Hemodialysis Access: US for Preprocedural Mapping and Evaluation of Maturity and Access Dysfunction.

Patients with kidney failure require kidney replacement therapy. While renal transplantation remains the treatment of choice for kidney failure, renal replacement therapy with hemodialysis may be required owing to the limited availability and length of time patients may wait for allografts or for patients ineligible for transplant owing to advanced age or comorbidities. The ideal hemodialysis access should provide complication-free dialysis by creating a direct connection between an artery and vein with adequate blood flow that can be reliably and easily accessed percutaneously several times a week. Surgical arteriovenous fistulas and grafts are commonly created for hemodialysis access, with newer techniques that involve the use of minimally invasive endovascular approaches. The emphasis on proactive planning for the placement, protection, and preservation of the next vascular access before the current one fails has increased the use of US for preoperative mapping and monitoring of complications for potential interventions. Preoperative US of the extremity vasculature helps assess anatomic suitability before vascular access creation, increasing the rates of successful maturation. A US mapping protocol ensures reliable measurements and clear communication of anatomic variants that may alter surgical planning. Postoperative imaging helps assess fistula maturation before cannulation for dialysis and evaluates for early and late complications associated with arteriovenous access. Clinical and US findings can suggest developing stenosis that may progress to thrombosis and loss of access function, which can be treated with percutaneous vascular interventions to preserve access patency. Vascular access steal, aneurysms and pseudoaneurysms, and fluid collections are other complications amenable to US evaluation. ©RSNA, 2023 Supplemental material is available for this article. Test Your Knowledge questions for this article are available through the Online Learning Center.

Quantitative Abdominal Arterial Calcification Correlates with Kidney Transplant Waitlist Mortality.

INTRODUCTION: The scarcity of available organs for kidney transplantation has resulted in a substantial waiting time for patients with end-stage kidney disease. This prolonged wait contributes to an increased risk of cardiovascular mortality. Calcification of large arteries is a high-risk factor in the development of cardiovascular diseases, and it is common among candidates for kidney transplant. The aim of this study was to correlate abdominal arterial calcification (AAC) score value with mortality on the waitlist. METHODS: We modified the coronary calcium score and used it to quantitate the AAC. We conducted a retrospective clinical study of all adult patients who were listed for kidney transplant, between 2005 and 2015, and had abdominal computed tomography scan. Patients were divided into two groups: those who died on the waiting list group and those who survived on the waiting list group. RESULTS: Each 1,000 increase in the AAC score value of the sum score of the abdominal aorta, bilateral common iliac, bilateral external iliac, and bilateral internal iliac was associated with increased risk of death (HR 1.034, 95% CI: 1.013, 1.055) (p = 0.001). This association remained significant even after adjusting for various patient characteristics, including age, tobacco use, diabetes, coronary artery disease, and dialysis status. CONCLUSION: The study highlights the potential value of the AAC score as a noninvasive imaging biomarker for kidney transplant waitlist patients. Incorporating the AAC scoring system into routine imaging reports could facilitate improved risk assessment and personalized care for kidney transplant candidates.

Imaging Patients with Kidney Failure.

The approach to imaging a patient with kidney failure continues to evolve. Overstatement of the risk of iodinated contrast material-induced (ie, contrast-induced) acute kidney injury and new guidelines for administration of gadolinium-based contrast media affect screening and the choice of contrast material. Treatment of kidney failure requires dialysis or a kidney transplant. Pretransplant imaging includes assessment for the feasibility of performing a transplant and evaluation for underlying malignancy and peripheral vascular disease. Patients with kidney failure are at high risk for renal cell carcinoma. Subtypes that occur exclusively or more commonly in patients with kidney failure, such as acquired cystic kidney disease, renal cell carcinoma, and clear cell papillary renal cell carcinoma, have specific clinical-pathologic characteristics, with indolent behavior. Performing US for dialysis planning increases the success of placement of an arteriovenous fistula, while postoperative US evaluation is essential in assessment of access dysfunction. Systemic manifestations in patients with kidney failure are multifactorial and may relate to the underlying cause of renal failure or may be secondary to treatment effects. Disturbances in mineral and bone metabolism and soft-tissue and vascular calcifications are seen in patients with chronic kidney disease and mineral bone disorder. Neurologic and cardiothoracic complications are also common. The authors provide a comprehensive overview of imaging considerations for patients with kidney failure, including the appropriate use of CT, MRI, and US with their respective contrast agents; the use of imaging in transplant workup and dialysis assessment; and the common renal and extrarenal manifestations of kidney failure. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Imaging of Castleman Disease.

