Dorsal Wrist Carpal Boss Impingement-Dynamic Ultrasound to the Rescue!

The "carpal boss" is a variant present in 19% of the population according to cadaveric studies but becomes symptomatic in only 1% of cases. With the rising popularity of "yoga," which includes prolonged hyperextension at the wrist joint with weight bearing, an increasing number of individuals with silent carpal boss present with dorsal wrist pain due to impingement over the dorsal soft tissues by this innocuous bony protuberance. This warrants the attention of radiologists and clinicians while dealing with wrist pain. It can be challenging to identify this bossing on routine radiographs, necessitating special views. We describe the use of dynamic ultrasound in diagnosing "symptomatic" carpal boss, the effects of which become even more evident on imaging during hyperextension-the triggering movement.

Imaging Review of Alpine Ski Injuries.

Skiing is a continuously evolving winter sport, responsible for a considerable number of musculoskeletal injuries. Specific injury patterns and mechanisms in the upper and lower extremities, head, and spine are influenced by skier expertise and skill, position during injury, and environmental conditions. Predilection for certain joints and injury patterns have changed over time, largely due to technological advancements in equipment, increased awareness campaigns, and preventive protocols. Knowledge and understanding of these trends and developments can aid the radiologist to reach a timely and accurate diagnosis, thereby guiding clinical management and potentially reducing the overall incidence of debilitation and death.

Treatment response assessment following transarterial radioembolization for hepatocellular carcinoma.

Transarterial radioembolization with yttrium-90 microspheres is an established therapy for hepatocellular carcinoma. Post-procedural imaging is important for the assessment of both treatment response and procedural complications. A variety of challenging treatment-specific imaging phenomena complicate imaging assessment, such as changes in tumoral size, tumoral and peritumoral enhancement, and extrahepatic complications. A review of the procedural steps, emerging variations, and timelines for post-treatment tumoral and extra-tumoral imaging changes are presented, which may aid the reporting radiologist in the interpretation of post-procedural imaging. Furthermore, a description of post-procedural complications and their significance is provided.

How to Approach a Hip PARTI With Confidence: Ultrasound-Guided Parallel Transverse in-Plane Technique for Intra-articular Hip Interventions.

The "parallel transverse in-plane" technique for ultrasound-guided intra-articular hip interventions ensures needle visualization for the entire procedure, with the needle clearly shown entering the joint. With the widely described longitudinal in-plane approach, needle visualization can be poor, necessitating reliance on tissue distortion, which can reduce user confidence and safety. The parallel transverse in-plane approach is invaluable in those with anterior thigh skin breakdown and where anterior access is contraindicated. The approach also allows a broad width of the synovium to be traversed and is therefore well suited to synovial biopsy. This short Technical Innovation highlights this alternative approach to hip joint intervention.

Quality of same-day CT colonography following incomplete optical colonoscopy.

OBJECTIVES: Same-day CT colonography (CTC) following incomplete optical colonoscopy allows patients to avoid both a delayed diagnosis and the need for repeat bowel preparation. The aim of our study is to establish the diagnostic quality of same-day CT colonography following an incomplete optical colonoscopy. METHODS: We performed a retrospective review of patients undergoing same-day CT colonography following an incomplete colonoscopy at our center between July 2015 and December 2017 (N = 245). We divided the large bowel into thirteen subsegments in each patient. Using a semiquantitative scoring system, the quality of bowel preparation, adequacy of fecal tagging, and luminal distension were assessed in each subsegment on all views performed. A combined score for each subsection was obtained. RESULTS: Ninety-nine percent of studies did not require a repeat CTC or optical colonoscopy. Median values for bowel preparation and fecal tagging were satisfactory across the bowel segments for the cohort and luminal distension was acceptable in all but three patients. CONCLUSIONS: Same-day CTC should be considered in centers with capacity, following an incomplete optical colonoscopy. Same-day completion CTCs are of high diagnostic quality and this approach allows patients to avoid repeat bowel cleansing or a delayed diagnosis. KEY POINTS: • Same-day CT colonography is a high-quality examination that can be performed following incomplete optical colonoscopy. • Same-day CT colonography should be considered for patients with incomplete optical colonoscopy in centers with the capacity to offer this service. • Same-day CTC can avoid a delay in diagnosis and avoids repeat bowel preparation.

