Intranasal foreign body mimicking a fat-containing lesion.

We present a 21-month-old child with a foreign body (an intranasal almond) measuring fat attenuation on CT. To the best of our knowledge, this appearance has not been previously described and can be confused with other diagnoses resulting in inappropriate or delayed treatment.

Adult female with hematemesis-Dieulafoy lesion.

A 40-year-old healthy woman presented to the emergency department with a complaint of intermittent hematemesis, despite the absence of usual factors associated with upper gastrointestinal bleeding (ie, nonsteroidal anti-inflammatory drugs, alcoholism, etc). The patient was diagnosed with a Dieulafoy lesion. This is an uncommon finding, which clinicians must be familiar with and maintain in the differential diagnosis because the consequences of this disease process are grave. It is vital to properly diagnose this condition and be familiar with the treatment.

Substantial interreader agreement for biopsy with reduction in biopsy rate: A multireader diagnostic performance study of ACR TI-RADS.

PURPOSE: To assess diagnostic performance of ACR TI-RADS in thyroid cancer detection and evaluate interobserver agreement among radiologists with lower interpreting experience. METHODS: Four radiologists retrospectively assessed 295 biopsied thyroid nodules from ultrasound studies performed between 2009 and 2019, blinded to histopathology. Diagnostic performance for cancer detection was determined individually, and interobserver agreement among four readers was evaluated with Fleiss kappa coefficient (ⱪ). RESULTS: 245 (83.1%) benign and 50 (16.9%) malignant nodules were evaluated. Diagnostic performance based on final TR level was consistent and without significant difference among four readers, with excellent sensitivity (≥98.0%) and negative predictive value (NPV) [≥94.4%] for TR levels 3 to 5. Diagnostic performance based on recommendation to biopsy has moderate sensitivity (≥62%) and high NPV (≥84.7%). Retrospective scoring with established ACR TI-RADS criteria would have substantially reduced the number of biopsies performed, with 63.2% of malignancy not biopsied meeting criteria for sonographic surveillance. Interobserver agreement on TI-RADS scoring for final TR level was fair (ⱪ = 0.39, 95% CI 0.32, 0.47), with substantial agreement for recommendation to biopsy (ⱪ = 0.64, 95% CI 0.58, 0.70). CONCLUSIONS: Substantial reduction in biopsy rate (up to 48%) would have been achieved using the ACR TI-RADS criteria, with 63% of malignancy not biopsied meeting criteria for sonographic surveillance. Interobserver agreement was fair for TI-RADS level scoring and substantial for recommendation to biopsy.

Recurrent Nasal-Type Extranodal Natural Killer/T-Cell Lymphoma with Meningeal Involvement.

Extranodal natural killer/T-cell lymphoma nasal type (NNKTL) is a type of non-Hodgkin's lymphoma that has been associated with Epstein-Barr virus (EBV). It has an aggressive behavior, known for predilection to metastasize to different organs. Central nervous system (CNS) spread from a primary location has been reported. Different modalities of treatment such as chemotherapy and radiation therapy have been employed in the management of this disease. Severe toxicities of currently available treatment have made clinicians seek more targeted therapies using molecular profiling. We present a 44-year-old Hispanic patient who was diagnosed with an early-stage NNKTL and treated with the modified SMILE regimen for 6 cycles. His EBV DNA PCR turned undetectable and remained so throughout the treatment. He sustained complete right vision loss due to right optic nerve invasion by the tumor, leading to prophylactic intravitreal methotrexate to the contralateral eye. The patient achieved good response with minimal residual disease. He was supposed to start radiation as a sequential therapy. However, the acute development of severe headache and confusion lead to a complete workup showing leptomeningeal spread. He eventually succumbed to the disease.

MD and DO: Differing Medical Degrees and the Associated Perceptions.

PURPOSE: To highlight perspectives about differing medical degrees and graduate medical education amongst current allopathic (MD) and osteopathic (DO) radiology residents. MATERIALS AND METHOD: Two hundred sixty-eight radiology residents were interviewed using an approved Association of Program Coordinators in Radiology (APCR) survey designed to evaluate perceptions of allopathic and osteopathic radiology residents regarding type of medical degree and their career development. The surveys were kept anonymous with no identifiable information. Residents in their first through fourth years of training replied with an approximate equal distribution amongst the different years. RESULTS: Based on the 268 respondents, DOs' more so than MDs', reported that their degree type altered their medical careers (P < 0.0001) and that they were advised to not pursue a radiology residency based on degree type (P< 0.0001). In addition, a large majority of both DOs' and MDs' felt that residency selection is favored towards the allopathic degree (P= 0.0451). CONCLUSION: This survey-based study does reveal perceived differences in the residency recruitment process based on degree type. Future discussions to bridge this perceived gap will be important, especially in light of the recent ACGME merger between the 2 educational pathways.

Adding value to imaging services: a survey of patient and referring physician preferences for direct radiologic reporting of results.

