ACR Appropriateness Criteria® Screening for Abdominal Aortic Aneurysm.

Abdominal aortic aneurysm (AAA) is a significant vascular disease found in 4% to 8% of the screening population. If ruptured, its mortality rate is between 75% and 90%, and it accounts for up to 5% of sudden deaths in the United States. Therefore, screening of AAA while asymptomatic has been a crucial portion of preventive health care worldwide. Ultrasound of the abdominal aorta is the primary imaging modality for screening of AAA recommended for asymptomatic adults regardless of their family history or smoking history. Alternatively, duplex ultrasound and CT abdomen and pelvis without contrast may be appropriate for screening. 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 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 where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery): 2022 Update.

Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy followed by breast reconstruction. Deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle. Multiple perforators are identified by preoperative imaging, which are typically ranked based on size, location, and intramuscular course. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients. The objective of this document is to review the imaging modalities that can be used preoperatively to identify the optimal perforator and thereby reduce intraoperative complications, reduce postoperative complications, and improve clinical outcomes. 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.

Multimodality Imaging of Large-Vessel Vasculitis, From the AJR Special Series on Inflammation.

Large-vessel vasculitis (LVV) is a noninfectious inflammation of the large vessels, including the aorta and its main branches. Imaging plays an essential role in diagnosing LVV given the challenges of tissue biopsy. This article reviews the types of LVV and the multimodality imaging tools available to establish its diagnosis. The cornerstone of imaging diagnosis is morphologic assessment using gray-scale ultrasound (US), gray-scale US combined with color Doppler US, CTA, or MRA. In the last decade, substantial progress has been made in functional and molecular imaging with FDG PET/CT for the diagnosis of LVV. Investigation is ongoing to develop novel MRA techniques and new PET tracers to assess disease activity and to differentiate the various vasculitides. An algorithm is provided to guide imaging technique selection based on the patient's specific clinical presentation.

Multimodality imaging to distinguish between benign and malignant cardiac masses.

BACKGROUND: To compare the diagnostic accuracy of CMR and FDG-PET/CT and their complementary role to distinguish benign vs malignant cardiac masses. METHODS: Retrospectively assessed patients with cardiac mass who underwent CMR and FDG-PET/CT within a month between 2003 and 2018. RESULTS: 72 patients who had CMR and FDG-PET/CT were included. 25 patients (35%) were diagnosed with benign and 47 (65%) were diagnosed with malignant masses. 56 patients had histological correlation: 9 benign and 47 malignant masses. CMR and FDG-PET/CT had a high accuracy in differentiating benign vs malignant masses, with the presence of CMR features demonstrating a higher sensitivity (98%), while FDG uptake with SUVmax/blood pool ≥ 3.0 demonstrating a high specificity (88%). Combining multiple (> 4) CMR features and FDG uptake (SUVmax/blood pool ratio ≥ 3.0) yielded a sensitivity of 85% and specificity of 88% to diagnose malignant masses. Over a mean follow-up of 2.6 years (IQR 0.3-3.8 years), risk-adjusted mortality were highest among patients with an infiltrative border on CMR (adjusted HR 3.1; 95% CI 1.5-6.5; P = .002) or focal extracardiac FDG uptake (adjusted HR 3.8; 95% CI 1.9-7.7; P < .001). CONCLUSION: Although CMR and FDG-PET/CT can independently diagnose benign and malignant masses, the combination of these modalities provides complementary value in select cases.

ACR Appropriateness Criteria® Noncerebral Vasculitis.

Noncerebral vasculitis is a wide-range noninfectious inflammatory disorder affecting the vessels. Vasculitides have been categorized based on the vessel size, such as large-vessel vasculitis, medium-vessel vasculitis, and small-vessel vasculitis. In this document, we cover large-vessel vasculitis and medium-vessel vasculitis. Due to the challenges of vessel biopsy, imaging plays a crucial role in diagnosing this entity. While CTA and MRA can both provide anatomical details of the vessel wall, including wall thickness and enhancement in large-vessel vasculitis, FDG-PET/CT can show functional assessment based on the glycolytic activity of inflammatory cells in the inflamed vessels. Given the size of the vessel in medium-vessel vasculitis, invasive arteriography is still a choice for imaging. However, high-resolution CTA images can depict small-caliber aneurysms, and thus can be utilized in the diagnosis of medium-vessel vasculitis. 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.