Castleman disease (CD) is a group of rare and complex lymphoproliferative disorders that can manifest in two general forms: unicentric CD (UCD) and multicentric CD (MCD). These two forms differ in clinical manifestation, imaging appearances, treatment options, and prognosis. UCD typically manifests as a solitary enlarging mass that is discovered incidentally or after development of compression-type symptoms. MCD usually manifests acutely with systemic symptoms including fever and weight loss. As a whole, CD involves lymph nodes throughout the chest, neck, abdomen, pelvis, and axilla and can have a wide variety of imaging appearances. Most commonly, lymph nodes or masses in UCD occur in the chest, classically with well-defined borders, hyperenhancement, and possible characteristic patterns of calcification and/or feeding vessels. Lymph nodes affected by MCD, while also hyperenhancing, tend to involve multiple nodal chains and manifest alongside anasarca or hepatosplenomegaly. The polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) subtype of MCD may demonstrate lytic or sclerotic osseous lesions in addition to features typical of MCD. Since a diagnosis of CD based solely on imaging findings is often not possible, pathologic confirmation with core needle biopsy and/or surgical excision is necessary. Nevertheless, imaging plays a crucial role in supporting the diagnosis of CD, guiding appropriate regions for biopsy, and excluding other potential causes or mimics of disease. CT is frequently the initial imaging technique used in evaluating potential CD. MRI and PET play important roles in thoroughly evaluating the disease and determining its extent, especially the MCD form. Complete surgical excision is typically curative for UCD. MCD usually requires systemic therapy. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Ultrasound Simulation Training for Radiology Residents-Curriculum Design and Implementation.

Medical simulation training can be used to improve clinician performance, teach communication and professionalism skills, and enhance team training. Radiology residents can benefit from simulation training in diagnostic ultrasound, procedural ultrasound, and communication skills prior to direct patient care experiences. This paper details a weeklong ultrasound simulation training curriculum for radiology residents during the PGY-1 clinical internship. The organization of established teaching methods into a dedicated course early in radiology residency training with the benefit of a multi-disciplinary approach makes this method unique. This framework can be adapted to fit learners at different skill levels or with specific procedural needs.

Focal Nodular Hyperplasia and Focal Nodular Hyperplasia-like Lesions.

Focal nodular hyperplasia (FNH) is a benign lesion occurring in a background of normal liver. FNH is seen most commonly in young women and can often be accurately diagnosed at imaging, including CT, MRI, or contrast-enhanced US. In the normal liver, FNH frequently must be differentiated from hepatocellular adenoma, which although benign, is managed differently because of the risks of hemorrhage and malignant transformation. When lesions that are histologically identical to FNH occur in a background of abnormal liver, they are termed FNH-like lesions. These lesions can be a source of diagnostic confusion and must be differentiated from malignancies. Radiologists' familiarity with the imaging appearance of FNH-like lesions and knowledge of the conditions that predispose a patient to their formation are critical to minimizing the risks of unnecessary intervention for these lesions, which are rarely symptomatic and carry no risk for malignant transformation. FNH is thought to form secondary to an underlying vascular disturbance, a theory supported by the predilection for formation of FNH-like lesions in patients with a variety of hepatic vascular abnormalities. These include abnormalities of hepatic outflow such as Budd-Chiari syndrome, abnormalities of hepatic inflow such as congenital absence of the portal vein, and hepatic microvascular disturbances, such as those that occur after exposure to certain chemotherapeutic agents. Familiarity with the imaging appearances of these varied conditions and knowledge of their association with formation of FNH-like lesions allow radiologists to identify with confidence these benign lesions that require no intervention. Online supplemental material is available for this article. ©RSNA, 2022.