PURPOSE: To identify preferences of patients and referring physicians for direct patient communication and notification of radiologic study results. METHODS: An anonymous survey was conducted of patients undergoing outpatient radiologic imaging studies and their referring physicians. The voluntary surveys elicited responses regarding preferences on a 5-point Likert scale (Strongly disagree, disagree, neutral, agree and strongly agree), as well as indicated by responding yes or no to specific questions. RESULTS: 368 patients completed the survey. 81.5% of patient responders preferred all results communicated from the radiologist within the same day. 65.9% of patients preferred same day results if normal vs 65.8% if abnormal. 34.5% preferred to wait and review normal results with the referring physician. 41.5% preferred to wait and review abnormal results with the referring physician. It was found that patients were more likely to strongly agree with waiting to review results with the referring physician if the results were abnormal, as opposed to normal (18.5% vs 11.9%, respectively; P < 0.014). 64% of physicians did not want results reviewed with their patients; 87.6% did not want a report sent to the patient by the radiologist, even after report was sent to their office. 66.4% of patients surveyed indicated that waiting for imaging results gives them anxiety. CONCLUSIONS: 58-82% of patients preferred same day radiologist communication of their results while 55-87.6% of physicians did not prefer same day radiologist communication of results directly with their patients. 66.4% of patients surveyed indicated that waiting for imaging results gives them anxiety.

The Use of FDG PET Parametric Imaging in the Diagnosis of Olivopontocerebellar Atrophy.

Olivopontocerebellar atrophy is a rare neurodegenerative syndrome associated with 2 distinct disorders: multiple system atrophy and spinocerebellar ataxia. We present a case involving a 66-year-old man with adult-onset progressing cerebellar signs reflective of a cerebellar syndrome with no significant family history and unremarkable genetic testing for spinocerebellar ataxia. This case was found to be most consistent with sporadic olivopontocerebellar atrophy, which falls under the multiple system atrophy category. This diagnosis can be made using F-FDG PET/CT scanning and with MRI in some cases. However, in this case, relatively new PET/CT quantification and parametric imaging software was used for analysis, CortexID Suite.

Secondary encephalocele in an adult leading to subdural empyema.

Brain abscesses are an uncommon but potentially fatal infection. They can spread directly from an adjacent source or hematogenously from a distant source. Encephaloceles represent a rare form of neural tube defects that can potentially be complicated by the development of meningitis or brain abscess. We report a case of a 63-year-old female who presented with bilateral lower extremity weakness and was ultimately found to have a Streptococcus pneumoniae subdural empyema and an associated frontal lobe encephalocele extending through the left frontal sinus. She was treated with surgical drainage, intravenous antimicrobials, and ultimately surgical repair of the encephalocele. This report highlights a unique presentation of brain abscess. Clinicians should be aware of this potential infectious complication of a neural tube defect.

Congenital absence of the internal carotid artery with intercavernous anastomosis.

Congenitally absent internal carotid artery with intercavernous anastomosis is an exceedingly rare vascular anomaly. We report such a case in a 65-year-old man with chronic symptoms resembling sporadic transient ischemic attacks. While these patients are usually asymptomatic due to compensatory collateralization, they are at increased risk of aneurysm formation, and thus proper identification is important. This report serves as both a case of a very rare anomaly and as a lesson on how to avoid this misdiagnosis by carotid duplex sonography. Additionally, we review the limited number of published cases of congenitally absent internal carotid artery with intercavernous anastomosis.

Neck-Tongue Syndrome: Viewpoints on Etiology in a Patient with Bilateral Symptoms.

Neck-Tongue Syndrome is a rare entity, and when it presents in the pediatric age group, it is usually due to osseous, ligamentous, or nervous anatomic variation. We present below a case involving a patient whose bilateral symptoms were intermittently present from the age of five to the age of twenty-one years and discuss this case in light of the present theories of the anatomic substrate underlying this syndrome.

Sacral intraspinal meningocele in a patient presenting with abdominal pain. Case report.

Sacral meningoceles are typically asymptomatic. When they are symptomatic, patients commonly present with signs and symptoms of nerve root compression and back pain. The authors report the case of a 10-year-old girl with an intraspinal sacral meningocele who presented initially only with severe right lower quadrant pain. The patient underwent successful surgical treatment of the meningocele and experienced subsequent resolution of the abdominal pain. This is the first reported case of an intraspinal sacral meningeal cyst in which the only presenting symptom was abdominal pain and which was successfully treated with surgery. It is postulated that the sacral meningocele caused severe abdominal pain secondary to compression of the sacral parasympathetic fibers that pass through the sacral plexus on each side of the cord corresponding to the S-2 and S-3 levels.

Ultrasound to Detect Pressure-related Deep Tissue Injuries in Adults Admitted via the Emergency Department: A Prospective, Descriptive, Pilot Study.

