacts which limit DECT bone marrow
assessment.
METHOD AND MATERIALS
In this retrospective study, 26 trauma patients who underwent DECT scanning of the thoracic and lumbar using a third generation
dual source CT scanner (Definition FORCE, Siemens Health care, Germany) between January and April of 2016 were evaluated.
There were 57 vertebral bodies assessed for bone marrow edema. The DECT data (100 kv and 150kvSN) was reconstructed using
bone marrow edema algorithm on the syngovia platform VB 10. Visual analysis using color overlay images and quantitative objective
analysis was performed using dual energy region of interest on the vertebral bodies to evaluate presence of bone marrow edema
RESULTS
Dual energy CT showed a sensitivity of 89% and specificity of 88%. The positive predictive value of was close to 96% and a
negative predictive value close to 70%. There were 12 cases, which were indeterminate on grey scale mixed data CT sets
simulating a 120 kvp scan and analysis of dual energy CT BME helped differentiate acute versus chronic fractures.Subtle end plate
compression fracture may be difficult to evaluate on dual energy due to close proximity of the area of interest to the cortex.
Movement and streak artifact cause spurious positive results and that could be alleviated with faster rotation, wider collimation and
higher pitch.
CONCLUSION
Due to its superior quality and the advancements in dual-energy CT technology with materialdecomposition, detection of bone
marrow edema helps to identify subtle fractures and to differentiate acute from chronic fractures with high sensitivity and
specificity.
CLINICAL RELEVANCE/APPLICATION
We believe that dual-energy CT will serve as a good replacement for detection of bone marrow edema for patients who have a
contraindication to MR imaging or when there is no immediate availability MRI due to resource constraints. But more importantly
DECT can increase the diagnostic confidence in confirming a spinal fracture as acute when BME is present in the setting of trauma
where CT is recognized as the Gold standard for the evaluation of spinal trauma.
ER229-SDWEA2
Utilization of MRI and CT Imaging for ED Patients with Clinically Suspected Stroke: A Retrospective
Institutional Review, Comparing True Negatives to True Positive Stroke Population
Station #2
Participants
Sarika Pamarthy, MBBS, MS, Columbus, OH (Abstract Co-Author) Nothing to Disclose
Manav Bhalla, MD , Milwaukee, WI (Presenter) Nothing to Disclose
John L. Ulmer, MD, Milwaukee, WI (Abstract Co-Author) Stockholder, Prism Clinical Imaging, Inc Medical Advisory Board, General
Electric Company
Andrew P. Klein, MD, Pewaukee, WI (Abstract Co-Author) Nothing to Disclose
Kieran E. McAvoy, Milwaukee, WI (Abstract Co-Author) Nothing to Disclose
Leighton P. Mark, MD, Milwaukee, WI (Abstract Co-Author) Nothing to Disclose
Stephen A. Quinet, MD, Milwaukee, WI (Abstract Co-Author) Nothing to Disclose
Namrata Bhalla, Brookfield, WI (Abstract Co-Author) Nothing to Disclose
PURPOSE
CT/MRI neurologic stroke (3rd leading cause of death in the US) imaging has immense value in guiding patient management.
However, the rate of CT and MRI utilization in patients ultimately found not to have stroke is understandably high in the ED setting,
as ‘time is brain’ and the consequences of misdiagnosing a vascular event are profound. Yet, the judicious utilization of imaging
resources in today’s healthcare environment is more important than ever. Our study seeks to evaluate the clinical parameters that
differentiate stroke negative patients to those who were positive. The information could aid clinical decision-making and optimize
stroke imaging algorithms.
METHOD AND MATERIALS
The EHR of 500 patients who presented with stroke like symptoms, and had CT/MRI performed in a span of 24 hours, were
retrospectively reviewed. The predictive values of CT and MRI were obtained by comparing imaging diagnosis with the final clinical
diagnosis at discharge. Final diagnosis of stroke negative patients were reviewed, and their clinical profile (age, gender, race and
risk factors) were compared with stroke positive patients.
RESULTS
Radiologic data analysis revealed 250/500 patients (50%) were ‘true negative for stroke based on final clinical discharge diagnoses.
The clinical non-stroke diagnoses were as follows: 53/250 with TIA, 19/250 with migraine, 15/250 with seizure, 10/250 with
emergent hypertension, 10/250 with behavioral or psychogenic (depression, adjustment disorder, etc.), 9/250 with UTI, and 138
with miscellaneous neurologic or non-neurologic diagnoses. Significant differences in mean age, absence of vascular risk factors and
mean NIHSS score were noted between the true negatives and true positives.
CONCLUSION
Many neurological presentations may mimic stroke clinically, requiring imaging for diagnosis and management. However, imaging
resources are limited and are ever shrinking in the current healthcare environment, fostering an emphasis on appropriate utilization.
Our data indicates that up to 50% of patients imaged for stroke are ultimately found to have other diagnoses, providing a baseline
to test refinements in clinical stroke algorithms that may optimize utilization of neuroimaging in the ED.
CLINICAL RELEVANCE/APPLICATION
Clinical parameters of patients presenting with stroke like symptoms may be used to optimize algorithms that facilitate appropriate
utilization of imaging modalities for stroke imaging.
ER230-SDWEA3
Spontaneous Visceral Artery Dissection: Clinical and Radiologic Characteristics, Management
Strategies and Patients' Outcome
Station #3
Participants
Min Yeong Kim, MD, Seoul, Korea, Republic Of (Presenter) Nothing to Disclose
PURPOSE
To report CT finidngs of spontaneous visceral artery dissection (SVAD) with clinical circumstances.To evaluate treatment
strategies correlated with patients' prognosis.
METHOD AND MATERIALS
For 4 years, 18 patients had been diagnosed as SVAD on enhanced abdominal CT scans. The clinical characteristics,
comorbidities, risk factors and the treatment with prognosis were evaluated by data from the electronic medical records. Analysis of
CT exams included location of SVAD, affected visceral organs, abnormalities of other abdominal arteries. If endovascular
intervention was performed, angiographic finidngs were also reviewed.
RESULTS
Fifteteen patients were men and average age was 49.9 years (range, 29-84). The location of SVAD was superior mesenteric artery
(SMA) only in 9, celiac axis (CA) only in 5, both SMA and CA in 2, renal artery (RA) in 2 patients. In one patient, CA dissection
developed 20 months after SMA dissection. Most common symptoms were acute abdominal pain in 10 patients, but all two patients
with RA dissection complained acute flank pain with segmental infarct in corresponding renal parenchyma. There are no organic
ischemia in SMA dissection and only one case of CA dissection resulted in segmental splenic infarct. Only 7 patients had
hypertension, no patients had coronary arterial diseases while metabolic diseases were more common: diabetus mellitus (DM) in 5,
impaired glucose tolerance (IGT) in 7, dyslipidemia in 8 patients. Smokers were 6 patients and CT finidngs of atherosclerosis were
found in 3 patients. No patients underwent for surgical procedures and 4 patient underwent endovascular procedures, one stenting
and 3 angioplasty. The others were managed by medical treatment.
CONCLUSION
Clinical manifestation of SVAD is very similar to other conditions of acute abdomen. Most affected persons are late thirties to ealry
fifties males. SMA is most common site of SVAD. The major risk factors are metabolic disease such as DM, IGT and dyslipidemia,
however smoking, hypertension or other cardiovascular diseases are not frequent in SVAD. Most SVAD do not result visceral
ischemia and are treated by medical management. Although dissection in RA is rarer than in CA or SMA, renal infarct is serious
problem and prompt management must be performed.
CLINICAL RELEVANCE/APPLICATION
SVAD is emerging disease entity in acute abdomen. It is important to understand both CT finidngs and clinical characteristics of
SVAD for accurate diagnosis and appropriate management.
ER231-SDWEA4
Criteria-based Direct Access to Polytrauma Whole-body CT Scans in the Emergency Department, and
Impact on Proportion of Normal Scans at a Major Trauma Centre
Station #4
Awards
Student Travel Stipend Award
Participants
James S. Kho, MBBCh, Brighton, United Kingdom (Presenter) Nothing to Disclose
Ahmed Daghir, MRCP, FRCR, Oxford, United Kingdom (Abstract Co-Author) Nothing to Disclose
PURPOSE
A set of criteria for direct Emergency Department access to polytrauma whole-body CT scans, was introduced to help guide clinical
decision making and speed up patient imaging in the Emergency Department. This study aims to determine if use of criteria-based
patient selection for polytrauma whole-body CT scans in the Emergency Department is associated with a change in proportion of
normal polytrauma whole-body CT scans.
METHOD AND MATERIALS
Criteria-based direct Emergency Department access to polytrauma whole-body CT scans was introduced over 2013 at our
institution, with criteria modified from patient inclusion criteria to the REACT-2 trial. When the criteria are met the patient
proceeds directly to CT without prior discussion with a radiologist.
A retrospective sample of 60 polytrauma whole-body CT scans per year was obtained over a fixed 2 month period in 2012, 2014
and 2015. The consultant radiology reports of these CT scans were retrieved from the hospital's radiology information system.
Scans were categorised based on the consultant reports as normal (no acute injury or subcutaneous soft tissue injury only), or
abnormal (any acute injury other than subcutaneous soft tissue injury). The proportion of normal polytrauma CT scans for 2012
prior to the introduction of the criteria-based patient selection, was compared to 2014 and 2015 post-introduction of the criteria.
RESULTS
The proportion of normal polytrauma whole-body CT scans in this major trauma centre, rose from 27% in 2012, to 33% in 2014, to
47% in 2015 (p = 0.02, Z test for equality of proportions). The introduction of criteria-based direct Emergency Department access
to polytrauma whole-body CT scans in 2013 thus appears to be associated with a significant rise in proportion of normal scans in
our major trauma centre. Our percentage of normal polytrauma whole-body CT scans in 2015 of 47% exceeds published
percentages of 27-37% for such scans at other trauma centres in this country.
CONCLUSION
Introduction of criteria-based direct access of Emergency Department to polytrauma whole-body CT has been associated with a
rise in proportion of normal scans at our major trauma centre, from 27% to 47%.
CLINICAL RELEVANCE/APPLICATION
The rising proportion of normal polytrauma CT studies suggests criteria-based direct access to polytrauma whole-body CT in our
institution has lowered the threshold for selection of patients that receive these scans.
ER232-SDWEA5
Reasonable Utilization of CT Angiogram for Evaluation of Spontaneous Parenchymal Hemorrhage
Station #5
Awards
Student Travel Stipend Award
Participants
Li-Hsiang Yen, MD, West Orange, NJ (Presenter) Nothing to Disclose
Ali F. Jon, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Shira Slasky, MD, Tenafly, NJ (Abstract Co-Author) Nothing to Disclose
PURPOSE
Spontaneous, non-traumatic parenchymal hemorrhage may be caused by a variety of etiologies. CT angiogram (CTA) is a fast and
effective modality to diagnose underlying vascular malformations. CTA has limitations due to its high ionizing radiation dose and its
cost. Judicious utilization of CTA is necessary to follow the dictum of ALARA. Current guidelines (AHA/ASA 2015) recommend using
CTA to evaluate for an underlying structural lesion if there is clinical or radiological suspicion. Risk factors for underlying structural
lesions include: age <65 years, female sex, nonsmoker, lobar hemorrhage, intraventricular extension, and absence of hypertension
or coagulopathy. Our hypothesis was that many low risk patients with parenchymal hemorrhage in our institution were imaged with
CTA unnecessarily.
METHOD AND MATERIALS
We reviewed our PACS for CT angiograms of the head performed during 2014 and 2015 to identify all patients with intracranial
parenchymal hemorrhage. Any abnormality of the cerebral vasculature was subsequently reviewed. Arteriovenous malformation or
cerebral aneurysm that may have potentially caused the hematoma were considered positive findings. Other vascular abnormalities
such as stenosis were considered negative. Electronic medical records were reviewed for relevant clinical information.
RESULTS
We identified a total of 74 patients with parenchymal hemorrhage, 36 male and 38 female. 12% of the total patients had positive
CTA findings. 20% of these patients were older than 65 years. 10 patients (13.5%) were imaged despite not having any of the risk
factors and all had a negative CTA result. The yield of CTA for evaluation of parenchymal hemorrhage was previously reported as
14.6% (AJNR 2009), which is similar to our study.
CONCLUSION
13.5% of CT angiograms of the head performed for parenchymal hemorrhage were unnecessary as per the AHA/ASA guidelines.
Implementation of clinical guidelines into a clinical decision making system may be helpful to reduce unnecessary examinations. We
will try to implement the guidelines into our electronic ordering system and follow up on results after implementation.
CLINICAL RELEVANCE/APPLICATION
We have identified a number of unnecessary examination that may be avoided by following the AHA/ASA guideline and will perform a
follow-up study to assess the reduction of unnecessary examinations after implementing a check list into our electronic ordering
system.
ERS-W EB
Emergency Radiology Wednesday Poster Discussions
W ednesday, Nov. 30 12:45PM - 1:15PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Douglas S. Katz, MD, Mineola, NY (Moderator) Nothing to Disclose
Sub-Events
ER233-SDWEB1
The role of MD-CECT in the Diagnosis of Necrotizing Fasciitis and Correlation with the LRINEC Score
Station #1
Participants
Marco Di Girolamo, MD, Rome, Italy (Presenter) Nothing to Disclose
Francesco Carbonetti, MD, Rome-Roma, Italy (Abstract Co-Author) Nothing to Disclose
Antonio Cremona, Rome, Italy (Abstract Co-Author) Nothing to Disclose
Daniela Sergi, Rome, Italy (Abstract Co-Author) Nothing to Disclose
Valentina Caturano, Rome, Italy (Abstract Co-Author) Nothing to Disclose
Elsa Iannicelli, MD, Rome, Italy (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate the diagnostic efficacy of the CT findings in predicting the diagnosis of Necrotizing Fasciitis (NF).
METHOD AND MATERIALS
In a period of a year 36 pts with a clinical suspicion of NF underwent to CE-MDCT .CT findings studied were : involvement and
thickening of the muscular fascia, fluid collections along the deep fascial sheaths , extension of oedema into the intramuscular
septa and the muscles, low attenuation areas in the deeper fascial planes suggestive for colliquative necrosis, a non enhancement
of the muscular fascia and vascular thrombosis.Radiological findings were compared with the LRINEC score and with the surgical
data.
RESULTS
CT findings were suggestive for NF in 10 pts , for non-NF in 2 pts and for gas-gangrene in 2 pts .The rest of the pts showed CT
finding suggestive for cellulitis (10 pts) , myositis (5 pts) , soft tissue abscess ( 7 pts).Among the patients with CT findings
suggestive for NF, non-NF and gas gangrene , 9 pts showed a non enhancing fascia, subcutaneous gas was present in 12 pts,
involvement of the fascia in 12 pts, fluid collections along the deep fascial sheaths in 7 pts ,low attenuation areas in the deeper
fascial planes in 3 pts. Surgical examination confirmed the diagnosis of NF in 12 pts who showed at the CE-MDCT a non
enhancement of the fascia (9/12), low areas of attenuation (3/12), fluid collections ( 4/12), presence of subcutaneous gas (10/12)
. The LRINEC score in pts with NF was equal or superior to 6 points : 6 pts had a score of 6/8 , 4 pts a score of 7/8 , 2 pts a score
of 8/8 . The diagnoses of the other pts (cellulitis 10 pts, myositis 5 pts, musculoskeletal abscess 7 pts) were confirmed.