Aortic Root Replacement to Accommodate Future Valve-in-Valve Transcatheter Aortic Valve Replacement.

Coronary obstruction is a feared complication associated with valve-in-valve transcatheter aortic valve replacement (TAVR) that may prevent patients with high anatomical risk from being considered. Aortic root replacement at the time of the index TAVR allows higher coronary implantation and augmentation of transcatheter heart valve to coronary ostial distance. This approach permits future valve-in-valve TAVR and may be an important strategy in lifetime valve selection management, particularly in young patients.

Clinically isolated aortitis: imaging features and clinical outcomes: comparison with giant cell arteritis and giant cell aortitis.

(1) describe imaging features of CIA, (2) compare dilation rate and wall thickening of aortic aneurysms in patients with CIA versus those with giant cell arteritis/aortitis (GCA), (3) present clinical outcomes of CIA patients. Retrospective search of electronic records from 2004 to 2018 yielded 71 patients, 52 of whom were female, with a mean age of 67.5 ± 9.0 years old, with a new clinical diagnosis of cranial or extracranial GCA (GCA group), and giant cell aortitis revealed by the aortic biopsy (CIA group). Comparisons between groups were conducted using the Wilcoxon rank-sum and Fisher's exact tests. Survival from the date of initial diagnosis to the end of data collection was compared between the two groups through a log-rank test. CIA patients (n = 23; 32%) presented with cardiovascular symptoms, and none had systemic inflammatory symptoms. Inflammatory markers were significantly higher among GCA patients than among CIA patients (p < 0.0001). The CIA group demonstrated thoracic aortic aneurysms without wall thickening. None of the GCA patients (n = 48; 68%) had aneurysmal dilation in the aorta at the time of diagnosis. None of the four CIA patients had FDG uptake in the aorta, while nine out of 13 GCA patients had FDG uptake in the vessels. There was no statistically significant difference in the survival between the two groups (p = 0.12). CIA patients presented with cardiovascular symptoms and was characterized by aneurysm of the aorta without the involvement of the infrarenal aortic segment. The role of FDG-PET/CT in CIA is less certain, though none of the patients in this cohort had FDG uptake in the vessels.

Alternative Diagnostic Strategy for the Assessment and Treatment of Pulmonary Embolus: A Case Series.

INTRODUCTION: Ferumoxytol-enhanced magnetic resonance angiography (FeMRA) can be used as an alternate and safe method to diagnose patients with compromised renal function who present with acute pulmonary embolus in the emergency department (ED) setting. CASE REPORT: A 62-year old man with a history of renal transplant and lymphoproliferative disease described new onset of breathlessness. His clinical symptoms were suggestive of pulmonary embolus. He underwent FeMRA in the ED to avoid exposure to intravenous iodinated contrast. FeMRA demonstrated a left main pulmonary artery embolus, which extended to the left interlobar pulmonary artery. Afterward, the patient initiated anticoagulation therapy. With preserved renal function he was able to continue his outpatient chemotherapy regimen. CONCLUSION: This case highlights a safe imaging technique for emergency physicians to diagnose pulmonary embolus and subsequently guide anticoagulation therapy for patients in whom use of conventional contrast is contraindicated.

Imaging findings during and after percutaneous cryoablation of hepatic tumors.

