Autosomal Dominant Polycystic Kidney Disease: Role of Imaging in Diagnosis and Management.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney disorder with progressive renal function decline, and disease severity is determined based on the type of genetic mutation. The diagnosis is usually established at imaging, primarily at US, and is based on age-dependent criteria and the number of visible cysts. ADPKD is classified into class 1 (typical) and class 2 (atypical) according to the Mayo Clinic Imaging Classification (MCIC) system. Height-adjusted total kidney volume (TKV) has emerged as a predictor of future renal function decline and renal failure in ADPKD, and several methods can be used for estimation. MCIC class 1 ADPKD is further subdivided into five types based on height-adjusted TKV (A, B, C, D, and E). Patients with a larger height-adjusted TKV (ie, MCIC 1C-E) are at high risk for progression to end-stage renal disease and will potentially benefit from vasopressin receptor antagonists, which have been shown to reduce the rate of cyst growth and slow renal function decline. Other renal complications primarily relate to hemorrhage within cysts or cyst infections. Subtraction images are key for assessment of complex cysts when malignancy is suspected, as the presence of protein and blood can limit the assessment for an enhancing component. The radiologist has a central role in establishing a diagnosis, excluding mimics, identifying complications, assessing severity, and predicting future renal failure. Interventional radiologists play a therapeutic role in management of complications by cyst drainage, sclerotherapy, or embolization. © RSNA, 2022 Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

Imaging of Trauma in Pregnancy.

A pregnant patient with acute trauma is not commonly encountered by clinicians and radiologists. A multidisciplinary approach is key. Although radiography and ultrasound examination are frequently used modalities in the setting of maternal-fetal trauma, the fear of radiation should not preclude from carrying out a thorough diagnostic workup of the patient with a computed tomography scan. MRI mainly serves as a problem solving and follow-up modality. After stabilizing the mother, fetal well-being should be assessed with external fetal monitoring and a dedicated obstetric ultrasound examination. Radiologists should be familiar with the sonographic and computed tomography findings of catastrophic entities.

Comparison of international guidelines for diagnosis of hepatocellular carcinoma and implications for transplant allocation in liver transplantation candidates with gadoxetic acid enhanced liver MRI versus contrast enhanced CT: a prospective study with liver explant histopathological correlation.

OBJECTIVES: To compare the diagnostic performance of international hepatocellular carcinoma (HCC) guidelines with gadoxetic acid-enhanced MRI (EOB-MRI) and contrast-enhanced Computed tomography (CECT) and their impact on liver transplant (LT) allocation in cirrhotic patients with explant histopathology correlation. METHODS: In this prospective single-centre ethics-approved study, 101 cirrhotic patients were consecutively enrolled with informed consent from the pre-LT clinic. They underwent CECT and EOB-MRI alternately at three monthly intervals until LT or removal from LT list. Two abdominal radiologists, blinded to explant histopathology, independently recorded liver lesions visible on CECT and EOB-MRI. Imaging-based HCC scores were assigned to non-treated liver lesions utilizing Liver Imaging Reporting and Data System (LI-RADS), European Association for the Study of the Liver (EASL), Asian-Pacific Association for the Study of the Liver (APASL) and Korean Liver Cancer Association-National Cancer Center (KLCA) guidelines. Liver explant histopathology was the reference standard. Simulated LT eligibility was assessed as per Milan criteria (MC) in reference to explant histopathology. RESULTS: One hundred and three non-treated HCC and 12 non-HCC malignancy were identified at explant histopathology in 34 patients (29 men, 5 women, age 55-73 years). Higher HCC sensitivities of statistical significance were observed with EOB-MRI for LI-RADS 4 + 5, APASL and KLCA compared to LI-RADS 5 and EASL with greatest sensitivity obtained for LIRADS 4 + 5 lesions. HCC sensitivities by all guidelines with both EOB-MRI and CECT were significantly lower if all histopathology-detected HCCs were included in the analysis, compared to imaging-visible lesions only. A significantly greater variation in HCC sensitivity was noted across the guidelines with EOB-MRI compared to CECT. No significant differences in simulated LT eligibility based on MC were observed across the HCC scoring guidelines with EOB-MRI or CECT. CONCLUSION: HCC sensitivities are variable depending on scoring guideline, lesion size and imaging modality utilised. Prior studies that included only lesions visible on pre-operative imaging overestimate the diagnostic performance of HCC scoring guidelines. Per-lesion differences in HCC diagnosis across these guidelines did not impact patient-level LT eligibility based on MC.