CONCLUSION
The presence of a non-enhancing fascia after contrast medium administration, the involvement of the fascia and the presence of
subcutaneous gas are the radiological findings mostly related to NF, and could strongly suggest to the radiologist the presence of
NF; these findings with an intermediate-high LRINEC should address to a surgical evaluation. CT could discriminate NF from the most
common musculoskeletal infections.
CLINICAL RELEVANCE/APPLICATION
NF is a fatal disease if it is not treated, in order to permit a prompt surgical intervention radiological findings correlated with the
LRINEC score permit a better evaluation of the pts disease and a prompt surgical intervention in order to avoid the complication of
NF.
ER234-SDWEB2
Acute Mesenteric Isquemia? Can We Predict It?
Station #2
Participants
Lorena F. Rodriguez-Gijon, MD, Madrid, Spain (Presenter) Nothing to Disclose
Angel Aguado, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Milagros Marti, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Aurea Diez Tascon, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Maria Jose Simon, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Alfonso Martin Diaz, BMedSc, San Sebastian De Los Reyes, Spain (Abstract Co-Author) Nothing to Disclose
Lucia Fernandez Rodriguez, BMBS, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Carolina Martinez Gamarra, MD, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
Maria Claudia Pulido, Madrid, Spain (Abstract Co-Author) Nothing to Disclose
PURPOSE
Acute mesenteric ischemia remains a difficult diagnosis to establish on a clinic base, so diagnosis requires advanced imaging
techniques, such as CT angiography or invasive techniques.Recent studies suggest that the elevation of the neutrophyl to
lymphocyte ratio (NLR) is present in the moment of the acute mesenteric ischemia (AMI) diagnosis.The objective of our work is to
study the association between NRL and radiological signs of AMI by all causes.
METHOD AND MATERIALS
A retrospective, case-control study has been performed, within the years 2013-2016 in a third level hospital. 34 cases with AMI
diagnosed by TC and confirmed by histology or clinical outcome has been taken. As control group, there were 34 patients
diagnosed with a no-AMI disease by TC and confirmed by surgical or histological findings.Study variables were sex, age, NRL, CT
diagnosis, pathological diagnosis, cause of AMI and radiological signs described in other reports for AMI.Non parametric test (MannWhitney) and chi 2 or Fischer`s exact test were performed to analyze the differences between case and control groups. To
evaluate the NLR discriminative capacity, ROC curves were used.
RESULTS
We observed statistically significant association of NRL with the following radiological signs in patients with AMI: parietal thickening
of the ascending colon (p = 0.04), transverse colon (p = 0.04), descending colon (p = 0.029) and sigma (p = 0.03) and with
occlusion of the superior mesenteric artery (SMA) (p = 0.03).Including AMI of any cause, the area under the ROC curve (AUC) was
0.6 (CI 95%: 0.46-0.74; p=0.151). In the cases of AMI by SMA occlusion, the AUC was 0.83 (CI 95%: 0.67-0.98; p=0.004). There
was no patient with diagnose of SMA occlusion AMI with a NLR <5. (Negative predictive value: 100%). The optimal cut-off by
Youden’s index was 18.7 (sensitivity 77.8% and specificity of 80%).
CONCLUSION
In our study, ability NRL to discriminate between cases and controls was low but the area under the curve of NRL to classify AMI
by SMA occlusion with respect to other causes was 0.83, so we propose that at high values of NRL, an arterial phase helix should
be performed.
CLINICAL RELEVANCE/APPLICATION
The results of our study show an association between NRL and ischemia of arterial origin, so that a high NRL value could consider a
predictor factor of arterial origin AMI and an arterial phase helix should be performed in these cases.
ER235-SDWEB3
Role of CT in the Definition of Therapeutic Approach in Polytrauma Patients with Kidney Injury
Station #3
Awards
Student Travel Stipend Award
Participants
Bruno Tuscano, MD, Milano, Italy (Presenter) Nothing to Disclose
Luca Caschera, MD, Milano, Italy (Abstract Co-Author) Nothing to Disclose
Ettore Colombo, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Stefania Cimbanassi, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Osvaldo Chiara, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Angelo Vanzulli, MD, Segrate, Italy (Abstract Co-Author) Travel support, Bracco Group
PURPOSE
To evaluate the role of CT in the management of kidney injury, on basis of OIS degree (Organ Injury Scale) and outcome.
METHOD AND MATERIALS
Retrospective study of 91 polytrauma patients with kidney lesions classified according to the American Association of Trauma
Surgery in five degrees of gravity. Patients were admitted to a large metropolitan hospital from 2011 to 2015 (44 OIS 1, 18 OIS 2,
11 OIS 3, 16 OIS 4 and 2 OIS 5). For each case imaging data (CT) and treatment strategy were collected.
RESULTS
In almost all OIS 1 to 3 degree kidney lesions conservative treatment was chosen, while in lesions of OIS 4 and 5, surgical (n = 2)
or minimally invasive (n = 12) procedures were performed. CT revealed urinoma in 12.1% of cases. In 6 cases a ureteral stent was
positioned after ascending pyelography which confirmed the injury; in 5, with limited spreading of the contrast agent, a
conservative approach was chosen. The CT scan showed in 3 patients (OIS 4) arterial blushing of renal vessels and embolization
was performed. In 1 patient (OIS 2) the first CT did not reveal the presence of renal artery branch pseudoaneurysm, identified in
the subsequent CT, treated with embolization. In 2 patients (OIS 4) total nephrectomy was done for the impossibility to
reconstruct the urinary tract and renal parenchyma. In 2 patients (1 OIS 4, 1 OIS 5) CT documented renal artery occlusion, and
both cases were treated with stenting.
CONCLUSION
CT has provided reliable evaluation of all lesion degrees, allowing in most cases minimally invasive interventions and reducing
nephrectomy rates. CT monitoring allowed non operative management in many patients.
CLINICAL RELEVANCE/APPLICATION
Contrast enhanced CT in polytrauma patients with renal injuries reduce total or partial nephrectomy rate in favor of conservative
management.
ER236-SDWEB4
The Application of Dual-energy Technique to Whole-body CT in Blunt Trauma Patients: Can the
Virtual-unenhanced CT Images Substitute Unenhanced CT Images?
Station #4
Participants
Yukichi Tanahashi, MD, Tokyo, Japan (Presenter) Nothing to Disclose
Hiroshi Kondo, MD, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose
Satoshi Goshima, MD, PhD, Gifu, Japan (Abstract Co-Author) Nothing to Disclose
Nobuyuki Kawai, MD, Gifu, Japan (Abstract Co-Author) Nothing to Disclose
Yoshifumi Noda, MD,PhD, Gifu, Japan (Abstract Co-Author) Nothing to Disclose
Hiroshi Kawada, MD, Gifu, Japan (Abstract Co-Author) Nothing to Disclose
Toshihisa Kojima, MD, Gifu, Japan (Abstract Co-Author) Nothing to Disclose
Shigeru Furui, MD, Itabashi-Ku, Japan (Abstract Co-Author) Nothing to Disclose
Masayuki Matsuo, Gifu, Japan (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate the efficacy of virtual-unenhanced CT for the assessment of blunt trauma patients.
METHOD AND MATERIALS
Eighty-two trauma patients (55 men and 27 women; mean age, 51.6 yrs; range, 12-90 yrs) who underwent whole-body dynamic
contrast-enhanced CT with dual-energy technique, following unenhanced CT, constituted study population. The virtualunenhanced CT image was reconstructed. Two observers independently and randomly reviewed images in three image sets; 1st,
contrast-enhanced images, 2nd, combined unenhanced and contrast-enhanced images, and 3rd, combined virtual-unenhanced and
contrast-enhanced images for the evaluation of traumatic change. The confidence level of traumatic change probability (visceral
trauma, bone trauma, and extravasation of contrast media) were scored by 5-point scale for each image sets. Areas under the
receiver operating characteristic curve (AUC) for the detection of traumatic change was evaluated. The image quality and radiation
exposure were assessed.
RESULTS
Diagnosis of 63 visceral injuries in 47 patients and 138 bone fracture in 59 patients were clinically established. No significant
difference was found in AUCs for visceral (0.90, 0.90, and 0.90), bone injury (0.87, 0.87 and 0.87), extravasation of contrast media
(0.72, 0.72, and 0.72) among three image sets (P = 0.68, 0.50, and 0.51). The artifact and noise were worth in virtual-unenhanced
images (P < 0.017). The Diagnostic acceptability of virtual-unenhanced image was substantial for all image. Mean DLP of
unenhanced CT, arterial phase and venous phase were 1249.9 mGy*cm, 742.2 mGy*cm, and 1246.0mGy*cm, respectively.
CONCLUSION
Combined virtual-unenhanced and contrast-enhanced images showed comparable diagnostic performance of trauma with contrastenhanced images alone and combined unenhanced and contrast-enhanced images.
CLINICAL RELEVANCE/APPLICATION
Our result showed unenhanced CT can be omitted in trauma patients and substituted by virtual-unenhanced CT reconstructed from
dual-energy CT as needed, resulting in the decrease of radiation exposure.
ER237-SDWEB5
Pattern of Head Injuries in the Elderly
Station #5
Awards
Student Travel Stipend Award
Participants
Kenedy A. Foryoung, MD, Hamden, DC (Presenter) Nothing to Disclose
Felix T. Nautsch, MS, BA, New Haven, CT (Abstract Co-Author) Nothing to Disclose
Xiao Wu, New Haven, CT (Abstract Co-Author) Nothing to Disclose
Ajay Malhotra, MD, Stamford, CT (Abstract Co-Author) Nothing to Disclose
Diego B. Nunez JR, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
Head and cervical spine computed tomography (CT) are the workhorse modalities for the evaluation of neurologic trauma in the
emergency setting. Knowledge of typical injury patterns and typical injury mechanisms as they occur in different age groups may
help improve performance by guiding search patterns, key ancillary data given to the radiologist and possibly reformatting
algorithms.
METHOD AND MATERIALS
CT studies of the brain and brain and cervical spine of adults performed in the Emergency Department between 2/15/2014 and
2/15/2015 were retrieved from the electronic medical records. For all studies with critical findings, the images, reports and
associated medical record were manually reviewed. Histories of trauma or possible trauma with findings of traumatic injuries by CT
were included. The data was separated by Age into two groups aged above 65 and 18-64. We grouped fractures and hemorrhages
by type and anatomic location. Collateral information such as anticoagulation status and additional history were manually retrieved.
RESULTS
A total of 384 studies with patients above the age of 65 and 518 studies with patients aged between 18 and 65 with critical results
were identified for manual review. Following preliminary manual review approximately 70% met inclusion criteria by history and
findings in both age groups. 85% of the group aged above 65 suffered a traumatic fall and 37% were on anti-coagulation. The most
common traumatic bleed above the age of 65 was an acute subdural bleed, which occurred 35% of the time. The predominant
cranial area of fracture was the face in 30% of all studies above 65. High velocity mechanisms of injury in the elderly were present
in only 6% of the cases. Diffuse axonal injuries, parenchymal hemorrhage and arterial epidural collections were rare. While epidural
and subarachnoid hemorrhage remained a relatively rare finding in the younger age group, the preponderance of subdural
hemorrhages decreased to 23%. Similarly, high velocity injury mechanisms occurred about 10% of the time and a second
predominant mechanism of injury, assault, occurred 12% of the time.
CONCLUSION
The elderly suffer specific injury patterns closely associated with their typical mechanisms of injury and anti-coagulation state.
CLINICAL RELEVANCE/APPLICATION
Injury patterns after blunt trauma might be different in the elderly patients relative to younger population.
SSM07
Emergency Radiology (Emergency Neuroradiology)
W ednesday, Nov. 30 3:00PM - 4:00PM Room: S403B
NR
CT
ER
AMA PRA Category 1 Credit ™: 1.00
ARRT Category A+ Credit: 1.00
Participants
Jamlik-Omari Johnson, MD, Atlanta, GA (Moderator) Research Grant, Koninklijke Philips NV; Royalties, Cambridge University Press
Scott D. Steenburg, MD, Zionsville, IN (Moderator) Nothing to Disclose
Sub-Events
SSM07-01
Potential for Lower Dose Spiral Head CT to Detect Intracranial Findings Causing Neurologic Deficit
W ednesday, Nov. 30 3:00PM - 3:10PM Room: S403B
Participants
Joel G. Fletcher, MD, Rochester, MN (Presenter) Grant, Siemens AG; ;
David R. De Lone, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Amy L. Kotsenas, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Norbert G. Campeau, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Vance Lehman, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Lifeng Yu, PhD, Chicago, IL (Abstract Co-Author) Nothing to Disclose
Maria Shiung, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Adam Bartley, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Shuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to Disclose
David R. Holmes Iii, PhD, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Alicia Toledano, DSc, Kensington, MD (Abstract Co-Author) Consultant, iCAD, Inc
Rickey Carter, PhD, Rochester, MN (Abstract Co-Author) Nothing to Disclose
Cynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG
PURPOSE
To evaluate the ability of lower dose head CT using either standard filtered back projection (FBP) or iterative reconstruction (IR) to
display intracranial findings (ICF) that may cause neurologic deficit.
METHOD AND MATERIALS
Using a retrospective, case-control design, CT projection data from 83 unenhanced spiral head CT exams in patients with
suspected neurologic deficit were collected. Positive cases required presence of histopathology, surgery, progression of findings, or
corresponding neurological deficit. Negative cases required negative CT findings and negative neurological assessment. Routine
clinical images were obtained using 250 effective. mAs (emAs) and IR. Based on prior results and using validated noise insertion,
four additional lower dose configurations were reconstructed (25 emAs -IR, 50 emAs -FBP and -IR, 100 emAs -FBP and -IR, 200
emAs -FBP). Three neuroradiologists circled ICF’s and provided a diagnosis, confidence (0 – 100), and image quality rating.
Matching of reference and reader markings was performed by a non-reader neuroradiologist. The difference between the JAFROC
figure-of-merit (FOM) at routine and lower dose configurations was estimated along with 95% confidence intervals (CIs), with the
lower 95% CI limit required to be greater than -0.10 to demonstrate non-inferiority.
RESULTS
63 ICF’s (25 infarcts, 6 intra- and 9 extra-axial hemorrhages, 25 masses; non-exclusive) were identified by reference standard in
40/83 (48%) patients with routine head CT (CTDI 38.3 mGy). JAFROC FOM at 250 emAs routine dose was 0.82 (95% CI: 0.76,
0.89). Using non-inferiority criteria, the JAFROC FOM was non-inferior for dose levels corresponding to ≥ 100 emAs when IR was
utilized [100 emAs -IR FOM 0.78 (95% CI: 0.71, 0.85), with the difference from routine dose being -0.04 (95% CI: -0.08, 0.01)].
