Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney.

According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Daytime, evening, and overnight: the 24-h radiology cycle and impact on interpretative accuracy.

PURPOSE: To assess the influence of time of day when a study is interpreted on discrepancy rates for common and advanced studies performed in the acute community setting. METHODS: This retrospective study used the databank of a U.S. teleradiology company to retrieve studies between 2012 and 2016 with a preliminary report followed by a final report by the on-site client hospital. Neuroradiology, abdominal radiology, and musculoskeletal radiology studies were included. Teleradiologists were fellowship trained in one of these subspecialty areas. Daytime, evening, and overnight times were defined. Associations between major and minor discrepancies, time of day, and whether the study was common or advanced were tested with significance set at p = .05. RESULTS: A total of 5,883,980 studies were analyzed. There were 8444 major discrepancies (0.14%) and 17,208 minor discrepancies (0.29%). For common studies, daytime (0.13%) and evening (0.13%) had lower major discrepancy rates compared to overnight (0.14%) (daytime to overnight, RR = 0.57, 95%CI: 0.45, 0.72, p < 0.01 and evening to overnight, RR = 0.57, 95%CI: 0.49,0.67, p < 0.01). Minor discrepancy rates for common studies were decreased for evening (0.29%) compared to overnight (0.30%) (RR = 0.89, 95%CI: 0.80,0.99, p = 0.029). For advanced studies, daytime (.15%) had lower major discrepancy rates compared to evening (0.20%) and overnight (.23%) (daytime to evening, RR = 0.77, 95%CI: 0.61, 0.97, p = 0.028 and daytime to overnight, RR = 0.66, 95%CI: 0.50, 0.87, p ≤ 0.01). CONCLUSION: Significantly higher major discrepancy rates for studies interpreted overnight suggest the need for radiologists to exercise greater caution when interpreting studies overnight and may require practice management strategies to help optimize overnight work conditions. The lower major discrepancy rates on advanced studies interpreted during the daytime suggest the need for reserving advanced studies for interpretation during the day when possible.

In-person radiologist to review the trauma panscan: a high-fidelity simulation training program for radiology trainees at an academic level 1 trauma center.

BACKGROUND: Radiology trainees were uncomfortable going to the CT scanner to review trauma panscans and interacting with trauma surgeons. OBJECTIVE: This study aims to determine if radiology residents can be trained to accurately identify injuries requiring immediate surgical attention at the CT scanner. METHODS: A high-fidelity simulation model was created to provide an immersive training experience. Between February 2015 and April 2017, 62 class 1 trauma panscans were read at the CT scanner by 11 PGY-3 radiology residents. Findings made at the scanner were compared to resident preliminary and attending radiology reports and correlated with clinical outcomes. Timestamps were recorded and analyzed. Surveys were administered to assess the impact of training on radiology residents' self-confidence and to assess trauma surgeons' preference for radiology at the scanner. Significance level was set at p < 0.05. RESULTS: The mean time to provide results at the CT scanner was 11.1 min. Mean time for the preliminary report for CT head and cervical spine was 24.4 ± 9.8 min, and for the CT chest, abdomen, and pelvis was 16.3 ± 6.9 min. 53 traumatic findings on 62 panscans were identified at the scanner and confirmed at preliminary and final reports, for a concordance rate of 85%, compared to 72% for the control group. Radiology residents agreed or strongly agreed the training prepared them for trauma panscan reporting. Trauma surgeons shifted in favor of radiology presence at the scanner. CONCLUSION: Radiology residents can be trained to accurately and rapidly identify injuries requiring immediate surgical attention at the CT scanner. CLINICAL IMPACT: These findings support the value-added of an in-person radiologist at the CT scanner for whole-body trauma panscans to facilitate timely detection of life-threatening injuries and improve professional relations between radiologists and trauma surgeons.

Traumatic abdominal wall hernias in the pediatric population: a 13-year institutional review.

