MR Evaluation of Placenta Accreta Spectrum: Concordance Rates and Effect of Structured Reporting on Patient Outcomes.

OBJECTIVE: To examine the concordance rate of MRI findings with intraoperative and pathologic findings in patients with Placenta Accreta Spectrum (PAS), as well as the use of structured reporting, and their relationship to clinical outcomes. METHODS: An IRB approved retrospective chart review was performed for patients with a history of cesarean delivery, a diagnosis of PAS on post-operative pathology report, and a placental MRI prior to delivery between 2008-2022. Concordance rates were calculated between final MRI, ultrasound, operative, and pathologic diagnoses, as well as impact on clinical outcomes. Quantitative variables were analyzed using a t-test. Categorical variables were analyzed using chi-squared and Fischer's exact tests. RESULTS: A total of 59 patients met initial inclusion criteria. Of these 59 patients, 8 (13.6%) were interpreted using structured reporting. Discordance between preoperative imaging, operative findings and final pathology diagnoses were associated with increased blood loss, blood transfusion, ICU admission, and postpartum length of stay. Structured reporting was found to significantly reduce the amount of diagnostic discordance (p=.017) and was associated with decreased ICU admissions when utilized (p=.045). CONCLUSIONS: Use of structured reporting in the interpretation of placental MRI may decrease the amount of discordance between imaging and intraoperative or pathologic diagnoses, which in our study is associated with improved patient outcomes including decreased blood loss and amount of blood transfused. Radiologists must be cognizant of key imaging features of PAS on MRI, as interpretation provides an opportunity to positively impact the quality and safety of patient care.

Assessment of arterial supply to the stomach after bariatric surgery using multidetector CT arteriography.

PURPOSE: To describe residual arterial supply to the stomach after bariatric surgery via a systematic arterial-phase CT assessment approach that can aid in diagnosis and treatment of postoperative complications and facilitate planning for future procedures. METHODS: Arterial-phase CT of 46 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at 3 academic institutions were retrospectively reviewed to assess patency of left gastric artery (LGA), right gastric artery (RGA), gastroepiploic artery (GEA), and left inferior phrenic artery (LIPA) and presence of gastric perforators. RESULTS: In 25 RYGB and 21 SG patients, mean diameters were LGA 2.2 ± 0.4 mm, RGA 1.6 ± 0.5 mm, and GEA 1.7 ± 0.4 mm. On RYGB scans, all LGAs, RGAs, and 24/25 (96%) of GEAs were identified. Excellent to good patency was seen in 20/25 (80%) LGAs, 21/25 (84%) RGAs, and 23/24 (96%) GEAs. On SG scans, all LGAs, 18/21 (86%) of RGAs, and 20/21 (95%) GEAs were identified. Excellent to good patency was seen in 17/21 (81%) LGAs, 15/18 (83%) RGAs, and 20/20 (100%) GEAs. In terms of gastric perforators, LGA supply was seen on 23/25 (92%) of RYGB and 17/17 (100%) of SG scans. RGA supply was seen on 13/21 (62%) RYGB and 9/18 (50%) SG scans. GEA supply was seen on 19/23 (83%) RYGB scans. No gastric supply via GEA was seen on SG scans. CONCLUSION: In this study, arterial supply to the stomach through the LGA was consistently identified in all RYGB and SG cases, indicating an uncomplicated surgical approach with regard to preserving the LGA. Dedicated CT angiography protocol or catheter-directed angiography is recommended for accurate and comprehensive assessment of the gastric blood supply, particularly before surgical re-intervention.

Don't be thrown for a loop: a review of internal hernias for the abdominal imager.

Internal hernias are herniations of abdominal viscera, usually small bowel, through congenital or acquired openings of the peritoneum or mesentery. Congenital hernias may involve anatomic fossae such as the epiploic foramen as well as those related to abnormal peritoneal or mesenteric defects; these include left and right paraduodenal, transomental, transmesenteric, pericecal and broad ligament hernias. Acquired hernias are due to defects in the mesentery or peritoneum, usually resulting from prior surgeries, and include those associated with Roux-en-Y surgery as well as colorectal cancer resections. Internal hernias account for 5.8% of small obstructions. Obstructed internal hernias are considered surgical emergencies due to the high risk of bowel strangulation. This review summarizes the various types of congenital and acquired internal hernias, their relevant anatomy, embryology, associated surgical history and imaging appearance. We will also discuss a location-based approach to identifying internal hernias on CT, as well as complications and relevant signs, of which abdominal imagers should be vigilant.

'That's just the Ovary!' and other cases of mistaken identity on CT of the female pelvis.