For 100 emAs -FBP, this difference was -0.06 (95% CI: -0.11, -0.02). This difference was worse and larger for lower dose levels.
Diagnostic image quality was better at higher dose levels and with IR (p<0.05).
CONCLUSION
Observer performance for dose levels from 100 to 200 emAs was non-inferior to that observed at 250 emAs with IR, with IR
preserving non-inferiority at a mean CTDI/SSDE of 15.2/10.5 mGy.
CLINICAL RELEVANCE/APPLICATION
Substantial opportunity exists for lowering radiation dose at unenhanced head CT with the use of iterative reconstruction, but is
limited by lower radiologist performance at very low doses.
SSM07-02
Analysis of the Causes of Overuse of Head CT Examinations for the Investigation of Minor Head
Trauma
W ednesday, Nov. 30 3:10PM - 3:20PM Room: S403B
Participants
Arkadi Beytelman, MA, Rosh Haayin, Israel (Presenter) Nothing to Disclose
Eli Konen, MD, Ramat Gan, Israel (Abstract Co-Author) Research Consultant, RadLogics Inc
Dan Greenberg, Beer Sheva, Israel (Abstract Co-Author) Nothing to Disclose
Eyal Zimlichman, Ramat Gan, Israel (Abstract Co-Author) Nothing to Disclose
Eyal Klang, Ramat Gan, Israel (Abstract Co-Author) Nothing to Disclose
PURPOSE
Minor head injury is a common cause for emergency CT. There are known protocols in assessing the need for CT in minor head
injury. One of the most recognizable protocols is the Canadian CT Head Rule (CCHR). The purpose of this study was to estimate the
volume and rate of CTs performed in the emergency department of a large tertiary hospital that are unwarranted by CCHR criteria
and to analyze factors that contribute to unnecessary examinations.
METHOD AND MATERIALS
One thousand brain CT scans performed due to minor head injury during 2014 were randomly collected.Medical records were
assessed for the following parameters: whether the CT referral met the CCHR criteria, type of the referring physician (emergency
physician, internal medicine, surgery, neurologist, other), seniority of the referring physician (beginning resident, experienced
resident, senior), cause of head trauma (four wheels motor vehicle accident, two wheels accident, fall accident, etc.).
RESULTS
A total of 955 cases were included in the analysis of which 104/955 (10.9%) examinations were unjustified by the CHCR criteria. In
patients younger than sixty five, 104/279 (37.3%) of the examinations were unjustified.
When assessing contributing factors, we found that neurologists conducted more unwarranted CTs (odds ratio 3.5, p=0.011) while
surgeons tended to order less (odds ratio 0.676, p=0.126). There was no statistically significant difference between the seniority of
the referring physician and over referral.
The type of injury that was found to cause the most unjustified CTs was involvement in a four wheels motor vehicle accident (odds
ratio 3.034, p<0.001).
CONCLUSION
The study demonstrates excess use of CTs due to minor head injuries that are not justified by CCHR criteria, especially in the
younger patients with an excess of 37.3%. Contributing factors are the type of the referring physician and the type of injury.
CLINICAL RELEVANCE/APPLICATION
CT overuse cause both unnecessary radiation exposure and waste of healthcare resources. Analysis of the causes for overuse can
be implemented both for specific education programs and also for implementation of computerized referring protocols that can help
as decision support.
SSM07-03
Comparing CT/MRI Diagnostic Accuracy in Posterior Fossa Strokes, Analyzing Diagnostic Yield in
Patients with Localizing Symptoms
W ednesday, Nov. 30 3:20PM - 3:30PM Room: S403B
Awards
Student Travel Stipend Award
Participants
Manav Bhalla, MD , Milwaukee, WI (Presenter) Nothing to Disclose
Andrew P. Klein, MD, Pewaukee, WI (Abstract Co-Author) Nothing to Disclose
John L. Ulmer, MD, Milwaukee, WI (Abstract Co-Author) Stockholder, Prism Clinical Imaging, Inc Medical Advisory Board, General
Electric Company
Sarika Pamarthy, MBBS, MS, Columbus, OH (Abstract Co-Author) Nothing to Disclose
Kieran E. McAvoy, Milwaukee, WI (Abstract Co-Author) Nothing to Disclose
Brian Fitzsimmons, MD, Milwaukee, WI (Abstract Co-Author) Nothing to Disclose
Leighton P. Mark, MD, Milwaukee, WI (Abstract Co-Author) Nothing to Disclose
Stephen A. Quinet, MD, Milwaukee, WI (Abstract Co-Author) Nothing to Disclose
Namrata Bhalla, Brookfield, WI (Abstract Co-Author) Nothing to Disclose
PURPOSE
Cerebellar and brain stem strokes present with diverse symptomatology and often may not present with the classic stroke symptom
of unilateral weakness. Patients presenting with dizziness, vertigo, ataxia/gait disturbances, often receive suboptimal stroke
imaging. Our study analyzes distribution patterns in CT and MRI accuracy in posterior fossa stroke to identify possible causes of
under diagnosis and pitfalls in ED stroke screening protocols. Formulating refined clinical filters in the decision tree will improve
effective use of imaging and patient outcomes.
METHOD AND MATERIALS
77/500 patients (of 1000 planned in this ongoing retrospective institutional study) presented with posterior fossa symptoms
including dizziness, vertigo, ataxia and gait disturbances. CT/MRI imaging was performed within a 24-hour interval. The accuracy,
positive (PPV) and negative (NPV) predictive values of final CT/MRI interpretations were calculated using final clinical discharge
diagnosis as the gold standard.
RESULTS
Overall, 42/500 patients had posterior fossa strokes which were all identified by MRI; 11 presented within the 0-4.5 hr tPA window
period (only 1 CT positive, i.e. 9%), 6 within 4.5-24 hrs period (1 CT positive, i.e. 17%) and 25 after 24 hours (7 CT positive, i.e.
28%) of presentation. Amongst the patients presenting with localizing symptoms, 26/77 (33%) patients had stroke (compared to
overall stroke incidence of 47.7%). Half of these strokes were located in cerebellar and/or brain stem, where CT is only 21%
sensitive. If this happens to be in 0-4.5 hrs period, it further drops to 9%. MRI is highly sensitive and superior to CT, in accuracy
and predictive value, across different time frames and symptom profiles.
CONCLUSION
Appropriate patient selection and robust clinical filters will improve quality of CT/MRI stroke evaluation of the posterior fossa. MRI
has greater diagnostic value, especially in CT negative patients with unresolved symptoms. Other confounding factors that favor
use of MRI include symptom overlap with varying territory of involvement and the need to rule out non-vascular etiology.
CLINICAL RELEVANCE/APPLICATION
Preferential utilization of MRI may be justified in critical posterior fossa strokes where there is significant risk of a missed
diagnosis/mortality.
SSM07-04
Eliminating Medical Waste: Unnecessary Head CTs in Healthy Adults
W ednesday, Nov. 30 3:30PM - 3:40PM Room: S403B
Awards
Trainee Research Prize - Resident
Participants
Douglas T. Hidlay Jr, MD, Providence, RI (Presenter) Nothing to Disclose
Jin K. Jung, MD, Providence, RI (Abstract Co-Author) Nothing to Disclose
Matthew R. Shalvoy, MD, Cumberland, RI (Abstract Co-Author) Nothing to Disclose
Brian L. Murphy, MD, Barrington, RI (Abstract Co-Author) Nothing to Disclose
PURPOSE
To examine the diagnostic yield of brain imaging in adults without trauma presenting to the emergency room.
METHOD AND MATERIALS
All brain computed tomography (CT) examinations performed at our institution as part of an emergency room (ER) visit during 2015
for patients age 18-40 were reviewed (n = 3302). Exclusion criteria were pregnancy or within 2 weeks postpartum, head trauma
within the previous two weeks, prior known intracranial pathology and/or procedure, and referral based on outpatient imaging. In
the end, 685 cases met inclusion criteria and were reviewed for positive findings. For each study, the patient's demographics and a
brief clinical history were recorded, including presenting complaint(s), Glasgow Coma Scale (GCS), and both prior and subsequent
imaging findings.
RESULTS
Nineteen cases had positive intracranial findings (2.8%). Their chief complaints were altered mental status (9),
new/unevaluated seizures (5), hemiplegia (3), and progressive focal visual deficits (2). If a patient was GCS 15 at time of
presentation without hypertensive emergency/urgency, a new/unevaluated seizure disorder, visual changes, or hemiplegia, their CT
scan was negative. In absence of a known malignancy or hypertensive urgency/emergency, a prior negative CT brain examination
also had a NPV of 100%.
CONCLUSION
During 2015, 685 head CTs performed in patients 18-40 years old presenting to the ER without trauma yielded 19 positive results,
translating to a diagnostic yield of 2.8%. If CTs were only performed for patients with a GCS of 14 or less, hypertensive
urgency/emergency, new/unevaluated seizures, persistent visual deficits, or hemiplegia, 579 head CTs (85%) could have been
omitted without missing any of the 19 positives cases, eliminating substantial healthcare cost and reducing unnecessary radiation
exposure to patients. This finding represents a significant opportunity for improving the quality of care delivered in the ER
nationwide and warrants further investigation.
CLINICAL RELEVANCE/APPLICATION
Adults under 40 presenting to the ER without trauma are a low-risk population for intracranial pathology and as many as 85% of
brain CTs could potentially be eliminated from the diagnostic work-up.
SSM07-05
The Role of Computed Tomography (CT) in Predicting Diplopia in Orbital Blunt Trauma
W ednesday, Nov. 30 3:40PM - 3:50PM Room: S403B
Participants
Michaela I. Cellina, Milan, Italy (Presenter) Nothing to Disclose
Caterina Bebbere, Sassari, Italy (Abstract Co-Author) Nothing to Disclose
Marcello A. Orsi, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose
Giancarlo Oliva, Milan, Italy (Abstract Co-Author) Nothing to Disclose
PURPOSE
The management of orbital fracture, in terms of need of surgical repair and timing of surgery, is controversial: the evaluation of
diplopia is the most important criterion for planning whether to undertake surgical intervention.Or aim was to determine the orbital
CT findings that can be used to predict the development of permanent diplopia in patient with orbital fractures.
METHOD AND MATERIALS
We retrospectively evaluated CT of all patients presented to our Emergency Department for blunt craniofacial trauma (N=3334)
from January 2014 to March 2016, selecting only patient with CT-demonstrated orbital fracture.The following CT variables were
assessed: fracture location (medial wall, floor, lateral wall, roof, medial wall + floor, lateral wall +floor, lateral wall + roof, multiple
locations), fracture multifocality, bone fragments displacement, extraocular muscle thickening, muscle entrapment, muscle
displacement, muscle hooking, intraconal emphysema, extraconal emphysema, intraconal hematoma, extraconal hematoma, fat
herniation.All patients underwent complete ophthalmological evaluation and Hess-Lancaster test, in order to establish the presence
of diplopia.After performing group comparison with Pearson χ2 test, we derived our prediction model by using logistic regression,
with diplopia as the prediction and CT variables as predictors.
RESULTS
We observed 299 patients (male: 221; female: 78; age range:4-93 years; mean age:46) with orbital fracture due to a blunt
trauma, 46 (15.4 %) with a Hess Lancaster test-proven diplopia.The CT variables with statistically significant difference between
the group with diplopia and the group without diplopia were as follows: floor fracture (p=.014), bone fragments displacement
(p=.001), multifocality (p=.005), muscle thickening (p=.001), muscle entrapment (p<.001), muscle displacement (p<.001), fat
herniation (p=.003)The CT variables with significance as predictors of diplopia were: floor location (odds ratio [OR], 2.87; 95%
confidence interval [CI]:1.22, 6.73; p=.01), muscle thickening, muscle entrapment (OR, 10.69; 95% CI:3.76, 30.4; p<.001) and
muscle displacement (OR, 11.51; 95% CI:3.05, 43.3; p<.001).
CONCLUSION
The development of persistent diplopia can be predicted on the basis of CT findings after an orbital trauma.
CLINICAL RELEVANCE/APPLICATION
Such patients should be directed toward early surgical repair in order to re-establish extraocular muscle function.
SSM07-06
Blunt External Larynegeal Injuries: Factors that Influence Accurate Prospective Diagnosis with
Computed Tomography
W ednesday, Nov. 30 3:50PM - 4:00PM Room: S403B
Awards
Student Travel Stipend Award
Participants
Sonya Khan, MD, Baltimore, MD (Presenter) Nothing to Disclose
Clint W. Sliker, MD, Ellicott City, MD (Abstract Co-Author) Nothing to Disclose
Deborah M. Stein, MD, PhD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Elizabeth A. Guardiani, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
PURPOSE
Determine accuracy of prospectively diagnosed blunt external laryngeal injury (BELI) with computed tomography (CT). Determine if
available clinical history or observation of coexisting facial or cervical injuries on the CT influences diagnostic accuracy.
METHOD AND MATERIALS
IRB approved, retrospective review of patients who presented to a Level I Trauma Center between January 2000
and September 2015, diagnosed with BELI and imaged with CT. Initial CT reports were reviewed, noting: if BELI was prospectively
diagnosed by reporting radiologist, the study indication, and if there were coexisting midfacial/mandible fractures and/or cervical
artery or spine injury. Multivariate linear regression analysis (p > 0.05) was used to determine likelihood of prospective CT diagnosis
of BELI when history suggesting injury or relevant mechanism was provided relative to when nonspecific history was provided.
RESULTS
76 patients met inclusion criteria (age 15-77 years, mean 42.3, SD 15.7). BELI was prospectively diagnosed by CT in 57.89%
(44/76) of patients. When history specifying laryngeal injury or anterior neck trauma was available at initial CT interpretation, BELI
was prospectively diagnosed in 50% (26/44) and 36% (16/44) of patients, respectively. Frequencies of coexisting
injuries were: 36.84% (28/76) midface/mandibular fractures, 13.16% (10/76) cervical spine injuries, and 6.67% (5/76) common
or cervical internal carotid artery injuries. Multivariate linear regression analysis shows that clinical history suggesting laryngeal
injury was significantly associated with accurate prospective diagnosis, coefficient 0.440222 (p = 0.044, CI [0.0125, 0.8678]).
Cervical spine injury was also significantly associated with a positive diagnosis, coefficient 0.4825736 (p= 0.014, CI [0.1008,
0.8642]).
CONCLUSION
When reviewing CT scans of the cervical region in patients with history of acute blunt trauma, radiologists will accurately diagnose
BELI more frequently if provided with a clinical history suggesting a laryngeal injury or if diagnosis is made of a coexisting cervical
spine injury.
CLINICAL RELEVANCE/APPLICATION
Blunt external laryngeal injuries are rare (incidence 0.04-0.06%) but clinically significant injuries for which early intervention can
improve outcomes. Early clinical diagnosis can be difficult, thus the radiologist may be first to suspect BELI, rendering it crucial for
him/her to understand when risk for BELI is high when reviewing cervical CT’s in post-blunt trauma patients.
MSES44
Essentials of Trauma Imaging
W ednesday, Nov. 30 3:30PM - 5:00PM Room: S100AB
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
FDA
Discussions may include off-label uses.
