Upfront vascular imaging in acute stroke: Impact on thrombectomy transfer time at a primary stroke center.

OBJECTIVES: Early cerebral arterial imaging is currently only recommended in the subgroup of acute ischemic stroke (AIS) patients suspected of having large vessel occlusion (LVO). There is limited data on the impact of early cerebrovascular imaging in all suspected AIS patients presenting within 24 h of symptom onset and the impact on door in-door out (DIDO) time. MATERIALS AND METHODS: In January 2020, our Primary Stroke Center implemented a protocol to perform upfront head and neck CT angiography (CTA) with initial non-contrast CT head for all suspected ischemic stroke patients screening positive for BE-FAST stroke symptoms within 24 h from last known normal time. We retrospectively reviewed IV alteplase and thrombectomy-eligible patients before (January 1-December 31, 2019) and after protocol implementation (January 1, 2020-June 30, 2022). RESULTS: Of 86 patients meeting study criteria, up-front CTA was associated with significant reductions in door-to-CTA start (median 37 vs 15 min, p = 0.003), door-to-CTA result (median 83 vs 52 min, p = 0.023) and DIDO times (median 150 vs 106 min, p = 0.023). There was no significant difference in door-to-needle time before and after protocol implementation (median 48 vs 43 min, p = 0.450). CONCLUSION: Up-front cerebrovascular imaging with CTA in suspected AIS patients presenting within 24 h resulted in shorter DIDO times without delaying door-to-needle times. Primary Stroke Centers should consider this approach to detect LVO early and expedite patient transport to thrombectomy capable centers.

Emergency department imaging superusers.

PURPOSE: To identify and characterize the most frequent users of emergency department (ED) imaging. MATERIALS AND METHODS: All patients with at least one ED visit in 2016 across a four-hospital healthcare system were retrospectively identified and their ED imaging utilization characterized. RESULTS: Overall, 126,940 unique patients underwent 187,603 ED visits (mean 1.5 ± 1.7) and a total of 192,142 imaging examinations (mean 1.7 ± 2.7). Fifty-eight percent of patients were imaged (73,672) and underwent a mean 2.6 ± 2.7 exams. When ranked by ED visits, 1.6% (2007) of patients had ≥ 4 ED visits (mean 6.1 ± 5.4). These ED "clinical superusers" accounted for 7.7% (14,409) of total ED visits and underwent 6.8 ± 5.4 imaging examinations, while non-superusers underwent 1.5 ± 2.2 (p < 0.01). When ranked by ED imaging utilization, 12.3% (15,575) of patients underwent ≥ 4 ED imaging examinations and consumed 49.5% (95,053) of all imaging services. A subset of just 1.3% (1608) of ED patients underwent > 10 annual ED examinations (ED "imaging superusers") and accounted for 12.4% (23,787) of all ED imaging services. Only 0.4% (n = 472) of patients were both clinical and imaging superusers. Despite similar ED visits to clinical superusers (6.0 ± 5.6 vs. 6.1 ± 5.4, p = 0.92), imaging superusers underwent significantly more imaging (14.8 ± 4.8 vs. 6.8 ± 5.4 examinations, p < 0.01). CONCLUSION: Just 12% of ED patients consume 50% of all ED imaging services, and 1.3% consume 12.4%. These ED imaging superusers represent a distinct group from clinical superusers. Prospective identification of this newly described subgroup might permit targeted interventions to control ED imaging volume, restrain costs, and minimize per-patient radiation exposure.

Mammography Patient Information at Hospital Websites: Most Neither Comprehensible Nor Guideline Supported.