Contrast-enhanced US Evaluation of Endoleaks after Endovascular Stent Repair of Abdominal Aortic Aneurysm.

Ruptured abdominal aortic aneurysm (AAA) carries high morbidity and mortality. Elective repair of AAA with endovascular stent-grafts requires lifetime imaging surveillance for potential complications, most commonly endoleaks. Because endoleaks result in antegrade or retrograde systemic arterialized flow into the excluded aneurysm sac, patients are at risk for recurrent aneurysm sac growth with the potential to rupture. Multiphasic CT has been the main imaging modality for surveillance and symptom evaluation, but contrast-enhanced US (CEUS) offers a useful alternative that avoids radiation and iodinated contrast material. CEUS is at least equivalent to CT for detecting endoleak and may be more sensitive. The authors provide a general protocol and technical considerations needed to perform CEUS of the abdominal aorta after endovascular stent repair. When there are no complications, the stent-graft lumen has homogeneous enhancement, and no contrast material is present in the aneurysm sac outside the stented lumen. In patients with an antegrade endoleak, contrast material is seen simultaneously in the aneurysm sac and stent-graft lumen, while delayed enhancement in the sac is due to retrograde leak. Recognition of artifacts and other potential pitfalls for CEUS studies is important for examination performance and interpretation. Online supplemental material is available for this article. ©RSNA, 2022.

Association of Abdominal Arterial Calcification Score with Patients' Survival and Kidney Allograft Function after Kidney Transplant.

BACKGROUND: Abdominal arterial calcification (AAC) is common among candidates for kidney transplant. The aim of this study is to correlate AAC score value with post-kidney transplant outcomes. METHODS: We modified the coronary calcium score by changing the intake data points and used it to quantitate the AAC. We conducted a retrospective clinical study of all adult patients who were transplanted at our center, between 2010 and 2013, and had abdominal computed tomography scan done before transplantation. Outcomes included mortality, pulse pressure (PP) measured by 24 h ambulatory blood pressure monitoring system, and kidney allograft function measured by iothalamate clearance. RESULTS: For each 1000 increase of AAC score value, there is an associated 1.05 increase in the risk of death (95% CI 1.02, 1.08) (p < 0.001). Overall median AAC value for all patients was 1784; Kaplan-Meier curve showed reduced survival of all-cause mortality for patients with AAC score value above median and reduced survival among patients with cardiac related mortality. The iothalamate clearance was lower among patients with total AAC score value above the median. Patients with abnormal PP (< 40 or > 60 mmHg) had an elevated median AAC score value at 4319.3 (IQR 1210.4, 11097.1) compared to patients with normal PP with AAC score value at 595.9 (IQR 9.9, 2959.9) (p < 0.001). CONCLUSION: We showed an association of AAC with patients' survival and kidney allograft function after kidney transplant. The AAC score value could be used as a risk stratification when patients are considered for kidney transplant.

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion.

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ©RSNA, 2020.

Assessing Public Attitudes to Electroconvulsive Therapy: Validation of the Modified ECT Attitudes Questionnaire Using a Systematic Analysis.

INTRODUCTION: Electroconvulsive therapy (ECT) is an established treatment for major depressive disorder, yet it remains controversial. Attitudes toward ECT have been studied in members of the public and service users, with diverse findings. There is no systematically validated scale to quantify attitudes. OBJECTIVES: The aim of this study was to validate a scale measuring attitudes toward ECT using a systematic analysis. METHODS: Validation consisted of 3 stages: item generation, theoretical analysis, and psychometric analysis. A total of 196 members of the public were surveyed, and the findings were used to perform principal component analysis, Cronbach alpha (CA), and interitem correlation. RESULTS: The Modified ECT Attitudes Questionnaire (EAQ) is a 22-item participant-rated questionnaire (0-44) consisting of 2 principal components: "moral and ethical perceptions of ECT" and "ECT as a last resort treatment." There was adequate reliability for the total EAQ (CA, 0.873) and each of the components (component 1 CA, 0.907; component 2 interitem correlation, 0.389). Among the 196 members of the public, the mean score was 20.4 (SD, 8.4), which equates to 46% positive responses. Component 1 elicited 39% positive responses; component 2 elicited 52% positive responses. The emotion components of attitudes elicited particularly negative responses. CONCLUSIONS: The EAQ is a validated and reliable scale for the measurement of attitudes toward ECT. Application of this scale to 196 members of the public indicates that negative attitudes are rooted in individuals' moral and ethical objections to ECT, particularly the emotion components of such attitudes. This scale can be applied to other groups, including service users, to further characterize attitudes that underlie the stigma toward ECT.