Dynamic ultrasound-guided trochanteric bursal injection.

Injection of steroid and anesthetic into the greater trochanteric bursa is commonly performed for trochanteric bursitis, gluteus medius/minimus tendinopathy, or as a part of a barbotage procedure for gluteus medius or minimus calcific tendonosis. Trochanteric bursal injection is widely performed both with and without image guidance, and is typically viewed as low-difficulty; however optimum needle tip position can be challenging. We discuss a simple dynamic technique to aid the practitioner in optimal needle placement.

Imaging features of Benign Perianal lesions.

Magnetic resonance imaging provides detailed visualisation, identification and extent assessment of many anal disorders. While many studies are performed in the evaluation of malignant processes such as anorectal carcinoma, the primary focus of this pictorial review is benign lesions, which involve the anal canal and perianal spaces. This pictorial review will illustrate the MRI appearances of a variety of benign conditions, which predominantly affect the anal canal, including abscess, fistulae, lipomas, developmental cysts and inflammatory conditions. MRI aids in the identification and characterisation of these abnormalities, of coexisting complications and differentiation from other perineal abnormalities. This pictorial review highlights the spectrum of non-malignant processes involving the perianal region.

Autonomic Dysreflexia in Patients With Spinal Cord Injury: What the Radiologist Needs to Know.

OBJECTIVE. Autonomic dysreflexia (AD) is a potentially life-threatening condition that occurs in patients with cervical and high thoracic spinal cord injury (SCI). AD is not completely understood and has a high incidence that increases proportional to the level and severity of the SCI. The signs and symptoms can vary, but severe hypertension is a dominant feature and may be fatal. This condition can be precipitated by a wide range of triggers occurring below the level of the injury, several of which are common to both diagnostic and interventional radiology, such as manipulation or distention of the genitourinary or gastrointestinal tract, patient positioning, or the use of certain anesthetic techniques. There is little guidance in the radiology literature specific to risk stratification or the use of premedication in this population. The incidence and pathophysiology of AD are discussed, along with pragmatic tips to aid the radiologist in selecting patients who may require a higher level of care or anesthesiologist involvement, with instructions for the conservative and medical management of acute episodes of AD. CONCLUSION. Awareness of AD is essential for all health care practitioners involved in the care of patients with SCI. A variety of procedures in the radiology department, both diagnostic and interventional, may precipitate AD. Planning, monitoring procedures, knowledge of the relevant pathophysiology and pharmacology, and communication with clinical colleagues are essential to ensure safe practice. Clinicians ordering procedures and radiologists selecting protocols for those procedures should identify at-risk patients before booking a procedure to ensure appropriate supervision and anesthesiology support. Education of radiologists, interventional nursing staff, and technical staff can assist in prevention, early recognition, and successful management of AD.

Prevalence of Incidental Findings on Multidetector Computed Tomography in Potential Nephrectomy Donors: A Prospective Observational Study.

