Childhood Interstitial (Diffuse) Lung Disease: Pattern Recognition Approach to Diagnosis in Infants.

OBJECTIVE. The purpose of this article is to discuss imaging techniques and a pattern-based approach for diagnosing childhood interstitial (diffuse) lung diseases in infants. CONCLUSION. Childhood interstitial (diffuse) lung disease in infants consists of a heterogeneous group of disorders previously classified with clinical, radiologic, and pathologic features. By use of an imaging-guided algorithm, the assessment of lung volumes and the presence of ground-glass opacities or cysts can assist the radiologist in making an accurate and timely diagnosis.

Clinical Utility of Dual-Energy CT Analysis of Bone Marrow Edema in Acute Wrist Fractures.

OBJECTIVE: The purpose of this study is to determine the utility of dual-energy CT (DECT) for assessing carpal fractures and to obtain an attenuation value cutoff (in Hounsfield units) to identify bone marrow edema due to an acute carpal fracture. MATERIALS AND METHODS: In this retrospective study, 24 patients who presented with wrist fractures from September 3, 2014, through March 9, 2015, underwent imaging with DECT (80 and 140 kVp). Using the three-material decomposition algorithm specific for virtual noncalcium to construct images, two radiologists identified carpal fractures and associated bone marrow edema. Readers noted the attenuation at areas with and without bone marrow edema. The cutoff value was obtained by ROC analysis and was internally validated on 13 separate patients with suspected wrist fractures. A p < 0.05 was considered statistically significant. RESULTS: CT attenuation was significantly higher in areas of bone marrow edema than in areas without it (p < 0.0001, t test). A cutoff of 5.90 HU allows detection of bone marrow edema associated with acute wrist fractures with 100% sensitivity and 99.5% specificity, compared with visual DECT interpretation. In the 13 validation cases, the cutoff of 5.90 HU identified bone marrow edema with 100% accuracy, compared with visual interpretation. Kappa values were 0.83 between the two readings by reader 1, and 0.73 and 0.96 comparing the two readings of reader 1 with the reading by reader 2. CONCLUSION: DECT is a useful tool for identifying bone marrow edema in the setting of acute wrist fractures, providing an alternative to MRI. A cutoff value of 5.90 HU can be used for accurate diagnosis and exclusion of carpal fractures.

Dual-source CT in blunt trauma patients: elimination of diaphragmatic motion using high-pitch spiral technique.

The purpose of this study was to compare diaphragmatic motion on dual-source high-pitch (DS-HP) and conventional single-source (SS) CT scans in trauma patients. Seventy-five consecutive trauma patients who presented to a level one trauma center over a 6-month period were scanned with a standardized whole body trauma CT protocol including both DS-HP chest (pitch = 2.1-2.5) and SS abdominal CT scans. Subjective analysis of diaphragmatic motion was performed by two readers using a four-point motion scale in seven regions of the diaphragm on coronal and axial slices. An overall confidence score to exclude a diaphragmatic tear was determined (1 to 10, 10: completely confident and 1: impossible to exclude). Wilcoxon rank sum tests were used for statistical analysis, and p < 0.05 was considered significant. Mean confidence score of 9.85 for DS-HP was significantly better than the mean score of 7.66 for SS images (p < 0.0001). Diaphragmatic motion scores and subjective diaphragmatic motion artifact on coronal and axial images were significantly better for DS-HP images in all areas when compared individually (p < 0.0001) and overall (p < 0.0001). Regions of DS-HP (99.2 %) were diagnostic, whereas only 87.0 % % regions on SS were. Complete agreement of motion scores was present in 92 % of cases, with moderate overall agreement for confidence to exclude a diaphragmatic tear (κ = 0.45). Dual-source high-pitch CT scanning is advantageous as it allows for significantly better evaluation of diaphragmatic structures by minimizing motion artifacts on images of freely breathing trauma patients.

Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum.

OBJECTIVE: Testicular torsion is a common acute condition in boys requiring prompt accurate management. The objective of this article was to evaluate ultrasound accuracy, findings, and clinical predictors in testicular torsion in boys presenting to the Stollery pediatric emergency department with acute scrotal pain. METHODS: Retrospective review of surgical and emergency department ultrasound records for boys from 1 month to 17 years old presenting with acute scrotal pain from 2008 to 2011 was performed. Clinical symptoms, ultrasound and surgical findings, and diagnoses were recorded. Surgical results and follow-up were used as the reference standard. RESULTS: Of 342 patients who presented to the emergency department with acute scrotum, 35 had testicular torsion. Of 266 ultrasound examinations performed, 29 boys had torsion confirmed by surgery. The false-positive rate for ultrasound was 2.6%, and there were no false-negative findings. Mean times from presentation at the emergency department to ultrasound and surgery were 209.4 and 309.4 minutes, respectively. Of the torsed testicles, 69% were salvageable. Sensitivity, specificity, and diagnostic accuracy of ultrasound for testicular torsion were 100%, 97.9%, and 98.1%, respectively. Sonographic heterogeneity was seen in 80% of nonviable testes at surgery and 58% of patients with viable testes (p = 0.41). Sudden-onset scrotal pain (88%), abnormal position (86%), and absent cremasteric reflex (91%) were most prevalent in torsion patients. CONCLUSION: Color Doppler ultrasound is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. Despite heterogeneity on preoperative ultrasound, many testes were considered to be salvageable at surgery. The salvage rate of torsed testes was high.