BACKGROUND: Pediatric traumatic abdominal wall hernias are rare but potentially devastating injuries. Although classically considered to be caused by handlebar injuries from bicycle accidents, our anecdotal experience suggests pediatric traumatic abdominal wall hernias are far more likely to occur following road traffic accidents and have a high association with other significant intra-abdominal injuries. OBJECTIVE: The purpose of this study was to determine the frequency, mechanisms of injury, and associated injuries of traumatic abdominal wall hernias in the pediatric population. MATERIALS AND METHODS: This is a retrospective observational cohort study from two large urban level 1 trauma centers. Institutional trauma registries were queried from January 1, 2008, to December 31, 2020, for patients under 18 years of age diagnosed with traumatic abdominal wall hernias, excluding those without initial abdominopelvic CT imaging. Finalized CT reports and images were reviewed to confirm the presence of a traumatic abdominal wall hernia and document any associated secondary injuries. The medical record was reviewed to extract pertinent physical findings, interventions performed, and outcomes. Injury Severity Score (ISS) for each patient was calculated by the trauma registrar. RESULTS: A total of 19 patients with TAWH met inclusion criteria, with an overall frequency of 0.095% and a mean age of 10.6 years (range 3-17). Eleven patients were male (57.9%) with a mean ISS of 18.6 (range 1-48, including 63.2% with ISS > 15). The most common mechanism of injury was motor vehicle collision (N = 11, 57.9%) followed by bicycle accident (N = 3, 15.8%). A total of 17 (89.5%) had associated injuries, including 11 (57.9%) with intestinal injuries, 5 (26.3%) with pelvic fractures, 4 (21.1%) with femur fractures, 3 (15.8%) with splenic injuries, 3 (15.8%) with kidney injuries, and 3 (15.8%) with Chance fractures of the lumbar spine. All patients required surgery for the traumatic abdominal wall hernias and associated injuries. CONCLUSION: Pediatric traumatic abdominal wall hernias are more likely to be seen following motor vehicle collisions, with a majority (89.5%) having associated injuries, most frequently to the bowel (57.9%). Handlebar injuries were seen in a minority of patients (15.8%) and were less likely to be associated with additional injuries. CLINICAL IMPACT: Pediatric patients with a traumatic abdominal wall hernia on admission CT should be thoroughly evaluated for bowel injuries, especially in the setting of a motor vehicle collision.

Starting an Emergency Radiology Division: Scheduling and Staffing, Compensation, and Equity and Parity.

Establishing an emergency radiology division in a practice that has long-standing patterns of operational routines comes with both challenges and opportunities. In this article, considerations around scheduling and staffing, compensation, and equity and parity are provided with supporting literature references. Furthermore, a panel of experts having established, grown and managed emergency radiology divisions in North America and Europe share their experiences through a question and answer format.

ACR Appropriateness Criteria® Acute Pyelonephritis: 2022 Update.

Acute pyelonephritis (APN) is a severe urinary tract infection (UTI) that has the potential to cause sepsis, shock, and death. In the majority of patients, uncomplicated APN is diagnosed clinically and is responsive to treatment with appropriate antibiotics. In patients who are high risk or when treatment is delayed, microabscesses may coalesce to form an acute renal abscess. High-risk patients include those with a prior history of pyelonephritis, lack of response to therapy for lower UTI or for APN, diabetes, anatomic or congenital abnormalities of the urinary system, infections by treatment-resistant organisms, nosocomial infection, urolithiasis, renal obstruction, prior renal surgery, advanced age, pregnancy, renal transplant recipients, and immunosuppressed or immunocompromised patients. Pregnant patients and patients with renal transplants on immunosuppression are at an elevated risk of severe complications. Imaging studies are often requested to aid with the diagnosis, identify precipitating factors, and differentiate lower UTI from renal parenchymal involvement, particularly in high-risk individuals. Imaging is usually not appropriate for the first-time presentation of suspected APN in an uncomplicated patient. The primary imaging modalities used in high-risk patients with suspected APN are CT, MRI, and ultrasound, although CT was usually not appropriate for initial imaging in a pregnant patient with no other complications. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Interpretations of Examinations Outside of Radiologists' Fellowship Training: Assessment of Discrepancy Rates Among 5.9 Million Examinations From a National Teleradiology Databank.

