Carotid web prevalence in a large hospital-based cohort and its association with ischemic stroke.

Carotid artery webs are shelf-like protrusions of intimal fibrous tissue arising from the posterior wall of the carotid bulb, found to have a 2.3% prevalence in the United States. Previous studies have demonstrated its association with ipsilateral anterior circulation stroke. The aim of this study is to assess the prevalence of carotid webs in the largest US epidemiologic study to date, and to further characterize the clinical features of carotid web patients. We assembled a cohort of 1467 adult patients with CT angiogram neck from January 1, 2011 to January 1, 2017. CT angiograms were reviewed for diagnosis of carotid web. Demographic and clinical details of web patients were obtained. Differences in demographics and CT angiogram indication between patients with and without carotid web were assessed using appropriate statistical tests. Twenty-four (24/1467 = 1.6%) carotid web patients were identified (mean age: 63 years; 62.5% female; 50% African American). Twelve (12/24 = 50%) had ipsilateral anterior circulation stroke. Of them, 8 were deemed cryptogenic. Four (4/24 = 16.7%) web patients had at least one recurrent stroke in the ipsilateral anterior circulation. One case was reported on the radiology report at the time the study was initially performed. This study confirms a prevalence of 1.6% in our urban, North American cohort. Among carotid web patients, there was a high incidence of ipsilateral anterior circulation stroke, the majority of which were classified as cryptogenic. This study affirms the importance of the diagnosis of carotid web, especially in cryptogenic stroke patients, as a potential unrecognized stroke risk factor.

Comparison of the Prevalence of Ruptured and Unruptured Cerebral Aneurysms in a Poor Urban Minority Population.

BACKGROUND: Most ruptured cerebral aneurysms are small (<7 mm). Evidence suggests low rupture rates for such lesions (<1% per year). Population studies demonstrate a prevalence rate of 3.2%. This study simultaneously estimates the prevalence of aneurysms in a single geographic population while reporting the observed rate of aneurysmal subarachnoid hemorrhage (aSAH) in the same geographic region composed of a poor urban minority demographic. METHODS: This is an institutional review board-approved, Health Insurance Portability and Accountability Act of 1996-compliant retrospective study performed between 2005 and 2011 at a single center. Part 1 used the electronic medical record to identify all patients with a magnetic resonance angiography demonstrating a cerebral aneurysm. Part 2 used the electronic medical record to identify all patients from the same geographic area presenting with aSAH during the study period. RESULTS: A total of 11,160 subjects had a magnetic resonance angiography from the study area. In this group, 422 intradural cerebral aneurysms were incidentally discovered. Ninety-one percent were less than 10 mm (mean 5.49, standard deviation 4.6). Twenty-one percent were aneurysms of the anterior communicating artery complex. Fourteen percent were of posterior communicating artery origin. A total of 237 patients had aSAH. Ninety-two percent of the aneurysms were less than 10 mm (mean 6 mm, standard deviation 3.2 mm). Both groups were composed of poor urban minority patients. CONCLUSIONS: The observed annual rate of rupture of small anterior circulation aneurysms in this study was .06%-.15% per year. The extrapolated population prevalence of such aneurysms (4.0%-1.5%) may explain the observed rate of rupture of these small aneurysms in a poor urban minority population.

Viruses, Immunity and Unusual Lymphoproliferative Disorders of the Chest: Integrating Imaging With Pathogenesis and Clinical Presentations.

Unusual lymphoproliferative diseases result from the stimulation of intrathoracic lymphoid tissue by viruses and immune dysfunction, ranging from benign hyperplasia to malignant transformation. We review the clinical, radiological, and histopathological findings of unusual lymphoproliferative disorders, which have been linked to viruses or immune dysfunction, focusing on thoracic manifestations. Understanding these advances in science enhances the radiologist's skills in integrating the imaging findings to the clinical scenario to suggest the correct diagnosis.

Significance of post-traumatic maxillary sinus fluid, or lack of fluid, in a level II trauma population.