Imaging of blunt vascular neck injuries: a review of screening and imaging modalities.

OBJECTIVE: We will review the epidemiology of blunt cerebrovascular injuries (BCVIs) and the rationale for screening. Current imaging modalities used to screen for BCVIs will be discussed with an emphasis on CT angiography. CONCLUSION: Screening for BCVIs can decrease rates of postinjury complications, such as stroke. The use of standardized screening criteria and the appropriate imaging modalities can allow early detection of BCVIs and effective intervention.

Imaging of blunt vascular neck injuries: a clinical perspective.

OBJECTIVE: We will review the common injuries and anatomic distributions of blunt cerebrovascular injuries (BCVIs) of the neck, explain the grading criteria, and discuss the corresponding management. Artifacts associated with BCVI on CT will also be examined. CONCLUSION: Identifying common injury patterns and anatomic distributions associated with BCVI can help decide the grade and management earlier and reduce the risk for potential complications. Recognizing the common artifacts associated with BCVI helps the reader successfully recognize a true BCVI.

Review of multidetector computed tomography angiography as a screening modality in the assessment of blunt vascular neck injuries.

Blunt vascular neck injuries (BVNI), previously thought to be rare, have demonstrated increasing incidence rates in recent literature and are associated with significant mortality and morbidity. A radiologist needs to efficiently recognize these injuries on preliminary screening to enable initiation of early management. When initiation of accurate management is started promptly, decreased rates of postinjury complications, for example, stroke, have been demonstrated. This article reviews the incidence, pathophysiology, and rationale for screening for these BVNI injuries. The utility of computed tomography angiography (CTA) as the potential new criterion standard as the screening and follow-up imaging modality for BVNI will be discussed. The application of new multidetector CTA techniques available, such as dual-energy CT and iterative reconstruction, are also reviewed. In addition, the characteristic imaging findings on CTA and the associated Denver Grading scale for BVNI will be reviewed to allow readers to become familiar with the injury patterns and to understand the prognostic and clinical implications, respectively. Examples of the spectrum of injuries, potential injury mimics, and different artifacts on multidetector CTA are shown to help familiarize readers and allow them to successfully and confidently recognize a true BVNI.

Dual-energy CT: a promising new technique for assessment of the musculoskeletal system.

OBJECTIVE: Dual-energy CT (DECT) characterizes the chemical composition of material according to its differential x-ray attenuation at two different energy levels. Applications of DECT in musculoskeletal imaging include imaging of bone marrow edema, tendons, and ligaments and the use of monoenergetic techniques to minimize metal prosthesis beam-attenuating artifacts. CONCLUSION: The most validated application of DECT is undoubtedly its noninvasive and highly specific ability for confirming the presence of monosodium urate deposits in the assessment of gout.

Pediatric Pulmonary Nodules: Imaging Guidelines and Recommendations.

Incidental pulmonary nodules are not infrequently identified on computed tomography imaging in the pediatric population and can be a challenge in suggesting appropriate follow-up recommendations. An evidence-based and practical imaging approach for diagnosis and appropriate directed management is essential for optimal patient care. This article provides an up-to-date review of the pediatric pulmonary nodule literature and suggests a practical algorithm to manage pulmonary nodules in the pediatric population.

Clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the paediatric population: Part 2.

Children, especially toddlers, because of their behaviour, physiology and anatomical characteristics such as oral exploration of their surroundings, have a tendency to place objects in their mouth. Therefore, ingestion or aspiration of foreign bodies (FBs) in children is a potentially life-threatening and common problem seen across the world. In this second part of our pictorial review on ingested and aspirated FBs, we focus on the paediatric population, reviewing the current literature and examining the epidemiology, clinical presentation, anatomic considerations, appropriate imaging modalities, key imaging characteristics associated with clinically relevant FBs in the emergency department (ED) and current management protocols.

Interstitial Lung Diseases in Children, Adolescents, and Young Adults: Different from Infants and Older Adults.