BACKGROUND. In community settings, radiologists commonly function as multispecialty radiologists, interpreting examinations outside of their area of fellowship training. OBJECTIVE. The purpose of this article was to compare discrepancy rates for preliminary interpretations of acute community-setting examinations that are concordant versus discordant with interpreting radiologists' area of fellowship training. METHODS. This retrospective study used the databank of a U.S. teleradiology company that provides preliminary interpretations for client community hospitals. The analysis included 5,883,980 acute examinations performed from 2012 to 2016 that were preliminarily interpreted by 269 teleradiologists with a fellowship of neuroradiology, abdominal radiology, or musculoskeletal radiology. When providing final interpretations, client on-site radiologists voluntarily submitted quality assurance (QA) requests if preliminary and final interpretations were discrepant; the teleradiology company's QA committee categorized discrepancies as major (n = 8444) or minor (n = 17,208). Associations among examination type (common vs advanced), relationship between examination subspecialty and the teleradiologist's fellowship (concordant vs discordant), and major and minor discrepancies were assessed using three-way conditional analyses with generalized estimating equations. RESULTS. For examinations with a concordant subspecialty, the major discrepancy rate was lower for common than for advanced examinations (0.13% vs 0.26%; relative risk [RR], 0.50, 95% CI, 0.42-0.60; p < .001). For examinations with a discordant subspecialty, the major discrepancy rate was lower for common than advanced examinations (0.14% vs 0.18%; RR, 0.81; 95% CI, 0.72-0.90; p < .001). For common examinations, the major discrepancy rate was not different between examinations with concordant versus discordant subspecialty (0.13% vs 0.14%; RR, 0.90; 95% CI, 0.81-1.01; p = .07). For advanced examinations, the major discrepancy rate was higher for examinations with concordant versus discordant subspecialty (0.26% vs 0.18%; RR, 1.45; 95% CI, 1.18-1.79; p < .001). The minor discrepancy rate was higher among advanced examinations for those with concordant versus discordant subspecialty (0.34% vs 0.29%; RR, 1.17; 95% CI, 1.00-1.36; p = .04), but not different for other comparisons (p > .05). CONCLUSION. Major and minor discrepancy rates were not higher for acute community-setting examinations outside of interpreting radiologists' fellowship training. Discrepancy rates increased for advanced examinations. CLINICAL IMPACT. The findings support multispecialty radiologist practice in acute community settings. Efforts to match examination and interpreting radiologist sub-specialty may not reduce diagnostic discrepancies.

ACR Appropriateness Criteria® Suspected Retroperitoneal Bleed.

The initial diagnosis of retroperitoneal bleeding can be challenging by physical examination and clinical presentation. Prompt imaging can make the diagnosis and be lifesaving. When selecting appropriate imaging for these patient's, consideration must be made for sensitivity and ability to image the retroperitoneum, as well as speed of imaging.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

American Society of Emergency Radiology Multicenter Blunt Splenic Trauma Study: CT and Clinical Findings.