OBJECTIVE: Ongoing controversy regarding screening mammography guidelines has created confusion for many patients. Given recommendations that patient educational material be prepared at or below the 7th grade reading level of average Americans, the purpose of this study was to assess the readability of online mammography information offered by hospitals nationwide. MATERIALS AND METHODS: During 2015, online mammography patient educational materials were identified for all Medicare-recognized hospitals nationwide for which screening mammography metrics were publicly available. Patient educational materials were assessed using six validated readability score algorithms. All references to official screening guidelines were captured. RESULTS: Of 4105 hospitals nationwide, 3252 had websites and confirmable screening mammography services. Of those, 1753 (54%) offered mammography information material online. Only 919 (28%) referenced any professional society guidelines. After excluding information not formatted in HTML and shorter than 100 words (to improve algorithm reliability), 1524 hospital mammography webpages were assessed for grade level scores. Nationally, the mean of each readability score for all hospitals varied between the 10th and 14th grade levels, all higher than the recommended 7th grade level (p < 0.001). At the individual hospital level, only 14 hospitals (0.4%) had mean scores at or below the 7th grade level. CONCLUSION: Of U.S. hospitals that offer screening mammography and have websites, only 54% provide online mammography educational material. Of those, only 0.4% present information at a reading level comprehensible to average Americans, and only 28% offer specific information to help patients reconcile conflicting guidelines. Health systems offering mammography should strive to better meet women's health information and literacy needs.

"Cell blocking" the parasitic imposter: In a rare case of isolated pulmonary cysticercosis.

Isolated pulmonary cysticercosis is a rare manifestation of human cysticercosis which mainly affects central nervous system, skeletal muscles, eyes and subcutaneous tissues. Pulmonary involvement is usually a part of disseminated disease and mainly presents as bilateral pulmonary nodules. We report a rare case of isolated pulmonary cysticercosis presenting as lung cyst with pleural effusion. The diagnosis was made on pleural fluid cytology and cell block preparation. Herein we wish to recapitulate the importance of cell block as a diagnostic aid for parasitic infections, where morphological features and architectural patterns are as clearly discernable as in histopathology.

Magnetic resonance imaging features of osteochondral lesions of the talus.

BACKGROUND: Osteochondral lesions of the talus (OLT) traditionally have been thought to occur anterolaterally or posteromedially. Recent studies utilizing magnetic resonance imaging (MRI) have questioned this teaching. The purpose of this study was to use MRI to describe the location, frequency, and morphology of OLT and determine if any correlations exist between lesion location and other data points. METHODS: The location, frequency, and size of OLT based on a nine-zone grid were recorded on 77 MRI examinations. Lateral ligaments were inspected for evidence of injury. Stability of the lesions was assessed based on four MRI criteria: presence or absence of cartilage defects, edema-like signal abnormality, T2 bright rim, and/or subchondral cysts. Demographic data including patient age, injury mechanism, and chronicity were recorded. An ANOVA model was used to determine if statistical differences existed between lesion size and location. Pearson correlation coefficients were used to examine any association between lesion location and demographic data. RESULTS: Most of the lesions were located medially and centrally on the talar dome (54.5%), with the second highest frequency found laterally and centrally (31.2%). With the numbers available there was no statistical difference between the size of the lesions based on location. No strong correlations were found between lesion location and demographic data. CONCLUSION: This study refutes traditional teachings regarding the location of OLT and supports recent studies showing that most lesions are located medially and centrally on the talar dome.

Clinical Yield of Routine Chest Radiography after Ultrasound-Guided Thoracentesis.

RATIONALE AND OBJECTIVES: To evaluate the clinical yield of routine chest radiography in identifying pneumothorax warranting chest tube decompression in patients undergoing ultrasound-guided thoracentesis. MATERIALS AND METHODS: All adult patients without pre-existing pneumothorax who underwent ultrasound-guided thoracentesis by a radiologist within a four-hospital large metropolitan academic health system over a 10-year period were identified. Demographic, clinical, and radiographic report information were obtained. Chest radiographic reports were assessed for the presence of pneumothorax and, if positive, manual image and chart review were performed. RESULTS: Of 2541 consecutive ultrasound-guided thoracentesis procedures, 12 were excluded due to pre-existing pneumothorax, yielding 2529 cases. Mean patient age was 67.7 years; 54.5% were male. Overall, 89 procedures (3.5%) resulted in a postprocedural pneumothorax. Of those, only six (6.7%) had documented changes in patient symptoms. Chest tubes were placed in 15, representing 16.9% (15/89) of cases with postprocedural pneumothoraces and 0.59% (15/2,529) of all procedures. Of these 15, 5 (33.3%) had symptomatic pneumothoraces, most commonly shortness of breath. CONCLUSION: Following ultrasound-guided thoracentesis, the incidence of pneumothorax requiring chest tube decompression is only 1 in 170. Of the 1 in 30 patients who develop a pneumothorax, only 1 in 6 require a chest tube. This information can inform procedural consent discussions as well as future guidelines about the necessity of routine postprocedural chest radiography.

