Radiographic signs of hook of hamate fracture: evaluation of diagnostic utility.

OBJECTIVE: Hook of hamate fracture, the most common swing-related wrist fracture, is commonly seen in high-level athletes. The fracture is rarely diagnosed on routine wrist radiographs, thus generally requiring CT or MR for diagnosis. Surgical excision has a high success rate, however diagnostic delay contributes to a high complication rate. Radiographic signs of hook of hamate fracture have been published, but uncertainty of the diagnostic accuracy limits application. The purpose of this study is to determine accuracy and interobserver reliability of radiographic signs of hook of hamate. MATERIALS AND METHODS: This retrospective case-control study evaluated wrist radiographs of 50 patients, including 24 positive and 26 negative, for hook of hamate fracture, each proven by CT or MR. Five reviewers performed blinded, randomized evaluation of radiographs documenting whether the hook of hamate was normal or fractured, and if fractured, the radiographic signs present (ring sign, ghostly shadow, and diffuse sclerosis) and views that contributed to diagnosis. RESULTS: Radiographic signs demonstrated high sensitivity (85%; 95% CI: 77-91), specificity (92%; 95% CI: 86-96), and accuracy (89%; 95% CI: 84-92) with substantial interobserver reliability (k = 0.652). The ring sign was the most sensitive radiographic sign. Diagnosis was most often supported by the oblique view (38%) and rarely the lateral view (15%). CONCLUSIONS: Radiographic signs of hook of hamate fracture on routine radiographs can accurately and reliably diagnose hook of hamate fractures. Evaluation for discontinuity of the cortical ring will optimize sensitivity, allowing for timely diagnosis and treatment, and a reduction of complications.

The Utility of a Benign Biliary Stricture Protocol in Preventing Symptomatic Recurrence and Surgical Revision.

PURPOSE: To determine whether treating benign biliary strictures via a stricture protocol reduced the probability of developing symptomatic recurrence and requiring surgical revision compared to nonprotocol treatment. MATERIALS AND METHODS: A stricture protocol was designed to include serial upsizing of internal/external biliary drainage catheters to a target maximum dilation of 18-French, optional cholangioplasty at each upsizing, and maintenance of the largest catheter for at least 6 months. Patients were included in this retrospective analysis if they underwent biliary ductal dilation at a single institution from 2005 to 2016. Forty-two patients were included, 25 women and 17 men, with an average age of 51.9 years (standard deviation ± 14.6). Logistic regression models were used to determine the probability of symptomatic recurrence and surgical revision by stricture treatment type. RESULTS: Twenty-two patients received nonprotocol treatment, while 20 received treatment on a stricture protocol. After treatment, 7 (32%) patients in the nonprotocol group experienced clinical or laboratory recurrence of a benign stricture, whereas only 1 patient in the stricture protocol group experienced symptom recurrence. Patients in the protocol group were 8.9 times (95% confidence interval [CI] = 1.4-175.3) more likely to remain symptom free than patients in the nonprotocol group. Moreover, patients in the protocol group had an estimated 89% reduction in the probability of undergoing surgical revision compared to patients receiving nonprotocol treatment (odds ratio = .11, 95% CI = .01-.73). CONCLUSIONS: Establishing a stricture protocol may decrease the risk of stricture recurrence and the need for surgical revision when compared to a nonprotocol treatment approach.

Reducing radiation exposure with iterative reconstruction: an inter- and intra-scanner analysis.

Our purpose in this study was to compare delivered radiation exposure via computed tomography dose index volume (CTDIvol) and dose length production (DLP) measurements from computed tomography (CT) examinations performed on scanners with and without image-quality enhancing iterative reconstruction (IR) software. A retrospective analysis was conducted on randomly selected chest, abdomen, and/or pelvis CT examinations from three different scanners from 1 January 2013 to 31 December 2013. CTDIvol and DLP measurements were obtained from two CT scanners with and one CT scanner without IR software. To evaluate inter-scanner variability, we compared measurements from the same model CT scanners, one with and one without IR software. To evaluate intra-scanner variability, we compared measurements between two scanners with IR software from different manufacturers. CT scanners with IR software aided in the overall reduction in radiation exposure, measured as CTDIvol by 30% and DLP by 39% when compared to a scanner without IR. There was no significant difference in CTDlvol or DLP measurements across different manufacturers with IR software. As a result, IR software significantly decreased the radiation exposure to patients, but there were no differences in radiation measurements across CT manufacturers with IR software.