Background Treatment of blunt splenic trauma (BST) continues to evolve with improved imaging for detection of splenic vascular injuries. Purpose To report on treatments for BST from 11 trauma centers, the frequency and clinical impact of splenic vascular injuries, and factors influencing treatment. Materials and Methods Patients were retrospectively identified as having BST between January 2011 and December 2018, and clinical, imaging, and outcome data were recorded. Patient data were summarized descriptively, both overall and stratified by initial treatment received (nonoperative management [NOM], angiography, or surgery). Regression analyses were used to examine the primary outcomes of interest, which were initial treatment received and length of stay (LOS). Results This study evaluated 1373 patients (mean age, 42 years ± 18; 845 men). Initial treatments included NOM in 849 patients, interventional radiology (IR) in 240 patients, and surgery in 284 patients. Rates from CT reporting were 22% (304 of 1373) for active splenic hemorrhage (ASH) and 20% (276 of 1373) for contained vascular injury (CVI). IR management of high-grade injuries increased 15.6%, from 28.6% (eight of 28) to 44.2% (57 of 129) (2011-2012 vs 2017-2018). Patients who were treated invasively had a higher injury severity score (odds ratio [OR], 1.04; 95% CI: 1.02, 1.05; P < .001), lower temperature (OR, 0.97; 95% CI: 0.97, 1.00; P = .03), and a lower hematocrit (OR, 0.96; 95% CI: 0.93, 0.99; P = .003) and were more likely to show ASH (OR, 8.05; 95% CI: 5.35, 12.26; P < .001) or CVI (OR, 2.70; 95% CI: 1.64, 4.44; P < .001) on CT images, have spleen-only injures (OR, 2.35; 95% CI: 1.45, 3.8; P < .001), and have been administered blood product for fewer than 24 hours (OR, 2.35; 95% CI: 1.58, 3.51; P < .001) compared with those chosen for NOM, after adjusting for key demographic and clinical variables. After adjustment, factors associated with a shorter LOS were female sex (OR, 0.84; 95% CI: 0.73, 0.96; P = .009), spleen-only injury (OR, 0.72; 95% CI: 0.6, 0.86; P < .001), higher admission hematocrit (OR, 0.98; 95% CI: 0.6, 0.86; P < .001), and presence of ASH at CT (OR, 0.74; 95% CI: 0.62, 0.88; P < .001). Conclusion Contained vascular injury and active splenic hemorrhage (ASH) were frequently reported, and rates of interventional radiologic management increased during the study period. ASH was associated with a shorter length of stay, and patients with ASH had eight times the odds of undergoing invasive treatment compared with undergoing nonoperative management. © RSNA, 2021 See also the editorial by Patlas in this issue.

Traumatic abdominal wall injuries-a primer for radiologists.

Traumatic abdominal wall injuries encompass a broad clinical and radiological spectrum and are identified in approximately 9% of blunt trauma patients. The most severe form of abdominal wall injury-a traumatic abdominal wall hernia-is seen in less than 1.5% of blunt abdominal trauma patients. However, the incidence of concurrent intra-abdominal injuries in these patients is high and can result in significant morbidity and mortality. Although the diagnosis of abdominal wall injuries is typically straight forward on CT, associated injuries may distract the interpreting radiologist in more subtle cases. Thus, it is important for the radiologist to identify abdominal wall injuries and their associated injuries on admission CT, as these injuries typically require surgical correction early in the course of their management. Untreated abdominal wall injuries subject the patient to increased risk of delayed bowel incarceration and strangulation. Therefore, it is important for the radiologist to be knowledgeable of injuries to the abdominal wall and commonly associated injuries to provide optimal patient triage and expedite management.

Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center.

Introduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis. Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes. Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow. Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.

ACR Appropriateness Criteria® Seizures and Epilepsy.

Seizures and epilepsy are a set of conditions that can be challenging to diagnose, treat, and manage. This document summarizes recommendations for imaging in different clinical scenarios for a patient presenting with seizures and epilepsy. MRI of the brain is usually appropriate for each clinical scenario described with the exception of known seizures and unchanged semiology (Variant 3). In this scenario, it is unclear if any imaging would provide a benefit to patients. In the emergent situation, a noncontrast CT of the head is also usually appropriate as it can diagnose or exclude emergent findings quickly and is an alternative to MRI of the brain in these clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Differences in Outcomes Associated With Individual Radiologists for Emergency Department Patients With Headache Imaged With CT: A Retrospective Cohort Study of 25,596 Patients.