Reoperation in adult patients with recurrent glioblastoma: A matched cohort analysis.

Background: Despite maximal safe cytoreductive surgery and postoperative adjuvant therapies, glioblastoma (GBM) inevitably recurs and leads to deterioration of neurological status and eventual death. There is no consensus regarding the benefit of repeat resection for enhancing survival or quality of life in patients with recurrent GBM. We aimed to examine if reoperation for GBM recurrence incurs a survival benefit as well as examine its complication profile. Methods: We performed a single-center retrospective chart review on all adult patients who underwent resection of supratentorial GBM between January 1, 2008 and December 1, 2013 at our center. Patients with repeat resection were manually matched for age, sex, tumor location, and Karnofsky Performance Status (KPS) with patients who underwent single resection to compare overall survival (OS), and postoperative morbidity. Results: Of 237 patients operated with GBM, 204 underwent single resection and 33 were selected for repeat surgical resections. In a matched analysis there was no difference in the OS between groups (17.8 ± 17.6 months vs 17 ± 13.5 months, P = .221). In addition, repeat surgical resection had a higher rate of postoperative neurological complications compared to the initial surgery. Conclusions: When compared with matched patients who underwent a single surgical resection, patients undergoing repeat surgical resection did not show significant increase in OS and may have incurred more neurological complications related to the repeat resection. Further studies are required to assess which patients would benefit from repeat surgical resection and optimize timing of the repeat resection in selected patients.

Dual Energy CT Physics-A Primer for the Emergency Radiologist.

Dual energy CT (DECT) refers to the acquisition of CT images at two energy spectra and can provide information about tissue composition beyond that obtainable by conventional CT. The attenuation of a photon beam varies depends on the atomic number and density of the attenuating material and the energy of the incoming photon beam. This differential attenuation of the beam at varying energy levels forms the basis of DECT imaging and enables separation of materials with different atomic numbers but similar CT attenuation. DECT can be used to detect and quantify materials like iodine, calcium, or uric acid. Several post-processing techniques are available to generate virtual non-contrast images, iodine maps, virtual mono-chromatic images, Mixed or weighted images and material specific images. Although initially the concept of dual energy CT was introduced in 1970, it is only over the past two decades that it has been extensively used in clinical practice owing to advances in CT hardware and post-processing capabilities. There are numerous applications of DECT in Emergency radiology including stroke imaging to differentiate intracranial hemorrhage and contrast staining, diagnosis of pulmonary embolism, characterization of incidentally detected renal and adrenal lesions, to reduce beam and metal hardening artifacts, in identification of uric acid renal stones and in the diagnosis of gout. This review article aims to provide the emergency radiologist with an overview of the physics and basic principles of dual energy CT. In addition, we discuss the types of DECT acquisition and post processing techniques including newer advances such as photon-counting CT followed by a brief discussion on the applications of DECT in Emergency radiology.

Impact of COVID-19 on Canadian Radiology Residency Training Programs.

