The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

Evidence of Strong Orbital-Selective Spin-Orbital-Phonon Coupling in CrVO_{4}.

Coupling of orbital degree of freedom with a spin exchange, i.e., Kugel-Khomskii-type interaction (KK), governs a host of material properties, including colossal magnetoresistance, enhanced magnetoelectric response, and photoinduced high-temperature magnetism. In general, KK-type interactions lead to deviation in experimental observables of coupled Hamiltonian near or below the magnetic transition. Using diffraction and spectroscopy experiments, here we report anomalous changes in lattice parameters, electronic states, spin dynamics, and phonons at four times the Néel transition temperature (T_{N}) in CrVO_{4}. The temperature is significantly higher than other d-orbital compounds such as manganites and vanadates, where effects are limited to near or below T_{N}. The experimental observations are rationalized using first-principles and Green's function-based phonon and spin simulations that show unprecedentedly strong KK-type interactions via a superexchange process and an orbital-selective spin-phonon coupling coefficient at least double the magnitude previously reported for strongly coupled spin-phonon systems. Our results present an opportunity to explore the effect of KK-type interactions and spin-phonon coupling well above T_{N} and possibly bring various properties closer to application, for example, strong room-temperature magnetoelectric coupling.

Li-Fraumeni Syndrome: Imaging Features and Guidelines.

Li-Fraumeni syndrome (LFS) is a rare autosomal dominant familial cancer syndrome caused by germline mutations of the tumor protein p53 gene (TP53), which encodes the p53 transcription factor, also known as the "guardian of the genome." The most common types of cancer found in families with LFS include sarcomas, leukemia, breast malignancies, brain tumors, and adrenocortical cancers. Osteosarcoma and rhabdomyosarcoma are the most common sarcomas. Patients with LFS are at increased risk of developing early-onset gastric and colon cancers. They are also at increased risk for several other cancers involving the thyroid, lungs, ovaries, and skin. The lifetime risk of cancer in individuals with LFS is greater than 70% in males and greater than 90% in females. Some patients with LFS develop multiple primary cancers during their lifetime, and guidelines have been established for screening these patients. Whole-body MRI is the preferred modality for annual screening of these patients. The management guidelines for patients with LFS vary, as these individuals are more susceptible to developing radiation-induced cancers-for example, women with LFS and breast cancer are treated with total mastectomy instead of lumpectomy with radiation to the breast. The authors review the role of imaging, imaging guidelines, and imaging features of tumors in the setting of LFS. ©RSNA, 2024 Supplemental material is available for this article.

Deciphering ovarian torsion: insights from CT imaging analysis.

PURPOSE: In the milieu of emergency medicine, pelvic and lower abdominal pain present recurrently, with ovarian torsion posing a formidable diagnostic quandary amid multifarious etiologies. Given the burgeoning reliance on CT in acute care settings, it invariably assumes primacy as the principal imaging modality. This study endeavors to elucidate the CT imaging manifestations encountered by surgically confirmed ovarian torsion patients and utilizing CT to differentiate necrosis. METHODS: A retrospective analysis (January, 2015- April, 2019) utilizing hospital archives was conducted on patients diagnosed with ovarian torsion, post-surgery. Inclusion criteria encompassed patients who underwent CT examinations within one week of diagnosis. A large array of CT findings encompassing midline orientation, uterine deviation, intraovarian hematoma/mass, and multiple others were systematically documented. RESULTS: 90 patients were diagnosed with ovarian torsion- 53 (59%) had CT within one week of diagnosis, 41(77%) underwent a CT with IV contrast and 12 (23%) without IV contrast. Mean age was 43 years (range 19-77 years), with near equal distribution of involvement of each ovary. Mean maximum ovarian diameter was 11.7 ± 6.3 cm (4.2-34.8 cm). Most common imaging features include the presence of thickened pedicle (43/53, 81%), midline ovary (41/53, 77%), presence of thickened fallopian tube (31/49, 63%), and ipsilateral uterine deviation (33/53, 62%). Based on contemporaneous imaging report, torsion was diagnosed in 25/ 53 studies giving a sensitivity of 47%. CONCLUSION: Enlarged ovarian dimensions (> 3.0 cm), thickened vascular pedicle or fallopian tube, midline ovarian disposition with ipsilateral uterine deviation, and the presence of a whirlpool sign emerged as predominant CT imaging features in surgically confirmed ovarian torsion cases, serving as pivotal diagnostic aides for radiologists. Concomitant pelvic free fluid and intraovarian hematoma signify necrotic changes, indicative of ischemic severity and disease progression.

