Imaging of Antepartum and Postpartum Hemorrhage.

Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.

Implementation of Medical Students as Radiology Reading Room Coordinators.

OBJECTIVE: Effort has been made to minimize the burden of non-interpretive tasks (NITs), in particular by hiring and training non-radiologist support staff as reading room coordinators (RRCs). Our medical center recruited and trained senior medical students from our affiliated school of medicine to work alongside on-call radiology residents as RRCs. METHODS: A 12-month Malpractice Carrier monetary grant was acquired to fund medical students at with the aim to reduce malpractice risk. After the first year, residents were surveyed regarding the impact of the RRCs on perceived on-call efficiency and morale. Furthermore, report turnaround times (TAT) on call shifts that were and were not accompanied by a RRC were compared. RESULTS: 89 % of residents strongly agreed that the RRC improved workflow efficiency, decreased distractions, and felt less stressed during the call shift when the RRC was on duty. 78 % strongly agreed to be more likely to contact a referring clinician when the RRC was able to help coordinate. The mean TAT in the presence of a RRC was 36.8 min, and the mean TAT in the absence of a RRC was 36.9 min DISCUSSION: After hiring medical students to assist on-call radiology residents with noninterpretive tasks, residents reported subjective indicators of program success, but average report turnaround time was unaffected. Nevertheless, we predict that this type of program will continue to grow among academic radiology departments, though additional research is required to evaluate national trends and impacts on radiologist productivity and well-being.

Benign and Malignant Ovarian Teratomas: Multimodality Imaging Findings With Histopathologic Correlation.

ABSTRACT: The purpose of this article is to provide a comprehensive review of the imaging findings along with histopathologic correlation of mature (benign) teratomas and malignant ovarian teratomas, which include both immature teratomas and malignant degeneration of mature teratomas. The radiologist's ability to provide an accurate diagnosis plays an essential role in guiding the interdisciplinary care of patients with malignant teratomas and improving their outcomes.

Cancer in pregnancy: treatment effects.

PURPOSE: Pregnant patients present a unique challenge to cancer therapy. Due to the potential catastrophic implications related to teratogenic effects or pregnancy loss, oncologic management of this vulnerable patient group must be strategic and personalized. METHODS: This article will discuss the unique treatment approach to the pregnant cancer patient. This includes discussion of the role of imaging during staging, treatment, and follow-up with an emphasis on avoiding ionizing radiation when possible. RESULTS AND CONCLUSION: Specific considerations and modifications to standard cancer treatments, including surgery and systemic therapies such as chemotherapy, immunotherapy, targeted and hormone therapies are crucial components of providing oncologic care to minimize negative effects to the mother and developing fetus. Radiation and proton therapy are also options that may be employed in specific circumstances. Finally, this article will address the long-term treatment effects of these therapies on future fertility.

Prognosis, counseling, and indications for termination of pregnancy.

As the coincidence of pregnancy and cancer rise, clinicians must be prepared to counsel their patients on the complex relationship between maternal and fetal health. In most types of cancer, maternal prognosis mirrors that of non-pregnant women. However, challenges associated with the timing of diagnosis and treatment can present additional risks. Consequently, pregnant cancer patients must be counseled early and effectively with regard to how their pregnancy status affects treatment options and the range of expected outcomes for both mother and fetus. Some patients choose to terminate pregnancy after such counseling, though the specific course of action depends on the cancer in question, the stage at diagnosis, and the personal priorities and values of the patient.

Radiological and pathological assessment with EOB-MRI after Y90 radiation lobectomy prior to liver resection for hepatocellular carcinoma.

BACKGROUND: Radiation lobectomy (RL) utilizes Yttrium-90 (Y90) radioembolization for achieving tumor control and inducing contralateral lobe hypertrophy. Our objective was to evaluate the chronological changes occurring radiologically and histopathologically after Y90 RL. METHODS: We retrospectively reviewed 22 patients with chronic liver disease who underwent Y90 RL prior to planned liver resection for hepatocellular carcinoma. Gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA) enhanced magnetic resonance imaging (EOB-MRI) was performed every 3 months. RESULTS: Future liver remnant volume (FLRV) significantly increased up to 9 months after Y90 RL. Gd-EOB-DTPA uptake in the treated lobe experienced a 40% reduction in enhancement ratio (ER) during ensuing first 3 months, and never recovered. The reduced ER in the non-tumoral parenchyma was significantly correlated with increased FLRV and FLR (r = 0.41 and r = 0.35, respectively; both p < 0.01). Histopathological evaluation of non-tumor liver tissue found features of sinusoidal obstruction syndrome as an early change after Y90 RL (median 5.7 months) and parenchymal collapse as a late change (mean 11 months). DISCUSSION: The reduced uptake of Gd-EOB-DTPA at 3 months post Y90 RL correlates with a significant increase in FLRV prior to liver resection. EOB-MRI evaluation at 3 months can guide future plan of action after Y90 RL.

