Embracing Remote Academic Radiologists.

Over the past two years at our large academic center, we successfully developed a formal remote academic radiologist division - composed of permanent fully remote radiologists across multiple subspecialties, living geographically distant from our institution. In this article, we share our experience implementing a remote radiologist division, review the benefits and challenges of this approach, discuss expectations of academic remote radiologists as clinicians, educators, and scholars, and provide tips for success.

Testing telediagnostic right upper quadrant abdominal ultrasound in Peru: A new horizon in expanding access to imaging in rural and underserved areas.

BACKGROUND: Hepatic and biliary diseases are prevalent worldwide, but the majority of people lack access to diagnostic medical imaging for their assessment. The liver and gallbladder are readily amenable to sonographic examination, and ultrasound is a portable, cost-effective imaging modality suitable for use in rural and underserved areas. However, the deployment of ultrasound in these settings is limited by the lack of experienced sonographers to perform the exam. In this study, we tested an asynchronous telediagnostic system for right upper quadrant abdominal ultrasound examination operated by individuals without prior ultrasound experience to facilitate deployment of ultrasound to rural and underserved areas. METHODS: The teleultrasound system utilized in this study employs volume sweep imaging and a telemedicine app installed on a tablet which connects to an ultrasound machine. Volume sweep imaging is an ultrasound technique in which an individual scans the target region utilizing preset ultrasound sweeps demarcated by easily recognized external body landmarks. The sweeps are saved as video clips for later interpretation by an experienced radiologist. Teleultrasound scans from a Peruvian clinic obtained by individuals without prior ultrasound experience were sent to the United States for remote interpretation and quality assessment. Standard of care comparison was made to a same-day ultrasound examination performed by a radiologist. RESULTS: Individuals without prior ultrasound experience scanned 144 subjects. Image quality was rated "poor" on 36.8% of exams, "acceptable" on 38.9% of exams, and "excellent" on 24.3% of exams. Among telemedicine exams of "acceptable" or "excellent" image quality (n = 91), greater than 80% of the liver and gallbladder were visualized in the majority of cases. In this group, there was 95% agreement between standard of care and teleultrasound on whether an exam was normal or abnormal, with a Cohen's kappa of 0.84 (95% CI 0.7-0.98, p <0.0001). Finally, among these teleultrasound exams of "acceptable" or "excellent" image quality, the sensitivity for cholelithiasis was 93% (95% CI 68.1%-99.8%), and the specificity was 97% (95% CI 89.5%-99.6%). CONCLUSION: This asynchronous telediagnostic system allows individuals without prior ultrasound experience to effectively scan the liver, gallbladder, and right kidney with a high degree of agreement with standard of care ultrasound. This system can be deployed to improve access to diagnostic imaging in low-resource areas.

New Ultrasound Telediagnostic System for Low-Resource Areas: Pilot Results From Peru.

Billions of people around the world lack access to diagnostic imaging. To address this issue, we piloted a comprehensive ultrasound telediagnostic system, which uses ultrasound volume sweep imaging (VSI) acquisitions capable of being performed by operators without prior traditional ultrasound training and new telemedicine software capable of sending imaging acquisitions asynchronously over low Internet bandwidth for remote interpretation. The telediagnostic system was tested with obstetric, right upper quadrant abdominal, and thyroid volume sweep imaging protocols in Peru. Scans obtained by operators without prior ultrasound experience were sent for remote interpretation by specialists using the telemedicine platform. Scans obtained allowed visualization of the target region in 96% of cases with diagnostic imaging quality. This telediagnostic system shows promise in improving health care disparities in the developing world.

Imaging of Abdominal Wall Masses, Masslike Lesions, and Diffuse Processes.

Abdominal wall masses, masslike lesions, and diffuse processes are common and often incidental findings at cross-sectional imaging. Distinguishing among these types of masses on the basis of imaging features alone can be challenging. The authors present a diagnostic algorithm that may help in distinguishing different types of abdominal wall masses accurately. Hernias may mimic discrete masses at clinical examination, and imaging is often ordered for evaluation of a possible abdominal wall mass. Once a discrete mass is confirmed to be present, the next step is to determine if it is a fat-containing, cystic, or solid mass. The most common fat-containing masses are lipomas. Fluid or cystic masses include postoperative abscesses, seromas, and rectus sheath hematomas. Solid masses are the most common abdominal wall masses and include desmoid tumors, sarcomas, endometriomas, and metastases. Multiple masses and other diffuse abdominal wall processes are often manifestations of an underlying condition or insult. The most frequently found diffuse processes are multiple injection granulomas from administration of subcutaneous medication. This article offers an algorithmic approach to characterizing abdominal wall masses on the basis of their composition and reviews abdominal wall diffuse processes. Online supplemental material is available for this article. ©RSNA, 2020.