Our goal was to test the predictive value of high-attenuation material within the maxillary sinus for adjacent facial bone fracture. After IRB approval, all blunt trauma facial CTs performed over a 5-month period at a level II trauma center were reviewed in consensus by three radiologists for the presence of facial fractures or high attenuation maxillary sinus opacity (≥30HU, ≥40HU, or ≥50HU). Three classes of fractures were analyzed: any fracture, any fracture contiguous with the maxillary sinus, and only fractures not contiguous with the maxillary sinus. Statistics were calculated using two-by-two tables. A total of 844 cases were reviewed with 273 patients having any fracture. There were 402 hemi-faces with any fracture and 62 hemi-faces with fracture contiguous with the maxillary sinus. Sensitivity, specificity, positive predictive value, and negative predictive value for any fracture (using the ≥40HU threshold) were 13, 99, 85, and 78 % respectively; for fracture contiguous with the sinus, these were 71, 99, 72, and 99 % respectively; and for only non-contiguous fractures, these were 2.3, 96, 13, and 80 %, respectively. We conclude that in this level II trauma population, lack of high attenuation maxillary sinus material nearly ruled out fractures in contiguity with the sinus. High-attenuation sinus material is only moderately predictive of a fracture contiguous with the maxillary sinus. Therefore, if after careful review a fracture is not identified, the radiologist should not be overly concerned that a fracture is being missed. High-attenuation sinus material is a poor marker for fractures not contiguous with the maxillary sinus.

COVID-19 Neuroimaging Update: Pathophysiology, Acute Findings, and Post-Acute Developments.

COVID-19 has prominent effects on the nervous system with important manifestations on neuroimaging. In this review, we discuss the neuroimaging appearance of acute COVID-19 that became evident during the early stages of the pandemic. We highlight the underlying pathophysiology mediating nervous system effects and neuroimaging appearances including systemic inflammatory response such as cytokine storm, coagulopathy, and para/post-infections immune mediated phenomena. We also discuss the nervous system manifestations of COVID-19 and the role of imaging as the pandemic has evolved over time, including related to the development of vaccines and the emergence of post-acute sequalae such as long COVID.

Evolving Trainee Participation in Radiologists' Workload: A National Medicare-Focused Analysis From 2008 to 2020.

PURPOSE: Increasing volumes and productivity expectations, along with practice type consolidation, may be impacting trainees' roles in the work effort of radiologists involved in education. We assessed temporal shifts in trainee participation in radiologists' workload nationally. METHODS: All US radiologists interpreting noninvasive diagnostic imaging for Medicare fee-for-service beneficiaries were identified from annual 5% Research Identifiable Files from 2008 to 2020 (n = 35,595). Teaching radiologists were defined as those billing services using Medicare's GC modifier, indicating trainee supervision. Billed work relative value units were used to determine the percentage of teaching radiologists' total workload with trainee participation. Mean trainee participation in workload was calculated for teaching radiologists overall and stratified by radiologist and practice characteristics determined using National Downloadable Files. RESULTS: The percentage of radiologists involved in teaching increased from 13.6% (2008) to 20.4% (2020). Among teaching radiologists, mean total workload increased 7% from 2008 to 2019 and decreased in 2020 to 2% below 2008's level; mean teaching workload decreased 19% from 2008 to 2019 and decreased in 2020 to 31% below 2008's level. Mean trainee participation in teaching radiologists' total workload decreased from 35.3% (2008) to 26.3% (2019) and 24.5% (2020). Teaching radiologists showed decreased mean trainee participation when stratified by gender, experience, subspecialty, geography, practice type, and practice size. CONCLUSIONS: The percentage of US radiologists involved in resident teaching has increased, likely reflecting academic practice expansion and academic-community practice consolidation. However, a declining percentage of teaching radiologists' total workload involves trainees; this dispersion effect could have implications for education quality.

ACR Appropriateness Criteria® Dizziness and Ataxia: 2023 Update.

Diagnostic evaluation of a patient with dizziness or vertigo is complicated by a lack of standardized nomenclature, significant overlap in symptom descriptions, and the subjective nature of the patient's symptoms. Although dizziness is an imprecise term often used by patients to describe a feeling of being off-balance, in many cases dizziness can be subcategorized based on symptomatology as vertigo (false sense of motion or spinning), disequilibrium (imbalance with gait instability), presyncope (nearly fainting or blacking out), or lightheadedness (nonspecific). As such, current diagnostic paradigms focus on timing, triggers, and associated symptoms rather than subjective descriptions of dizziness type. Regardless, these factors complicate the selection of appropriate diagnostic imaging in patients presenting with dizziness or vertigo. This document serves to aid providers in this selection by using a framework of definable clinical variants. 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® Cerebrovascular Diseases-Stroke and Stroke-Related Conditions.