OBJECTIVE. The purpose of this study was to determine whether diagnostic radiologists impart variation into resource use and patient outcomes in emergency department (ED) patients undergoing CT for headache. MATERIALS AND METHODS. This was a single-institution retrospective quality assurance cohort study of 25,596 unique adult ED patients undergoing head CT for headache from January 2012 to October 2017. CT examinations were interpreted by 55 attending radiologists (25 neuroradiologists, 30 radiologists of other specialties) who each interpreted a mean of 1469.8 ± 787.9 CT examinations. Risk adjustment for variables thought to influence outcome included baseline risk (demographics, Elixhauser comorbidity score), clinical factors (vital signs, ED triage and pain scores, laboratory data, hydrocephalus, prior intracranial hemorrhage, neurosurgical consultation within last 12 months), and system factors (time of CT, physician experience, neuroradiology training). Multivariable models were built to analyze the effect of individual radiologists on subsequent outcomes. Any p value less than 0.007 was considered significant after Bonferroni correction. RESULTS. The study found 57.5% (14,718/25,596) of CT interpretations were performed by neuroradiologists, and most patients (98.1% [25,119/25,596]) had no neurosurgical history. After risk adjustment, individual radiologists were not an independent predictor of hospital admission (p = 0.49), 30-day readmission (p = 0.30), 30-day mortality (p = 0.14), or neurosurgical intervention (p = 0.04) but did predict MRI use (p < 0.001; odds ratio [OR] range among radiologists, 0.009-38.2), neurology consultation (p < 0.001; OR range, 0.4-3.2), and neurosurgical consultation (p < 0.001; OR range, 0.1-9.9). CONCLUSION. Radiologists with different skills, experience, and practice patterns appear interchangeable for major clinical outcomes when interpreting CT for headache in the ED, but their differences predict differential use of downstream health care resources. Resource use measures are potential quality indicators in this cohort.

Pelvic Fractures and Associated Genitourinary and Vascular Injuries: A Multisystem Review of Pelvic Trauma.

OBJECTIVE. Blunt pelvic trauma is associated with injuries to the musculoskeletal, lower genitourinary, and vascular systems, leading to significant morbidity and mortality. This article provides a comprehensive review of these injuries, reviews classification systems that are helpful in predicting prognosis, describes the most appropriate imaging tests for injury detection, and emphasizes the role that interventional radiology plays in the setting of pelvic trauma. CONCLUSION. Blunt pelvic injuries can involve the musculoskeletal, genitourinary, and vascular systems, often concomitantly, making it imperative for radiologists to recognize injury patterns and understand implications for management. Injury classifications can be helpful in determining management and predicting prognosis. Contrast-enhanced CT is the imaging modality test of choice in evaluating pelvic trauma, and protocols should be optimized for best detection of injuries. Transcatheter arterial embolization plays a critical role in stopping acute hemorrhage and improving clinical outcomes.

Emergency Radiology: Current Challenges and Preparing for Continued Growth.

The escalation of imaging volumes in the emergency department and intensifying demands for rapid radiology results have increased the demand for emergency radiology. The provision of emergency radiology is essential for nearly all radiology practices, from the smallest to the largest. As our radiology specialty responds to the challenge posed by the triple threat of providing 24-7 coverage, high imaging volumes, and rapid turnaround time, various questions regarding emergency radiology have emerged, including its definition and scope, unique operational demands, quality and safety concerns, impact on physician well-being, and future directions. This article reviews the current challenges confronting the subspecialty of emergency radiology and offers insights into preparing for continued growth.

Unifying the Silos of Subspecialized Radiology: The Essential Role of the General Radiologist.

As radiology becomes increasingly subspecialized, conversations focus on whether the general radiologist is trending toward extinction. Current data indicate that the vast majority of graduating radiology residents now seek fellowship training. Practicing entirely within the narrow confines of one's fellowship subspecialty area, however, is uncommon, with recent data indicating that more than half of all radiologists spend the majority of their work effort as generalists. From the traditional concept of the generalist as the non-fellowship-trained radiologist who interprets everything to the multispecialty-trained radiologist to the emergency radiologist who is a subspecialist but reads across the traditional anatomic divisions, the general radiologist of today and the future is one who remains broadly skilled and equipped to provide a wide spectrum of radiologic services. The successful future of many practices of all types and the specialty as a whole will require ongoing collaborative partnerships that include both general and subspecialized radiologists. This review article highlights various scenarios in which general radiologists provide value to different types of radiology practices.