Over the Cuckoo's Nest: Does Experiencing Electroconvulsive Therapy Change Your Mind? A Mixed Methods Study of Attitudes and Impact of Electroconvulsive Therapy on Patients and Their Relatives.

OBJECTIVE: Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder, but some aspects remain controversial. Few studies have taken an in-depth mixed methods approach toward the study of attitudes, and there are no significant studies that explore the change of attitudes before and after treatment. The aim was to compare attitudes of patients and their relatives before and after ECT using quantitative and qualitative methods. METHODS: One hundred twenty-three participants were recruited. Forty-one patient/relative participants were recruited from 2 accredited ECT centers along with 82 age- and sex-matched general population controls. A validated 22-item survey about attitudes toward ECT was administered. Patient/relative participants completed the survey before treatment with ECT and engaged in a repeat survey and a semistructured interview 1 month after completion of ECT. Control participants completed the survey on a single occasion. RESULTS: Control versus pre-ECT surveys and pre-ECT versus post-ECT surveys both demonstrated statistically and clinically significant positive attitudinal differences (Cohen d = 1.37, P < 0.001; Cohen d = 1.2, P < 0.001). These differences were maintained for both the patient and relative pre/post subgroups (Cohen d = 1.15, P < 0.001; Cohen d = 1.33, P < 0.001). Qualitative analysis identified 13 attitudinal transitions in cognition, emotion, and imagery domains. CONCLUSIONS: This is the first study to examine a change in attitudes toward ECT of patients, their relatives, and with controls using mixed methods. The findings suggest a 2-phase positive attitudinal change, in which accurate information (phase 1) and experiential learning (phase 2) are both key components. These findings address stigma through accurate knowledge and experiential learning, with a positive outcome through changed attitudes.

Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries.

After experiencing blunt or penetrating trauma, patients in unstable condition who are more likely to die of uncorrected shock than of incomplete injury repairs undergo emergency limited exploratory laparotomy, which is also known as damage control surgery (DCS). This surgery is part of a series of resuscitation steps, with the goal of stabilizing the patient's condition, with rapid surgical control of hemorrhage followed by supportive measures in the intensive care unit before definitive repair of injuries. These patients often are imaged with multidetector CT within 24-48 hours of the initial surgery. Knowledge of this treatment plan is critical to CT interpretation, because there are anatomic derangements and foreign bodies that would not be present in patients undergoing surgery for other reasons. Patients may have injuries beyond the surgical field that are only identified at imaging, which can alter the care plan. Abnormalities related to the resuscitation period such as the CT hypoperfusion complex and ongoing hemorrhage can be recognized at CT. Familiarity with these imaging and clinical findings is important, because they can be seen not only in trauma patients after DCS but also in other patients in the critical care setting. The interpretation of imaging studies can be helped by an understanding of the diagnostic challenges of grading organ injuries with surgical materials in place and the awareness of potential artifacts on images in these patients. Online supplemental material is available for this article. ©RSNA, 2019 See discussion on this article by LeBedis .

Prediction of Arteriovenous Fistula Clinical Maturation from Postoperative Ultrasound Measurements: Findings from the Hemodialysis Fistula Maturation Study.