CT pulmonary angiography in the emergency department: utilization and positivity rates during various phases of the COVID-19 pandemic.

PURPOSE: To evaluate the trends in utilization and results of computed tomography pulmonary angiography (CTPA study) for detection of acute pulmonary embolism (PE) in the Emergency Department (ED) during different phases of COVID-19 public health emergency. METHODS: We conducted a retrospective review of CTPA studies ordered through our ED in the months of March through May during five consecutive years from 2019 to 2023, designated as pre-pandemic, early, ongoing, recovery, and post-pandemic periods respectively. Collected characteristics included patient age, patient sex, and result of the study. RESULTS: The utilization of CTPA studies for ED patients increased during the early, ongoing, and recovery periods. CTPA study utilization in the post-pandemic period was not significantly different from the pre-pandemic period (p = 0.08). No significant difference in CTPA study utilization was noted in the other periods when stratified by age group or sex, compared to the pre-pandemic period. The positivity rate of acute PE in ED patients was not significantly different in other periods compared to the pre-pandemic period. CONCLUSION: At our institution, the utilization and positivity rates of CTPA studies for the ED patients were not significantly different in the post-pandemic period compared to the pre-pandemic period. While studies spanning a larger timeframe and involving multiple institutions are needed to test the applicability of this observation to a wider patient population beyond our defined post-pandemic period, we conclude that our study provides some confidence to the ordering provider and the radiologist in embracing the end of COVID-19 public health emergency by the WHO and the United States HHS with respect to CTPA studies.

Imaging of Bowel Ischemia: An Update, From the AJR Special Series on Emergency Radiology.

Acute mesenteric ischemia is a life-threatening condition that results from abrupt reduction in or cessation of blood flow to the bowel. Characterized by nonspecific abdominal symptoms, mesenteric ischemia is infrequently encountered and commonly misdiagnosed, with potentially catastrophic consequences. Prompt clinical diagnosis and early implementation of therapeutic interventions are critical to improving patient outcomes. Because cross-sectional imaging plays a key role in the diagnosis of mesenteric ischemia, radiologists must be familiar with the varied imaging manifestations of intestinal ischemia. Thus, the objectives of this article are to review the various types and common causes of mesenteric ischemia and to describe its spectrum of multimodality imaging findings, with special attention to novel imaging techniques and emerging diagnoses.

Dual-Energy CT Evaluation of Gastrointestinal Bleeding.

Gastrointestinal (GI) bleeding is a potentially life-threatening condition accounting for more than 300 000 annual hospitalizations. Multidetector abdominopelvic CT angiography is commonly used in the evaluation of patients with GI bleeding. Given that many patients with severe overt GI bleeding are unlikely to tolerate bowel preparation, and inpatient colonoscopy is frequently limited by suboptimal preparation obscuring mucosal visibility, CT angiography is recommended as a first-line diagnostic test in patients with severe hematochezia to localize a source of bleeding. Assessment of these patients with conventional single-energy CT systems typically requires the performance of a noncontrast series followed by imaging during multiple postcontrast phases. Dual-energy CT (DECT) offers several potential advantages for performing these examinations. DECT may eliminate the need for a noncontrast acquisition by allowing the creation of virtual noncontrast (VNC) images from contrast-enhanced data, affording significant radiation dose reduction while maintaining diagnostic accuracy. VNC images can help radiologists to differentiate active bleeding, hyperattenuating enteric contents, hematomas, and enhancing masses. Additional postprocessing techniques such as low-kiloelectron voltage virtual monoenergetic images, iodine maps, and iodine overlay images can increase the conspicuity of contrast material extravasation and improve the visibility of subtle causes of GI bleeding, thereby increasing diagnostic confidence and assisting with problem solving. GI bleeding can also be diagnosed with routine single-phase DECT scans by constructing VNC images and iodine maps. Radiologists should also be aware of the potential pitfalls and limitations of DECT. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Impact of dual-energy 50-keV virtual monoenergetic images on radiologist confidence in detection of key imaging findings of small hepatocellular carcinomas using multiphase liver CT.