Comparing outcomes of right verse left hepatic approach percutaneous biliary drainage catheters.

Purpose: Determine if there is a difference in adverse events (AE) between right or left hepatic percutaneous biliary drain placement (PTBD) in patients with biliary strictures. Materials & methods: This retrospective study included patients with benign or malignant biliary stricture treated with PTBD at a single institution from 7/28/2004-3/30/2021. 357 patients met inclusion criteria, 77 (21.6 %) had PTBD on the left and 280 (78.4 %) on the right. AEs associated with the initial drain placement or during subsequent intervention were collected and categorized. AEs that were grouped as periprocedural included: surgery, infection, hemorrhage, and drain failure. AEs in the postprocedural group included: chills, catheter displacement, cholangitis, biliary stones, drain malfunction, fever resolving without treatment, and pericatheter leakage. Surgery was considered a major AE and the remaining AEs were categorized as minor. Statistical analyses were performed using Logistic Regression Analysis and p-values less than 0.05 were considered statistically significant. Results: Overall, there was no statistically significant difference in AEs between right and left drains in the periprocedural and postprocedural period (p = 0.832, OR = 0.95 and p = 0.808, OR = 0.93 respectively). When analyzing minor AEs individually, only cholangitis occurred at a higher rate on the right side (p = 0.033, OR = 0.43). There was no statistical difference in the rate of major AEs in the periprocedural period between left and right drains (p = 0.311, OR = 1.37). Conclusion: Current literature is equivocal when comparing right versus left percutaneous biliary drains. This analysis describes no statistically significant difference in AEs between right and left hepatobiliary drains aside from slightly higher incidence of cholangitis for right sided drains.

Re-expansion Pulmonary Edema (REPE) Following Thoracentesis: Is Large-Volume Thoracentesis Associated with Increased Incidence of REPE?

PURPOSE: To determine the safety and efficacy associated with drainage volumes greater than 1,500 mL in a single, unilateral thoracentesis without pleural manometry measurements. MATERIALS AND METHODS: This retrospective, single-institution study included 872 patients (18 years and older) who underwent ultrasound-guided thoracentesis. Patient and procedures data were collected including demographics, number of and laterality of thoracenteses, volume and consistency of fluid removed, and whether clinical or radiologic evidence of re-expansion pulmonary edema (REPE) developed within 24 h of thoracentesis. Fisher's exact test was used to test the significance of the relationship between volume of fluid removed and evidence of REPE. RESULTS: A total of 1376 thoracenteses were performed among the patients included in the study. The mean volume of fluid removed among all procedures was 901.1 mL (SD = 641.7 mL), with 194 (14.1%) procedures involving the removal of ≥ 1,500 mL of fluid. In total, six (0.7%) patients developed signs of REPE following thoracentesis, five of which were a first-time thoracentesis. No statistically significant difference in incidence of REPE was observed between those with ≥ 1,500 mL of fluid removed compared to those with < 1,500 mL of fluid removed (p-value = 0.599). CONCLUSIONS: Large-volume thoracentesis may safely improve patients' symptoms while preventing the need for repeat procedures.

Safety of non-cuffed tunneled central venous catheters in adults with cystic fibrosis.

BACKGROUND: Peripherally inserted central catheters (PICCs) are the most common route of intravenous (I.V.) access for treatment of cystic fibrosis (CF) pulmonary exacerbations, but repeated PICC placement can result in upper extremity peripheral venous stenosis. Once peripheral stenosis develops, a non-cuffed tunneled central venous catheter (NcTCVC) is an alternative route for IV access. While these are regularly used at some CF centers, the safety and complication rate compared to PICCs in adults with CF has not been reported. This study aims to describe the safety of NcTCVCs in adults with CF. METHODS: A retrospective cohort study was performed at a CF Foundation accredited institution including adults with CF who received NcTCVCs in interventional radiology from 7/19/2007 to 3/09/2020. Complications analyzed included catheter related deep venous thrombosis (DVT), central line associated blood stream infection (CLABSI), and catheter related central venous stenosis. Complications were considered attributable if they occurred while the catheter was in place or within 30 days of catheter removal. RESULTS: During the study duration, 386 NcTCVCs were placed in 60 unique patients (55 % female) with a mean of 6.4 catheters per patient. Majority of NcTCVCs placed were 4 French (61.4 %). Average duration of indwelling NcTCVC was 16.2 days. No patients demonstrated catheter attributable symptomatic DVT. The incidence of DVT, CLABSI, and central venous stenosis was 0 (0 %), 4 (1 %), and 1 (0.3 %), respectively. CONCLUSIONS: Many adults with CF have required insertion of numerous PICCs for the treatment of recurrent pulmonary exacerbations. In those adults that develop PICC-associated peripheral vein stenosis precluding PICC placement, these results indicate NcTCVCs are a safe alternative.