Stage 4 pressure ulcers (PUs) start with tissue death at the level of the bone, also known as deep tissue injury (DTI). Studies have shown the appearance of DTI on the skin is delayed for several days after the original pressure-related injury to the deep soft tissues. Studies also suggest DTI can be seen using ultrasound (US) technology. A prospective, descriptive, correlational pilot study was conducted to evaluate the use of US technology to detect DTI in the soft tissues that are not visible on the skin upon hospital admission. Study participants included a convenience sample of 33 persons at risk for PUs (ie, Braden score <18) admitted through the emergency department. Each participant had US scans of 13 common PU body sites. All scans were documented in the radiologist report in the electronic medical record. Creatinine phosphokinase, calcium levels, and urine myoglobin levels also were assessed upon enrollment. Skin failure risk factors (SFRFs), including fever, hypotension, weight loss, coagulopathy, and acidosis/respiratory failure, also were documented. Patients were examined for skin PUs every day for 7 days after US scan. Twenty-three (23) patients completed the study. US scans identified pressure necrosis at 2 levels: bone (54 positive [US+]) and subcutaneous (SC); 79 US+, respectively). US+ bone sites resulted in 5 PUs appearing 6 to 7 days post-admission (sensitivity = 100%, specificity 84.7%, positive predictive value 10%, and negative predictive value 100%), indicating all DTI that later became purple skin DTI were detected by the US. US+ SC sites, located immediately under the skin, yielded 5 PUs appearing on day 2 after admission (sensitivity 100%, specificity 74.8%, positive predictive value 6.3%, and negative predictive value 100%). The participants with PU occurrence in both bone and SC groups had low Braden scores (bone group mean = 13.25, SC group mean = 11.2). Study patients who were positive for PU also had >4 SFRFs. Creatinine phosphokinase, calcium, and myoglobin levels were inconsistent and did not correlate with US+ scans. These observations warrant larger studies to confirm findings and optimize the validity of US screening for DTI in select populations, which may help improve protocols of care and PU admission documentation. The preliminary results suggest inclusion of the Braden Scale score and known PU risk factors may improve the positive predictive value of this test.

A Survey of Academic Radiology Department Chairs on Hiring Recent Graduates as New Attending Physicians.

RATIONALE AND OBJECTIVES: To determine hiring preferences among academic radiology department chairs with emphasis on recent residency and fellowship graduates. MATERIALS AND METHODS: With the assistance of the Society of Chairs of Academic Radiology Departments (SCARD), an anonymous survey was distributed to academic radiology department chairs during the time period December 2014-March 2015, with additional reminder emails during the study period. Varied multiple choice questions were designed to gather information regarding program details; qualities most valued in new attending hires; level of difficulty recruiting subspecialty fellowship-trained radiologists; and the effect of the new ABR certification process on hiring practices. Descriptive statistics and analyses are reported. RESULTS: Surveys were completed by 79 of 184 eligible academic radiology chairs, a response rate of 43%. The most important hiring criteria cited were expertise in subspecialty, fellowship training, and perceived ability to work well with referring physicians. The most popular recruitment tools cited were hiring candidates from a chair's own program, journal ads, and academic networks. A minority of chairs (16%), primarily those of smaller departments, will not hire new graduates before completing board certification under the new certification structure (P = .0143). CONCLUSIONS: Expertise in a candidate's subspecialty was consistently cited as the most important hiring criterion. Changes to the ABR certification process, however, will affect hiring decisions, particularly within smaller academic departments.

A patient with multiple synchronous gliomas of distinctly different grades and correlative radiographic findings.

BACKGROUND: Multiple gliomas represent approximately 2 to 5% of all high-grade gliomas which are categorized as multifocal or multicentric depending on the timing, location and pattern of spread. We present a patient with bi-hemispheric, noncontiguous, low- and high-grade gliomas proven by biopsy. She underwent surgical excision and radiotherapy, but unfortunately succumbed to her disease shortly thereafter. CASE DESCRIPTION: A 64-year-old female presented to the hospital with confusion, disorientation and retrograde amnesia after an unwitnessed fall. There were no symptoms of headaches or visual disturbances before presentation. Magnetic resonance imaging (MRI) with and without gadolinium revealed a nonenhancing left temporal lobe mass without surrounding edema, an enhancing left frontal lobe mass with surrounding edema, and an enhancing right parietal lobe mass with surrounding edema. The patient underwent a left frontal craniotomy with gross total resection of the left frontal mass and a left temporal craniotomy, anterior temporal lobectomy and sub-total resection of the temporal lobe mass. Intraoperative Brainlab® image-guided navigation was used. Postoperative treatment consisted of radiotherapy. CONCLUSION: This is the first reported case of multiple separate glial tumors, each with differing grades in which an MRI can be correlated with the tissue diagnoses. This case also highlights the possible mechanisms of transformation of glial tumors in the continuum from benign to malignant forms, lending insight to the possibility of using advanced genetic analysis in the treatment and diagnosis of these entities.