BACKGROUND: Dual-energy virtual monoenergetic images can increase iodine signal, potentially increasing the conspicuity of hepatic masses. PURPOSE: To determine if dual-energy 50-keV virtual monoenergetic images improve visualization of key imaging findings or diagnostic confidence for small (≤2 cm) hepatocellular carcinomas (HCC) at multiphase, contrast-enhanced liver computed tomography (CT). MATERIAL AND METHODS: Patients with chronic liver disease underwent multiphase dual-energy CT imaging for HCC, with late arterial and delayed phase dual-energy 50-keV images reconstructed. Two non-reader subspecialized gastrointestinal (GI) radiologists established the reference standard, determining the location and diagnosis of all hepatic lesions using predetermined criteria. Three GI radiologists interpreted mixed kV CT images without or with dual-energy 50-keV images. Radiologists identified potential HCCs and rated their confidence (0-100 scales) in imaging findings of arterial enhancement, enhancing capsule, tumor washout, and LI-RADS 5 (2018) category. RESULTS: In total, 45 patients (14 women; mean age = 59.5 ± 10.9 years) with chronic liver disease were included. Of them, 19 patients had 25 HCCs ≤2 cm (mean size = 1.5 ± 0.4 cm). There were 17 LI-RADS 3 and 4 lesions and 19 benign lesions. Reader confidence in imaging findings of arterial enhancement, enhancing capsule, and non-peripheral washout significantly increased with dual-energy images (P ≤ 0.022). Overall confidence in HCC diagnosis increased significantly with dual-energy 50-keV images (52.4 vs. 68.8; P = 0.001). Dual-energy images demonstrated a slight but significant decrease in overall image quality. CONCLUSION: Radiologist confidence in key imaging features of small HCCs and confidence in imaging diagnosis increases with use of dual-energy 50-keV images at multiphase, contrast-enhanced liver CT.

Challenges in Diagnosis and Management of Hemobilia.

Hemobilia, or hemorrhage within the biliary system, is an uncommon form of upper gastrointestinal (GI) bleeding that presents unique diagnostic and therapeutic challenges. Most cases are the result of iatrogenic trauma, although accidental trauma and a variety of inflammatory, infectious, and neoplastic processes have also been implicated. Timely diagnosis can often be difficult, as the classic triad of upper GI hemorrhage, biliary colic, and jaundice is present in a minority of cases, and there may be considerable delay in the onset of bleeding after the initial injury. Therefore, the radiologist must maintain a high index of suspicion for this condition and be attuned to its imaging characteristics across a variety of modalities. CT is the first-line diagnostic modality in evaluation of hemobilia, while catheter angiography and endoscopy play vital and complementary roles in both diagnosis and treatment. The authors review the clinical manifestations and multimodality imaging features of hemobilia, describe the wide variety of underlying causes, and highlight key management considerations.©RSNA, 2021.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms.

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Imaging primer for CT angiography in peripheral vascular trauma.

The use of computed tomography angiography (CTA) for the evaluation of peripheral vascular trauma has become increasingly prevalent in the past decade with the development of multidetector CT (MDCT) and multiple studies subsequently demonstrating high sensitivity, specificity, and diagnostic accuracy when compared with conventional angiography. Additional benefits of MDCT include the ability to rapidly acquire the images, perform multiplanar and 3D reconstructions, and assess the adjacent soft tissues and bones. Rapid intravenous injection of iodinated contrast material is required for optimal arterial enhancement. CTA manifestations of an arterial injury may be direct, and include active contrast extravasation, pseudoaneurysm, arteriovenous fistula (AVF), intimal injury, dissection, or occlusion. There are also indirect signs which have a high association with vascular injury, and should raise suspicion, when present. Pitfalls related to image acquisition or patient factors can be mitigated with appropriate planning and post-processing techniques.

Problem-solving with MRI in acute abdominopelvic conditions, part 2: gynecological, obstetric, vascular, and renal diseases.

The purpose of this article is to illustrate the benefits of magnetic resonance imaging (MRI) in the setting of abdominopelvic emergencies. Owing to intrinsically high soft-tissue contrast resolution, and ability to resolve different soft tissue, MRI holds notable advantages over other imaging modalities and can be used as a problem-solving tool. Additional advantages of MRI include lack of radiation-related risks to children and pregnant women, and the ability to acquire detailed diagnostic information even without intravenous contrast which can be beneficial in patients with contrast allergy and end-stage renal disease. In the part 2, the authors focus on MRI features of female pelvic gynecological diseases, pregnancy- related complications, abdominal vascular complications, and renal diseases.