Pirated Manuscripts From Radiology's Most Impactful Journals: An International Analysis of Copyright-Infringing Downloads.

OBJECTIVES: The world's largest scholarly literature pirate website, Sci-Hub, permits readers to bypass journal paywalls, thus facilitating no-cost copyright-infringing article downloads. We studied download characteristics of internationally pirated radiology journal articles. METHODS: All download request events between September 2015 and February 2016 were retrieved from Sci-Hub's public server logs. Focusing on high-impact factor radiology journals, we targeted uniquely identifiable diagnostic imaging and radiation oncology journals with a 2015 Thompson Reuters impact factor of ≥2. Pirated article download characteristics were assessed at the individual article, journal, and geographic level. RESULTS: Of all 27,819,965 pirated article downloads, 105,075 (0.4%) were from 49 radiology journals with high impact factor. Total monthly radiology downloads ranged from 6,715 to 24,449. Downloads were most frequent for papers from Radiology (10,357 of 105,075; 9.9%), NeuroImage (10,121; 9.6%), and the International Journal of Radiation Oncology Biology (8,025; 7.6%). The most downloaded articles were published in European Radiology, RadioGraphics, and NeuroImage. By country, download requests were most frequent from China (17,975 of 105,075; 17.1%), India (7,969; 7.6%), and Iran (7,327; 7.0%), but on a per capita basis, were most common in Portugal (210.8 per 1,000,000 population), Chile (135.4), and Tunisia (113.8). Only 4,450 (4.2%) of download requests were from the United States. CONCLUSIONS: Copyright-infringing downloading of pirated radiology journal articles occurs frequently across the world and impacts nearly all top impact-factor journals. New publisher pricing and business models, akin to those for digital music, may be necessary to disincentivize pirating and ensure journal financial sustainability.

Unexpected intrathecal haemorrhage following uncomplicated placement and removal of an epidural catheter.

We report a case of intrathecal and epidural haemorrhage 2 weeks after uncomplicated placement and removal of an epidural catheter in a patient that was initially scheduled for surgical repair of an aortic dissection and aneurysm. Included in this case report is a literature review and discussion of similar entities, differential diagnoses, and high yield learning points.

Alternative Metrics ("Altmetrics") for Assessing Article Impact in Popular General Radiology Journals.

RATIONALE AND OBJECTIVES: Emerging alternative metrics leverage social media and other online platforms to provide immediate measures of biomedical articles' reach among diverse public audiences. We aimed to compare traditional citation and alternative impact metrics for articles in popular general radiology journals. MATERIALS AND METHODS: All 892 original investigations published in 2013 issues of Academic Radiology, American Journal of Roentgenology, Journal of the American College of Radiology, and Radiology were included. Each article's content was classified as imaging vs nonimaging. Traditional journal citations to articles were obtained from Web of Science. Each article's Altmetric Attention Score (Altmetric), representing weighted mentions across a variety of online platforms, was obtained from Altmetric.com. Statistical assessment included the McNemar test, the Mann-Whitney test, and the Pearson correlation. RESULTS: Mean and median traditional citation counts were 10.7 ± 15.4 and 5 vs 3.3 ± 13.3 and 0 for Altmetric. Among all articles, 96.4% had ≥1 traditional citation vs 41.8% for Altmetric (P < 0.001). Online platforms for which at least 5% of the articles were represented included Mendeley (42.8%), Twitter (34.2%), Facebook (10.7%), and news outlets (8.4%). Citations and Altmetric were weakly correlated (r = 0.20), with only a 25.0% overlap in terms of articles within their top 10th percentiles. Traditional citations were higher for articles with imaging vs nonimaging content (11.5 ± 16.2 vs 6.9 ± 9.8, P < 0.001), but Altmetric scores were higher in articles with nonimaging content (5.1 ± 11.1 vs 2.8 ± 13.7, P = 0.006). CONCLUSIONS: Although overall online attention to radiology journal content was low, alternative metrics exhibited unique trends, particularly for nonclinical articles, and may provide a complementary measure of radiology research impact compared to traditional citation counts.