Imaging Evaluation of Living Liver Donor Candidates: Techniques, Protocols, and Anatomy.

The need for liver transplants is increasing because the prevalence of liver diseases and the indications for transplants are growing. In response to the shortage of grafts from deceased donors, more transplants are being performed worldwide with grafts from living donors. Radiologic evaluation is an integral component in the assessment of donor candidates to ensure their eligibility and to choose the most appropriate surgical approach. MRI is the preferred modality for evaluation of the liver parenchyma and biliary tree. In most centers, a combination of MRI and CT is used to take advantage of the higher spatial resolution of CT for evaluation of arteries. However, MRI-only assessment is feasible. In addition to assessment of the liver parenchyma for abnormalities such as steatosis, a detailed evaluation of the hepatic vascular and biliary system for pertinent anatomic variants is crucial, because these variants can affect surgical techniques and outcomes in both recipients and donors. In this pictorial article, after a brief review of the most common surgical techniques and postsurgical liver anatomy, the biliary and vascular anatomy are discussed, with specific attention paid to the variants that are pertinent to this surgical procedure. The roles of liver segmentation and volumetric assessment and current imaging techniques and protocols are also discussed. Online supplemental material is available for this article. ©RSNA, 2021.

Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons.

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

Assessing locoregional treatment response to Hepatocellular Carcinoma: comparison of hepatobiliary contrast agents to extracellular contrast agents.

Cross-sectional imaging with contrast-enhanced magnetic resonance imaging (MRI) is routinely performed in patients with hepatocellular carcinoma (HCC) to assess tumor response to locoregional therapy (LRT). Current response assessment algorithms, such as the Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA), allow assessment using conventional gadolinium-based extracellular contrast agents (ECA) for accurate tumor response assessment following LRT. MRI with hepatobiliary agents (HBA) allows an acquisition of hepatobiliary phase (HBP), which is proven to increase sensitivity for detection of observations in at-risk patients, particularly for findings < 2 cm. The use of HBA is not yet incorporated into the TRA; however, it is increasingly used in clinical practice. Few published studies have evaluated the performance of LI-RADS TRA by applying ancillary features related to HBP that has resulted in category adjustment, enabling more sensitive and unequivocal diagnosis. This may help timely management of viable cases, without a significant loss of specificity in comparison with the ECA-based LI-RADS TRA assessment. In this review, we will describe and compare the imaging appearance of treated HCC on MRI using extracellular and hepatobiliary contrast agents and discuss emerging evidence and pitfalls in the assessment of tumor response following LRT with HBA.

A comparative study of portal vein embolization versus radiation lobectomy with Yttrium-90 micropheres in preparation for liver resection for initially unresectable hepatocellular carcinoma.

BACKGROUND: Portal vein embolization before liver resection is considered the therapy of choice for patients with inadequate future liver remnants. The concept of radioembolization with Yttrium-90 to achieve the same goal has limited data. METHODS: We retrospectively compared patients who underwent portal vein embolization and Yttrium-90 lobectomy before resection of hepatocellular carcinoma in patients with chronic liver disease. RESULTS: Seventy-three patients underwent portal vein embolization and 22 patients underwent Yttrium-90. Forty-seven percent of patients before portal vein embolization required additional procedures for tumor control, and 27% of patients after Yttrium-90 required additional procedure to mainly induce further hypertrophy. Both therapies achieved the goal of future liver remnants >40%, but the degree of hypertrophy was significantly higher in Yttrium-90 patients (63% for Yttrium-90, 36% for portal vein embolization, P < .01). Tumor response was significantly better with Yttrium-90, achieving complete response in 50% of patients. Resectability rate was higher after portal vein embolization (85% for portal vein embolization, 64% for Yttrium-90, P = .03). Tumor progression was the most common reason precluding surgery. Complete tumor control was the reason not to pursue surgery in 18% of patients after Yttrium-90. CONCLUSION: Both preoperative portal vein embolization and Yttrium-90, increases liver resectability rates by inducing hypertrophy of future liver remnants in patients with hepatocellular carcinoma and chronic liver disease. Yttrium-90 lobectomy achieved better tumor control and provided more time to assess therapy response, optimizing the indication for surgery.