CT is often the first imaging test in female patients with lower abdominal and pelvic pain because of the wide availability of CT and differential diagnoses that span both gynecologic and gastrointestinal disease. Pathology within the female pelvis may be difficult to diagnose on CT owing to suboptimal delineation of anatomy in comparison to MRI and ultrasound. These challenges are confounded by overlapping imaging features of a wide range of gynecologic entities and can lead to diagnostic dilemmas. High value CT interpretation will direct the clinician to the best next diagnostic step as ultrasound and MRI provide superior soft tissue delineation. Other imaging modalities, laboratory investigations, or tissue sampling may be necessary to definitively characterize indeterminate lesions. In this review, we illustrate various cases of mistaken identity on CT of the female pelvis involving the ovaries, uterus, and peritoneal cavity while highlighting clinical pearls that may aid the radiologist in arriving at the correct diagnosis and avoiding potential pitfalls.

Night and Day, Why Radiologists Need Play.

What is play and why does it matter for radiologists? Play can take many forms in the workplace, including organic, managed, task-related, diversionary, and resistive forms of play, and play may also take the form of authentic self-expression and creation. In this review article, we will discuss the benefits of play including improved problem solving, gaining perspective, and stress reduction, and also provide low-tech and high-tech examples of beneficial play for the radiology team in work and personal contexts.

CT angiography for characterization of advanced placenta accreta spectrum: indications, risks, and benefits.

Placenta accreta spectrum disorder (PASD) encompasses various types of abnormal placentation in which chorionic villi directly adhere to or invade the myometrium. The incidence of PASD has dramatically risen in the US over the past 3 decades owing to the increased rates of patients undergoing cesarean sections. While PASD remains a significant cause of maternal morbidity and mortality, accurate prenatal identification and characterization of PASD is associated with improved outcomes. Although ultrasound is the first-line imaging modality in the evaluation of PASD, with MRI serving as an adjunct, computed tomography angiography (CTA) may also offer unique diagnostic advantages in cases of advanced PASD by providing superior visualization of placental and abdominopelvic vasculature and enabling the creation of comprehensive vascular maps to roadmap complex surgical interventions. This paper represents the first evaluation of CTA as a diagnostic tool and operative planning aid in this context. Appropriate indications and diagnostic advantages of CTA in this setting are reviewed, and key multimodal imaging features of normal and abnormal placentation are highlighted.

Dichorionic diamniotic heterotopic twin gestation with cesarean section scar implantation and placenta increta.

Heterotopic cesarean scar pregnancy is an extremely rare form of pregnancy and is defined as an intrauterine pregnancy coexisting with an ectopic pregnancy implanted in the cesarean scar. Cesarean scar ectopic pregnancy can also be a precursor for placenta accreta spectrum, a potentially life-threatening condition in which the placenta is abnormally adherent to the uterine myometrium and possibly adjacent organs. Although cesarean scar ectopic pregnancies are rare, there has been an increase in their incidence due to the rise in cesarean deliveries. We present the case of a 35-year-old patient with a heterotopic pregnancy with ectopic implantation in a cesarean scar and associated placenta increta, as well as the radiologic evaluation of placenta accreta spectrum and subsequent management.

Metastatic melanoma presenting as rapidly enlarging hepatic cysts.

Malignant melanoma is a highly aggressive disease with a propensity for metastatic spread. Although recent advances in targeted therapies have improved outcomes, effective screening for metastasis remains an important area of further research. We present a case of a man in his 70s who was recently diagnosed with recurrent, locally advanced melanoma. He presented with abdominal fullness, jaundice, and poor appetite. MR imaging of the abdomen revealed innumerable hepatic cysts with internal fluid-fluid levels which were markedly increased in size and number from recent imaging. These findings necessitated a broad differential that included parasitic or bacterial infection, metastases, or drug-induced polycystic liver disease. Subsequent biopsy revealed metastatic melanoma consistent with the patient's primary tumor. The patient was ultimately transitioned to comfort care measures due to the burden of the liver metastases and passed away shortly after presentation.

Evaluation and Comparison of Two Media-Rich Radiology Apps Regarding Pathology of the Lumbar Spine: Lessons for Medical Education App Developers and Content Creators.