OBJECTIVES: Prospective renal donors are a select population of healthy individuals who have been thoroughly screened for significant comorbidities before they undergo multidetector computed tomography. Our aim was to determine the prevalence of incidental findings on preoperative multidetector computed tomography in a healthy cohort of potential living donors for kidney transplant. MATERIALS AND METHODS: A prospective study was performed of prospective living kidney transplant donors at a national kidney transplant center. Study inclusion criteria were all potential kidney donors who underwent multidetector computed tomography during the living-donor assessment process over a 5-year period (January 2012 to 2017). RESULTS: Our cohort included 375 potential living donors who had multidetector computed tomography; mean age was 44.33 years (range, 21-71.5 y). In total, there were 228 incidental findings identified in 158 individuals. Of the 375 potential donors, 193 (51%) proceeded to living donor nephrectomy. On multidetector computed tomography, 97 incidental findings were identified in the donor cohort versus 131 in the cohort that did not proceed to donation. Bosniak 1 renal cysts were the most common incidental finding (n = 46) followed by liver cysts < 1.5 cm (n = 42) and urinary tract calculi (n = 21). There was 1 incidentally detected pathologically proven malignancy. CONCLUSIONS: A variety of incidentally detected lesions of moderate to high importance were detected in this healthy donor cohort. Individuals undergoing assessment with multidetector computed tomography for living donor nephrectomy should be counseled on medical, financial, and psychological implications of incidentally detected lesions during the kidney transplant evaluation process.

Medical device patents-a review of contemporary global trends with an Irish comparison.

INTRODUCTION: Trends in medical technology patents provide an objective comparison of research and development between countries and over time. An analysis of these trends can benchmark innovation within Ireland in a worldwide context. By identifying and examining leading countries, domestic educational, infrastructural, regulatory and fiscal planning may be optimised. MATERIALS AND METHODS: Published data filing and granting reports from the two major patent offices (United States Patent and Trademark Office (USPTO) and European Patent Office (EPO)) were analysed. RESULTS: USPTO statistics demonstrated an 83.1% decrease in the overall number of medical device patents filed over the 10-year period, from 2005 (n = 1092) to 2015 (n = 185). Conversely, there was a 166% increase in the number of medical device patents granted over the same period. EPO applications in the field of medical technology represented the single largest industry category. The proportion of patents granted of Irish origin have increased from 0.7 (n = 22) to 0.9% (n = 73) over 10 years. Switzerland ranks first for medical device patents granted per head of population by the EPO, with Ireland ranking 5th. Ireland's medical device patents have increased dramatically per head of population, from 4.1 per million in 2012, to 15.3 in 2016. Israel has the highest number of USPTO patents granted per head of population, with Ireland ranking 5th. CONCLUSIONS: Ireland demonstrates high levels of medical technology patent filing per head of population, reflecting the importance of this industry. However, both Switzerland and Israel demonstrate dominance amongst smaller nations, and serving as benchmarks for national planning.

A Custom Radiopaque Thermoresponsive Chemotherapy-Loaded Hydrogel for Intratumoural Injection: An In Vitro and Ex Vivo Assessment of Imaging Characteristics and Material Properties.

PURPOSE: Thermoresponsive hydrogels are gels which have different properties at varying temperatures. The objective of this study was to assess the material characteristics, imaging properties and chemotherapeutic drug release profile of a novel radiopaque thermoresponsive hydrogel in vitro, which is liquid at room temperature but solidifies at body temperature, to determine potential suitability for intratumoural delivery. MATERIALS AND METHODS: An iodinated radiopaque thermoresponsive hydrogel was formulated using iodixanol at a range of concentrations and assessed for sol-gel transition, radiopacity and imaging using CT and US. A lead formulation containing iodixanol at a concentration of 9.22% weight by weight (w/w, g of iodixanol per g of hydrogel) was evaluated in vitro for injectability, disintegration and dual drug release of cisplatin and paclitaxel from the hydrogel formulation. RESULTS: Radiopacity of the hydrogel increased in a concentration-dependent manner, but the highest concentration of iodixanol evaluated in this study (13.83% w/w) adversely affected the sol-gel transition of the hydrogel; therefore, 9.22% w/w iodixanol hydrogel was identified as the lead formulation. This formulation was readily visible on both CT and US. The formulation was hand injectable through a range of clinically relevant devices, had a sustained disintegration profile for up to 28 days and was able to deliver a sustained release of chemotherapeutic drug for up to 10 days. CONCLUSIONS: Favourable in vitro and ex vivo imaging and material characteristics of this thermoresponsive gel are demonstrated, suggesting potential interventional oncology applications for image-guided intratumoural delivery of sustained-release chemotherapy.