The Impact of Closed-Loop Imaging on Actionable CT-Detected Breast Findings.

PURPOSE: Closed-loop imaging programs (CLIPs) are designed to ensure that patients receive appropriate follow-up, but a review of incidental CT-detected breast findings in the setting of CLIPs has not been performed. METHODS: A retrospective review was conducted of CT reports at a single academic institution from July 1, 2020, to January 31, 2022, to identify reports with recommendations for breast imaging follow-up. Medical records were reviewed to evaluate patient adherence to follow-up, CLIP intervention, subsequent BI-RADS assessment, and diagnosis. Adherence was defined as diagnostic breast imaging performed within 6 months of the CT recommendation. RESULTS: Follow-up recommendations for breast imaging were included in CT report impressions for 311 patients. Almost half of patients (47.3% [147 of 311]) underwent follow-up breast imaging within 6 months, yielding breast cancer diagnoses in 12.9% (19 of 147) and a biopsy-proven positive predictive value of 65.5% (19 of 29). Most patients who returned for follow-up within 6 months did so without CLIP intervention. The majority of CT report impressions in the follow-up group (85.0% [125 of 147]) contained specific recommendations for "diagnostic breast imaging." For patients who did not receive follow-up, the CLIP team tracked all cases and intervened in 19.1% (28 of 147). The most common intervention was a phone call and/or fax to the primary care provider. Outpatient CT examination setting and specific recommendation for diagnostic breast imaging were significantly associated with higher follow-up adherence (P < .0001). CONCLUSIONS: Actionable CT-detected breast findings require follow-up diagnostic breast imaging because of a relevant cancer detection rate of 12.9%. Although many patients return for breast imaging without intervention, almost half of patients did not receive follow-up and may account for a significant number of missed cancer diagnoses. Specific CT recommendation verbiage is associated with higher follow-up adherence, which can be addressed across settings even without CLIPs.

Utilizing 3D printing to assist pre-procedure planning of transjugular intrahepatic portosystemic shunt (TIPS) procedures: a pilot study.

BACKGROUND: 3D (three-dimensional) printing has been adopted by the medical community in several ways, procedure planning being one example. This application of technology has been adopted by several subspecialties including interventional radiology, however the planning of transjugular intrahepatic portosystemic shunt (TIPS) placement has not yet been described. The impact of a 3D printed model on procedural measures such as procedure time, radiation exposure, intravascular contrast dosage, fluoroscopy time, and provider confidence has also not been reported. METHODS: This pilot study utilized a quasi-experimental design including patients who underwent TIPS. For the control group, retrospective data was collected on patients who received a TIPS prior to Oct 1, 2020. For the experimental group, patient-specific 3D printed models were integrated in the care of patients that received TIPS between Oct 1, 2020 and April 15, 2021. Data was collected on patient demographics and procedural measures. The interventionalists were surveyed on their confidence level and model usage following each procedure in the experimental group. RESULTS: 3D printed models were created for six TIPS. Procedure time (p = 0.93), fluoroscopy time (p = 0.26), and intravascular contrast dosage (p = 0.75) did not have significant difference between groups. Mean radiation exposure was 808.8 mGy in the group with a model compared to 1731.7 mGy without, however this was also not statistically significant (p = 0.09). Out of 11 survey responses from interventionists, 10 reported "increased" or "significantly increased" confidence after reviewing the 3D printed model and all responded that the models were a valuable tool for trainees. CONCLUSIONS: 3D printed models of patient anatomy can consistently be made using consumer-level, desktop 3D printing technology. This study was not adequately powered to measure the impact that including 3D printed models in the planning of TIPS procedures may have on procedural measures. The majority of interventionists reported that patient-specific models were valuable tools for teaching trainees and that confidence levels increased as a result of model inclusion in procedure planning.