BACKGROUND: Mobile applications have become an increasingly popular component of medical education over the past 2 decades. Visual layout and aesthetics are important considerations in app design given Generation Z's strong preference for visually appealing digital content. In this study, we evaluate students' perceptions of an educational app related to pathology of the lumbar spine before and after a redesign of its workflow and illustrations. OBJECTIVE, MATERIAL AND METHODS: A professional user experience and interface designer was recruited for the revision of an iOS app focused on anatomy and pathology of the lumbar spine on abdominal computed tomography (CT). Revisions focused on developing the app to make it more visually appealing, increasing ease of use, and fixing bugs. An IRB-approved study was conducted in which participants were asked to interact with the original and revised versions of the app prior to completing a survey regarding their perception of the graphics, animation style, overall app design, and content. RESULTS: Overall impressions of the revised app were more positive than the original app, with 89% of respondents finding the revised app's graphics to be visually appealing compared to 39% regarding the original app. Further, 95% of respondents indicated that the revised app's layout was organized and user-friendly compared to 73% regarding the original. Both apps received similarly positive ratings for participants' understanding of the presented materials. CONCLUSION: User feedback is key when designing mobile health and educational applications. Feedback may be sought via formal usability testing or app-specific surveys. The aesthetics, layout, and ease of use of mobile apps are important considerations and, in the absence of content alteration, may influence user engagement. Knowledge regarding these factors may guide content creators when developing and deploying mobile health applications.

Placental bands on MRI in the setting of placenta accreta spectrum: Case report with radiologic-pathologic correlation.

Placental bands on T2-weighted magnetic resonance imaging (MRI) are a known imaging finding in placenta accreta spectrum (PAS). It is believed that these linear T2 hypo-intensities may reflect increased fibrin deposition in the setting of placental hemorrhage or infarct. However, to date there is little published data regarding histopathologic analysis of placental parenchyma at the site of identified bands. We report the case of a 34-year-old female with a single placental band demonstrated on preoperative MRI which was evaluated postoperatively and found to represent a placental infarct.

Multimodal imaging appearance including cinematic rendering of renal malakoplakia in a patient with E. coli bacteremia.

Renal malakoplakia is a rare inflammatory disorder that predominantly affects the bladder, but has also been known to affect the kidneys. We present a case of a young woman with renal malakoplakia and concomitant E. coli bacteremia. The patient underwent numerous imaging studies during her clinical evaluation including ultrasound, magnetic resonance imaging, and computed tomography with 3-dimensional and cinematic renderings. Diagnosis was ultimately confirmed with renal biopsy which demonstrated Michaelis-Gutman bodies, a pathognomonic pathological finding in malakoplakia. She was started on antibiotics as well as bethanechol and ascorbic acid. Although her renal function improved with this treatment, she continued to have signs and symptoms of infection and she is planned for upcoming left nephrectomy.

3D and cinematic rendering of abdominopelvic pathology in the peripartum period.

3D with volume rendering and the more recently described technique of cinematic rendering are post-processing techniques that create reconstructions of cross sectional imaging data which enhance image interpretation. This review illustrates the potential applications of volume rendering, 3D, and cinematic rendering in the evaluation of abdominopelvic pathology in the peripartum period. These techniques show promise in improving visualization of pelvic structures, vascular mapping, highlighting textural differences between tissues, and improving understanding of spatial relationships.

Pulmonary Embolism and Amniotic Fluid Embolism.

Venous thromboembolism (VTE) as well as other embolic events including amniotic fluid embolism (AFE) remain a leading cause of maternal death in the United States and worldwide. The pregnant patient is at a higher risk of developing VTE including pulmonary embolism. In contrast, AFE is a rare, but catastrophic event that remains incompletely understood. Here the authors review the cause of VTE in pregnancy and look at contemporary and evidence-based practices for the evaluation, diagnosis, and management in pregnancy. Then the cause and diagnostic difficulty of AFE as well as what is known regarding the pathogenesis are reviewed.

Development of Educational Media for Medical Trainees Studying MRI Physics: Effect of Media Format on Learning and Engagement.

PURPOSE: MRI physics is a challenging subject for radiology residents and comprises a significant portion of the ABR CORE examination, which must be passed to achieve board certification. Despite established needs for increased quality and quantity of radiology physics resources, there is little information regarding the most effective method of engaging learners and delivering this content. METHODS: To assess trainee perceptions of currently available MRI physics learning resources, a needs assessment survey was distributed to current members and recent graduates of our diagnostic radiology residency program. Based on the results of the needs assessment, we created three different types of media illustrating the fundamentals of MRI physics: text with images, text with animations, and a narrated video. Formal evaluation of the media via an institutional review board-approved, experimentally designed study helped us better understand the impact that media format had on deep structure learning, efficiency, and engagement. RESULTS: Respondents to the needs assessment indicated a desire for physics resources that were visually appealing with simplified details and associated practice questions. Participants demonstrated significant learning across all media formats but rated video as the most engaging media type. CONCLUSION: Knowledge of media attributes that positively impact trainee performance may inform content creators and educators alike when designing and distributing educational materials related to MRI physics.