Participants
Sub-Events
MSES44A
Imaging of Pediatric Skeletal Trauma
Participants
Rutger A. Nievelstein, MD, PhD, Utrecht, Netherlands (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the important hallmarks of normal development of the pediatric skeleton relevant for the radiological evaluation of
skeletal trauma. 2) Learn about the key issues in imaging of pediatric skeletal trauma. 3) Discuss the most important differential
diagnoses including non-accidental injury.
ABSTRACT
Due to differences in anatomy, biomechanics, and physiology, the presentation of traumatic lesions in children will differ from that in
adults. This is reflected in the types of fractures specific to the pediatric age group and its healing propensity. Conventional
radiography is still the corner stone of imaging in pediatric skeletal trauma, although US, CT and MRI may be used for specific
indications such as complex injuries and suspected involvement of ligaments and/or internal articular structures. This lecture will
focus on the important hallmarks of normal skeletal development, the age-specific distribution and types of pediatric fractures, as
well as several differential diagnostic considerations (including non-accidental injury). Furthermore, imaging strategies in pediatric
skeletal trauma will be discussed.
Active Handout:Rutger A. J. Nievelstein
http://abstract.rsna.org/uploads/2016/16000917/MSES44A HANDOUT.pdf
MSES44B
Imaging Male Pelvic Trauma
Participants
Matthew T. Heller, MD, Gibsonia, PA, ([email protected] ​ ​ ​ ) (Presenter) Author, Reed Elsevier; Consultant, Reed Elsevier
LEARNING OBJECTIVES
1) List the most common injuries of the male pelvis. 2) Select the most appropriate imaging modality and summarize protocol
optimization. 3) Describe the key imaging findings of male pelvic trauma and their role in management.
ABSTRACT
Emergency imaging plays a critical role in triage of male pelvic trauma patients.Evaluation of testis rupture and other scrotal injuries
are accurately assessed with ultrasound. Characterization of bladder rupture as intraperitoneal versus extraperitoneal is efficiently
diagnosed with CT cystography. Suspected urethral injuries are best depicted with retrograde urethrography. MR is useful in the
evaluation of penile injuries. Choosing the most appropriate imaging modality and protocol optimization are essential components of
prompt diagnosis and initiation of treatment.
MSES44C
Blunt Traumatic Aortic Injuries
Participants
Ferco H. Berger, MD, Toronto, ON, ([email protected] ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Apply and choose the correct imaging protocol after blunt chest trauma. 2) Detect features indicating injury to the aorta after
blunt trauma, including more subtle injuries. 3) Explain the trauma mechanisms and associated injuries. 4) Develop confidence in
being a team player in the trauma team.
ABSTRACT
Blunt trauma to the chest can cause injury to the aorta and its major branching arteries. These injuries are still the second most
lethal condition in blunt trauma patients, after head injuries, and need urgent detection and treatment. In this presentation,
aortic injuries resulting from blunt trauma mechanisms will be discussed. These almost invariably result from high-impact trauma,
usually with rapid deceleration forces. Patients sustaining blunt traumatic aortic injury (BTAI) usually have many concomitant
injuries, that will distract from scrutinizing the aorta. Advancements in CT protocols, imaging findings, classification systems
and practice guidelines dealing with BTAI will be discussed. The goal is to increase confidence in diagnosing BTAI and making
recommendations for further treatment, increasing our value in the trauma team.
Active Handout:Ferco H. Berger
http://abstract.rsna.org/uploads/2016/16001482/mses44c BTAI - handout.pdf
http://abstract.rsna.org/uploads/2016/16001482/mses44c BTAI - handout.pdf
MSES44D
Interventional Radiology in Trauma Patients
Participants
Brian J. Schiro, MD, Miami, FL, ([email protected] ​ ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Learn the role of interventional radiology in the evaluation and treatment of trauma patients. 2) Review the embolization
methods in treating traumatic injury. 3) Review indications for IVC filters in trauma patients.
ABSTRACT
Interventional radiologists have a crucial role in the evaluation and management of trauma patients. Transcatheter arteriography
for the diagnosis of traumatic injury has been supplanted by accurate and expedient advanced cross-sectional imaging. However,
continued progress in endovascular and percutaneous therapies have propelled interventional radiology to the forefront of trauma
care. This discussion will focus on the vital impact that interventional radiology has on the trauma patient and will review various
therapeutic techniques and prophylactic interventions.
Active Handout:Brian Jason Schiro
http://abstract.rsna.org/uploads/2016/16000915/Trauma in IR_Handout.pdf
SPSC42
Controversy Session: Emergency Imaging: Is Pain in the Chest a Pain in the Neck?
W ednesday, Nov. 30 4:30PM - 6:00PM Room: E450B
CA
CT
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Charles S. White, MD, Baltimore, MD, ([email protected] ​ ​ ) (Moderator) Consultant, Koninklijke Philips NV
LEARNING OBJECTIVES
1) Review the clinical challenges related to diagnosing the cause of acute chest pain in the ED. 2) Describe the role of current
imaging techniques in evaluating patients who present with acute chest pain. 3) Discuss the feasibility, advantages, and challenges
related to use of coronary CTA to evaluate ED chest pain. 4) Review the advantages and disadvantages of using a triple rule-out
vs dedicated coronary CTA protocol to assess acute chest pain.
ABSTRACT
URL
Sub-Events
SPSC42A
Traditional Strategies Are Still Valuable for Evaluating Acute Coronary Syndromes (ACS)
Participants
Vasken Dilsizian, MD, Baltimore, MD (Presenter) Research Grant, General Electric Company; Research Grant, Siemens AG
LEARNING OBJECTIVES
View learning objectives under the main course title.
SPSC42B
Coronary CT Angiography (CCTA) Improves Over Traditional Strategies for ACS
Participants
Ricardo C. Cury, MD, Miami, FL, ([email protected] ​ ) (Presenter) Research Grant, General Electric Company; Research
Consultant, General Electric Company
LEARNING OBJECTIVES
1) Effectively utilize coronary computed tomography angiography (CTA) to properly diagnose, detect and evaluate emergency
department patients with acute chest pain or other symptoms suggestive of coronary artery syndrome. 2) Explain the relationship
between coronary CTA findings and the clinical outcome of patients with acute chest pain. 3) Utilize the appropriate noninvasive
studies to assess risk of acute coronary syndrome.
ABSTRACT
Coronary computed tomography angiography (CCTA) is a rapid and accurate technique to exclude the presence of CAD.
Furthermore, the immediate and future likelihood of cardiac events in patients with no or minimal CAD is extremely low for patients
with acute chest pain. In light of these favorable test characteristics, several single-center and more recently, multicenter studies
have demonstrated the feasibility, safety, and accuracy of CCTA in the ED to assess chest pain patients.
URL
SPSC42C
Which is Better: Triple Rule-out or Standard CCTA?
Participants
Charles S. White, MD, Baltimore, MD, ([email protected]) (Presenter) Consultant, Koninklijke Philips NV
LEARNING OBJECTIVES
View learning objectives under the main course title.
SPSC43
Controversy Session: Pelvic Imaging in the Emergency Department: Ultrasound, CT or MRI?
W ednesday, Nov. 30 4:30PM - 6:00PM Room: S404CD
GU
OB
CT
MR
US
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Douglas S. Katz, MD, Mineola, NY, ([email protected]) (Moderator) Nothing to Disclose
Mariam Moshiri, MD, Seattle, WA, ([email protected]) (Moderator) Consultant, Reed Elsevier; Author, Reed Elsevier;
LEARNING OBJECTIVES
1) To overview the current role of ultrasound, CT, and MR in the imaging of non-pregnant and pregnant women with known or
suspected acute pelvic conditions, with an emphasis on evidence-based information and societal guidelines, to discuss the
advantages and disadvantages of ultrasound, CT, and MR for imaging the acute female pelvis in several common/relatively common
scenarios to overview specific protocols for performing effective and accurate ultrasound, CT, and MR imaging examinations of the
acute female pelvis, to discuss current controversies regarding the roles of ultrasound, CT, and MR in the imaging of the acute
female pelvis.
ABSTRACT
URL
Sub-Events
SPSC43A
US
Participants
Sheila Sheth, MD, Cockeysville, MD, ([email protected]) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under the main course title.
ABSTRACT
URL
SPSC43B
CT
Participants
Ana P. Lourenco, MD, Providence, RI, ([email protected]) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) To review radiation dose associated with current pelvic CT imaging. 2) To describe available strategies for minimizing radiation
dose. 3) To identify CT imaging findings in a variety of diagnoses in both pregnant and non-pregnant patients presenting with acute
pelvic pain.
ABSTRACT
In this session, we will review CT radiation dose, associated risks, and strategies to minimize patient dose. Cases will be shown to
highlight the diagnostic accuracy of CT in the ED as well as to illustrate how protocols may be optimized depending upon the
leading differential diagnosis.
URL
SPSC43C
MRI
Participants
Christine O. Menias, MD, Chicago, IL, ([email protected]) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Review the Role of MRI in acute Pelvic conditions in the Pregnant and Nonpregnant Patient in Case-Based format. 2) Discuss the
role of MRI in evaluating indeterminant lesions at US and CT in acute GYN conditions.
ABSTRACT
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Christine O. Menias, MD - 2013 Honored Educator
Christine O. Menias, MD - 2014 Honored Educator
Christine O. Menias, MD - 2015 Honored Educator
Christine O. Menias, MD - 2016 Honored Educator
ED004-TH
Emergency Radiology Thursday Case of the Day
Thursday, Dec. 1 7:00AM - 11:59PM Room: Case of Day, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON (Presenter) Nothing to Disclose
Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose
Christina A. LeBedis, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
David Dreizin, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose
Manickam Kumaravel, MD, FRCR, Houston, TX (Abstract Co-Author) Nothing to Disclose
Constantine A. Raptis, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose
David D. Bates, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Thomas Battey, Timonium, MD (Abstract Co-Author) Nothing to Disclose
Nicholas M. Beckmann, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose
TEACHING POINTS
1) Recognize key imaging findings on multimodality imaging of emergency/trauma patients. 2) Develop differential diagnosis based on
the clinical information and imaging findings. 3) Recommend appropriate management including image-guided interventions.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
SPDL50
RSNA Diagnosis Live™: Musculoskeletal and Emergency Department Imaging-From Sports to Trauma
Thursday, Dec. 1 7:15AM - 8:15AM Room: E451B
MK
MR
ER
AMA PRA Category 1 Credit ™: 1.00
ARRT Category A+ Credit: 1.00
Participants
Eric B. England, MD, Cincinnati, OH, ([email protected] ​ ) (Presenter) Nothing to Disclose
Carl C. Flink, MD, Cincinnati, OH (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Identify a variety of common sports injuries utilizing MRI. 2) Review clinical presentations of sports injuries that present to
orthopedic clinics and how these presentations can assist in the diagnosis when correlated with imaging. 3) Review a variety of
typical and atypical musculoskeletal injuries that present to the Emergency Department. This interactive session will use RSNA
Diagnosis Live™. Please bring your charged mobile wireless device (phone, tablet or laptop) to participate.
ABSTRACT
URL
RC608
Updating Your Emergency Radiology Practice
Thursday, Dec. 1 8:30AM - 10:00AM Room: E353B
CT
MR
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
FDA
Discussions may include off-label uses.
Participants
Sub-Events
RC608A
Improving Imaging Appropriateness
Participants
Bruce E. Lehnert, MD, Seattle, WA (Presenter) Research support, Koninklijke Philips NV
LEARNING OBJECTIVES
1) Discuss the variability in and appropriateness of advanced imaging utilization and address potential sources of variability in
practice. 2) Review utilization control strategies and their effectiveness in improving imaging appropriateness, including Clinical
Decision Support. 3) Discuss PAMA legislation and its implications for radiology.
RC608B
Optimizing Emergency Cardiothoracic CT and MR Imaging Protocols
Participants
Constantine A. Raptis, MD, Saint Louis, MO (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the key components of CT protocols which are appropriate for thoracic imaging in the emergency department setting. 2)
Review indications and protocols for MRI of the thorax in the emergency department setting. 3) Identify potential pitfalls and
artifacts which may be encountered on CT and MRI of the thorax which are relevant to imaging in the emergency department.
ABSTRACT
RC608C
Update on Dual-energy CT in the Emergency Department
Participants
Savvas Nicolaou, MD, Vancouver, BC (Presenter) Institutional research agreement, Siemens AG
LEARNING OBJECTIVES
1) Review the basic principles of dual energy CT/Spectral imaging. 2) Discuss novel techniques implemented using dual energy CT in
the acute setting including: material characterization/decomposition, bone subtraction, virtual non-contrast, iodine distribution
maps, and monoenergetic spectral imaging. 3) To explain the utility of dual energy/spectral imaging in the acute care setting with
examples in cardiopulmonary imaging, vascular imaging, intracranial aneurysms and stroke imaging, blunt vascular neck injuries,
abdominal imaging and musculoskeletal applications.
ABSTRACT
RC608D
Optimizing Emergency Musculoskeletal CT and MR Protocols
Participants
Meir H. Scheinfeld, MD, PhD, Bronx, NY, ([email protected] ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Identify clinical scenarios where MR or CT would be appropriate for the evaluation of emergency musculoskeletal conditions. 2)
Optimize emergency department musculoskeletal CT protocols for detection of pathology. 3) Optimize emergency department
musculoskeletal MR protocols for detection of pathology.
ABSTRACT
SSQ05
Emergency Radiology (Musculoskeletal and Spine Imaging)
Thursday, Dec. 1 10:30AM - 12:00PM Room: S405AB
MK
CT
MR
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
FDA
Discussions may include off-label uses.
Participants
Clint W. Sliker, MD, Ellicott City, MD (Moderator) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Moderator) Institutional research agreement, Siemens AG
Sub-Events
SSQ05-01
Evaluating the AAST Clinical Decision Rule for Thoracolumbar Spine Evaluation after Blunt Trauma in
a Large Level 1 Trauma Center-Is it as Effective as Screening Imaging?
Thursday, Dec. 1 10:30AM - 10:40AM Room: S405AB
Participants
Enrique Rodriguez, MD, Detroit, MI (Presenter) Nothing to Disclose
Brent D. Griffith, MD, Troy, MI (Abstract Co-Author) Nothing to Disclose
Britton J. Carter, MD, Detroit, MI (Abstract Co-Author) Nothing to Disclose
Feras Mossa-Basha, MD, Detroit, MI (Abstract Co-Author) Nothing to Disclose
Stephen Zintsmaster, MD,MPH, Royal Oak, MI (Abstract Co-Author) Nothing to Disclose
Suresh C. Patel, MD, Detroit, MI (Abstract Co-Author) Nothing to Disclose
Todd Williams, MD, Detroit, MI (Abstract Co-Author) Nothing to Disclose
Phyllis Vallee, MD, Detroit, MI (Abstract Co-Author) Nothing to Disclose
PURPOSE
Injuries to the thoracic and lumbar (TL) spine due to blunt trauma are a common cause for presentation to emergency departments
(ED). In 2015, the American Association for the Surgery of Trauma (AAST) published a prospectively derived clinical decision rule
for thoracolumbar spine evaluation after blunt trauma. The purpose of this study was to evaluate the accuracy of this decision rule
and determine how many TL spine reformats would have been unnecessary had the rule been prospectively applied.