Cerebrospinal Fluid Leaks: A Case Series of Sinus Opacification on Computed Tomography (CT) Imaging.

Introduction: Cerebrospinal fluid (CSF) leaks occur when fluid seeps through a dural or skull base defect, typically in the nose or ear. CSF leaks commonly are identified and diagnosed by use of computed tomography (CT) and CT cisternogram. CT findings suggestive of a CSF leak include a skull-based bone defect along with opacification of the contiguous sinus. This study examined a series of CSF leaks on CT imaging to document imaging findings. Methods: A single-institution retrospective review of cases of CSF leak diagnosed by CT maxillofacial or CT cisternogram from January 1, 2008 to March 12, 2018 was performed. Patient demographics, history, imaging findings, and treatment were recorded. Results: Thirty-nine patients met the inclusion criteria for the study. The average age was 51, and a large majority were female (76.9%). Among the 25 patients in which it was reported, the mean size of skull base defect was 0.472 cm. Of the 39 total cases, 27 patients (69.2%) presented with sinus opacification on CT imaging. Conclusions: Radiologists should be aware of the possibility of notable sinus opacification observable on CT when investigating a potential CSF leak. Opacification may vary in both location and size depending on the nature and location of a CSF leak. Further research is needed to draw a correlation between sinus opacification seen on CT scan and the diagnosed origin of a CSF leak.

Post-Biopsy Pneumothorax Incidence in Patients Treated with Biosentry™ Plug Device.

INTRODUCTION: This study aimed to determine if the Biosentry™ Plug Device (BPD), a prophylactic sealant used to prevent pneumothorax after lung biopsies, reduced post-lung biopsy pneumothorax rates, and other complications compared to no device utilization. METHODS: This single institution, retrospective cohort study included patients who received a lung biopsy in the Department of Interventional Radiology from May 1, 2015 to August 31, 2017. Data such as sex, race, ethnicity, chronic obstructive pulmonary disease status, degree of lung bullae if present, smoking status, and use of BPD were recorded. Decisions to use BPD were based on operator preference. A chi squared analysis was used with a p value greater than 0.05 considered significant. RESULTS: The study included 521 patients who underwent a lung biopsy during the study timeframe. Of these, 74 (14.2%) received the BPD, while 447 (85.8%) did not. One-hundred ninety (36.4%) had a pneumothorax within one month of the lung biopsy. Of the total 190 that experienced pneumothorax, 36.7% of non-BPD biopsies resulted in pneumothorax, while 35.1% of BPD biopsies resulted in pneumothorax (p value = 0.7970; degrees of freedom = 1). CONCLUSIONS: These findings indicated that BPD may not reduce pneumothorax incidence nor limit the severity of complications in patients.

Incidental Breast Cancer on Chest CT: Is the Radiology Report Enough?

OBJECTIVE: To determine the frequency of incidental breast findings reported on chest CT for which breast imaging follow-up is recommended, the follow-up adherence rate, and the breast malignancy rate. The relationship between strength of recommendation verbiage and follow-up was also explored. METHODS: A retrospective review was conducted of chest CT reports from July 1, 2018, to June 30, 2019, to identify those with recommendation for breast imaging follow-up. Patients with recently diagnosed or prior history of breast malignancy were excluded. Medical records were reviewed to evaluate patient adherence to follow-up, subsequent BI-RADS assessment, and diagnosis (if tissue sampling performed). Adherence was defined as diagnostic breast imaging performed within 6 months of CT recommendation. Chi-square and Mann-Whitney U tests were used to determine statistical significance of categorical and continuous variables, respectively. RESULTS: A follow-up recommendation for breast imaging was included in chest CT reports of 210 patients; 23% (48/210) returned for follow-up breast imaging. All patients assessed as BI-RADS 4 or 5 underwent image-guided biopsy. Incidental breast cancer was diagnosed in 15% (7/48) of patients who underwent follow-up breast imaging as a result of a CT report recommendation and 78% (7/9) of patients undergoing biopsy. There was no significant difference in follow-up adherence when comparing report verbiage strength. CONCLUSION: It is imperative that incidental breast findings detected on chest CT undergo follow-up breast imaging to establish accurate and timely diagnosis of breast malignancy. Outreach to referring providers and patients may have greater impact on the diagnosis of previously unsuspected breast cancer.