Problem-solving with MRI in acute abdominopelvic conditions, part 1: gastrointestinal, hepatobiliary, and pancreatic diseases.

The purpose of this article is to review the benefit and added value and advantages of magnetic resonance imaging (MRI) compared with other cross-sectional imaging in patients presenting with abdominopelvic emergencies. During the past decade, there has been increased utilization of MRI in the emergency department with widespread availability of MR scanners, improvement in rapid imaging techniques, and methods to overcome motion-related artifacts. This has benefited patients at higher risk of radiation, particularly children and pregnant women, and patients with contraindications to iodinated contrast including allergy and renal dysfunction. Still the challenges are: on site MR scanner in the emergency department, after-hour services, as well as availability of time slot to rapidly scan emergency patient. MRI has additional advantages over other imaging modalities due to its high contrast resolution, which allows it to better characterize tissue and fluid collections, and may avoid the need for intravenous contrast. Radiologists must be familiar with the role and added value of MRI, spectrum of imaging findings, and problem-oriented modified MR protocols in abdominal and pelvic emergencies. In part 1, we will discuss the utility of MRI in gastrointestinal, hepatobiliary, and pancreatic diseases. In part 2, the authors will focus on the key MR imaging features of female pelvic gynecological diseases, pregnancy related complications, abdominal vascular complications, and renal diseases.

Automated radiomic analysis of CT images to predict likelihood of spontaneous passage of symptomatic renal stones.

PURPOSE: To evaluate the ability of a semi-automated radiomic analysis software in predicting the likelihood of spontaneous passage of urinary stones compared with manual measurements. METHODS: Symptomatic patients visiting the emergency department with suspected stones in either kidney or ureters who underwent a CT scan were included. Patients were followed for up to 6 months for the outcome of a trial of passage. Maximum stone diameters in axial and coronal images were measured manually. Stone length, width, height, max diameter, volume, the mean and standard deviation of the Hounsfield units, and morphologic features were also measured using automated radiomic analysis software. Multivariate models were developed using these data to predict subsequent spontaneous stone passage, with results expressed as the area under a receiver operating curve (AUC). RESULTS: One hundred eighty-four patients (69 females) with a median age of 56 years were included. Spontaneous stone passage occurred in 114 patients (62%). Univariate analysis demonstrated an AUC of 0.83 and 0.82 for the maximum stone diameter determined manually in the axial and coronal planes, respectively. Multivariate models demonstrated an AUC of 0.82 for a model including manual measurement of maximum stone diameter in axial and coronal planes. The same AUC was found for a model including automatic measurement of maximum height and diameter of the stone. Further addition of morphological parameters measured automatically did not increase AUC beyond 0.83. CONCLUSION: The semi-automated radiomic analysis of urinary stones shows similar accuracy compared with manual measurements for predicting urinary stone passage. Further studies are needed to predict clinical impacts of reporting the likelihood of urinary stone passage and improving inter-observer variation using automatic radiomic analysis software.

Image quality in abdominal CT using an iodine contrast reduction algorithm employing patient size and weight and low kV CT technique.