OBJECTIVE: Imaging plays a key role in the assessment of patients before, during, and after percutaneous cryoablation of hepatic tumors. Intra-procedural and early post-procedure imaging with CT and MRI is vital to the assessment of technical success including adequacy of ablation zone coverage. Recognition of the normal expected post-procedure findings of hepatic cryoablation such as ice ball formation, hydrodissection, and the normal appearance of the ablation zone is crucial to be able to differentiate from complications including vascular, biliary, or non-target organ injury. Delayed imaging is essential for determination of clinical effectiveness and detection of unexpected findings such as residual unablated tumor and local tumor progression. The purpose of this article is to review the spectrum of expected and unexpected imaging findings that may occur during or after percutaneous cryoablation of hepatic tumors. CONCLUSION: Differentiating expected from unexpected findings during and after hepatic cryoablation helps radiologists identify residual or recurrent tumor and detect procedure-related complications.

Assessment of Cardiac Masses by Cardiac Magnetic Resonance Imaging: Histological Correlation and Clinical Outcomes.

Background Cardiac magnetic resonance imaging ( CMR ) provides useful information for characterizing cardiac masses, but there are limited data on whether CMR can accurately distinguish benign from malignant lesions. We aimed to describe the distribution and imaging characteristics of cardiac masses identified by CMR and to determine the diagnostic accuracy of CMR for distinguishing benign from malignant tumors. Methods and Results We examined consecutive patients referred for CMR between May 2008 and August 2013 to identify those with a cardiac mass. In patients for whom there was histological correlation, 2 investigators blinded to all data analyzed the CMR images to categorize the mass as benign or malignant. For benign masses, readers were also asked to specify the most likely diagnosis. Benign masses were defined as benign neoplastic or non-neoplastic. Malignant masses were defined as primary cardiac or metastatic. Of 8069 patients (mean age: 58±16 years; 55% female) undergoing CMR , 145 (1.8%) had a cardiac mass. In most cases (142, 98%), there was a known cardiac mass before the CMR study. Among 145 patients with a cardiac mass, 93 (64%) had a known history of malignancy. Among 53 cases that had histological correlation, 25 (47%) were benign, 26 (49%) were metastatic, and 2 (4%) were malignant primary cardiac masses. Blinded readers correctly diagnosed 89% to 94% of the cases as benign versus malignant, with a 95% agreement rate (κ=0.83). Conclusions Although C MR can be highly effective in distinguishing benign from malignant lesions, pathology remains the gold standard in accurately determining the type of mass.

Prognostic Value of Cardiac Magnetic Resonance Tissue Characterization in Risk Stratifying Patients With Suspected Myocarditis.

BACKGROUND: Diagnosing myocarditis is challenged by nonspecific clinical signs and symptoms and low accuracy of endomyocardial biopsy. Cardiac magnetic resonance imaging (CMR) provides both cardiac anatomy and tissue characterization in this setting, but the prognostic value of this method as a primary assessment tool in patients with suspected myocarditis remains limited. OBJECTIVES: This study sought to determine cardiac event-free survival of a consecutive cohort with suspected myocarditis with regard to CMR findings. METHODS: Six hundred seventy patients with suspected myocarditis underwent CMR including late gadolinium enhancement (LGE) parameters between 2002 and 2015 and were included and followed. We performed multivariable model for major adverse cardiovascular events (MACE) and determined the continuous net reclassification improvement by LGE markers. RESULTS: At a median follow-up of 4.7 years (interquartile range [IQR]: 2.3 to 7.3 years), 98 patients experienced a MACE. Two hundred ninety-four (44%) patients showed LGE presence, which was associated with a more than doubling risk of MACE (hazard ratio [HR]: 2.22; 95% confidence interval [CI]: 1.47 to 3.35; p < 0.001). Annualized MACE rates were 4.8% and 2.1% corresponding to LGE presence and absence, respectively (p < 0.001). In the multivariable model, LGE presence maintained significant association with MACE (HR: 1.72; 95% CI: 1.08 to 2.76; p = 0.023). The computed continuous net reclassification improvement was 0.39 (95% CI: 0.10 to 0.67) when LGE presence was added to the multivariable model for MACE. Regarding location and pattern, septal and midwall LGE showed strongest associations with MACE (HR: 2.55; 95% CI: 1.77 to 3.83 and HR: 2.39; 95% CI: 1.54 to 3.69, respectively; both p < 0.001). A patchy distribution portended to a near 3-fold increased hazard to MACE (HR: 2.93; 95% CI: 1.79 to 4.80; p < 0.001). LGE extent (per 10% increase) corresponded to a 79% increase in risk of MACE (HR: 1.79; 95% CI: 1.25 to 2.57; p = 0.002). A normal CMR study corresponded to low annual MACE and death rates of 0.8% and 0.3%, respectively. CONCLUSIONS: CMR tissue characterization provides effective risk stratification in patients with suspected myocarditis.