Hidradenocarcinoma: a rare but challenging diagnosis.

Hidradenocarcinoma is a rare, aggressive cancer arising from sweat glands. Hidradenocarcinoma has no definitive histologic features compared to its benign hidradenoma, thereby posing a diagnostic challenge for clinicians and pathologists. This novel case report demonstrates specific MRI signs that suggested malignant degeneration of hidradenoma.

MR defecography review.

Pelvic floor dysfunction is a relatively common but often complex condition, presenting with a variety of clinical symptoms, especially when it involves multiple compartments. Clinical exam alone is often inadequate and requires a complementary imaging study. Magnetic resonance defecography (MRD) is an excellent noninvasive diagnostic study with its multiplanar capability, lack of ionizing radiation and excellent soft tissue resolution. It can identify both anatomic and functional abnormalities in the pelvic floor and specifically excels in its ability to simultaneously detect multicompartmental pathology and help with vital pre-operative assessment. This manuscript reviews the relevant anatomical landmarks, describes the optimal technique, highlights an approach to the interpretation of MRD, and provides an overview of the various pelvic floor disorders in the different anatomical compartments.

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography.

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

MR defecography technique: recommendations of the society of abdominal radiology's disease-focused panel on pelvic floor imaging.

PURPOSE: To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR). METHODS: An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus. RESULTS: The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%. CONCLUSION: We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.

Peripheral arterial occlusion due to COVID-19: CT angiography findings of nine patients.

BACKGROUND: Reports have indicated an association of large vessel peripheral arterial occlusion in the setting of Coronavirus Disease 2019 (COVID-19). While prior investigations have mostly focused on venous or cerebral arterial occlusions, we examined patients presenting exclusively with peripheral arterial extremity occlusions to investigate for any predisposing factors in this subset of COVID-19 patients. MATERIALS AND METHODS: This is a retrospective study of COVID-19 patients with peripheral arterial occlusions presenting to a multi-hospital health care system in New York City between February 1st, 2020 and April 30th, 2020. Patient data and computed tomography angiography (CTA) exams in this subset were then collected and analyzed. RESULTS: For the months of February, March, and April 2020, we identified 9 patients (ages 37-93 yrs) at our health care system who underwent extremity CTA for large vessel upper or lower extremity arterial occlusion and were diagnosed with COVID-19. Patient medical histories and clinical parameters were evaluated to identify common risk factors including obesity, hypertension, hyperlipidemia, and diabetes. Patients presented with increased inflammatory markers including ferritin, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as well as increased D-dimer. CONCLUSION: Our findings suggest patients with COVID-19 and comorbidities presenting with elevated inflammatory markers and D-dimer may be at increased risk of large vessel peripheral arterial occlusion.

Angiogenesis in Hepatocellular Carcinoma; Pathophysiology, Targeted Therapy, and Role of Imaging.

Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide, usually occurring on a background of liver cirrhosis. HCC is a highly vascular tumor in which angiogenesis plays a major role in tumor growth and spread. Tumor-induced angiogenesis is usually related to a complex interplay between multiple factors and pathways, with vascular endothelial growth factor being a major player in angiogenesis. In the past decade, understanding of tumor-induced angiogenesis has led to the emergence of novel anti-angiogenic therapies, which act by reducing neo-angiogenesis, and improving patient survival. Currently, Sorafenib and Lenvatinib are being used as the first-line treatment for advanced unresectable HCC. However, a disadvantage of these agents is the presence of numerous side effects. A major challenge in the management of HCC patients being treated with anti-angiogenic therapy is effective monitoring of treatment response, which decides whether to continue treatment or to seek second-line treatment. Several criteria can be used to assess response to treatment, such as quantitative perfusion on cross-sectional imaging and novel/emerging MRI techniques, including a host of known and emerging biomarkers and radiogenomics. This review addresses the pathophysiology of angiogenesis in HCC, accurate imaging assessment of angiogenesis, monitoring effects of anti-angiogenic therapy to guide future treatment and assessing prognosis.