PURPOSE: The novel coronavirus disease (COVID-19) pandemic has swept the globe, with a domino effect on medical education and training. In this study, we surveyed Canadian radiology residents to understand the impact of the pandemic on their residency training, strategies utilized by the residency programs in mitigating those impacts, and factors important to residents in the selection of educational resources on COVID-19. METHODS: A 10-item questionnaire was distributed to 460 resident members of the Canadian Association of Radiologists. The survey was open for 2 weeks, with a reminder sent at half-way mark. RESULTS: We received 96 responses (response rate: 20.9%). The 4 highest affected domains of training were daytime case volumes (92.4%), daytime schedules (87.4%), internal and external assessments (86.5%), and vacation/travel (83.3%). Virtual teaching rounds (91.7%), change in schedules to allow staying home (78.1%), and virtual/phone readouts (72.9%) were the most utilized strategies by the Canadian radiology residency programs. Overall stress of exposure to the disease was moderate to low (86.5%). A minority of the residents were redeployed (6.2%), although most (68.8%) were on standby for redeployment. Residents preferred published society guidelines (92.3%), review papers (79.3%), video lectures (79.3%), and web tools (76.9%) for learning about COVID-19 imaging manifestations. CONCLUSION: The COVID-19 pandemic has had a significant impact on various domains of the Canadian radiology residency programs, which has been mitigated by several strategies employed by the training programs.

Imaging of Blunt Pancreatic Trauma: A Systematic Review.

PURPOSE: Despite several published reports on the value of imaging in acute blunt pancreatic trauma, there remains a large variability in the reported performance of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). The purpose of this study is to present a systematic review on the utility of these imaging modalities in the acute assessment of blunt pancreatic trauma. In addition, a brief overview of the various signs of pancreatic trauma will be presented. METHODS: Keyword search was performed in MEDLINE, EMBASE, and Web of Science databases for relevant studies in the last 20 years (1999 onward). Titles and abstracts were screened, followed by full-text screening. Inclusion criteria were defined as studies reporting on the effectiveness of imaging modality (US, CT, or MRI) in detecting blunt pancreatic trauma. RESULTS: After initial search of 743 studies, a total of 37 studies were included in the final summary. Thirty-six studies were retrospective in nature. Pancreatic injury was the primary study objective in 21 studies. Relevant study population varied from 5 to 299. Seventeen studies compared the imaging findings against intraoperative findings. Seven studies performed separate analysis for pancreatic ductal injuries and 9 studies only investigated ductal injuries. The reported sensitivities for the detection of pancreatic injuries at CT ranged from 33% to 100% and specificity ranged from 62% to 100%. Sensitivity at US ranged from 27% to 96%. The sensitivity at MRI was only reported in 1 study and was 92%. CONCLUSION: There remains a large heterogeneity among reported studies in the accuracy of initial imaging modalities for blunt pancreatic injury. Although technological advances in imaging equipment would be expected to improve accuracy, the current body of literature remains largely divided. There is a need for future studies utilizing the most advanced imaging equipment with appropriately defined gold standards and outcome measures.

Twin pregnancy with metastatic complete molar pregnancy and coexisting live fetus.

We present a case of a 34-year old G1P0 female with twin-gestation and positive prenatal screening. Initial ultrasounds demonstrated a normal live fetus with an indeterminate but persistent placental lesion. The patient presented at 23 weeks of gestational age with vaginal bleeding. On examination, a 2 cm vaginal lesion was identified. Further cross-sectional imaging demonstrated a normal appearing fetus with a mixed solid and cystic placental lesion as well as an additional lesion in the vagina. Metastatic workup revealed diffuse pulmonary metastases. Intravascular embolization was carried out to minimize the bleeding from the vaginal lesion, followed by the delivery of the fetus with an urgent Caesarean section and treatment with chemotherapy. Pathology and genetics testing confirmed diagnosis of a complete molar pregnancy with a coexisting live fetus. This case highlights the importance of any unexpected findings within the placenta or the uterus in a pregnant patient. The radiologist should maintain a high index of suspicion for gestational trophoblastic disease in such cases, communicate clearly with the clinical team and suggest appropriate additional imaging.

A 2019 international survey to assess trends in follow-up imaging of blunt splenic trauma.