MRI appearance of Wrisberg variant of discoid lateral meniscus.

OBJECTIVE: A discoid lateral meniscus is a common normal variant, occurring in approximately 3-5% of the population. A subgroup of the discoid lateral meniscus known as the Wrisberg variant occurs when there is no posterior attachment of the lateral meniscus. Instead, Wrisberg's ligament becomes the only lateral meniscus posterior stabilizer, with a symptomatic hypermobile meniscus. Although it is commonly described in the orthopedics literature, to our knowledge the Wrisberg variant of the discoid lateral meniscus is not mentioned in the radiology literature. This article describes the MRI appearance of this important yet often unrecognized process. CONCLUSION: The Wrisberg variant of the discoid lateral meniscus is a rare condition with a highly suggestive clinical history. The musculoskeletal radiologist should consider this diagnosis whenever a discoid lateral meniscus is identified because making this elusive diagnosis may prove immensely useful for the orthopedic surgeon.

Use of a bioabsorbable anterior cervical plate in the treatment of cervical degenerative and traumatic disc disruption.

OBJECT: Anterior cervical discectomy and fusion (ACDF) is a widely accepted treatment for anterior degenerative or traumatic instability of the cervical spine. To reduce or eliminate complications such as implant migration and failure, imaging degradation, and fusion stress shielding that are occasionally associated with spinal instrumentation, attention has been given to the use of bioresorbable anterior cervical plate (ACP) devices. This paper is a preliminary report of a retrospective series in which a resorbable mesh and screw system was used for graft containment in single-level ACDF. METHODS: A review of patient charts and imaging studies was conducted to determine functional outcome, fusion success, and potential soft-tissue reaction to implant resorption. Nine patients with a cervical degenerative disc disease or traumatic disc disruption were treated between October 2001 and March 2002. Follow up averaged 206 days. Eight patients were found to have an excellent result, one patient had a good result, and no patients had a satisfactory or poor result. At the time of follow-up examination, 77% of patients were found to have a radiographically solid fusion. The two patients without a solid fusion were examined only an average 8 months postoperatively and manifested no symptoms related to fusion nonhealing. No significant soft-tissue reaction was noted clinically or radiographically in any of the patients. CONCLUSIONS: The results of this preliminary study indicate that bioresorbable ACP systems for single-level ACDF are both safe and effective.

The use of bioabsorbable implants in the spine.