CT of acute abdominopelvic hemorrhage: protocols, pearls, and pitfalls.

Abdominal and pelvic hemorrhage may be secondary to a number of causes and is often a medical emergency. Patient presentation ranges from obvious trauma with evidence of hemodynamic instability to vague symptoms. CT has become the imaging modality of choice for identifying abdominopelvic hemorrhage. Recognizing acute hemorrhage as well as identifying its location and severity are key to expediting management. In the Emergency Department, ultrasound often used in the initial evaluation of trauma patients, but is not sensitive for subtle bleeds or injuries. CT is the best first-line imaging tool to identify abdominal hemorrhage and, compared with angiography, has been shown to be superior in detecting intra-abdominal bleeding, especially when the bleeding rate is low. Depending on location and etiology, abdominopelvic hemorrhage may have a characteristic appearance, such as the "sentinel clot" sign associated with blunt trauma to the solid organs or the "triangle sign" of a mesenteric bleed. The following pictorial essay reviews CT technique, study interpretation, and interpretative pearls and pitfalls in the recognition of acute abdominopelvic hemorrhage.

Preparing junior radiology residents for overnight call via peer-led, hands-on simulation.

PURPOSE: The aim of this study was to assess the perceived value and impact of a hands-on mock call simulation program on resident confidence with interpretation of emergency department overnight call cases. METHODS: A five-session course was implemented in June of 2018 for rising PGY-3/R2 residents to mimic the experience of overnight call with indirect supervision. Sessions were led by senior residents in the program and consisted of timed, independent interpretation of 15-20 high-yield cases per day which highlighted "do-not miss" critical findings and simulated workflow interruptions including phone calls, consultations, and questions from technologists. IRB-approved, and anonymous pre- and post-course surveys were administered to participants which assessed residents' degree of confidence in interpretation of on-call cases and comparison of the mock call experience with existing preparatory strategies. Survey responses were analyzed using McNemar's test and Mann-Whitney U test. RESULTS: Our survey response rate was 91% (29/32). After completing the mock call simulation, there was a significant increase in the mean Likert score of resident confidence levels and feelings of preparedness from 4.59 to 7.38 (p < 0.01). The majority of respondents (72.4% [21/29]) felt that the mock call simulation was "extremely useful." One hundred percent of respondents indicated that the mock call simulation should be implemented for the following year. CONCLUSION: Implementation of a hands-on mock call simulation significantly improves the confidence levels of radiology residents before assuming on-call responsibilities and may serve as an adjunct to existing preparatory strategies.

MRI-based pictorial review of the FIGO classification system for uterine fibroids.

Uterine fibroids are the most common gynecologic neoplasm and contribute to significant morbidity, particularly when submucosal in location or large enough to cause bulk symptoms. Correctly classifying fibroids is essential for treatment planning and prevention of complications. Ultrasound is the first-line imaging modality for characterizing uterine fibroids. However, MRI allows for high-resolution, multiplanar visualization of leiomyomata that affords a more accurate assessment than ultrasound, particularly when fibroids are numerous. The FIGO system was developed in order to more uniformly and consistently describe and classify uterine fibroids. In this article, we review the MRI appearance of each of the FIGO classification types, detailing key features to report. Additionally, we present a proposed template for structured reporting of uterine fibroids based on the FIGO classification system.

Innovation Born in Isolation: Rapid Transformation of an In-Person Medical Student Radiology Elective to a Remote Learning Experience During the COVID-19 Pandemic.

RATIONALE AND OBJECTIVES: With social distancing measures in place both nationally and globally, the current COVID-19 pandemic has forced the cancellation of in-person classes at universities and medical schools across the country. This has presented unique challenges for educators in all fields as they have embarked, many for the first time, on the journey into remote education in order to provide distance learning opportunities for students. MATERIALS AND METHODS: In this article we will review our approach to rapidly converting an in-person diagnostic radiology elective to an entirely remote learning experience for medical students at our institution, including modification of course structure, software tools and materials utilized, and strategies for learner engagement and collaboration. RESULTS: Development of an online elective led to a 10-fold increase in student enrollment compared to the traditional course offering, providing a unique opportunity to reach a broad number of students, many of whom were in the early clinical stages of their medical school career. Lastly, we will review faculty feedback after participating in the remote course as well as lessons learned from the transition to distance learning and its implications for future work CONCLUSION: The current state of technology makes radiology particularly well-suited for distance learning, and with the proper tools and approaches, effective remote radiology instruction can be achieved.