METHOD AND MATERIALS
1000 consecutive patients who underwent CT Chest, Abdomen, Pelvis (CT CAP) with TL spine reformatted images following blunt
trauma were retrospectively reviewed. Patients with penetrating injury, age < 15 yrs, injury > 48 hrs prior to presentation, known
TL spine fracture, and those not evaluated by an ED physician were excluded. Clinical and imaging records of the patients were
reviewed to identify all AAST decision rule criteria (alert and evaluable, physical exam, high risk mechanism, age > 60 yrs) and
determine the presence of TL spine fracture.
RESULTS
Of the 1000 patients, 900 met study inclusion criteria, of which 66 (7.3%) had TL spine fractures. Of the 900, 535 patients were
not evaluable by the AAST decision rule (i.e., not alert and evaluable, C-spine or other distracting injury)(Fig 1). Of the remaining
365 patients, 20 (5.5%) had TL spine fractures. The decision rule correctly identified 17 of these 20 patients with fractures for a
sensitivity of 85%, but with a100% sensitivity for fractures requiring surgical management or bracing. Of the 365 patients evaluable
by the AAST decision rule, 102 (27.9%) would have met the criteria for not requiring imaging, of which 3 had fractures detected
(Fig 2).
CONCLUSION
The AAST clinical decision rule for TL spine evaluation after blunt trauma identified all fractures of the TL spine requiring surgical
management or bracing and would have resulted in a 27.9% reduction in the number of required TL spine reformats. However, the
performance of the decision rule in detecting fractures not requiring surgical management or bracing was suboptimal for a screening
tool and further evaluation of its accuracy is necessary prior to widespread implementation.
CLINICAL RELEVANCE/APPLICATION
Fractures not requiring surgical management or bracing can still alter patient management and clinicians utilizing this clinical
decision rule must take this into consideration when forgoing imaging.
SSQ05-02
Revisiting the ACR Appropriateness Criteria for Acute Midfoot Fractures: 5-Year Study of Limitations
of Radiography in 400 Patients
Thursday, Dec. 1 10:40AM - 10:50AM Room: S405AB
Awards
Student Travel Stipend Award
Participants
Mohammad Mansouri, MD, MPH, Boston, MA (Presenter) Nothing to Disclose
Renata R. Almeida, boston, MA (Abstract Co-Author) Nothing to Disclose
Michael H. Lev, MD, Boston, MA (Abstract Co-Author) Consulant, General Electric Company; Institutional Research Support, General
Electric Company; Stockholder, General Electric Company; Consultant, MedyMatch Technology, Ltd; Consultant, Takeda
Pharmaceutical Company Limited; Consultant, D-Pharm Ltd
Ajay K. Singh, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Efren J. Flores, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
Midfoot fractures are missed in 20%of initial visits.Missing midfoot fractures can cause pain, pseudoarthrosis,arthritis,deformity and
amputation.Our aim is to analyze Lisfranc and Chopart fractures and to provide an evidence-based flowchart to reduce missed
fractures.
METHOD AND MATERIALS
This is a HIPAA compliant,IRB approved,retrospective study conducted between 2010 and2014.PACS system of our institution was
searched for Lisfranc and Chopart fractures.Diagnosis was made based on imaging modalities.Patients were divided into
2categories:high-energy(motor vehicle accidents,fall from height)and low-energy trauma(slips and twisting,simple fall,blunt
trauma)based on medical records.
RESULTS
400 patients were analyzed(mean 46.5 years;54.3% male).Lisfranc fracture was diagnosed in 65.0%(260/400), Chopart in 33.3%
(133/400) and 1.8%(7/400)had both.The most common associated fracture was fibular diaphysis (8.5%;34/400).CT had the highest
overall sensitivity (98.5%;203/206),followed by MRI (98.3%;58/59),weight bearing radiography (81.3%;65/80)and plain radiography
(79.7%;286/359).Overall, CT and MRI were significantly more sensitive than plain radiography and weight bearing radiography(all
p<0.001). Fractures were missed in 19.2%(77/400)of first visits.In missed cases,MRI and CT were significantly more sensitive
(97.7% and 92.9% respectively)comparing weight bearing radiography(42.9%)and plain radiography (18.1%)(all p<0.05).Most
common trauma history was low-energy (66.0%;264/400).Low-energy trauma cases were significantly missed more than highenergy trauma (p=0.04). In low-energy trauma,plain radiography and weight bearing radiography had the sensitivity of 77.5%and
80.3%respectively.CT and MRI are next steps and significantly more sensitive (99.1% and 98.0%respectively;both p<0.001).In
high-energy trauma,first step is plain radiography (82.9%sensitive)followed by CT which is significantly more
sensitive(97.9%;p<0.001).
CONCLUSION
Lisfranc and Chopart fractures were missed in the first presentation in19.2%of patients.Overall,CT and MRI were more sensitive to
detect these fractures.If radiographs are negative in the first visit and clinical suspicion remains for midfoot fracture,CT or MRI are
both equally efficient for the diagnosis of midfoot fractures.
CLINICAL RELEVANCE/APPLICATION
This study provides an opportunity to reassess imaging appropriateness of acute midfoot fractures to reduce delayed diagnosis that
negatively impact patient care
SSQ05-03
The (Lack of) Impact of Published Guidelines on Appropriate Imaging for Low Back Pain in the
Emergency Department
Thursday, Dec. 1 10:50AM - 11:00AM Room: S405AB
Awards
Student Travel Stipend Award
Participants
Sarvenaz Pourjabbar, MD, New Haven, CT (Presenter) Nothing to Disclose
Ali Raja, MD, MBA, Boston, MA (Abstract Co-Author) Nothing to Disclose
Ivan Ip, MD, MPH, Brookline, MA (Abstract Co-Author) Nothing to Disclose
Ramin Khorasani, MD, Boston, MA (Abstract Co-Author) Consultant, Medicalis Corp
PURPOSE
To quantify the impact of a Clinical Practice Guideline for imaging of patients with low back pain (LBP) (published by the American
College of Physicians and the American Pain Society in 2007) on imaging practices in the emergency department (ED).
METHOD AND MATERIALS
Informed consent was waived for this IRB-approved retrospective observational study. ICD-9 diagnosis codes were used to fetch
ED visits related to low back pain in patients 18-64 years old in two 2-year periods: 2005/2006 (just before the guideline was
published) and 2013/2014 (5 years after the guideline was published). Imaging performed within 24 hours of the ED admission was
considered related to that visit. As per the guideline, each imaging indication was linked to specific diagnosis and procedure codes
(ICD-9/CPT) which was used to confirm appropriateness of the imaging. In order to verify the accuracy of ICD-9/CPT method, 160
charts were randomly selected from the study cohort and manually reviewed. The primary outcome was the overall utility of imaging
and the secondary outcome was the proportion of inappropriate imaging. Chi-square test was used to compare the pre and post
guideline publication groups.
RESULTS
In 2005/2006, 3,221 unique ED visits (age: 40.4 ± 10, F:M 1235:1986 ) were due to low back pain, compared to 3,766 in
2013/2014 (age: 42.5 ± 12, F:M 1621:2145 ). Chart review of 160 charts showed a sensitivity and specificity of 89% & 96% using
the ICD-9/CPT codes. The use of cross-sectional imaging for these patients increased from 46% to 58% over the two time periods
(p=0.0001), however, the proportion of imaging not adherent to the guidelines remained the same (61%, p-value= 0.6). In patients
with imaging indicated by the guideline, 29.8% (337/960) in 2005-2006 and 42% (412/986) in 2013-2014 had imaging performed
(p=0.002).
CONCLUSION
The implementation of the guideline resulted in an overall increase in imaging, primarily due to an increase in the amount of imaging
of patients who met appropriate guideline criteria. Inappropriate imaging did not decrease; suggesting that guideline publication
alone is unlikely to change image-ordering behavior
CLINICAL RELEVANCE/APPLICATION
Publication of a Clinical Practice Guideline for low back pain imaging has not optimized imaging use.
Publication of a Clinical Practice Guideline for low back pain imaging has not optimized imaging use.
SSQ05-04
Is MR of the C-spine in Acute Trauma Patients Indicated?
Thursday, Dec. 1 11:00AM - 11:10AM Room: S405AB
Participants
Marlen Pajcini, MD, San Jose, CA (Presenter) Nothing to Disclose
Mahesh R. Patel, MD, San Jose, CA (Abstract Co-Author) Nothing to Disclose
Rajul P. Pandit, MD, San Jose, CA (Abstract Co-Author) Nothing to Disclose
John Sherck, MD, San Jose, CA (Abstract Co-Author) Nothing to Disclose
Adella Garland, San Jose, CA (Abstract Co-Author) Nothing to Disclose
Young S. Kang, MD, San Jose, CA (Abstract Co-Author) Nothing to Disclose
PURPOSE
In recent years, MR of the cervical spine has become part of the routine imaging protocol for selected indications in many trauma
centers. Because of the expense and complex operational requirements of MR, it is imperative to establish its effectiveness. While
there is ample anecdotal evidence and some clinical series demonstrating the utility of MR, we set out to examine the spectrum and
frequency of findings in MR performed on patients presenting to our Level I trauma center.
METHOD AND MATERIALS
A retrospective review of consecutive C-spine MR imaging studies over a two-year period ordered in the context of an acute
trauma was performed. Each study was assessed for the presence of the following findings: cord injury, ligamentous injury, soft
tissue/muscle injury, marrow/disc injury, and/or vascular injury. If none of these acute findings were present or if the MR study
demonstrated only findings that were seen on prior imaging studies, the study was categorized as negative for the purposes of the
analysis.
RESULTS
241 studies were identified. Indications included neurologic deficit or inability to perform clinical assessment. Cord injury was noted
in 17% (41/241), ligamentous injury in 43% (104/241), soft tissue/muscle injury in 29% (69/241), marrow/disc injury in 28%
(67/241), and vascular injury in 12% (28/241). 36% (86/241) of the analyzed studies were negative for acute findings or only
demonstrated findings that were previously known from prior imaging.
CONCLUSION
Ligamentous injury is the most common pathological finding in MR. Cord injury, which can have the most severe clinical
repercussions, was the least frequent finding at 17%. Slightly over one-third of analyzed cases were negative for any acute
findings or demonstrated findings that had been previously described. This indicates that in the majority of trauma patients for
which a C-spine MR study is ordered, an acute finding is generally present. While there may be variations in treatment protocols
among trauma centers in response to specific findings on MR, the overall high frequency of positive findings found in our study
validates the general concept of the use of MR in acutely injured patients who demonstrate neurologic deficit or cannot be
assessed clinically.
CLINICAL RELEVANCE/APPLICATION
Understanding the frequency of findings on C-spine MR imaging studies on acute trauma patients can allow radiologists to guide
ordering physicians in appropriate utilization.
SSQ05-05
The Impact of Total Spine MRI on Targeted Patient Selection for Surgical Therapy of Geriatric
Vertebral Fractures
Thursday, Dec. 1 11:10AM - 11:20AM Room: S405AB
Participants
Christoph Weber, MD, Hamburg, Germany (Presenter) Nothing to Disclose
Corinna Ossadnik, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
Theo Abel, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
Jonas Hafner, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
Hannah Hentschel, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
Peter Bannas, MD, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
PURPOSE
To assess the diagnostic accuracy of total spine MRI in the diagnosis of vertebral fractures in comparison to conventional
radiographs (CR) and to evaluate its effect on surgical therapy (vertebro-/kyphoplasty, spondylodesis etc.) in geriatric patients.
METHOD AND MATERIALS
The vertebral bodies (n=2736) of 114 "geriatric" patients, average age 84y (75-96y) were measured by the method of Genant on
total spine MRI and CR performed on average within 2d (0-17d) before to determine morphology (normal, wedge, biconcave, crush)
and to graduate deformity."Geriatric" was defined as age >75y. All patients suffered from back pain after mild trauma. Two
radiologists independently evaluated the images (T1/T2/STIR sequences). Interobserver agreement was assessed by kappa
statistics. Surgical treatment was indicated, when the fracture was fresh (fluid sign on edema sensitive STIR sequence, fracture
line), the patient had <5 total fractures and the posterior border was involved.
RESULTS
Qualitatve analysis revealed n=520/2736 vertebral bodies fractured, quantitatve analysis by the method of Genant increased the
amount of vertebral fractures/deformities to n=1062/2736. The presence of a fluid sign on STIR sequences and a fracture line
indicated the recentness of the vertebral fracture in 7% (n=202/2736) of vertebral bodies measured. 38 % (n=78//202) of these
recent fractures were missed on CR (p=0.019), 7 % (n=14/202) were distant from the location of pain and not imaged by CR. The
method of Genant revealed a reduction of heights in deformed vertebral bodies of ~3 mm, either on CR and MRI. Surgical therapy
was indicated in 53% (n=60/114) patients, 55% (n=33/60) rejected the recommended surgical intervention, 18% underwent
vertebro-/kphoplasty, 6% spondylodesis. Surgical therapy was predominantly indicated based on MRI data. κ-scores for
interobserver agreement for existing fractures were as follows: MRI, κ = 0,754; CR, κ = 0,488; for posterior border involvement,
respectively: MRI, κ = 0,718; CR, κ = 0,567.
CONCLUSION
Interobserver agreements were much better for MRI than for CR. For an accurate selection of patients with vertebral fractures for
surgical therapy after mild trauma total spine MRI represents a significant improvement to detect recent vertebral fractures in
geriatric patients.
CLINICAL RELEVANCE/APPLICATION
Total spine MRI is the method of choice to detect vertebral fractures and to select vertebral fractures for surgical therapy in
geriatric patients.
SSQ05-07
140 kVp Spectral Filtration CT of the Lumbar Spine: Reduced Radiation Dose in the Emergency
Setting
Thursday, Dec. 1 11:30AM - 11:40AM Room: S405AB
Awards
Student Travel Stipend Award
Participants
Sheldon J. Clark, MD, Vancouver, BC (Presenter) Nothing to Disclose
Bo Gong, MSc, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Patrick J. Slipp, MD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose
Michael E. O'Keeffe, MBBCh, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG
Patrick D. McLaughlin, FFRRCSI, Vancouver, BC (Abstract Co-Author) Speaker, Siemens AG
PURPOSE
Imaging of the lumbar spine is often indicated in symptomatic patients who have undergone low velocity trauma. The purpose of
this study is to compare image quality and diagnostic accuracy of a conventional 120 kVp CT with a 140 kVp CT with tin filter in
acute trauma patients. A 140 kVp with tin filter CT can be obtained at 1/3 of the dose of a conventional 120 kVp CT.
METHOD AND MATERIALS
Institutional review board approval was obtained, with no informed consent required, for this retrospective analysis. 97 consecutive
trauma patients underwent abdominal scans using a dual source, dual energy 128-slice CT system (Definition FLASH; Siemens
Healthcare, Forchheim, Germany). Image noise, spatial resolution, contrast resolution, diagnostic acceptability, and diagnostic
accuracy for fractures/soft tissue injuries were compared between the conventional 120 kVp CT (mixed data set) and the 140 kVp
with tin filter CT (single data set) using a 10 point scoring system (1=unacceptable, 5=acceptable, 10=excellent). These
parameters were reviewed by two radiologists. Analysis between the two CT data sets were analyzed using one-way paired-ttests.