Quantification of radiation dose reduction by reducing z-axis coverage in 320-detector coronary CT angiography.

OBJECTIVE: To quantify the radiation dose reduction achievable by minimizing z-axis coverage in 320-detector coronary CT angiography (CCTA). METHODS: We retrospectively reviewed 130 CCTAs performed on 320-detector CT that offers up to 16 cm z-axis coverage (adjustable in 2-cm increments), allowing complete coverage of the heart in a single gantry rotation. For each CT, we obtained the radiation dose [CT dose index and dose-length product (DLP)], measured the z-axis field of view and measured the craniocaudal cardiac size (distance from the left main coronary artery to the cardiac apex). We calculated the radiation dose savings achievable by reducing the z-axis coverage to the minimum necessary to cover the heart using 320 × 0.5-mm (maximum 16 cm) and 256 × 0.5-mm (maximum 12.8 cm) detector collimations. RESULTS: Results are expressed as mean ± standard deviation. The mean craniocaudal cardiac size was 10.5 ± 1.0 cm, with 85% (n = 112) of CCTAs performed with 16 cm of z-axis coverage. The mean DLP was 417.6 ± 182.4 mGy cm, with the mean DLP saving achievable using the minimum z-axis coverage required to completely image the heart being 96.2 ± 47.4 mGy cm, an average dose reduction of 26.9 ± 7.0%. z-axis coverage of ≤12 cm was adequate for 92% and 12.8 cm for 98% of subjects. CONCLUSION: Using the minimal z-axis coverage to adequately image the heart is a simple step that can reduce the DLP in 320-detector CCTA by approximately 27%. z-axis coverage of ≤12 cm is adequate for 92%, 12.8 cm for 98% and 14 cm for 100% of patients undergoing CCTA. Advances in knowledge: Reducing z-axis coverage in 320-detector CCTA can reduce DLP by approximately 27%.

Sonography and Magnetic Resonance Imaging Characteristics of Testicular Adrenal Rest Tumors.

BACKGROUND: The aim of this study was to describe the gray-scale and color Doppler ultrasonography (US) and magnetic resonance (MR) imaging features of testicular adrenal rest tumors (TART) in patients with congenital adrenal hyperplasia. MATERIAL/METHODS: Forty-one patients with congenital adrenal hyperplasia were evaluated by gray-scale and color Doppler ultrasonography. Totally eighteen adrenal rest tumors in 9 patients were diagnosed TART on US and MR imaging. Gray-scale and color Doppler US and MR findings of the patients were documented. RESULTS: A total of eighteen masses were evaluated in nine patients. The mean age of these patients was 14.3±4.5 (range 10.1-23.3) years. US revealed hypoechoic lesions around the mediastinum testis with hypervascularity dispersing in ten patients and hypovascularity in two patients. In six patients, the lesions were hyperechoic with poor vascularity. Lesions exhibited homogeneous (n=8) and heterogeneous (n=10). Testicular microlithiasis was present in 4 of 9 patients with TART. Doppler ultrasound showed normal testicular vessels passing through the mass which were undisturbed, not displaced and not change in caliber. MRI features were the following: all lesions were hypointense on T2- and hyperintense (n=12) and isointense (n=6) on T1-weighted images. All masses revealed homogeneous contrast enhancement on postcontrast T1-weighted images. CONCLUSIONS: Ultrasonography and MRI are good methods for detecting and monitoring TART. US is the first preferable modality because it is quick and cheap than MRI. Bilateral mostly hypoechoic lesions depicted around the mediastinum testis with no mass effect is highly suggestive for the diagnosis of testicular adrenal rest tissues on ultrasonography. Normal testicular vessels coursing through the lesions undisturbed and not change in caliber is described specific for this kind of tumors.