BACKGROUND: Low tube potential-high tube current computed tomography (CT) imaging allows reduction in iodine-based contrast dose and may extend the benefit of routine contrast-enhanced CT exams to patients at risk of nephrotoxicity. PURPOSE: To determine the ability of an iodine contrast reduction algorithm to maintain diagnostic image quality for contrast-enhanced abdominal CT. MATERIAL AND METHODS: CT exams with iodine contrast reduction were prescribed for patients at risk for renal dysfunction. The iodine contrast reduction algorithm combines weight-based contrast volume reduction with patient width-based low tube potential selection and bolus-tracking. Control exams with routine iodine dose were selected based on weight, width, and scan protocol. Three radiologists evaluated image quality and diagnostic confidence using a 4-point scale (<2 acceptable). Another radiologist assessed contrast reduction indications and measured portal vein and liver contrast-to-noise ratios. RESULTS: Forty-six contrast reduction algorithm and control exams were compared (mean creatinine 1.6 vs. 1.2 mg/dL, P ≤ 0.0001). Thirty-nine contrast reduction patients had an eGFR <60 mL/min/1.73m2 and 15 had single or transplanted kidney. Mean iodine contrast dose was lower in the contrast reduction group (20.9 vs. 39.4 g/mL, P < 0.0001). Diagnostic confidence was rated as acceptable in 95% (131/138) of contrast reduction and 100% of control exams (1.18-1.28 vs. 1.02-1.13, respectively; P > 0.06). Liver attenuation and contrast-to-noise ratio (CNR) were similar (P = 0.08), but portal vein attenuation and CNR were lower with contrast-reduction (mean 176 vs. 198 HU, P = 0.02; 13 vs. 16, P = 0.0002). CONCLUSION: This size-based contrast reduction algorithm using low kV and bolus tracking reduced iodine contrast dose by 50%, while achieving acceptable image quality in 95% of exams.

Linear and Nonlinear Isotherm Models and Error Analysis for the Sorption of Kresoxim-Methyl in Agricultural Soils of India.

Kresoxim methyl sorption in soils of five agro-climatic zones of India varied from 41.6% to 84.7%. Highest sorption was recorded in organic carbon rich Almora soil. Isotherm parameters for linear and non-linear Freundlich and Temkin models were almost same, whereas Langmuir parameter Q0, for linear (1.60 to 9.434 µg g-1) and non-linear (8.48 to 17.129 µg g-1) models were quite different. For isotherms optimization different error functions such as sum of squares error (SSE), root mean square error (RMSE), Chi square error, hybrid fractional error (HYBRID) and average relative error (ARE) were calculated. Lowest error function values were obtained for Freundlich isotherm in all the soils except inceptisol (Kolkata) for which Langmuir isotherm gave the best fit. Statistical analysis using SAS 9.3 software and Tukey's HSD test revealed the significant effect (p < 0.001) of soil type on sorption. Sorption correlated positively with the organic carbon and clay contents of the soil.

Blunt traumatic vascular injuries of the head and neck in the ED.

Cerebrovascular injury is increasingly identified in patients presenting after blunt trauma due to the implementation of screening criteria and advances in noninvasive angiographic imaging by CT. The variable latent time before onset of secondary stroke presents a window of opportunity for prevention, reinforcing the importance of detection of asymptomatic patients via screening. Furthermore, the high morbidity and mortality associated with secondary stroke makes it imperative that radiologists recognize these challenging injuries. This article reviews the epidemiology of and the various proposed screening criteria for blunt cerebrovascular injury. The imaging findings of extra- and intracranial vascular injuries, including arterial and venous trauma, are reviewed along with the grading system. Conservative management with anticoagulation has gained favor over the years with intervention restricted to high-grade injuries such as transection and hemodynamically significant arteriovenous fistula. Many of these injuries also evolve over time, with or without anticoagulation, necessitating imaging follow-up.

Implementation and Performance of Automated Software for Computing Right-to-Left Ventricular Diameter Ratio From Computed Tomography Pulmonary Angiography Images.

OBJECTIVE: The aim of this study was to prospectively test the performance and potential for clinical integration of software that automatically calculates the right-to-left ventricular (RV/LV) diameter ratio from computed tomography pulmonary angiography images. METHODS: Using 115 computed tomography pulmonary angiography images that were positive for acute pulmonary embolism, we prospectively evaluated RV/LV ratio measurements that were obtained as follows: (1) completely manual measurement (reference standard), (2) completely automated measurement using the software, and (3 and 4) using a customized software interface that allowed 2 independent radiologists to manually adjust the automatically positioned calipers. RESULTS: Automated measurements underestimated (P < 0.001) the reference standard (1.09 [0.25] vs1.03 [0.35]). With manual correction of the automatically positioned calipers, the mean ratio became closer to the reference standard (1.06 [0.29] by read 1 and 1.07 [0.30] by read 2), and the correlation improved (r = 0.675 to 0.872 and 0.887). The mean time required for manual adjustment (37 [20] seconds) was significantly less than the time required to perform measurements entirely manually (100 [23] seconds). CONCLUSIONS: Automated CT RV/LV diameter ratio software shows promise for integration into the clinical workflow for patients with acute pulmonary embolism.