PURPOSE: There are no published guidelines on the follow-up imaging of non-operatively managed blunt splenic trauma (BST). We conducted an international survey of emergency radiologists to determine the ideal patient population, time period, and technique for follow-up imaging of BST. METHODS: An anonymous 10-question online survey was distributed via email to 34 emergency radiologists around the world. The survey was open for a 2-week period in 2019. A commercially available website (SurveyMonkey®) was used for survey generation and data acquisition. RESULTS: We received 29 responses (85% response rate) primarily from USA, Canada, and Europe. Majority of the institutions handled > 1000 trauma cases (69%). The initial protocol consisted of arterial and portal venous phases (PVP) in 72% of responses. Sixty-two percent of the institutions did not have a routine protocol for follow-up imaging of BST. There was no consensus on which patients received follow-up imaging. The most frequent responses had been case-per-case basis or injuries above a set AAST grade (42% and 37%, respectively). There was no set time period for follow-up imaging, but MDCT was most often performed at 24-48 h. Dual-phase protocol was utilized most commonly (69%). Majority of the institutions (88%) utilized angioembolization for hemodynamically stable patients with contained vascular injury or active extravasation. CONCLUSION: There is no consensus on the optimal patient population or time period for follow-up imaging of BST. A dual-phase follow-up MDCT protocol is utilized for follow-up by majority of institutions.

Planar Asymmetries in the C. elegans Embryo Emerge by Differential Retention of aPARs at Cell-Cell Contacts.

Formation of the anteroposterior and dorsoventral body axis in Caenorhabditis elegans depends on cortical flows and advection of polarity determinants. The role of this patterning mechanism in tissue polarization after formation of cell-cell contacts is not fully understood. Here, we demonstrate that planar asymmetries are established during left-right symmetry breaking: Centripetal cortical flows asymmetrically and differentially advect anterior polarity determinants (aPARs) from contacts to the medial cortex, resulting in their unmixing from apical myosin. Contact localization and advection of PAR-6 requires balanced CDC-42 activation, while asymmetric retention and advection of PAR-3 can occur independently of PAR-6. Concurrent asymmetric retention of PAR-3, E-cadherin/HMR-1 and opposing retention of antagonistic CDC-42 and Wnt pathway components leads to planar asymmetries. The most obvious mark of planar asymmetry, retention of PAR-3 at a single cell-cell contact, is required for proper cytokinetic cell intercalation. Hence, our data uncover how planar polarity is established in a system without the canonical planar cell polarity pathway through planar asymmetric retention of aPARs.

Mechanical stress induces a scalable switch in cortical flow polarization during cytokinesis.

During animal development, cells need to sense and adapt to mechanical forces from their environment. Ultimately, these forces are transduced through the actomyosin cortex. How the cortex simultaneously responds to and creates forces during cytokinesis is not well understood. Here we show that, under mechanical stress, cortical actomyosin flow can switch polarization during cytokinesis in the C. elegans embryo. In unstressed embryos, longitudinal cortical flow contributes to contractile ring formation, while rotational cortical flow is additionally induced in uniaxially loaded embryos, i.e. embryos compressed between two plates. Rotational flow depends on astral microtubule signals and is required for the redistribution of the actomyosin cortex in loaded embryos. Rupture of longitudinally aligned cortical fibers during cortex rotation releases tension, initiates orthogonal longitudinal flow and, thereby, contributes to furrowing in loaded embryos. Moreover, actomyosin regulators involved in RhoA regulation, cortical polarity and chirality are all required for rotational flow, and become essential for cytokinesis under mechanical stress. In sum, our findings extend the current framework of mechanical stress response during cell division and show scaling of orthogonal cortical flows to the amount of mechanical stress.

Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review.