Comparative diagnostic test accuracy of post-esophagectomy water-soluble computed tomography and fluoroscopic swallow studies: A meta-analysis.

AIMS: Both fluoroscopic water-soluble contrast swallow (FWSCS) and CT water-soluble contrast swallow (CTWSCS) are widely performed as a routine in the post-esophagectomy patient to assess for anastomotic leak. Several prospective studies have compared FWSCS and CTWSCS; however, no synthesis of the data exists. MATERIALS AND METHODS: Systematic review and meta-analysis of diagnostic test accuracy studies comparing FWSCS and CTWSCS in the adult patient following esophagectomy for malignancy was performed in accordance with PRISMA guidelines. RESULTS: Three diagnostic test accuracy studies met the inclusion criteria, directly comparing FWSCS and CTWSCS in 185 patients. FWSCS demonstrated high specificity (98%), but low sensitivity (64%). CTWSCS can be categorized as normal, mediastinal gas without contrast leak, or leakage of oral contrast. Visible leakage of oral contrast demonstrated high specificity (98%) but low sensitivity (56%). The presence of mediastinal gas increased sensitivity (84%), but reduced specificity (85%). The higher sensitivity of CTWSCS over FWSCS failed to reach significance (P = 0.125). CONCLUSION: CTWSCS shares the high specificity of FWSCS. Its higher sensitivity increases its utility as a rule-out test in the postoperative period. Additional factors that may influence decision-making are described.

Combining Ultrasound-Guided Vascular Access With Ultrasound-Guided Analgesia for Single Skin and Vessel Puncture.

PURPOSE: To describe a single skin puncture technique combining subcutaneous injection of anesthetic to the depth of the vessel wall with venipuncture in the same movement. TECHNIQUE: Using ultrasound guidance, controlled anesthetic instillation along the needle tract and outer vessel wall with a 21-G vascular access needle can be combined with vessel puncture. This technique reduces the number of skin punctures and ensures accurate anesthetic instillation. The maximum inadvertent intravascular dose of commercial local anesthetic preparations that can be delivered with a small syringe is far below toxicity thresholds. CONCLUSION: A technique for combining anesthetic administration and vascular access with a 21-G needle and ultrasound guidance is feasible.

Uterine Artery Embolization: An Analysis of Online Patient Information Quality and Readability with Historical Comparison.

RATIONALE AND OBJECTIVES: Investigators aimed to assess online information describing uterine artery embolization (UAE) to examine the quality and readability of websites patients are accessing. MATERIALS AND METHODS: A list of applicable, commonly used searchable terms was generated, including "Uterine Artery Embolization," "Fibroid Embolization," "Uterine Fibroid Embolization," and "Uterine Artery Embolisation." Each possible term was assessed across the five most-used English language search engines to determine the most commonly used term. The most common term was then investigated across each search engine, with the first 25 pages returned by each engine included for analysis. Duplicate pages, nontext content such as video or audio, and pages behind paywalls were excluded. Pages were analyzed for quality and readability using validated tools including DISCERN score, JAMA Benchmark Criteria, HONcode Certification, Flesch Reading Ease Score, Flesch-Kincaid Grade Level, and Gunning-Fog Index. Secondary features such as age, rank, author, and publisher were recorded. RESULTS: The most common applicable term was "Uterine Artery Embolization" (492,900 results). Mean DISCERN quality of information provided by UAE websites is "fair"; however, it has declined since comparative 2012 studies. Adherence to JAMA Benchmark Criteria has reduced to 6.7%. UAE website readability remains more difficult than the World Health Organization-recommended 7-8th grade reading levels. HONcode-certified websites (35.6%) demonstrated significantly higher quality than noncertified websites. CONCLUSIONS: Quality of online UAE information remains "fair." Adherence to JAMA benchmark criteria is poor. Readability is above recommended 7-8th grade levels. HONcode certification was predictive of higher website quality, a useful guide to patients requesting additional information.