Cerebrovascular disease encompasses a vast array of conditions. The imaging recommendations for stroke-related conditions involving noninflammatory steno-occlusive arterial and venous cerebrovascular disease including carotid stenosis, carotid dissection, intracranial large vessel occlusion, and cerebral venous sinus thrombosis are encompassed by this document. Additional imaging recommendations regarding complications of these conditions including intraparenchymal hemorrhage and completed ischemic strokes are also discussed. 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.

Appropriateness of imaging studies ordered by emergency medicine residents: results of an online survey.

OBJECTIVE: The purpose of this study is to determine the proficiency of emergency medicine residents in selecting appropriate radiologic examinations for specific clinical scenarios and to ascertain whether their training improves competency in this area over the course of their residency. MATERIALS AND METHODS: An online multiple-choice questionnaire was created. It included 10 clinical scenarios excerpted from the American College of Radiology Appropriateness Criteria guidelines and instructed residents to select the most appropriate initial imaging study. A link and invitation to the survey were e-mailed to the residency program directors and coordinators of all American Council for Graduate Medical Education-accredited emergency medicine residency training programs with the request that they be forwarded to their current residents. Responses were graded, with correct answers derived from the American College of Radiology guidelines. Results were stratified by year of emergency medicine training, and an analysis of variance was performed. RESULTS: A total of 583 residents from at least 77 different emergency medicine residency training programs completed the survey. Overall, the average number of questions answered correctly was 7.1 of 10 (SD, 1.2). First-through fourth-year residents averaged 6.9 (SD, 1.3), 7.1 (SD, 1.2), 7.1 (SD, 1.1), and 7.5 (SD, 1.1) correct answers, respectively. Analysis of variance found no significant difference between the scores of the four classes (p = 0.09). CONCLUSION: Emergency medicine residents do not show significant improvement over the course of their residency in their ability to choose appropriate imaging studies. This finding suggests that there is a role for more-rigorous focused instruction to better familiarize residents with appropriateness guidelines for diagnostic imaging selection.

Back to the scanner: expected and unexpected imaging findings following spinal puncture and access.

Spinal canal procedures to withdraw fluid or introduce drugs are common minimally invasive techniques after which patients may experience new symptoms causing presentation to the emergency department. CT or MR imaging as part of the diagnostic workup may reveal expected or unexpected findings which may explain these symptoms. Small foci of gas within the spinal canal or intracranial compartment are common but are usually self-limited. Postlumbar puncture headache, presumed to be due to intracranial hypotension, may manifest on brain MR as dural thickening and low-lying cerebellar tonsils. Treatment with a blood patch is sometimes required for persistent symptoms. Spinal subarachnoid hemorrhage may be a devastating complication of dural puncture and may result in pain and paraplegia. In this review, technical details of these procedures are described and examples of common and uncommon postprocedure appearances on imaging are presented.

Behavioral Economics in Radiology Training: Overcoming Irrational Behavior.

Behavioral economics studies how external influences subconsciously affect decision making. Everyone is subject to a range of cognitive biases, which can affect the radiology training environment and can impact resident selection, resident education, feedback, workflow, and report composition. Understanding the cognitive sources of error and patterns of deviation can help faculty and trainees better engage in an optimal learning environment. This review focuses on the role of cognitive biases as they impact multiple facets of radiology education and training environments.

Performance Anxiety in Radiology Education and Clinical Practice.

Performance anxiety is fear, anxiety, or avoidance of performative tasks, due to possible evaluation or criticism by others. Performance anxiety is well described in public speakers, musicians, and even surgeons. Its impact on radiologists and especially radiology trainees has not been explored. This article details performance anxiety, framing radiologists as performers, and highlights its potential impact on trainees and practicing radiologists. We offer strategies to manage and enhance the effects of performance anxiety that can be implemented in a training environment.