BACKGROUND: The utility of early postoperative ultrasound measurements in predicting arteriovenous fistula (AVF) clinical maturation is uncertain. METHODS: We investigated the relationships of ultrasound parameters with AVF clinical maturation in newly created AVF, measured at 1 day and 2 and 6 weeks, in 602 participants of a multicenter, observational cohort study. A backward elimination algorithm identified ultrasound measurements that independently predicted unassisted and overall AVF maturation. Candidate variables included AVF blood flow, diameter, and depth, upper arm arterial diameter, presence of stenosis, presence of accessory veins, seven case-mix factors (age, sex, black race, AVF location, diabetes, dialysis status, and body mass index), and clinical center. We evaluated the accuracy of the resulting models for clinical prediction. RESULTS: At each ultrasound measurement time, AVF blood flow, diameter, and depth each predicted in a statistically significant manner both unassisted and overall clinical maturation. Moreover, neither the remaining ultrasound parameters nor case-mix factors were associated with clinical AVF maturation after accounting for blood flow, diameter, and depth, although maturation probabilities differed among clinical centers before and after accounting for these parameters. The crossvalidated area under the receiver operating characteristic curve for models constructed using these three ultrasound parameters was 0.69, 0.74, and 0.79 at 1 day and 2 and 6 weeks, respectively, for unassisted AVF clinical maturation and 0.69, 0.71, and 0.76, respectively, for overall AVF maturation. CONCLUSIONS: AVF blood flow, diameter, and depth moderately predicted unassisted and overall AVF clinical maturation. The other factors considered did not further improve AVF maturation prediction.

Role of Imaging in the Evaluation of Male Infertility.

Infertility is defined herein as the inability to achieve pregnancy after frequently engaging in unprotected sexual intercourse for 1 year. Among infertile couples, the cause of infertility involves the male partner in approximately 50% of cases. Male infertility is usually caused by conditions affecting sperm production, sperm function, or both, or blockages that prevent the delivery of sperm. Chronic health problems, injuries, lifestyle choices, anatomic problems, hormonal imbalances, and genetic defects can have a role in male infertility. The diagnostic workup of male infertility should include a thorough medical and reproductive history, physical examination, and semen analysis, followed by imaging. The main role of imaging is identification of the causes of infertility, such as congenital anomalies and disorders that obstruct sperm transport and may be correctable. Scrotal ultrasonography is the most common initially performed noninvasive examination used to image the male reproductive system, including the testes and extratesticular structures such as the epididymis. Magnetic resonance (MR) imaging is another noninvasive imaging modality used in the pelvis to evaluate possible obstructive lesions involving the ductal system. MR imaging of the brain is extremely useful for evaluating relevant neurologic abnormalities, such as pituitary gland disorders, that are suspected on the basis of hormone analysis results. Invasive techniques are usually reserved for therapeutic interventions in patients with known abnormalities. In this article, the causes and imaging findings of obstructive and nonobstructive azoospermia are discussed. In addition to detecting treatable conditions that are related to male infertility, identifying the life-threatening entities associated with infertility and the genetic conditions that could be transmitted to offspring-especially in patients who undergo assisted reproduction-is critical. ©RSNA, 2017.

Scanner-Based Protocol-Driven Ultrasound: An Effective Method to Improve Efficiency in an Ultrasound Department.

OBJECTIVE: For ultrasound, a wide variation is often observed among the number and sequence of images acquired for a particular examination type. Scanner-based protocols are preset pathways in the ultrasound machine that guide a sonographer through the required study images. These protocols can streamline image acquisition by improving consistency and efficiency of ultrasound examinations. This study evaluated whether implementation of scanner-based protocol-driven ultrasound improves efficiency by decreasing the scanning duration and number of images acquired. MATERIALS AND METHODS: Retrospective evaluation of 437 carotid Doppler examinations, 395 complete abdominal ultrasound examinations with Doppler imaging, and 413 bilateral lower extremity venous Doppler examinations for deep venous thrombosis (DVT) performed by five sonographers before and after implementation of scanner-based protocol-driven ultrasound was performed. The scanning duration and number of images acquired for each study were recorded. Statistical analysis compared the scanning duration and number of images acquired before and after implementation of protocol-driven ultrasound. A p value of < 0.05 was considered significant. RESULTS: A significant decrease in scanning duration occurred for both carotid Doppler ultrasound examinations (decrease by 12.4% [2.7 minutes], p < 0.0001) and complete abdominal ultrasound examinations with Doppler imaging (decrease by 7.5% [2.0 minutes], p = 0.0054) after implementation of protocol-driven ultrasound. The decrease in scanning duration was not significant for lower extremity DVT Doppler examinations (p = 0.4192). In addition, there was a significant decrease in the overall number of images obtained for all three types of studies. CONCLUSION: Scanner-based protocol-driven ultrasound is an effective method that streamlines image acquisition and significantly improves efficiency in an ultrasound department while ensuring consistency and adherence to accreditation guidelines.