PURPOSE: Percutaneous tissue biopsy is a mainstay of diagnostic and interventional radiology, providing a minimally invasive method for diagnosing malignant and benign disease. The purpose of this review was to collect and summarize the best available evidence regarding the risk factors associated with bleeding complications in image-guided liver biopsy. METHODS: A literature review was performed, searching Medline, EMBASE, CINAHL, the Cochrane Library, the National Institute for Health and Care Excellence (NICE) and Canadian Agency for Drugs and Technology in Health (CADTH) databases for any studies evaluating bleeding complications in image-guided liver biopsy. A total of 68 articles, published between January 1994 and April 2015, were reviewed in full, with 34 ultimately eligible for inclusion in the review. RESULTS: Bleeding of any kind occurred in up to 10.9% of image-guided liver biopsies, with major bleeding episodes ranging from 0.1% to 4.6% and minor bleeding events occurring in up to 10.9% of biopsies. The overall rate of bleeding was, however, found to be less than 2%. Several risk factors (patient, operator, and procedure-related) were identified as potentially indicative of an increased risk of post-biopsy bleeding. Patient-related risk factors included patient age (>50 years or <2 years), inpatient status (8/12 vs. 4/12, P < 0.001), comorbidities and/or concurrent diagnoses and coagulation status (rate of bleeding was 3.3% for international normalized ratio [INR] 1.2-1.5 vs. 7.1% for INR >1.5, P < 0.001). There was no consensus on impact of operator experience (>200 biopsies/year vs. <50/year) on post-biopsy bleeding rate. Procedure-related risk factors included needle size (cutting biopsy vs. fine needle aspiration, P < 0.001) and the presence of a patent track on post-biopsy ultrasound (P < 0.001). Lastly there was no difference found between targeted vs. nontargeted biopsies and number of needle passes. CONCLUSION: Reported rate of post-biopsy bleeding ranges between 0% and 10.9%, although the vast majority of studies reported bleeding rates under 2%. Several patient, operator, and procedure-related risk factors are associated with a higher risk of bleeding following liver biopsy.

Enhanced pneumothorax visualization in ICU patients using portable chest radiography.

OBJECTIVE: Pneumothorax development can cause precipitous deterioration in ICU patients, therefore quick and accurate detection is vital. Portable chest radiography is commonly performed to exclude pneumothoraces but is hampered by supine patient position and overlying internal and external material. Also, the initial evaluation of the chest radiograph may be performed by a relatively inexperienced physician. Therefore, a tool that could significantly improve pneumothorax detection on portable radiography would be helpful in patient care. The aim of this study was to evaluate the clinical utility of novel enhancement software for pneumothorax detection in readers with varied clinical experience of detecting/excluding pneumothoraces on portable chest radiographs in ICU patients. SUBJECTS AND METHODS: 206 portable ICU chest radiographs, 103 with pneumothoraces, were processed with and without enhancement software and reviewed by 5 readers who varied in reading experience. Images were grouped for different complexity levels. RESULTS: The mean AUC for pneumothorax detection increased for 4/5 readers from 0.846-0.957 to 0.88-0.971 with a largest improvement for the reader with least experience. No significant change was noted for the reader with the longest reading experience. The image complexity had no impact on the interpretation result. CONCLUSION: Pneumothorax detection improves with novel enhancement software; the largest improvement is seen in less experienced readers.

Acute heat shock leads to cortical domain internalization and polarity loss in the C. elegans embryo.

Many developmental processes are inherently robust due to network organization of the participating factors and functional redundancy. The heterogeneity of the factors involved and their connectivity puts these processes at risk of abrupt system collapse under stress. The polarization of the one-cell C. elegans embryo constitutes such an inherently robust process with functional redundancy. However, how polarization is affected by acute stress has not been thoroughly investigated. Here, we report that heat shock (34°C, 1 h) triggers a highly reproducible loss of the anterior and collapse of the posterior polarity domains. Temperature-dependent loss of cortical non-muscle myosin II drastically reduces cortical tension and leads to internalization of large plasma membrane domains including the membrane-associated polarity factor PAR-2. After internalization, plasma membrane vesicles and associated factors cluster around centrosomes and are thereby withdrawn from the polarization process. Transient formation of the posterior polarity domain suggests that microtubule-induced self-organization of this domain is not compromised after heat shock. Hence, our data uncover that the polarization system undergoes a temperature-dependent collapse under acute stress.