Inferior Glenohumeral Ligament (IGHL) Injuries: A Case Series of Magnetic Resonance (MR) Imaging Findings and Arthroscopic Correlation.

INTRODUCTION: The inferior glenohumeral ligament (IGHL) complex commonly is assessed by both magnetic resonance imaging (MRI) and magnetic resonance (MR) arthrogram. Our study compared the accuracy of MR arthrogram compared to MRI using arthroscopic correlation as the gold standard. METHODS: A retrospective review of cases reporting an IGHL injury was performed. Seventy-seven cases met inclusion criteria, while five had arthroscopic reports that directly confirmed or refuted the presence of IGHL injury. Two arthroscopic reports confirmed concordant IGHL injuries, while three arthroscopic reports mentioned discordant findings compared to MR. All three discordant cases involved MR arthrogram. Findings included soft tissue edema, fraying of the axillary pouch fibers, and cortical irregularity of the humeral neck. Of the two concordant cases, one was diagnosed by MRI, revealing an avulsion of the anterior band, while the second was diagnosed by MR arthrogram showing ill-defined anterior band fibers. Many cases involved rotator cuff or labral tears, which may have been the focus of care for providers, given their importance for shoulder stability. Additionally, a lack of diagnostic confidence in MR reports may have influenced surgeons in the degree to which they assessed the IGHL complex during arthroscopy. CONCLUSION: Radiologists seemed more likely to make note of IGHL injuries when MR arthrograms were performed; meanwhile, all three discordant cases involved MR arthrogram reads. Therefore, additional larger studies are needed with arthroscopic correlation to elucidate MR findings that confidently suggest injury to the IGHL complex, to avoid false positive radiology reports.

Lidocaine Versus Bupivacaine in the Treatment of Headache with Intranasal Sphenopalatine Nerve Block.

BACKGROUND: Intranasal sphenopalatine ganglion (SPG) block has been shown to be an effective treatment for headaches. Multiple therapeutic agents have been studied, although the wide availability and low cost of lidocaine and bupivacaine have made them attractive treatment options. To the authors knowledge, no study has yet demonstrated superiority of one anesthetic over the other. OBJECTIVE: To determine the efficacy of lidocaine versus bupivacaine when performing intranasal sphenopalatine ganglion (SPG) block for the treatment of headaches. STUDY DESIGN: Retrospective cohort study. SETTING: A single tertiary care academic institutionMETHODS: This retrospective study identified patients who underwent SPG block at a single institution from January 1, 2014 to December 20, 2017. Patients were included if they were treated with either lidocaine or bupivacaine and had both pre- and post-procedure pain scores recorded on a 0-10 scale. Patients were excluded if they were less than 18 years of age. RESULTS: 386 total procedures were performed. 303 (78.5%) were lidocaine delivered via the SphenoCath device, and 83 (21.5%) were bupivacaine delivered via the Tx360 device. 90.2% of treatments (n = 348) decreased the patient's pain level. Of the treatments performed with lidocaine, 89.1% (n = 270) resulted in improvement of the patient's pain level with a mean decrease in pain level of 3.1 (SD ± 2.3). Of the treatments performed with bupivacaine, 94.0% (n = 78) resulted in improvement of the patient's pain level, with a mean decrease in pain level of 3.0 (SD ± 1.9). No statistically significant difference was found between the 2 anesthetics. LIMITATIONS: The retrospective study design may introduce selection bias. Both lidocaine and bupivacaine were administered by different devices (Sphenocath and Tx360 respectively) which may account for differences in initial treatment success. There were differences in the size of the two groups, which may also introduce error. CONCLUSIONS: This study demonstrates similar efficacy of SPG block performed with lidocaine or bupivacaine. While no difference was found, the particular advantages and disadvantages of the intranasal delivery device may influence physician choice. KEY WORDS: Sphenopalatine ganglion nerve block, lidocaine, bupivacaine, sphenocath, Tx360, pain intervetnio, headache, miimally invasive therapy.