Health Systems Science - A Primer for Radiologists.

Health systems science (HSS) is an educational framework designed to promote improved care through enhanced citizenship and the training of systems-fluent individuals trained in the science of health care delivery.  HSS education in residency builds upon foundations established during medical school, emphasizing practical skills development, and fostering a growth mindset among trainees.  The HSS framework organizes elements of system-based practice for radiology trainees, promoting practice-readiness for providing safe, timely, effective, efficient, equitable and patient centered radiological care. This paper serves as a primer for radiologists to understand and apply the HSS framework. Additionally, we highlight radiology-specific curricular elements aligned with the HSS framework, and provide teaching resources both for classroom education and for resident self-study.

Teaching with Technology-Matching Pedagogy with Purpose in Radiology Education.

The response to pandemic-related teaching disruption has revealed dynamic levels of learning and teaching flexibility and rapid technology adoption of radiology educators and trainees. Shutdowns and distancing requirements accelerated the adoption of technology as an educational tool, in some instances supplanting in-person education entirely. Despite the limitations of remote interaction, many educational advantages were recognized that can be leveraged in developing distance learning paradigms. The specific strategies employed should match modern learning science, enabling both students and educators to mutually grow as lifelong learners. As panel members of the "COVID: Faculty perspective" Task Force of the Association of University Radiologists Radiology Research Alliance, we present a review of key learning principles which educators can use to identify techniques that enhance resident learning and present an organized framework for applying technology-aided techniques aligned with modern learning principles. Our aim is to facilitate the purposeful integration of learning tools into the training environment by matching these tools to established educational frameworks. With these frameworks in mind, radiology educators have the opportunity to re-think the balance between traditional curricular design and modern digital teaching tools and models.

ACR Appropriateness Criteria® Staging and Post-Therapy Assessment of Head and Neck Cancer.

Imaging of head and neck cancer at initial staging and as part of post-treatment surveillance is a key component of patient care as it guides treatment strategy and aids determination of prognosis. Head and neck cancer includes a heterogenous group of malignancies encompassing several anatomic sites and histologies, with squamous cell carcinoma the most common. Together this comprises the seventh most common cancer worldwide. At initial staging comprehensive imaging delineating the anatomic extent of the primary site, while also assessing the nodal involvement of the neck is necessary. The treatment of head and neck cancer often includes a combination of surgery, radiation, and chemotherapy. Post-treatment imaging is tailored for the evaluation of treatment response and early detection of local, locoregional, and distant recurrent tumor. Cross-sectional imaging with CT or MRI is recommended for the detailed anatomic delineation of the primary site. PET/CT provides complementary metabolic information and can map systemic involvement. 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.

ACR Appropriateness Criteria® Tinnitus: 2023 Update.

Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. 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® Management of Vertebral Compression Fractures: 2022 Update.

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. 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 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 in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Headache: 2022 Update.

Headache is an ancient problem plaguing a large proportion of the population. At present, headache disorders rank third among the global causes of disability, accounting for over $78 billion per year in direct and indirect costs in the United States. Given the prevalence of headache and the wide range of possible etiologies, the goal of this document is to help clarify the most appropriate initial imaging guidelines for headache for eight clinical scenarios/variants, which range from acute onset, life-threatening etiologies to chronic benign scenarios. 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.

Malignant solitary fibrous tumor of the floor of the mouth in a 71-year-old male: A case report.

Solitary fibrous tumors are rare mesenchymal tumors originally described in the pleura that infrequently metastasize. We present a 71-year-old male complaining of hemoptysis and a mass with the characteristic appearance of a hemangioma in the floor of the mouth. The mass had nonspecific imaging features on CT and MRI. After unsuccessful fine needle aspiration, surgical excision and biopsy with histological analysis revealed a solitary fibrous tumor, high risk variant. CT Imaging and lymph node biopsy showed gross total resection and no metastatic adenopathy. Given the high risk for malignancy, the patient received adjuvant radiation without subsequent clinical or imaging signs of recurrence. This case report demonstrates the presentation of this rare entity that can often be confused with other tumors in this region, given its nonspecific clinical and imaging findings.