Neuropsychiatric presentations and outcomes in children and adolescents with primary brain tumours: Systematic review.

OBJECTIVE: The purpose of this study was to systematically review the literature relating to the neuropsychiatric symptoms at presentation and outcome of childhood brain tumours. METHODS: Seven online databases pertaining to the neuropsychiatric presentation and outcomes of childhood CNS tumours were searched and PRISMA guidelines were followed. Temporal limits were not applied to the searches. RESULTS: There were 1879 relevant search results in total. After discovering the large body of both primary and secondary research in the field of cognitive and neuropsychological outcomes of brain tumours in children, these studies were excluded. Quality-of-life studies were excluded for the same reason. Thirty-one papers were chosen for discussion in this review. CONCLUSION: This timely systematic review concluded that neuropsychiatric presentations are common in children with CNS tumours-with the presence of behavioural and psychological symptoms in up to 57% of cases, their frequency varies according to age of onset and is strongly associated with time since diagnosis. The findings highlight the necessity for routine psychological and psychiatric screenings of children with suspected brain tumours and at follow-up and a number of clinical recommendations to this effect are listed.

Multireader evaluation of lesion conspicuity in small pancreatic adenocarcinomas: complimentary value of iodine material density and low keV simulated monoenergetic images using multiphasic rapid kVp-switching dual energy CT.

OBJECTIVE: Perform multireader analysis of objective and subjective lesion conspicuity for small pancreatic adenocarcinomas using rapid switching dual energy CT (rsDECT). MATERIALS AND METHODS: With IRB approval, 51 abdominal multiphasic rsDECT scans in 46 subjects with small (<3 cm) pancreatic adenocarcinomas were retrospectively reviewed by three independent readers for objective and subjective lesion conspicuity. Measured variables during individual, blinded interpretive sessions of separate low (52) keV, PACS-equivalent (70) keV, and iodine material density (MD) image sets included Hounsfield units (HU) and mg/cc iodine for tumor, nontumoral pancreas, and subcutaneous fat. Objective measures included absolute lesion contrast (LC) and contrast to noise ratios (CNR). Subjective measures included image quality, lesion conspicuity, and reader confidence. Reader agreement was measured with kappa statistic; correlation with truth by Pearson coefficient, CNR with repeated mANOVA; subjective quality measures utilized Tukey-Cramer corrections for multiple testing, p < 0.05 considered significant. RESULTS: Demographics: 26 F, 20 M, mean age 68 years, weight 75 kg, tumor size of 2.3 cm. LC was highest on 52 keV images for all three readers (mean 90.1 HU). Mean CNR for iodine MD images (4.87) was significantly higher than 52 keV (4.13) or 70 keV (3.9). Very high to near-perfect kappa values were observed for all individual measured objective variables but were best for 52 keV images (52 keV 0.89-0.95, 70 keV 0.76-0.83, iodine 0.87-0.92). 70 keV images scored best for subjective image quality; iodine MD images scored best for lesion conspicuity and reader confidence. CONCLUSION: We observed very high reader agreement for independent objective rsDECT image variables and subjective rsDECT image scores in patients with small pancreatic adenocarcinomas. Maximal objective tumor to nontumoral LC was depicted on 52 keV and highest CNR on iodine MD images; readers scored the iodine MD images best for lesion conspicuity and confidence.