Autophagy and modular restructuring of metabolism control germline tumor differentiation and proliferation in C. elegans.

Autophagy can act either as a tumor suppressor or as a survival mechanism for established tumors. To understand how autophagy plays this dual role in cancer, in vivo models are required. By using a highly heterogeneous C. elegans germline tumor, we show that autophagy-related proteins are expressed in a specific subset of tumor cells, neurons. Inhibition of autophagy impairs neuronal differentiation and increases tumor cell number, resulting in a shorter life span of animals with tumors, while induction of autophagy extends their life span by impairing tumor proliferation. Fasting of animals with fully developed tumors leads to a doubling of their life span, which depends on modular changes in transcription including switches in transcription factor networks and mitochondrial metabolism. Hence, our results suggest that metabolic restructuring, cell-type specific regulation of autophagy and neuronal differentiation constitute central pathways preventing growth of heterogeneous tumors.

Tracking and Quantifying Developmental Processes in C. elegans Using Open-source Tools.

Quantitatively capturing developmental processes is crucial to derive mechanistic models and key to identify and describe mutant phenotypes. Here protocols are presented for preparing embryos and adult C. elegans animals for short- and long-term time-lapse microscopy and methods for tracking and quantification of developmental processes. The methods presented are all based on C. elegans strains available from the Caenorhabditis Genetics Center and on open-source software that can be easily implemented in any laboratory independently of the microscopy system used. A reconstruction of a 3D cell-shape model using the modelling software IMOD, manual tracking of fluorescently-labeled subcellular structures using the multi-purpose image analysis program Endrov, and an analysis of cortical contractile flow using PIVlab (Time-Resolved Digital Particle Image Velocimetry Tool for MATLAB) are shown. It is discussed how these methods can also be deployed to quantitatively capture other developmental processes in different models, e.g., cell tracking and lineage tracing, tracking of vesicle flow.

Hybrid iterative reconstruction technique for abdominal CT protocols in obese patients: assessment of image quality, radiation dose, and low-contrast detectability in a phantom.

OBJECTIVE: The purpose of this study was to assess the impact of a noise reduction technique on image quality, radiation dose, and low-contrast detectability in abdominal CT for obese patients. MATERIALS AND METHODS: A liver phantom with 12 different tumors was designed, and fat rings were added to mimic intermediately sized and large patients. The intermediate and large phantoms were scanned with our standard abdominal CT protocol (image noise level of 15 HU and filtered back projection [FBP]). The large phantom was scanned with five different noise levels (10, 12.5, 15, 17.5, and 20 HU). All datasets for the large phantom were reconstructed with FBP and the noise reduction technique. The image noise and the contrast-to-noise ratio (CNR) were assessed. Tumor detection was independently performed by three radiologists in a blinded fashion. RESULTS: The application of the noise reduction method to the large phantom decreased the measured image noise (range, -14.5% to -37.0%) and increased the CNR (range, 26.7-70.6%) compared with FBP at the same noise level (p < 0.001). However, noise reduction was unable to improve the sensitivity for tumor detection in the large phantom compared with FBP at the same noise level (p > 0.05). Applying a noise level of 15 HU, the overall sensitivity for tumor detection in the intermediate and large phantoms with FBP measured 75.5% and 87.7% and the radiation doses measured 42.0 and 23.7 mGy, respectively. CONCLUSION: Although noise reduction significantly improved the quantitative image quality in simulated large patients undergoing abdominal CT compared with FBP, no improvement was observed for low-contrast detectability.