Childhood interstitial lung disease (chILD) in children, teenagers, and young adults presents a challenge to the clinicians and radiologist, given its rarity, diverse imaging manifestations, and often nonspecific clinical examination findings. This article discusses the utility of available imaging techniques and associated characteristic imaging findings, and reviews the 2015 chILD classification scheme, with clinical examples highlighting the imaging features to help the radiologist aid in an efficient and accurate multidisciplinary diagnosis of chILD.

Dual-Source Computed Tomography of the Chest in Blunt Thoracic Trauma: Reduced Aortic Motion Using a Novel Temporal Resolution Optimization Method.

PURPOSE: The purpose of this study was to evaluate the clinical utility of temporal resolution optimization (TR-Opt), a computed tomography (CT) postprocessing technique, in reducing aortic motion artifacts in blunt thoracic trauma patients. MATERIALS AND METHODS: This was an IRB-approved study of 61 patients with blunt thoracic trauma carried out between February 18 and September 6, 2014; the patients had been imaged using a standardized dual-source high-pitch (DSHP) CT protocol. Image raw data were retrospectively postprocessed using the TR-Opt algorithm (DSHP-TR-Opt) and compared with conventional images (DSHP). Diagnostic ability to confidently identify and exclude potential injuries and qualitative aortic motion artifacts using a 5-point Likert scale (1=absence of motion artifacts; 5=severe motion artifact) was graded by 2 readers at multiple thoracic locations. Signal-to-noise and contrast-to-noise ratios were generated as quantitative indices of image quality. RESULTS: Motion artifacts degrading interpretation and limiting diagnosis of aortic injuries were present in 45% (442/976) of the assessed regions on DSHP. TR-Opt algorithm eliminated motion artifacts in 85% of the motion-degraded areas (375/442), leaving persistent motion artifacts in only 15% (67/442). Motion artifacts were most improved at the interventricular septum (1±1 vs. 3±1), aortic valve (2±1 vs. 4±1.5), and ascending aorta (1±1 vs. 3±2, P<0.005). Mean aorta noise (NAo) was 41.7% higher in the DSHP-TR-Opt images (26.5 vs. 18.7 HU, P<0.0001). CONCLUSIONS: Temporal resolution optimized reconstruction is a raw data-based CT postprocessing technique that can be used to remove the majority of thoracic aortic motion artifacts that commonly degrade interpretation when imaging blunt thoracic trauma patients.

Stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma: imaging evaluation post treatment.

Surgical resection, when feasible, is the standard of care for hepatocellular carcinoma. However, many tumours are not resectable at the time of diagnosis. Recently, stereotactic body radiation therapy (SBRT) has emerged as a non-invasive local therapy for both non-resectable primary hepatic malignancies as well as hepatic metastases. Knowledge of the expected hepatic parenchymal appearance post treatment, as well as potential pitfalls and complications, is essential for accurate evaluation of treatment response. This pictorial review provides a fundamental description of the SBRT technique, outlines the expected cross-sectional imaging appearances of tumour response, and highlights potential pitfalls in interpretation. The expected liver parenchymal changes post-SBRT are also reviewed, along with some common radiation-induced complications.

Assessing the Gap in Female Authorship in Radiology: Trends Over the Past Two Decades.

PURPOSE: The aim of this study was to retrospectively identify trends in the representation of female authorship in prominent general radiology journals over the past 2 decades. METHODS: A comprehensive search was conducted for all articles published in 1993, 2003, and 2013 in Radiology, the American Journal of Roentgenology (AJR), European Radiology, and Investigative Radiology. The genders of the first and last authors were collected. Chi-square tests were used for statistical analysis, and P values < .05 were considered to indicate statistical significance. RESULTS: A total of 3,786 articles were reviewed. Overall, women constituted 20.0% authorship, 24.7% of first authors, and 15.2% of senior authors. The average overall female first and senior authorship grew from 19.7% to 32.1% and from 13.6% to 19.1%, respectively from 1993 to 2013. Female first authorship grew over the past 2 decades in the journals reviewed, with significant growth in AJR and Radiology (P < .0001). Female first authorship in the individual journals grew from 16.4%-29.1% in 1993, to 29.1%-34.8% in 2013. Female senior authorship also demonstrated growth in the past 2 decades, growing from 4.3%-17.5% in 1993 to 15.5%-23.2% in 2013. There was significant growth in senior female authorship in Radiology (from 12.1% to 19.2%, P = .004) and European Radiology (from 4.3% to 15.5%, P = .0433). Female senior authorship remained significantly lower than first authorship over the past 2 decades (P = .002, P < .001, and P < .0001). CONCLUSIONS: Although women's growth in first authorship in radiology literature is proportional to their growth in the specialty, they continue to remain a minority, especially in senior authorship, and demonstrate similar participation to other medical specialties.

