Repeat Laparoscopic Cholecystectomy for Duplicated Gallbladder After 16-Year Interval.

Background: Gallbladder duplication can present a diagnostic challenge, particularly in patients who have had prior cholecystectomy with a missed duplicated gallbladder. Case Presentation: Presented is the case of a man with 16 years of recurrent, persistent right upper quadrant pain after cholecystectomy who was found to have a duplicated gallbladder. Conclusions: Gallbladder duplication can be difficult to diagnose and frequently evades preoperative visualization. In particular, patients who have had prior operations or infections that may lead to epigastric adhesions are at higher risk for a missed gallbladder duplication at time of operation. An intraoperative cholangiogram should be routinely performed when the inferior liver margin is poorly visualized due to scarring or patient habitus. Gallbladder anomalies should be considered in the differential preoperatively for all patients undergoing hepatobiliary procedures and for postoperative patients with persistent biliary symptoms.

The Reliability of a Standardized Reporting System for the Diagnosis of Appendicitis.

PURPOSE: Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis. METHODS: Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated. RESULTS: There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively). CONCLUSIONS: Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate.

Imaging in Lung Transplantation: Surgical Considerations of Donor and Recipient.

Modifications in recipient and donor criteria and innovations in donor management hold promise for increasing rates of lung transplantation, yet availability of donors remains a limiting resource. Imaging is critical in the work-up of donor and recipient including identification of conditions that may portend to poor posttransplant outcomes or necessitate modifications in surgical technique. This article describes the radiologic principles that guide selection of patients and surgical procedures in lung transplantation.

CT of Atypical and Uncommon Presentations of Hepatocellular Carcinoma.

OBJECTIVE: The purpose of this article is to familiarize radiologists with uncommon presentations of hepatocellular carcinoma (HCC) with an emphasis on the CT spectrum of atypical appearances. CONCLUSION: HCC is the fifth most common neoplasm worldwide and the second most common cause of cancer-related death. In many cases, HCC can be confidently diagnosed with noninvasive imaging. However, there are numerous unusual appearances of HCC with which the radiologist must be familiar.

A novel reporting system to improve accuracy in appendicitis imaging.

OBJECTIVE: The purpose of this study was to ascertain if standardized radiologic reporting for appendicitis imaging increases diagnostic accuracy. MATERIALS AND METHODS: We developed a standardized appendicitis reporting system that includes objective imaging findings common in appendicitis and a certainty score ranging from 1 (definitely not appendicitis) through 5 (definitely appendicitis). Four radiologists retrospectively reviewed the preoperative CT scans of 96 appendectomy patients using our reporting system. The presence of appendicitis-specific imaging findings and certainty scores were compared with final pathology. These comparisons were summarized using odds ratios (ORs) and the AUC. RESULTS: The appendix was visualized on CT in 89 patients, of whom 71 (80%) had pathologically proven appendicitis. Imaging findings associated with appendicitis included appendiceal diameter (odds ratio [OR] = 14 [> 10 vs < 6 mm]; p = 0.002), periappendiceal fat stranding (OR = 8.9; p < 0.001), and appendiceal mucosal hyperenhancement (OR = 8.7; p < 0.001). Of 35 patients whose initial clinical findings were reported as indeterminate, 28 (80%) had appendicitis. In this initially indeterminate group, using the standardized reporting system, radiologists assigned higher certainty scores (4 or 5) in 21 of the 28 patients with appendicitis (75%) and lower scores (1 or 2) in five of the seven patients without appendicitis (71%) (AUC = 0.90; p = 0.001). CONCLUSION: Standardized reporting and grading of objective imaging findings correlated well with postoperative pathology and may decrease the number of CT findings reported as indeterminate for appendicitis. Prospective evaluation of this reporting system on a cohort of patients with clinically suspected appendicitis is currently under way.

Multimodality imaging of pancreatic arteriovenous malformation.

Arteriovenous malformation of the pancreas (PAVM) is a very rare entity, although it may be increasingly diagnosed with the expanding use of cross-sectional imaging of the abdomen. PAVM is characterized by a network of tangled vasculature within and surrounding all or part of the pancreas, resulting in the shunting of the arteries of the pancreas directly into the portal venous system. Here, we present a patient with chronic abdominal pain and pancreatitis found to have PAVM, based on the findings of computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, and angiography. Differential considerations are discussed. Although PAVM is uncommon, it should be considered in the differential of patients with recurrent abdominal pain or gastrointestinal bleeding.