RESULTS
The average radiation dose for the conventional 120 kVp CT was 6.1 +/- 2.3 mSv. The 140 kVp with tin filter CT is approximately
1/3 of the dose, and would be 2 mSv. Image noise, spatial resolution, contrast resolution, diagnostic acceptability, and diagnostic
accuracy were well matched between the two readers. There were statistically significant (p<0.05) decreases in image noise
(9.7+/-0.5 vs. 8.4 +/-0.9), spatial resolution (9.6+/-0.6 vs. 8.4+/-1.0), contrast resolution (9.3+/-0.8 vs. 8.0+/-1.0), and
diagnostic acceptability (9.97 +/- 0.17 vs. 9.91+/-0.29). No fractures or soft tissue injuries were missed in either data sets.
CONCLUSION
No fractures or soft tissue injuries were missed on the 140 kVp with tin filter CT when compared with the conventional 120 kVp CT.
While image quality was statistically decreased, all parameters were within the range of acceptability. These results suggest that in
specific cases, an ultra low dose lumbar spine imaging protocol can be performed at 1/3 of the conventional dose.
CLINICAL RELEVANCE/APPLICATION
The ability to acquire a CT examination of the lumbar spine at approximately 1/3 of the conventional dose with no degradation in
image quality or reduction in diagnostic accuracy for vertebral body fracture or soft tissue injury is a substantial benefit.
SSQ05-08
Is Tomosynthesis More Accurate than Radiography in Detecting Subtle Hip Fractures?
Thursday, Dec. 1 11:40AM - 11:50AM Room: S405AB
Participants
Naveen Parasu, MBBS, Hamilton, ON (Presenter) Nothing to Disclose
Jane Castelli, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
Sandra Monteiro, PhD, Hamilton, ON (Abstract Co-Author) Nothing to Disclose
David A. Koff, MD,FRCPC, Hamilton, ON (Abstract Co-Author) Stockholder, Real Time Medical, Inc Spouse, President, Real Time
Medical, Inc
Katelyn Nye, Waukesha, WI (Abstract Co-Author) Employee, General Electric Company
John M. Sabol, PhD, Waukesha, WI (Abstract Co-Author) Employee, General Electric Company
PURPOSE
Digital tomosynthesis with flat-panel detector radiography is a novel application that allows easy, swift volume data acquisition of
any anatomical site of interest with arbitrary patient posture. A single sweep of the X-ray tube provides multiple tomographic
images of high resolution giving superior anatomical detail, potentially demonstrating fractures not identified on radiographs. The
purpose of this study is to demonstrate that using digital tomosynthesis, in conjunction with radiographs, is better at detecting
subtle and occult hip fractures than radiographs alone.
METHOD AND MATERIALS
This was a prospective 8-month study that assessed adult patients presenting to ER with a suspected hip fracture following a
fall. For study purposes, a hip fracture was defined as involving either proximal femur or pelvis. Patients with prior hip fractures
or surgery were excluded from study. 62 patients (M=24; F=38; average age=79 yrs) without an obvious hip fracture on
radiographs (as determined by the technologist) proceeded immediately to tomosynthesis. Images were reviewed by
musculoskeletal radiologists.
RESULTS
Of the 62 patients, 15 had hip fractures confirmed by either surgery or medical treatment. CT confirmed fracture in 3 patients.The
fracture location and corresponding patient numbers were as follows: Femoral neck/intertrochanteric region (5); acetabulum (5);
pubic rami (4); sacral ala (1). 6 patients (5 femoral and 1 acetabular fracture) had surgical management.Radiographs showed
fracture in 8 of the 15 patients with no false positive cases (sensitivity=53%; specificity=100%). Tomosynthesis detected all 15
fractures with no false positive cases (sensitivity and specificity were both 100%).Among the 47 patients with no fractures, 3 had
CT while 2 had MRI, which confirmed no evidence of bony trauma. The remaining 42 patients had their medical records reviewed 30
days following their initial ER visit and discharge, which confirmed no further admissions from the initial hip injury.
CONCLUSION
The study shows that tomosynthesis is an accurate imaging modality in detecting subtle, nondisplaced hip fractures which may not
be readily apparent on initial radiographs.
CLINICAL RELEVANCE/APPLICATION
Digital tomosynthesis provides an early and accurate diagnosis of hip fractures, particularly in centers where CT or MRI is not
readily available and is also significantly less expensive.
SSQ05-09
Systematic Radiation Dose Reduction in Cervical Spine Computed Tomography of Human Cadaveric
Specimens - How Low Can We Go?
Thursday, Dec. 1 11:50AM - 12:00PM Room: S405AB
Participants
Anna Hirschmann, MD, Basel, Switzerland (Presenter) Nothing to Disclose
Dorothee Harder, Basel, Switzerland (Abstract Co-Author) Nothing to Disclose
Clemens Reisinger, MD, Basel, Switzerland (Abstract Co-Author) Nothing to Disclose
Johanna Lieb, Basel, Switzerland (Abstract Co-Author) Nothing to Disclose
Zsolt Szucs-Farkas, MD, PhD, Berne, Switzerland (Abstract Co-Author) Nothing to Disclose
Sebastian T. Schindera, MD, Basel, Switzerland (Abstract Co-Author) Research Grant, Siemens AG; Research Grant, Ulrich GmbH &
Co KG; Research Grant, Bayer AG; Speakers Bureau, Bayer AG
Magdalini Tozakidou, MD , Basel, Switzerland (Abstract Co-Author) Nothing to Disclose
PURPOSE
To compare image quality of computed tomography (CT) images of the cervical spine of cadaveric specimens at different radiation
dose levels reconstructed with a filtered back projection (FBP) and an iterative reconstruction (IR) algorithm.
METHOD AND MATERIALS
The cervical spine of four human formalin-fixated cadavers (mean BMI; 30.5 kg/m2 ± 5.2; range 24-36) was examined using a 128MDCT scanner (DefinitionAS/Siemens) at nine different reference tube current-time products (45/ 75/ 105/ 135/ 150/ 165/ 195/
275/ 355 mAs) and a tube voltage of 120 kVp. Automatic tube current modulation was applied (CareDose 4D). Data were
reconstructed using both FBP and IR (SAFIRE/Siemens; strength 3). Morphological characteristics (vertebral cortex,
anterior/posterior vertebral integrity, conspicuity of trabecular bone, posterior vertebral alignment, facet joint alignment) were
quantified on a Likert-scale for each cervical segment by four independent and blinded radiologists. Subjective image noise was
evaluated on a three-point scale. Signal-to-noise ratio (SNR) was measured. Statistical analysis included analysis of variance and
Tukey’s-test.
RESULTS
IR provided significantly better image quality than FBP (P<0,001); noise increased as radiation dose decreased. Subjective image
noise at levels C1-C4 was rated as either “no noise” or as “acceptable noise” in all scans. At lower spine levels subjective image
noise was not acceptable, even at 355 mAs. Shoulder position of all human cadaveric specimens was found to be at level C5.
Analyzing all spinal levels, scores for morphological characteristics revealed no significant differences between 105 and 355 mAs
(P=0,555), but were significantly worse in scans at lower 45 (P < 0,001) and 75 mAs (P=0,025).
CONCLUSION
Clinically acceptable image quality of the cervical spine of cadaveric specimens with different body habitus can be achieved with
reference mAs of 105. High position of the shoulders is a limiting factor even with high radiation doses; therefore pulldown of both
shoulders during acquisition is fundamental.
CLINICAL RELEVANCE/APPLICATION
Radiation dose for cervical spine CT may be significantly reduced in patients with a low shoulder position.
ERS-THA
Emergency Radiology Thursday Poster Discussions
Thursday, Dec. 1 12:15PM - 12:45PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Clint W. Sliker, MD, Ellicott City, MD (Moderator) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Moderator) Institutional research agreement, Siemens AG
Sub-Events
ER238-SDTHA1
Clinical Relevance of Consecutive CT Scans for the Evaluation and Monitoring of Geriatric Pelvic
Fractures
Station #1
Participants
Christoph Weber, MD, Hamburg, Germany (Presenter) Nothing to Disclose
Peter Bannas, MD, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
Wolfgang Lehmann, MD, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
Thies H. Schroeder, MD, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose
PURPOSE
To evaluate consecutive computed tomography (CT) imaging in fragility fractures of the pelvis (FFP) in geriatric patients and to
prove its effect on the indication for surgical stabilisation treatment.
METHOD AND MATERIALS
60 CT Scans of 29 consecutive patients >75y (mean age 83,8±7,8y, 27f/2m) with a history of low impact energy trauma and
confirmed pelvic fracture, who had received CT for fracture evaluation and at least one consecutive CT for follow up during the
following month after pain adapted ambulation, were evaluated. Pelvic fractures were classified according to the system established
by Rommens/Hofmann for fragility fractures of the pelvis. The Barthel ADL index was used as a measure of physical disability after
admittance.
RESULTS
Follow up CT was acquired 14±4,6 days after initial CT. Isolated fractures of the anterior pelvic ring (FFP Type Ia,b) were initially
detected in 13,8% (n=4) of patients. Combined fractures of the anterior and posterior pelvic ring with moderate instability (FFP
Type IIa,b,c) accounted for 65,5% (n=19), higher (FFP Type IIIa,b,c) for 3,4% (n=1) and highest instability (FFP Type IVa,b,c) for
17,2% (n=5). 10 patients (34,5%) deteriorated in fracture classification during follow up (3 patients within one category, 4 patients
deteriorated by one category, and 3 patients by two categories). There was no significant difference in age or physical disability
between patients that showed fracture deterioration and those that did not.
CONCLUSION
Aggravation of fractures in over a third of patients may indicate that a more aggressive, surgical approach is needed in the
management of FFP in the elderly. A progressive surgical approach for FFP IIb+ fractures of the anterior and posterior pelvic ring
may prevent aggravation, e.g.by sacro-iliacal screw osteosynthesis.
CLINICAL RELEVANCE/APPLICATION
Conventional Radiography is insufficient in detecting fragility fractures of the pelvis in geriatric patients. CT is mandatory for
the initial grading with FFP-Classification and to indicate and plan surgical stabilisation therapy, e.g.by sacro-iliacal screw
osteosynthesis.
ER239-SDTHA2
Mild Traumatic Brain Injury (MTBI): Screening Computerized Tomography(CT)?Utility of Clinical
Guidelines in a Tertiary Referral Hospital in Spain
Station #2
Participants
Susana Manso Garcia, DDS, valladolid, Spain (Presenter) Nothing to Disclose
Maria J. Velasco-Marcos Sr, MD, PhD, Valladolid, Spain (Abstract Co-Author) Nothing to Disclose
Santiago Marzoa Ruiz, Valladolid, Spain (Abstract Co-Author) Nothing to Disclose
Marta Moya de la Calle, Valladolid, Spain (Abstract Co-Author) Nothing to Disclose
Arnold Antonio Montes Tome, Valladolid, Spain (Abstract Co-Author) Nothing to Disclose
PURPOSE
To analyze two available prognostic tools sus as the Canadian standard(CT) and New Orleans(NO),both internationally accepted,in
order to avoid unnecessary TC.To asses their applicability to decision making in the diagnosis of MTBI.
METHOD AND MATERIALS
Cross-sectional study in Emergency department of a tertiary hospital in patients with diagnosis of MTBI.SPSS20.0 computer
program was used to analyze the variables: demographic,clinical,classification,diagnostic management,complementary test,results
and CT and NO criteria.CT was performed to 308 out of 1329 patients with MTBI(23,17%).The data from these 308 patients who
were submitted to CT as additional proof were analyzed,showing that 47,4% of the applications did meet NO criteria for CT and
73,4%met CT criteria
RESULTS
The results to CT were normal in 83,4% cases. Amog those in which CT showed pathology,74,5% met CT criteria an 58,8% NO
criteria,statistically significant(ES).Among the pathological CT,56,9% patients suffered loss of consciousness and 37,6% were
hospitalized.In 58,8% of cases with a pathologic Ct a dangerous mechanic of injury was found as a cause(ES).
CONCLUSION
Most of the CT requested in patients with MTBI were no pathological.The CT criteria shows greater sensitivity and specify than NO
criteria.We haven,t found a relationship between pathological CT and loss of consciousness,however in this groupp a dangerous
mechanism of injury is often found a cause.
CLINICAL RELEVANCE/APPLICATION
The use of clinical guidelines in MTBI avoid unnecessary CT and radiation.CT criteria is better predictor of Clinically Important CT
Findings in our study.
ER240-SDTHA3
Does Criteria-based Direct Access to Polytrauma Whole-body CT in the Emergency Department lead
to Over-scanning? Could Plain Radiography have a Role in Selection of Patients for CT? Exploring a
Delicate Interplay between Specificity and Sensitivity
Station #3
Participants
Oliver Duxbury, MBBCh, BSc, Brighton, United Kingdom (Abstract Co-Author) Nothing to Disclose
Nikola Tomanovic, MBBS, Brighton, United Kingdom (Presenter) Nothing to Disclose
Ahmed Daghir, MRCP, FRCR, Oxford, United Kingdom (Abstract Co-Author) Nothing to Disclose
PURPOSE
A set of criteria for direct Emergency Department access to polytrauma whole-body CT scans were introduced in 2013 to help
guide clinical decision making and speed up patient imaging in the Emergency Department.This study looks at the use of plain
radiographs (XR) prior to CT acquisition and the proportion of “normal” scans, before and after the criteria implementation.
METHOD AND MATERIALS
A retrospective sample of 60 polytrauma whole-body CT scans, performed over a 2 month period, at a major trauma centre was
analysed in 2012, 2014 and 2015.We compare the proportion of patients undergoing XR of the chest or pelvis prior to whole body
CT, as well as the proportions of XR and CT studies reported as negative for acute injury, before (2012) and after (2014 and 2015)
introduction of these criteria.
RESULTS
The proportion of negative polytrauma whole-body CT scans rose from 27% in 2012, to 33% in 2014, to 47% in 2015.Over the
same time period, the proportion of patients undergoing chest XR has decreased from 73% in 2012 to 37% in 2014 and 0% in 2015
and the number undergoing pelvic XR from 60% in 2012 to 25% in 2014 and 2% in 2015.Of the 73% undergoing XR in 2012, 20% of
patients had negative XR and CT, 51% had positive XR and CT and 29% had a negative XR but positive CT. 27% of patients had no
XR, with 57% having positive and 43% negative CT.Of the 37% undergoing XR in 2014, 33% had negative XR and CT, 38% had
positive XR and CT and 28% had a negative XR but positive CT. 63% did not have XR, of which 48% had positive and 52% negative
CT.