Percutaneous Thrombin Injection for Treatment of a Hepatic Arterial Pseudoaneurysm after the Placement of a Transjugular Intrahepatic Portosystemic Shunt.

Transjugular intrahepatic portosystemic shunt (TIPS) is a widely accepted option for treating the complications of portal hypertension. The procedure involves creating a communication between the portal and hepatic venous systems using imaging guidance, thereby diverting the portal venous flow and reducing the portosystemic gradient. However, as with any procedure, TIPS insertion is not without potential complications. We present a case of a 37-year-old female who developed a hepatic artery pseudoaneurysm following the placement of a TIPS which was successfully treated with percutaneous thrombin injection.

Sonography of Acute Cholecystitis and Its Mimics.

Right upper quadrant (RUQ) abdominal pain is a common complaint. Acute cholecystitis (AC) is the primary diagnostic consideration in most adults presenting with acute onset RUQ abdominal pain; however, a variety of other conditions can mimic AC. Abdominal ultrasound (US) receives the highest score for imaging appropriateness for these patients. This article reviews the sonographic findings of uncomplicated and complicated AC and provides practical technical tips. The radiologist should be familiar with conditions that can mimic AC, be able to suggest these alternative diagnoses when findings are present on US, and recommend additional tests or procedures, if needed.

Attenuation of Shear Waves in Normal and Steatotic Livers.

Shear wave propagation in the liver has been a robust subject of research, with shear wave speed receiving the most attention. The correlation between increased shear wave speed and increased fibrosis in the liver has been established as a useful diagnostic tool. In comparison, the precise mechanisms of shear wave attenuation, and its relation to diseased states of the liver, are less well-established. This study focused on the hypothesis that steatosis adds a viscous (lossy) component to the liver, which increases shear wave attenuation. Twenty patients' livers were scanned with ultrasound and with induced shear wave propagation, and the resulting displacement profiles were analyzed using recently developed estimators to derive both the speed and attenuation of the shear waves within 6-cm2 regions of interest. The results were compared with pathology scores obtained from liver biopsies taken under ultrasound guidance. Across these cases, increases in shear wave attenuation were linked to increased steatosis score. This preliminary study supports the hypothesis and indicates the possible utility of the measurements for non-invasive and quantitative assessment of steatosis.

Magnetic resonance imaging of the placenta and gravid uterus: a pictorial essay.

The placenta is commonly overlooked on magnetic resonance imaging of the pregnant patient, which is frequently performed for alternative reasons such as to characterize fetal or uterine anomalies or to investigate the etiology of acute pelvic pain in pregnancy. Placental disorders have potential for significant maternal and fetal morbidity and peripartum complications if not recognized and treated in a timely manner. The radiologist must be familiar with normal placental variants and the spectrum of benign to life-threatening conditions affecting the placenta so that the Obstetrician can be promptly notified and patient management altered, if necessary. In this pictorial essay, we will describe our MR protocol for placental imaging, provide an image-rich review of the normal placenta, placental variants, and a variety of pathological conditions affecting the placenta and gravid uterus.

Direct Transversus Abdominis Plane Blocks With Exparel During Abdominoplasty.

BACKGROUND: Pain control following abdominoplasty is a major source of concern for the patient and surgeon alike. Pain pumps and opiate medications are currently the frontline therapies. With the following technique, Exparel (liposomal bupivacaine, 72-hour duration of action) has been used for transversus abdominis plane (TAP) blocks under direct visualization during abdominoplasty with the goal of improving pain control during the early and intermediate recovery period. MATERIALS AND METHODS: In this pilot study, 13 consecutive patients were treated with the direct, fascial-splitting technique to reach the TAP plane. Using a spinal needle, 20 mL of liposomal bupivacaine was injected deep to the internal oblique fascia bilaterally under direct vision. Primary and secondary endpoints of total opiate use and patient reported pain scores were assessed. RESULTS: All 13 patients met inclusion criteria as abdominoplasty patients with adequate follow-up data. The average visual analog scale pain score was 2.5 on postoperative day 1 and 1.7 on postoperative day 3. The average total opiate use (the number of 10 mg oxycodone tabs consumed) was 7.5 or 75 mg per patient. CONCLUSIONS: This pilot study demonstrates the safety and efficacy of liposomal bupivacaine TAP blocks under direct vision. Favorable pain control was demonstrated. This represents an exciting opportunity to decrease postoperative pain in the early and intermediate recovery period after abdominoplasty.

Ganglioglioma of the Spinal Cord.

Ganglioglioma is a rare tumor consisting of neoplastic glial and neuronal elements. It accounts for only 0.5% of all primary central nervous system (CNS) neoplasms. We report an unusual case of extensive intramedullary thoracic spinal cord ganglioglioma in a 14-month-old girl who underwent subtotal resection followed by adjuvant chemotherapy. The epidemiology, histopathologic features, imaging findings, treatment, and prognosis are subsequently reviewed.