Ultrasound-guided aspiration and injection of an intraneural ganglion cyst of the common peroneal nerve.

BACKGROUND: Intraneural ganglion cysts are rare, benign, mucinous lesions that occur within neural sheaths and are thought to involve cystic fluid exiting from nearby synovial joints. They often present as tender masses causing paresthesias in the distribution of the involved nerve, muscle weakness or cramping, or localized or referred pain. CASE DESCRIPTION: We present a case of a patient who initially presented with foot drop due to an intraneural ganglion cyst of the common peroneal nerve. This cyst was successfully treated using ultrasound guidance to aspirate the cyst and inject corticosteroid to prevent further inflammation. LITERATURE REVIEW: Standard of care has previously involved surgical resection, but this has been associated with a high frequency of recurrence. Due to the risks of nerve and vessel damage, there have been efforts to find alternative ways of resolving these cysts. PURPOSES AND CLINICAL RELEVANCE: Aspiration and injection of corticosteroid is a useful and minimally invasive alternative to surgery for managing intraneural ganglion cysts.

The evolving role of the radiologist: the Vancouver workload utilization evaluation study.

PURPOSE: The role of the present-day on-site hospital radiologist surpasses image interpretation-related duties. This study characterizes these workload activities, as well as quantifies the type of value-based interactions radiologists experience on a daily basis with allied health personnel. MATERIALS AND METHODS: A prospective, observational, randomized study was performed across 3 hospitals in the fall of 2012. One month of observation of 14 staff radiologists was performed by a trained observer. The observer followed the subject radiologists throughout the workday, recording activities using a time and motion methodology. RESULTS: Radiologists spent 36.4% of their time on image interpretation. The proportion of noninterpretative tasks was 43.8%, which includes activities such as protocolling requisitions, supervising and monitoring studies, performing image-guided procedures, consulting with physicians, and directly caring for patients. Total clinical productivity was 87.7%, and radiologists experienced, on average, 6 interactions per hour with other health personnel, of which over 81.2% directly influenced patient care in real time. CONCLUSION: This study demonstrates a new framework of characterizing the type of work radiologists perform on a daily basis, which helps further define the evolving role of the present-day radiologist to other physicians, administrators, and policy makers. Furthermore, the on-site added value that radiologists deliver suggests that radiologists are central figures in the medical imaging department who are difficult to replace by off-site or nonradiologist image interpreters.

Iterative reconstructed ultra high pitch CT pulmonary angiography with cardiac bowtie-shaped filter in the acute setting: effect on dose and image quality.

PURPOSE: To evaluate the effect of a cardiac bowtie-shaped filter in an ultra high pitch CTPA protocol at 100 kV on image quality and radiation dose. MATERIALS AND METHODS: Retrospective study of 100 patients referred for CTPA. 50 patients scanned with a standard 100 kV protocol at pitch 2.8 (Protocol A) and 50 patients scanned with a 100 kV protocol at pitch 3.2 with a cardiac bowtie-shaped filter (Protocol B). All other scanning parameters kept constant. Images from both groups reconstructed with filtered back projection and iterative reconstruction. Central pulmonary vessel attenuation and background noise were quantitatively measured and signal-to-noise (SNR) and contrast-to-noise (CNR) were calculated. Two radiologists performed qualitative assessment grading visualization of the pulmonary vasculature and noise level. CTDIvol and DLP were recorded and effective dose was calculated. RESULTS: CTDIvol, DLP and effective dose were significantly (p<0.0001) lower in Protocol B (2.3 ± 0.5 mGy, 78.4 ± 16.5 mGycm, 1.4 ± 0.3 mSy, respectively) compared to Protocol A (4.3 ± 0.5 mGy, 152.0 ± 19.6 mGycm, 2.7 ± 0.3 mSy, respectively). Protocol B had significantly (p<0.0001) higher noise than Protocol A (23.8 ± 6.9 HU vs 36.8 ± 7.3 HU) and lower SNR (11.8 ± 3.7 HU vs 19.2 ± 8.1 HU) and CNR (10.3 ± 3.7 HU vs 24.9 ± 13.4 HU) but there was no significant difference in the subjective visualization of the pulmonary vasculature (p=0.63). Furthermore, iterative reconstruction significantly (p<0.0001) improves image noise (29.4 ± 5.5 HU from 36.8 ± 7.3 HU). CONCLUSION: The addition of a cardiac bowtie-shaped filter with an ultra high pitch CTPA protocol at 100 kV resulted in a 48% dose reduction without significantly affecting diagnostic image quality. In addition, the use of iterative reconstruction significantly improves image quality by reducing noise permitting the possibility for further dose reduction strategies.