CONCLUSION
Our results show how a criteria-based direct Emergency Department access to CT protocol leads to a gradual increase in the
numbers of negative CT scans but a dramatic decrease in the use of plain radiographs prior to CT. This suggests a lower threshold
for selection of patients who receive whole-body CT.It is not clear from our data, that using plain radiographs to aid clinical
judgement for patient selection would increase specificity sufficiently to lead to better outcomes. Further work is needed to better
classify the positive CT findings not seen on XR.
CLINICAL RELEVANCE/APPLICATION
Current data implies that faster access to CT removes the need for plain radiographs to direct urgent intervention for lifethreatening injuries. However, further work is required to ascertain if plain radiographs have a role in patient selection for CT in
certain patient subsets.
ERS-THB
Emergency Radiology Thursday Poster Discussions
Thursday, Dec. 1 12:45PM - 1:15PM Room: ER Community, Learning Center
ER
AMA PRA Category 1 Credit ™: .50
Participants
Clint W. Sliker, MD, Ellicott City, MD (Moderator) Nothing to Disclose
Savvas Nicolaou, MD, Vancouver, BC (Moderator) Institutional research agreement, Siemens AG
Sub-Events
ER242-SDTHB1
Radiology Resident Interpretations of Diffusion-weighted MR Imaging in the Emergency Department:
Is the Diagnostic Performance Influenced by Level of Residency Training?
Station #1
Participants
Hye Jin Baek, Changwon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Seung Jin Kim, MD, Basan, Korea, Republic Of (Presenter) Nothing to Disclose
Kyungsoo Bae, MD, Changwon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Kyung Nyeo Jeon, MD, Changwon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Dae Seob Choi, BA, Jinju, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Soo Buem Cho, Jinju, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Bo Hwa Choi, Changwon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Jin Il Moon, MD, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Hwa Seon Shin, Jinju, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
Hyun Kyung Jung, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose
PURPOSE
To determine the diagnostic performance of radiology residents interpretations for diffusion-weighted MR imaging (DWI) in the
emergency department at different levels of residency training.
METHOD AND MATERIALS
A total 160 patients who underwent DWI with acute neurologic symptoms were included in this retrospective study with
institutional review board approval. Four radiology residents with different training years and one attending neuroradiologist
independently assessed the results of DWI. Discordancies between the results of residents and attending neuroradiologist were
classified as followings; false-positive (FP) and false-negative (FN). We also evaluated a diagnostic performance of four residents
according to the reference standard. All data was analyzed by using Fisher’s exact test, kappa statistics, and ROC analysis.
RESULTS
Overall, the agreement rate was 84.8% with 15.2% of overall discrepancy rate. All of discrepancies were insignificant. There were
83 FN results. The most common misses were acute focal infarction (n=13), extraparenchymal hemorrhages (n=18), small vessel
disease (n=34), diffuse axonal injury (n=7), solitary mass (n=6), osmotic demyelination syndrome (n=2), and postictal change
(n=3). There were 14 FP results including hemorrhage and acute infarction. The 4-year resident showed the highest diagnostic
performance (Az value: 0.906; 95% CI: 0.850, 0.947; 87.5% of sensitivity; and 93.8% of specificity). The level of training had a
significant influence (P < 0.05) on their interpretations. Kappa statistics showed good agreement of results between residents and
attending neuroradiologists.
CONCLUSION
The level of resident training had a significant effect on their diagnostic performance, and there was a good interobserver
agreement between the results of residents and attending neuroradiologists. Therefore, radiology residents could safely make the
initial interpretation of DWI which underwent in ER, and formal reporting may wait until a suitable experienced radiologist is
available.
CLINICAL RELEVANCE/APPLICATION
Under on-call duty system, radiology residents can make the initial interpretation of emergent DWI safely , and formal reporting may
wait until a suitable experienced radiologist is available.
ER243-SDTHB2
Fractures of the Foot Sesamoids: 5-year Imaging Efficacy Analysis of an Underdiagnosed Acute
Injury
Station #2
Participants
Mohammad Mansouri, MD, MPH, Boston, MA (Presenter) Nothing to Disclose
Renata R. Almeida, boston, MA (Abstract Co-Author) Nothing to Disclose
Michael H. Lev, MD, Boston, MA (Abstract Co-Author) Consulant, General Electric Company; Institutional Research Support, General
Electric Company; Stockholder, General Electric Company; Consultant, MedyMatch Technology, Ltd; Consultant, Takeda
Pharmaceutical Company Limited; Consultant, D-Pharm Ltd
Ajay K. Singh, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Efren J. Flores, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
PURPOSE
Sesamoid fractures of the foot are uncommon but often missed in the first radiology exam. Missing them can cause pain, nonunion,
malunion and avascular necrosis. We aim to analyze sesamoid fractures of our large academic medical center and to investigate
sensitivity of imaging modalities in detecting sesamoid fractures.
METHOD AND MATERIALS
This is a HIPAA compliant, IRB approved, retrospective study. The PACS system of our institution was searched for patients with
sesamoid fracture of the foot between 2010 and 2014. Medical records of these cases were investigated for variables.
RESULTS
Total of 20 patients (13 females, 7 males) were collected with mean age of 37.5 years. 80% of fractures were due to stress
fracture or blunt trauma. In 10% of cases (2/20), tight shoes were used at the time of starting the pain. Sesamoid fractures were
missed in 55% (11/20) of patients in the first radiology exam; 36.4% of the missed fractures (4/11) were considered as bipartite at
first. Fifty percent of patients (10/20) were diagnosed with fibular sesamoid fracture, 45% (9/20) with tibial and 5% (1/20) with
fifth sesamoid fracture. MRI had the highest sensitivity (100%; 9/9), followed by weight-bearing film (66.7%; 4/6), and radiography
(60%; 9/15). MRI had significantly higher sensitivity comparing radiography (p=0.02). Rate of sesamoid fractures in foot exams was
0.014% (15/104,962) in radiography, 0.268% (6/2242) in weight-bearing film, 0.032% (1/3164) in foot CT, 0.124% (9/7262) in foot
MRI and 0.026% (31/117,630) in total foot exams. This represents a ratio of 1 sesamoid fracture for every: 6997 radiographs, 374
weight-bearing films, 3164 foot CTs, 807 foot MRIs and 3795 in total foot exams. 90% of patients (18/20) were treated
conservatively, and 10% (2/20) were treated surgically.
CONCLUSION
Sesamoid fractures occur at a rate of 0.026% in total foot exams, are usually due to stress fracture or blunt trauma and are most
commonly treated conservatively. This study showed radiography has a sensitivity of 60.0% in diagnosing sesamoid fractures. MRI
has significantly higher sensitivity and is the next step in evaluating patients with normal radiographs.
CLINICAL RELEVANCE/APPLICATION
Radiography has a low sensitivity in diagnosing sesamoid fractures and MRI is the next step in evaluating patients with normal
radiographs.
ER244-SDTHB3
Quantitate Analysis of Initial Non-Contrast Computed Tomography in Acute Ischemic Stoke
Station #3
Participants
Wilson Altmeyer, MD, San Antonio, TX (Abstract Co-Author) Nothing to Disclose
Mamie Gao, San Antonio, TX (Abstract Co-Author) Nothing to Disclose
Junfei Li, San Antonio, TX (Abstract Co-Author) Nothing to Disclose
Geoffrey D. Clarke, PhD, San Antonio, TX (Abstract Co-Author) Nothing to Disclose
Feng Gao, MD, San Antonio, TX (Presenter) Nothing to Disclose
PURPOSE
Non-Contrast Computed Tomography (NCCT) is the imaging modality of choice for acute stroke because of its easy access,
efficiency, and cost effectiveness in excluding hemorrhage. However, according to earlier reports, approximately 39% cases show
no early signs of infarction on NCCT. The purpose of this study is to retrospectively compare the initial NCCT with the follow up MRI
results in patients with acute ischemic infarction and use CT density quantification to detect subtle infarctions that would have
been missed by routine qualitative evaluation by radiologist.
METHOD AND MATERIALS
We retrospectively reviewed 16 patients (20 foci) who presented to the emergency department with acute stroke symptoms,
obtained both NCCT and MRI scans. CT Hounsfield Units (HU) of both the infarctions, as defined by the MRI examination, and
contralateral normal brain were quantified and compared. The sizes of the infarctions also had been recorded.
RESULTS
MRI confirmed 20 different foci (3.9mm – 46.3mm) of infarction within the 16 patients with suspected stroke. 15 out of the 20
infarctions were not visualized on NCCT. The CT density of the 15 occult infarctions (16.23 to 29.53 HU) showed an average of
4.34 HU lower than the contralateral normal area (20.86 to 33.21 HU). 12 out of the 15 infarctions had an average difference more
than 5.27 HU while the other 3 differed less than 0.61 HU.
CONCLUSION
Earlier phantom studies indicates that 2 HU hypo-attenuation can be detected by using appropriate parameter settings. By
comparing the CT numbers of the ischemic region with the contralateral normal brain, it has been found that 12 out of the 15
negative NCCT results (80%) could have been correctly reported as positive. Therefore, systematic quantification of the initial
NCCT may aid in the CT diagnosis rate of acute ischemic stroke. The results of this study may serve as a base to establish a
threshold for automatic detecting software development. The method of this study, which quantifies the infarction by measuring CT
numbers, may also be used for further research to predict the prognosis of a stroke.
CLINICAL RELEVANCE/APPLICATION
(dealing with acute ischemic stroke by CT density quantification) “CT numbers have been used to quantify CT scans of acute
ischemic stroke patients and the results showed significant improvement in diagnostic rate.”
ER245-SDTHB4
Added Value of CT in Characterizing Lisfranc Injuries
Station #4
Awards
Student Travel Stipend Award
Participants
Brandon Roller, MD, PhD, Winston Salem, NC (Presenter) Consultant, Bone Solutions, Inc
Pat W. Whitworth III, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Thomas Kelsey, Winston-Salem, NC (Abstract Co-Author) Nothing to Disclose
Anna N. Miller, MD, Winston Salem, NC (Abstract Co-Author) Nothing to Disclose
Scott D. Wuertzer, MD, MS, Winston-Salem, NC (Abstract Co-Author) Nothing to Disclose
Leon Lenchik, MD, Winston-Salem, NC (Abstract Co-Author) Nothing to Disclose
Maha Torabi, MD, Winston Salem, NC (Abstract Co-Author) Nothing to Disclose
PURPOSE
To determine the added value of computed tomography (CT) compared to conventional radiography (CR) for the diagnosis of
fractures associated with Lisfranc injuries.
METHOD AND MATERIALS
A review of CT reports that specifically assessed the Lisfranc joint over the past 6 years was conducted. Only patients with foot
radiographs prior to CT were included. Patients with diabetes or neuropathic arthropathy were excluded. CR and CT diagnoses were
reviewed for the presence of the following fractures: medial, intermediate, and lateral cuneiforms; first, second, third, fourth, and
fifth metatarsal bases; cuboid. The rate of fractures and malalignment on CR and CT were compared. The number of patients that
had operative fixation of the Lisfranc injury was determined.
RESULTS
148 patients were included (5 patients had bilateral CTs). There were 79 men (3 bilateral) and 69 women (2 bilateral); mean age,
49 years; age range, 19-92 years. 65/153 (42%) showed Lisfranc malalignment on CR. 82/153 (54%) showed Lisfranc malalignment
on CT. 139/153 (91%) had fractures on CT. Compared to CT, CR diagnosed 17% (16/96) of medial cuneiform, 11% (5/47) of
intermediate cuneiform, 7% (5/73) of lateral cuneiform, 45% (26/58) of first metatarsal base, 41% (44/107) of second metatarsal
base, 31% (26/85) of third metatarsal base, 39% (31/79) of fourth metatarsal base, 44% (14/32) of fifth metatarsal base, and 34%
(23/68) of cuboid fractures. CR missed identifying a fracture 90% (125/139) of the time. 57/153 patients had operative fixations.
9/57 (16%) of the patients who required surgery were CR negative but CT positive for Lisfranc malalignment.
CONCLUSION
Compared to conventional radiography, CT provides a more accurate characterization of fractures associated with Lisfranc injuries.
CLINICAL RELEVANCE/APPLICATION
CT provides an accurate characterization of fractures associated with Lisfranc injuries, which impacts patient management.
MSCA52
Case-based Review of Abdomen (An Interactive Session)
Thursday, Dec. 1 3:30PM - 5:00PM Room: S406A
GI
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Julie H. Song, MD, Providence, RI (Director) Nothing to Disclose
Sub-Events
MSCA52A
Imaging of Abdominal Trauma
Participants
Michael N. Patlas, MD, FRCPC, Hamilton, ON, ([email protected] ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss common mistakes in interpretation of cases of blunt and penetrating abdominal trauma. 2) Analyze factors leading to
errors. 3) Discuss advantages of intraluminal contrast, delayed phase of imaging and multiplanar reconstructions for detection of
traumatic injuries.
ABSTRACT
This case-based presentation will focus on uncommon abdominal blunt and penetrating traumatic injuries including bowel,
pancreatic, biliary, adrenal, ureteric and vascular injuries. Misses and misinterpretations in the diagnosis of traumatic injuries on
MDCT will be illustrated, based on lessons learned from Morbidity & Mortality Rounds. Optimised imaging protocols will be reviewed.
Multimodality imaging evaluation of complications related to missed abdominal injuries will be discussed.
MSCA52B
Imaging of the Acute Abdomen
Participants
Douglas S. Katz, MD, Mineola, NY, ([email protected] ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Demonstrate and review a series of challenging cases of CT of the acute abdomen and pelvis, in a case-based review session. 2)
Review the differential diagnosis and potential pitfalls in the diagnosis of these entities. 3) Briefly review the further
workup/management of these entities.
ABSTRACT
This presentation, in conjunction with several other speakers demonstrating case-based examples of various aspects of
abdominal/pelvic imaging, will review a series of challenging CT cases of the acute abdomen and pelvis, with an emphasis on
differential diagnosis and potential pitfalls. The literature of these entities - clinical and imaging - will be briefly reviewed, and the
optimal management/further workup of these entities will be briefly discussed.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Douglas S. Katz, MD - 2013 Honored Educator
Douglas S. Katz, MD - 2015 Honored Educator
MSCA52C
Abdominal Pain in Pregnancy
Participants
Ana P. Lourenco, MD, Providence, RI, ([email protected] ​ ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Describe a differential diagnosis for abdominal pain in pregnancy, as well as the best initial imaging study depending upon the
leading differential diagnosis. 2) Recognize diagnostic findings across multiple modalities, including US, CT and MRI. 3) Explain some
of the imaging pitfalls associated with each modality.
ABSTRACT
In this session, we will review the varied differential of abdominal pain in pregnancy, both gynecologic and non-gynecologic. Cases
will be used to illustrate the imaging findings across multiple modalities, highlighting the importance of making the diagnosis at the
first opportunity whenever possible.
RC708
Imaging of the Extremities (An Interactive Session)
Thursday, Dec. 1 4:30PM - 6:00PM Room: E350
MK
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Sub-Events
RC708A
Shoulder
Participants
Manickam Kumaravel, MD, FRCR, Houston, TX, ([email protected]​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize subtle injuries of the glenohumeral joint, acromioclavicular joint complex, coracoid, scapula and other less recognized
injuries around the shoulder. 2) Understand the pathophysiology of shoulder injuries. 3) Learn to use cross-sectional imaging to
better evaluate for clinically pertinent injuries. 4) Identify postoperative hardware in treated shoulder injuries. 5) Correlate the
clinical significance of various types of injuries around the shoulder, so as to produce reports which will be relevant to the referring
clinician.