Post-traumatic internal mammary artery pseudoaneurysm: A rare complication of pericardiocentesis.

Before the advent of ultrasound, percutaneous pericardiocentesis was associated with relatively high mortality and complication rates (6% and 20-50%, respectively) [1-3]. Ultrasound (US)-guided pericardiocentesis has dramatically decreased the incidence of complications by direct visualization of the heart and other adjacent vital structures. US helps localize the size and location of the pericardial effusion, measure the distance from the chest wall, localize adjacent, vital organs, and determine the optimal access site to the effusion. We report a case of posttraumatic internal mammary artery pseudoaneurysm, a rare complication of pericardiocentesis.

Selective non-operative management of a left ventricular pseudoaneurysm after penetrating cardiac wound.

Post-traumatic cardiac pseudoaneurysm (PSA) is a rare, potentially life-threatening complication after penetrating cardiac injury. Early surgical intervention has been the treatment of choice for this sequela due to the risk of rupture. Nevertheless, selective non-operative management (SNOM) has been practiced in patients with postinfarct PSA that are small and stable. We report a case of a post-traumatic cardiac PSA subjected to SNOM.

Identifying, characterizing, and classifying congenital anomalies of the coronary arteries.

The clinical manifestations of coronary artery anomalies vary in severity, with some anomalies causing severe symptoms and cardiovascular sequelae and others being benign. Cardiovascular computed tomography (CT) has emerged as the standard of reference for identification and characterization of coronary artery anomalies. Therefore, it is important for the reader of cardiovascular CT images to be thoroughly familiar with the spectrum of coronary artery anomalies. Hemodynamically significant anomalies include atresia, origin from the pulmonary artery, interarterial course, and congenital fistula. Non-hemodynamically significant anomalies include duplication; high origin; a prepulmonic, transseptal, or retroaortic course; shepherd's crook right coronary artery; and systemic termination. In general, coronary arteries with an interarterial course are associated with an increased risk of sudden cardiac death. Coronary artery anomalies that result in shunting, including congenital fistula and origin from the pulmonary artery, are also commonly symptomatic and may cause steal of blood from the myocardium. Radiologists should be familiar with each specific variant and its specific constellation of potential implications.

Incidental myocardial infarct on conventional nongated CT: a review of the spectrum of findings with gated CT and cardiac MRI correlation.

OBJECTIVE: Myocardial infarctions (MIs) are frequently evident on routine chest or abdominal CT, even when studies are not performed for cardiac-specific indications. However, the telltale signs of an MI may be easily overlooked. Herein, we present the spectrum of appearances of MIs, including areas of fat attenuation, myocardial calcifications, focal areas of wall thinning or aneurysm formation, and perfusion abnormalities. Thrombi, especially when present at the apex of the left ventricle, may also suggest an MI. CONCLUSION: The increased use of CT in the evaluation of patients for a variety of indications gives the radiologist the unique opportunity to recognize findings consistent with MI in patients who may not have a prior diagnosis of ischemic heart disease.

Chemical shift artifact on steady-state free precession cardiac magnetic resonance sequences as a result of lipomatous metaplasia: a novel finding in chronic myocardial infarctions.

BACKGROUND: Because balanced steady-state free precession (SSFP) sequences are opposed-phase gradient echo techniques, linear low signal due to chemical shift artefact is observed at fat-water interfaces. We observed that some patients with chronic myocardial infarctions had linear low signal along the inner myocardial wall in areas of infarction, which we postulated was due to chemical shift artefact, as a result of lipomatous metaplasia. The purpose of this retrospective review was to evaluate whether subendocardial low signal on SSFP, likely related to chemical shift artifact, could be used to identify chronic myocardial infarctions. METHODS: Of 128 patients who underwent cardiac magnetic resonance, 79 with myocardial infarctions were included in this retrospective study. RESULTS: Of the 79 patients, 35 (44%) demonstrated areas of linear subendocardial decreased signal. In 16 of those 35 (46%), the infarcts were confirmed as fatty by correlation with CT. In 29 of 35 (83%) of these patients, the infarcts were likely chronic based on fixed wall thinning to less than 4 mm. In 3 patients, chemical shift artifact due to lipomatous metaplasia was also confirmed with conventional in-phase and opposed-phase T1-weighted sequences. Subendocardial chemical shift artefacts were not seen in any of the 19 patients with known, acute infarcts included in this series. Aneurysms were more common when subendocardial chemical shift artefact was present (22 of 35), in comparison to patients who did not have this finding (10 of 44, P = 0.02). CONCLUSIONS: Identification of linear subendocardial chemical shift artefacts on SSFP sequences is a sign of lipomatous metaplasia in chronic myocardial infarcts and is associated with an increased incidence of ventricular aneurysms.