Intravascular large B-cell lymphoma presenting with diffusely increased pulmonary fluorodeoxyglucose uptake without corresponding CT abnormality.

A 60-year-old male presented with complaints of dyspnea, intermittent fever, and 40 pounds of weight loss over the previous 9 months and was admitted for acute hypoxemic respiratory failure. Labs demonstrated elevated inflammatory markers, mild anemia, and thrombocytopenia. Fluorodeoxyglucose-positron emission tomography scan demonstrated diffusely increased pulmonary fluorodeoxyglucose uptake without corresponding abnormality on CT images. Excisional lung biopsy demonstrated intravascular large B-cell lymphoma (IV-LBCL). Presentation, imaging findings, and diagnosis of IV-LBCL will be discussed, as well as differential considerations for pulmonary involvement by IV-LBCL.

Implementing Contrast Reaction Management Training for Residents Through High-Fidelity Simulation.

RATIONALE AND OBJECTIVES: Adverse reactions to intravenous contrast for radiologic examinations can result in significant patient morbidity and mortality. It is critical that radiologists be proficient at recognizing and treating reactions in a timely and appropriate manner. Therefore, we developed a hands-on simulation curriculum to improve residents' ability and comfort in recognizing and responding to contrast reactions. MATERIALS AND METHODS: Contrast reaction management simulations were performed in 2016 and 2017 with 25 and 26 resident participants, respectively. Participants completed pre- and postsimulation surveys both years to assess knowledge and comfort in managing contrast reactions. RESULTS: In 2016, 25 participants answered 12 questions assessing knowledge of contrast reaction management. Percentage of correct answers increased from pre- to postsurvey in 83% of questions (10/12). Participants indicated their comfort level in managing contrast reactions increased on all six questions from pre- to postsurvey. In 2017, 26 participants answered 14 questions assessing knowledge of contrast reaction management. Similarly, percentage of correct answers increased from pre- to postsurvey in 86% of questions (12/14). Participant comfort levels also increased on all six questions from pre- to postsurvey. Subgroup analysis performed on 19 participants who completed the curriculum both years demonstrated further improvement in knowledge and comfort after completing the second year, showing added benefit of repeated simulation. CONCLUSION: These results suggest that incorporating high-fidelity contrast reaction management simulation into resident education improves both residents' knowledge and comfort in managing reactions. We have therefore incorporated annual contrast reaction simulation as a standard component of our residency curriculum.

Radiologic and Pathologic Features Associated With Upgrade of Atypical Ductal Hyperplasia at Surgical Excision.

RATIONALE AND OBJECTIVES: To evaluate radiologic and pathologic features associated with upgrade of atypical ductal hyperplasia (ADH) to ductal carcinoma in situ or invasive breast cancer at surgical excision, in order to identify patients who may consider alternatives to excision. MATERIALS AND METHODS: This retrospective analysis examined patients who underwent surgical excision of biopsy-proven ADH at our institution. Imaging and pathology from biopsy were reviewed to determine radiologic (lesion size, radiologic abnormality, biopsy type, needle gauge, number of cores, percent of lesion removed) and pathologic features (histologic calcifications, presence of necrosis, micropapillary features, extent of ADH) associated with ADH upgrade. RESULTS: One hundred twenty four cases of percutaneous biopsy-proven ADH with subsequent excision were included. The overall upgrade rate was 17.7% (n = 22), with 17 cases to ductal carcinoma in situ and five to invasive cancer. Radiologic features associated with a lower upgrade rate were smaller lesion size (p = 0.032) and larger percent of lesion removed at biopsy (p = 0.047). Larger needle gauge at biopsy (p = 0.070), absence of necrosis (p = 0.051) and focal ADH (<3 foci, p = 0.12) were nearly associated with a lower rate of upgrade and were included for the purpose of multi parameter analyses. CONCLUSION: For women with ADH identified on percutaneous biopsy, the risk of upgrade may in part be determined by lesion size, percent of lesion removed at biopsy, presence of necrosis, and extent of ADH. Using a combination of these radiographic and pathologic features to stratify patients with biopsy-proven ADH may help identify women who could be considered for alternative treatment options.