Are We Overtreating Renal Angiomyolipoma: A Review of the Literature and Assessment of Contemporary Management and Follow-Up Strategies.

Renal angiomyolipoma (AML) are benign tumours composed of fat, muscle, and disorganised blood vessels. Historic treatment algorithms for sporadic AML based on size fail to consider additional risk factors such as tumour vascularity and pseudoaneurysm formation. As AML is now predominantly incidental, rupture is rare and its mortality low. The recent publication of the largest longitudinal series to date also suggest that growth is uncommon, challenging existing surveillance paradigms. The evidence assessing treatment strategies in AML are reviewed, with particular emphasis on incidental sporadic AML. The relative merits of various AML treatments are discussed, and areas of clinical uncertainty highlighted.

Osteoporosis, obesity, and sarcopenia on abdominal CT: a review of epidemiology, diagnostic criteria, and management strategies for the reporting radiologist.

Abdominal computed tomography (CT) is a widely performed examination, with many indications. Assessment of bone, fat, and muscle on abdominal CT can be performed in a quantitative manner. Published studies have developed diagnostic cutoffs for osteoporosis, obesity, and sarcopenia, which are summarized with pictorial examples. The epidemiological and prognostic significance of these disease states are outlined. Further diagnostic steps and treatment strategies are outlined to inform both the managing clinician and reporting radiologist. This article summarizes an unglamorous yet information-rich field, which is ripe for assessment in the dawning era of personalized medicine, and one in which the radiologist is well placed to add value to patient care.

Rigid inflatable gastrostomy tube malposition.

Rigid inflatable gastrostomy (RIG) tubes are widely used in contemporary clinical practice for a variety of indications. Insertion of RIG tubes is associated with a high technical success rate and low incidence of mortality. In this case report, a procedural pitfall associated with intraperitoneal-extragastric malposition is described. Rigorous assessment of abdominal radiographs, as well as awareness of the expected appearance of the RIG tube and gastropexy T-fasteners, allows the abdominal radiologist to detect early RIG position in the early postprocedural period. Abdominal radiography is a widely available and inexpensive technique. The high spatial resolution it provides makes it a valuable tool in determining hardware position.

Transarterial Embolization of Angiomyolipoma: A Systematic Review.

INTRODUCTION: Transarterial embolization is increasingly used in the management of renal angiomyolipoma. The level of evidence establishing the safety and efficacy of transarterial embolization has not increased in parallel. MATERIALS AND METHODS: Using the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) criteria a systematic review of transarterial embolization of angiomyolipoma was performed to establish procedural safety and efficacy. A MEDLINE® PubMed® search revealed 1,739 publications, of which 31 studies met eligibility criteria. RESULTS: A total of 524 cases of transarterial embolization of angiomyolipoma were included in analysis. Self-limiting post-embolization syndrome developed following 35.9% of embolizations and further morbidity developed in 6.9%. No procedural mortality was reported. At a mean followup of 39 months the mean size reduction was 3.4 cm (-38.3% of angiomyolipoma diameter). Unplanned repeat embolization or surgery was required in 20.9% of cases during this period. The most frequent indications for repeat procedures included angiomyolipoma revascularization in 30.0% of cases, unchanged or increasing size in 22.6%, refractory or recurring symptoms in 16.7% and representation with acute retroperitoneal hemorrhage in 14.3%. Treatment included a combination of 2 or more embolic agents in 46.8% of cases, ethanol monotherapy in 41.7%, coil monotherapy in 6.2% and foam or microparticle monotherapy in 5.2%. CONCLUSIONS: Transarterial embolization of angiomyolipoma demonstrates low rates of mortality and serious complications. Re-treatment rates and size reduction at a mean followup of 39 months are presented. Longitudinal data assessing long-term size reduction and re-treatment rates are lacking. Recommendations guiding the indications for transarterial embolization and clear followup require further longitudinal data.