CT pulmonary angiography-based scoring system to predict the prognosis of acute pulmonary embolism.

BACKGROUND: The purpose is to develop a comprehensive risk-scoring system based on CT findings for predicting 30-day mortality after acute pulmonary embolism (PE), and to compare it with PE Severity Index (PESI). MATERIALS AND METHODS: The study included consecutive 1698 CT pulmonary angiograms (CTPA) positive for acute PE performed at a single institution (2003-2010). Two radiologists independently assessed each study regarding clinically relevant findings and then performed adjudication. These variables plus patient clinical information were included to build a LASSO logistic regression model to predict 30-day mortality. A point score for each significant variable was generated based on the final model. PESI score was calculated in 568 patients who visited the hospital after 2007. RESULTS: Inter-reader agreements of interpretations were >95% except for septal bowing (92%). The final prediction model showed superior ability over PESI (AUC = 0.822 vs 0.745) for predicting all-cause 30-day mortality (12.4%). The scoring system based on the significant variables (age (years), pleural effusion (+20), pericardial effusion (+20), lung/liver/bone lesions suggesting malignancy (+60), chronic interstitial lung disease (+20), enlarged lymph node in thorax (+20), and ascites (+40)) stratified patients into 4 severity categories, with mortality rates of 0.008% in class-I (≤50 pt), 3.8% in class-II (51-100 pt), 17.6% in class-III (101-150 pt), and 40.9% in class-IV (>150 pt). The mortality rate in the CTPA-high risk category (class-IV) was higher than those in the PESI's high risk (27.4%) and very high risk (25.2%) categories. CONCLUSION: The CTPA-based model was superior to PESI in predicting 30-day mortality. Incorporating the CTPA-based scoring system into image interpretation workflows may help physicians to select the most appropriate management approach for individual patients.

Incidence and clinical sequelae of portal and hepatic venous thrombosis following percutaneous cryoablation of liver tumors.

PURPOSE: To assess the incidence and sequelae of portal and hepatic venous thrombosis after percutaneous cryoablation of hepatic tumors. METHODS: From November 1998 through December 2010, 223 hepatic tumors were cryoablated during 170 ablation procedures in 135 patients. 24-h post-procedure MR images were reviewed retrospectively by two abdominal radiologists in consensus to identify tumor ablations that developed one or more new portal or hepatic venous thromboses in or outside the ablation zone. On follow-up MRI and CT examinations the outcomes of thromboses were classified as resolved, partially recanalized, persistent, or propagated. RESULTS: Venous thrombosis developed in association with 54 (24%) of 223 tumor ablations treated during 53 (31%) ablation procedures in 39 (28.8%) patients (15 women, 24 men; age range 40-82 years, mean 59 years). Of these 54 thromboses, 49 (91%) were located in portal vein branches, four (7%) in both portal and hepatic vein branches, and one (2%) in a hepatic vein branch. Thrombosed veins were outside but abutted the ablation zone in 36 (66.7%), and within it in 18 (33.3%). On follow-up imaging (n = 49), thrombi resolved in 29 (59%), partially recanalized in two (4%), persisted in 18 (37%) and propagated from sub-segmental or segmental branches to the left or right portal branches in five (10%). No thrombus propagated to the main portal vein or inferior vena cava. CONCLUSION: Portal and hepatic vein branch thromboses are common in small branches following percutaneous cryoablation of hepatic tumors and most resolve spontaneously without sequelae.