Classic images: coronary computed tomographic angiography.

A number of congenital and acquired conditions may affect the coronary arteries, ranging from very common entities, such as atherosclerotic disease, to very rare coronary anomalies. Some of the conditions that affect the coronary arteries are unique in the body. As a result, readers of cardiac computed tomography are faced with several unique challenges in classifying and stratifying a wide array of diseases. Herein, we discuss some of the technical aspects of coronary computed tomographic angiography and review the spectrum of coronary abnormalities that may be detected with this modality. The typical imaging findings of common and uncommon coronary disease states will be demonstrated.

Does coronary calcium score predict future cardiac function? Association of subclinical atherosclerosis with left ventricular systolic and diastolic dysfunction at MR imaging in an elderly cohort.

PURPOSE: To evaluate subclinical atherosclerosis measured by using coronary artery calcium (CAC) as a predictor of future left ventricular (LV) systolic and diastolic function in asymptomatic elderly participants. MATERIALS AND METHODS: The institutional review boards of the University of Southern California and the Harbor University of California Los Angeles Research and Education Institute (where the South Bay Heart Watch study was initially conducted) approved this HIPAA-compliant study of 386 participants (mean age, 75.2 years) from among the original 1461 participants in the longitudinal South Bay Heart Watch prospective investigation of subclinical atherosclerosis. CAC at computed tomography was correlated with LV ejection fraction (LVEF), regional wall motion abnormalities (RWMAs), and peak filling rate (PFR) assessed a mean of 11.4 years ± 0.6 (standard deviation) later with cardiac magnetic resonance imaging. Analysis of variance and covariance testing was performed with the Wald test, testing for trends across the CAC groups. Covariates included age, level of total cholesterol, level of high-density lipoprotein cholesterol, systolic blood pressure, use of lipid-lowering medication, and smoking status. RESULTS: Mean LVEF was 60.3% ± 9.9, with 11 (2.8%) of 386 participants having an LVEF of less than 40%. Forty-six (11.9%) of 386 participants had RWMAs. Higher CAC scores were associated with slightly lower LVEF (P for trend = .04) and a greater percentage of participants with decreased PFR (P for trend = .47) and RWMAs (P for trend = .01). After age- and risk factor-adjustment, only RWMA (P = .05) was associated with higher CAC. RWMAs were associated with significantly (P < .001) lower mean LVEF and PFR. Nineteen (41%) of 46 participants with RWMAs had documented Q-wave myocardial infarction, and three (7%) underwent coronary revascularization. CAC scores of 100 or greater were associated with a 2.2-fold (95% confidence interval: 1.30, 3.75) increase in RWMA (P < .001). CONCLUSION: Subclinical atherosclerosis assessed by using CAC is associated with an increased future likelihood of RWMA, as a marker of previous and possible subclinical coronary artery disease.

Calcific constrictive pericarditis demonstrated on 99mTc-MDP bone scintigraphy.

The authors present a case of calcific constrictive pericarditis, imaged with bone scintigraphy. The patient presented with three months of shortness of breath, chest pain, and chest tightness during exercise, among other nonspecific symptoms. Although the diagnosis was made based on chest radiography and cardiac MRI, bone scintigraphy was used to corroborate the diagnosis of calcific constrictive pericarditis. Bone scintigraphy showed a pattern of tracer accumulation consistent with pericardial uptake. Calcific constrictive pericarditis was also confirmed at the time of surgery.

Rare chronic gastric volvulus associated with left atrial and mediastinal compression.

We report a case of chronic gastric volvulus associated with left atrial compression in a 75-year-old woman who presented with chest pain, shortness of breath, and hypotension after elective hemiarthroplasty of the left hip. The patient's medical history included a paraesophageal hernia and gastric volvulus diagnosed in 1997 but left untreated. The present diagnosis of gastric volvulus was made on the basis of a chest radiograph and subsequent computed tomography. Echocardiography showed the volvulus compressing the left atrium. Surgery to repair the defect was successful, and there were no operative or postoperative complications. A review of the world medical literature revealed that gastric volvulus is rarely reported to cause hemodynamic compromise or compression of the heart and mediastinal structures.