ABSTRACT
RC708B
Pelvis
Participants
Ken F. Linnau, MD, MS, Seattle, WA, ([email protected] ​ ​ ​ ) (Presenter) Royalties, Cambridge University Press; Speaker, Siemens AG
LEARNING OBJECTIVES
1) Identify pelvic ring disruptions and acetabular fractures. 2) Examine emergency department radiographs and CT scans of the
pelvis to detect and describe PRD and acetabular fractures. 3) Differentiate PRD associated with a high risk of major pelvic
hemorrhage from less severe injuries in order to aide in efficient clinical decision making and patient triage to angiography. 4)
Describe acetabular fractures in a way that allows efficient communication with consultants and aid in clinical decision making for
treatment.
ABSTRACT
Injuries to the pelvic ring (pelvic ring disruption, PRD) and acetabulum are relatively uncommon. Accordingly, such injuries are often
treated at tertiary care centers by highly specialized providers. On the other hand, such injuries are often detected on trauma bay
radiographs in the Emergency Department. PRD and acetabular fractures tend to be complex and associated with substantial
morbidity and mortality. Pelvic radiographs are common initial studies for detection of PRD and acetabular fractures, but tend to be
insufficient for full characterization of them. As a result CT scanning is often performed to aid in treatment decision making and
operative planning. The purpose of this interactive presentation is to highlight specific clinical features and settings of such injuries
which mandate expedited clinical decision making while the patient is still in the emergency room.
Active Handout:Ken Floris Linnau
http://abstract.rsna.org/uploads/2016/16000649/RC708B RSNA 2016 Linnau pelvic trauma RC708.pdf
RC708C
Ankle/Foot
Participants
Claire K. Sandstrom, MD, Seattle, WA, ([email protected] ​ ) (Presenter) Royalties, Cambridge University Press; Speaker, Siemens AG
LEARNING OBJECTIVES
1) Detect common clinically significant imaging abnormalities encountered in the foot and ankle in the emergency setting. 2) Detect
subtle imaging abnormalities seen in the foot and ankle in the emergency setting. 3) Recommend appropriate follow up for various
findings in the foot and ankle in the emergency setting.
ABSTRACT
RC708D
Hand/Wrist
Participants
Jonathan A. Flug, MD, MBA, Denver, CO, ([email protected]​ ​ ​ ​ ​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Detect imaging abnormalities commonly seen in the hand and wrist in the emergency setting. 2) Identify commonly encountered
hand and wrist pathology in the emergency setting. 3) Recommend appropriate follow up for various findings in the hand and wrist
in the emergency setting.
ABSTRACT
Radiologists routinely encounter imaging of the hand and wrist in both the general and subspecialty radiology settings. Appropriate
recognition of various types of injuries and pathology are crucial for accurate diagnosis and optimal patient care. This lecture will
review the various types of pathology the radiologist may encounter in the hand and wrist with an explanation of injury mechanism
and appropriate follow up care.
RC712
Acute Abdominal Vascular Diseases (An Interactive Session)
Thursday, Dec. 1 4:30PM - 6:00PM Room: N229
GI
VA
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
Dominik Fleischmann, MD, Palo Alto, CA, ([email protected]) (Moderator) Research support, Siemens AG;
Handout:Dominik Fleischmann
http://abstract.rsna.org/uploads/2016/13012007/Fleischmann_RSNA2016_RC712_Aortic_Branch_Dissections_HANDOUT.pdf
Sub-Events
RC712A
Aortic Branch Dissections
Participants
Dominik Fleischmann, MD, Palo Alto, CA (Presenter) Research support, Siemens AG;
LEARNING OBJECTIVES
1) Review the epidemiology of aortic side-branch dissections, which can occur as a complication of aortic dissection, or as isolated
spontaneous dissections of the visceral or renal arteries. 2) Explain the pathophysiology of side branch malperfusion syndromes in
aortic dissection. 3) Present the spectrum of imaging findings in spontaneous aortic branch dissections, including the differential
diagnosis (vasculitis, connective tissue diseases, fibromuscular dysplasia, segmental arterial mediolysis).
ABSTRACT
Dissections of aortic side branches is a common complication of Type A and Type B acute aortic dissection which substantially
increases mortality. It is important to understand the pathophysiology and the two principle mechanisms of side branch malferfusion
in aortic dissection: flow obstruction can be due to (A) local abnormalities, such as occlusive dissection flaps, blind ending false
lumen with true lumen occlusion ('windsock'), or frank thrombosis. Side-branch malperfusion may also occur due to (B) limited
inflow: The classic situation is complete true lumen collapse in the upstream aorta, resulting in underperfusion of all downstream
branches supplied by the true lumen. Wile local obstructions are most commonly treated by stent placement into the diseased side
branch, inflow-lesions typically require surgical or endovascular repair of the upstream aorta.
Spontaneous dissections of the celiac, mesenteric, or renal arteries are relatively rare events, and typically present with acute
abdominal or flank pain. Dissections of side branch arteries can lead to ischemic complications or to frank rupture with intra- or
retroperitoneal hemorrhage. Patients presenting with mesenteric or renal artery dissection require a thorough workup to identify
genetic disorders (notably Ehlers Danlos IV), inflammatory conditions (vasculitis), and other entities such as fibromuscular dysplasia
and segmental arterial mediolysis (SAM). Imaging findings range from non-obstructive lesions such as intramural hematoma, doublebarrel lumen, to partial or complete obstruction ('windsock'). Complications include rupture or ischemia. Spontaneous dissections
may heal, or evolve into aortic branch aneurysms.
RC712B
Symptomatic Aneurysms
Participants
Phillip M. Young, MD, Rochester, MN, ([email protected]) (Presenter) Nothing to Disclose
ABSTRACT
Symptomatic aneurysms cover the spectrum of arterial aneurysms presenting with a) localized symptoms secondary to aneurysm
expansion and possible rupture b) regional symptoms secondary to dissection and embolism and c) systemic cardiovascular
dysfunction related to hypotension and organ dysfunction. Common clinical scenarios include aneurysm rupture – most commonly
abdominal aortic, popliteal and abdominal visceral aneurysms as well as thoracoabdominal aortic dissection. Symptomatic aneurysms
may also occur in patients with known arterial pathology including connective tissue disorders such as Marfan’s and Ehlers-Danlos
syndrome and Takayasu aortitis/arteritis. Patients with suspected rupture of abdominal aortic or ileofemoropopliteal artery
aneurysms may initially be evaluated by sonography. However, in all circumstances, CT angiography due to its robust
implementation and high-resolution imaging of the vasculature and regional anatomy that allows for planning of endovascular and
surgical intervention is the preferred technique. CT Angiographic protocols appropriate to the suspected anatomic location of the
aneurysm that provide an adequate roadmap for endovascular or surgical intervention are employed. Extended coverage is
particularly important in patients with suspected thoracoabdominal aortic dissection or aneurysms associated with peripheral
embolism. Cardiac gating should be utilized in any patient with a suspected type A aortic dissection or rupture of an ascending
aortic aneurysm. Aortic, cardiac and coronary artery imaging are integral to the evaluation and management of these patients. A
particular subset of the “symptomatic aneurysm” is post-trauma aortic disruption, usually thoracic in which diagnosis of traumatic
aneurysm is critical and the aneurysm is associated with additional sites of soft tissue and skeletal trauma. Guidelines for
endovascular or surgical intervention or non invasive management with serial CT Angiographic imaging will be discussed.
RC712C
Mesenteric Ischemia
Participants
Iain D. Kirkpatrick, MD, Winnipeg, MB, ([email protected]​ ) (Presenter) Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the various categories of mesenteric ischemia (arterial occlusive, embolic, venous thrombotic, and nonocclusive), and
the pathophysiologic basis behind the imaging findings in each case. 2) Understand the basis behind modern CT protocols for
mesenteric ischemia, particularly the biphasic examination with CT mesenteric angiography. 3) Demonstrate techniques to rapidly
analyze a mesenteric CT angiographic dataset. 4) Review the CT signs of mesenteric ischemia and their sensitivity and specificity.
5) Evaluate the current literature on mesenteric ischemia and discuss optimal diagnostic criteria.
ABSTRACT
Acute mesenteric schema (AMI) is a life-threatening condition said to affect up to 1% of patients presenting with an acute
abdomen, and it carries a mortality rate ranging between 59-93% in the published literature. Time to diagnosis and surgical
treatment are the only factors which have been shown to improve mortality, and evidence shows that the clear test of choice for
AMI is now biphasic CT. Water is preferably administered as a negative contrast agent, followed by CT mesenteric angiography and
then a portal venous phase exam. Diagnostic accuracy is significantly improved by analysis of the CT angiogram for arterial
stenoses or occlusions, evidence of emboli, or angiographic criteria of nonocclusive ischemia. It is the use of CT angiography in
addition to routine portal phase imaging which has pushed the sensitivity and specificity of the test to >90% in recent published
articles. Other nonangiographic CT findings that are relatively specific for AMI in the appropriate clinical setting include pneumatosis
intestinalis, portal or mesenteric venous gas or thrombosis, and decreased bowel wall enhancement. Bowel wall thickening,
mesenteric stranding, ascites, and mucosal hyperenhancement are more nonspecific findings which may also be seen. Nonocclusive
schema may be the most difficult form to diagnose, and findings of shock abdomen can aid in identification. Knowledge of the
patient's clinical history is critical not only for the selection of an appropriate study protocol but also for interpretation of the
imaging findings in context.
RC712D
Gastrointestinal Bleeding
Participants
Jorge A. Soto, MD, Boston, MA (Presenter) Royalties, Reed Elsevier
LEARNING OBJECTIVES
1) To review the appropriate implementation of CT angiography in the evaluation of patients presenting with acute lower intestinal
bleeding. 2) To describe the technical details that are necessary for acquiring good quality CT angiography examinations. 3)
Illustrate the characteristic CT angiographic findings of active or recent bleeding with specific examples of multiple etiologies.
ABSTRACT
Acute gastrointestinal bleeding is a serious condiition that may threaten a patient’s life depending on the severity and duration of
the event. Precise identification of the location, source and cause of bleeding are the primary objectivse of the diagnostic
evaluation. Implementation of colonoscopy in the emergency setting poses multiple challenges, especially the inability to
adequately cleanse the colon and poor visualization owing to the presence of intraluminal blood clots. Scintigraphy with technetium
99m–labeled red blood cells is highly sensitive but also has some limitations, such as the inability to precisely localize the source of
bleeding and determine its cause. Properly performed and interpreted CT angiography examinations offer logistical and diagnostic
advantages in the detection of active hemorrhage. A three-phase examination (non-contrast, arterial and portal venous) is
typically performed. Potential technical and interpretation pitfalls should be considered and will be explained. The information
derived from CT angiography helps direct therapy and select the most appropriate hemostatic intervention (when necessary):
endoscopic, angiographic, or surgical. Precise anatomic localization of the bleeding point also allows a targeted endovascular
embolization. The high diagnostic performance of CT angiography makes this test a good alternative for the initial emergent
evaluation of patients with acute lower intestinal bleeding.
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jorge A. Soto, MD - 2013 Honored Educator
Jorge A. Soto, MD - 2014 Honored Educator
Jorge A. Soto, MD - 2015 Honored Educator
RC801
Imaging of Cardiothoracic Emergencies (An Interactive Session)
Friday, Dec. 2 8:30AM - 10:00AM Room: E353C
CH
ER
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Participants
LEARNING OBJECTIVES
1) To review imaging manifestations of common life-threatening complications of thoracic trauma. 2) To highlight common
difficulties radiologists encounter when interpreting imaging studies in patients with thoracic trauma. 3) Overview current imaging
strategies and key facts in Pulmonary Embolism imaging. 4) Provide an update on current issues and challenges in Pulmonary
Embolism imaging.
Sub-Events
RC801A
Thoracic Trauma
Participants
Santiago Martinez-Jimenez, MD, Kansas City, MO (Presenter) Author, Reed Elsevier; Author, Oxford University Press
LEARNING OBJECTIVES
1) To review imaging manifestations of common life-threatening complications of thoracic trauma. 2) To highlight common
difficulties radiologists encounter when interpreting imaging studies in patients with thoracic trauma.
ABSTRACT
Thoracic trauma is common, may imply life-threatening complications, and could be especially challenging for radiologists. Several
reasons known to add complexity of interpretation of imaging studies include: lack of direct interaction with patients, unawareness
of the mechanism of trauma, inherent poor diagnostic quality, satisfaction of search, and lack of knowledge of resultant
pathophysiologic mechanisms. In this case based lecture several scenarios are presented with detailed analyses of imaging studies,
mechanisms of trauma and pertinent involved pathophysiological principles. Some of the cases included are: acute traumatic aortic
injury, diaphragmatic rupture, airway injury, aspiration, flail chest, and stenoclavicular dislocation.
Active Handout:Santiago Martinez-Jimenez
http://abstract.rsna.org/uploads/2016/16000670/RC801A Trauma RSNA 2016 003.pdf
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Santiago Martinez-Jimenez, MD - 2014 Honored Educator
Santiago Martinez-Jimenez, MD - 2015 Honored Educator
RC801B
Pulmonary Embolism
Participants
Ioannis Vlahos, MRCP, FRCR, London, United Kingdom, ([email protected] ​ ) (Presenter) Research Consultant,
Siemens AG; Research Consultant, General Electric Company;
LEARNING OBJECTIVES
1) Overview current imaging strategies and key facts in Pulmonary Embolism imaging. 2) Provide an update on current issues and
challenges in Pulmonary Embolism imaging.
ABSTRACT
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Ioannis Vlahos, MRCP, FRCR - 2015 Honored Educator
RC801C
Acute Aortic Syndrome
Participants
Jonathan H. Chung, MD, Chicago, IL (Presenter) Royalties, Reed Elsevier; Consultant, F. Hoffmann-La Roche Ltd; Consultant,
Boehringer Ingelheim GmbH; Consultant, Veracyte, Inc
Honored Educators
Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying
educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality
educational content in their field of study. Learn how you can become an honored educator by visiting the website at:
https://www.rsna.org/Honored-Educator-Award/
Jonathan H. Chung, MD - 2013 Honored Educator
RC801D
Acute Coronary Syndrome
Participants
Harold I. Litt, MD, PhD, Philadelphia, PA (Presenter) Research Grant, Siemens AG ; Research Grant, Heartflow, Inc; Travel Support,
General Electric Company;
LEARNING OBJECTIVES
1) Understand the demographics and clinical presentations of patients with suspected acute coronary syndromes and the pathways
and guidelines used in their care. 2) Describe the evidence supporting the use of coronary CT angiography, SPECT myocardial
perfusion imaging and stress echocardiography in low to intermediate risk chest pain patients. 3) Demonstrate typical findings at
coronary CT angiography in patients with suspected acute coronary syndromes.