BACKGROUND CONTEXT: Bioabsorbable implants are commonplace in sports medicine surgeries, especially in shoulder and knee ligamentous reconstruction. Their use is now expanding to the realm of spinal reconstructive surgery. Newer polymers offer reduced incidence of the side effects of aseptic sterile sinus formation and have appropriate resorption time parameters for spine use. These new bioabsorbable materials confer initial and intermediate-term stability that is adequate for stable bony healing in various applications. The majority of human clinical applications in the spine that have been documented involve bone graft harvest site reconstruction, posterior spinal graft containment, anterior interbody reconstruction and anterior cervical and lumbar spine tension band plating. PURPOSE: The purpose of this review article is to highlight the indications and outcomes of the use of bioabsorbable implants in specific spinal applications. STUDY DESIGN: A comprehensive literature review of the English and non-English literature on bioabsorbable implant technology. METHODS: A comprehensive literature review was performed to gather basic science, animal and human data on the use of bioabsorbable implants in spinal surgery. RESULTS: Bioabsorbable implants have demonstrated strength and resorption characteristics commensurate with the physiologic and biomechanical requirements of the human spinal axis. Histologic sampling has demonstrated successful time-patterned resorption accompanied by bony replacement and remodeling of intervertebral cage devices in the animal model. CONCLUSION: Bioresorbable compounds appear to have a role in specific spinal reconstructive procedures. Their radiolucent nature improves image assessment of fusion healing, and their time-engineered resorption characteristics allow controlled dynamization in interbody and plate applications. Their widespread use and acceptance may increase dramatically as further research and clinical studies report on their safety and efficacy.

Use of a bioabsorbable anterior cervical plate in the treatment of cervical degenerative and traumatic disk disruption.

Anterior cervical diskectomy and fusion is a widely accepted treatment for anterior management of degenerative or traumatic instability of the cervical spine. To reduce or eliminate complications such as implant migration and failure, imaging degradation, and fusion stress shielding that are occasionally associated with spinal instrumentation, attention has been given to the use of bioresorbable anterior cervical plating devices. This paper is a preliminary report of a retrospective series in which a resorbable mesh and screw system (OS Reconstructive Mesh, MacroPore Biosurgery Inc, San Diego, Calif) was used for graft containment in single-level anterior cervical diskectomy and fusion. A review of patient charts and imaging studies was conducted to determine functional outcome, fusion success, and potential soft-tissue reaction to implant resorption. Nine patients with a diagnosis of cervical degenerative disk disease or traumatic disk disruption were treated between October 2001 and March 2002. Follow-up averaged 206 days. Eight patients were found to have an excellent result, one patient had a good result, and no patients had a satisfactory or poor result. At the time of follow-up, 77% of patients (7/9) were found to have a radiographically solid fusion. The two patients without a solid fusion were only on average 8 months out from their fusion procedure and manifested no symptoms related to fusion nonhealing. No significant soft-tissue reaction was noted clinically or radiographically in any of the patients. The results of this preliminary study indicate that bioresorbable anterior cervical plating for single-level anterior cervical diskectomy and fusion is both safe and effective.

Disc space-targeted angled axial MR images of the lumbar spine: a potential source of diagnostic error.

OBJECTIVE: To compare the sensitivities of contiguous axial (CA) images and disc space-targeted angled axial (DSTAA) images of the lumbar spine for: (1) the detection of spondylolysis defects, and (2) the identification of disc material which has migrated away from the parent disc. MATERIALS AND METHODS: Prospective imaging of the lumbar spine was performed over a 22-month period in 103 patients. Imaging protocols included spin-echo T1- and fast spin-echo (FSE) T2-weighted images in the sagittal and axial planes. For each patient, axial images were obtained both contiguously throughout the lumbar spine and as angled images, targeted at the region of the disc space only. Two separate data sets were compiled: one that included contiguous axial images (CA data set) and another that included targeted angled images through the disc spaces only (DSTAA data set). Identical sagittal images were included with both sets. A single radiologist independently interpreted the two data sets for a given patient following an intervening time lapse. The radiologist was blinded to the initial interpretation. Results from the two independent interpretations were then compared. RESULTS: Spondylolysis defects were identified at 15 different levels in 14 patients (14%) using the contiguous axial imaging protocol compared with 8 (7%) identified using the disc space targeted angled axial imaging protocol (P = 0.12). Migrated disc material was identified in 12 patients (12%) using the CA protocol compared with 3 patients (3%) identified with the DSTAA protocol (P = 0.016). CONCLUSIONS: MR imaging of the lumbar spine using contiguous axial data obtained through both the level of the disc and vertebral body demonstrates migrated disc material and spondylolysis defects better than did disc space-targeted angled data.