Added Value of Contrast-enhanced US for Evaluation of Female Pelvic Disease.

Since the first application of contrast-enhanced US (CEUS) in the late 1960s, the use of US contrast agents has grown tremendously, and this examination has proved to be a valuable adjunct to diagnostic US for detection and characterization of disease. Also, CEUS has emerged as an excellent option for evaluation of indeterminate lesions that require additional imaging, given its excellent safety profile, including that in patients with end-stage renal disease or allergies to contrast material who are unable to undergo contrast-enhanced CT or MRI. US traditionally has been considered the imaging modality of choice for evaluation of the female pelvis, followed by MRI and rarely fluoroscopy, CT, PET, or angiography. CEUS has the potential to add significant value in imaging gynecologic disease, and indications for its use in the female pelvis are expected to continue evolving. It can aid in evaluation of nonvascular structures, such as assessment of tubal patency, uterine cavity morphology, and pelvic fistulas. CEUS can help characterize poorly vascularized gynecologic tumors or tissues with slow flow by using qualitative and quantitative parameters and aid in image-guided interventions or biopsies by facilitating visualization of lesions that are difficult to see with other imaging modalities. The authors provide an overview of current applications of US contrast agents in the female pelvis and discuss associated factors such as technique, interpretation, and image optimization. They also discuss the limitations of CEUS and describe its utility in the evaluation of female pelvic disease by using an organ system case-based approach. © RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

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.

Doppler Ultrasound of the Renal Vasculature.

Ultrasound is the first-line imaging modality used in patients with suspected renovascular disease. Common indications include renovascular hypertension and unexplained renal dysfunction. We review the ultrasound imaging findings of various pathologies involving the renal vessels, including the renal arteries (atherosclerotic stenosis, fibromuscular dysplasia, dissection, arteriovenous fistula, and aneurysm) and veins (tumor and bland thrombus as well as vascular compression syndromes). The current role of renal artery stent placement for atherosclerotic stenosis is also discussed.

Pitfalls in Carotid Doppler Interpretation and How to Avoid Them.

Imaging pitfalls commonly occur in carotid Doppler ultrasound and may lead to false positive diagnosis of stenosis, missed diagnosis of stenosis, and errors in grading stenosis severity. These pitfalls may result from suboptimal technique and/or patient-specific factors including coexisting cardiovascular pathology, contralateral high-grade stenosis/occlusion, tortuous vessels, tandem lesions, long-segment stenosis, nearly occlusive stenosis, and heavily calcified plaque. Awareness of these pitfalls and careful assessment of the extent of plaque on grayscale and color Doppler as well as analysis of the spectral Doppler waveforms can help avoid misinterpretation of the carotid Doppler examination.

Depression Predicts Delirium After Coronary Artery Bypass Graft Surgery Independent of Cognitive Impairment and Cerebrovascular Disease: An Analysis of the Neuropsychiatric Outcomes After Heart Surgery Study.

OBJECTIVE: Although depression is a known risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear whether this risk is independent of delirium risk attributable to cognitive impairment or cerebrovascular disease. This study examines depression, mild cognitive impairment (MCI), and cerebrovascular disease as post-CABG delirium risk factors. METHODS: This prospective observational cohort study was performed in a tertiary-care academic hospital. Subjects were without dementia and undergoing CABG surgery. Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview and Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCAs). Study psychiatrists assessed delirium on postoperative days 2-5 using the Confusion Assessment Method. RESULTS: Our analytic sample comprised 131 subjects (average age: 65.8 ± 9.2years, 27% women). MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (odds ratio [OR]: 5.1; 95% confidence interval [CI]: 1.3-20.1), and preoperative depression (OR: 9.9; 95% CI: 1.3-77.9)-but not lifetime depression-predicted delirium. MCA stenosis and severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity, but left-sided stenosis severity did not. CONCLUSION: We established that the risk of delirium attributable to depression extends beyond the potential moderating influence of cognitive impairment and cerebrovascular disease alone. Even mild depression and cognitive impairment before CABG deserve recognition for their effect on post-CABG cognitive health.

Accessible Personal Ultrasound Training Simulator.

OBJECTIVES: Ultrasound simulators are increasingly used for teaching and training purposes, but development has been limited by the need for dedicated and often expensive hardware. The objective of this study was to develop and deploy an accessible and very low-cost personal ultrasound training simulator and obtain trainee feedback. METHODS: An ultrasound simulator software program that uses a smartphone as a "mock-probe" and a laptop computer as a "mock ultrasound machine" was created. Spatial positional data is acquired from the smartphone's inbuilt accelerometer and gyroscope and transmitted to the laptop computer for processing and display of simulated ultrasound images in real time by the software program. After obtaining institutional review board approval and informed consent, all first-year radiology residents at our institution were provided access to the simulator program during the "bootcamp" introductory conference series, and a written survey was conducted to obtain feedback. RESULTS: A personal ultrasound training simulator software program (Persimus) that reliably performs motion sensing along 2 axes and displays simulated ultrasound images was developed. Nine of 12 (75%) first-year residents at our institution participated in the written survey. Residents' scored values were 8.44 ± 1.33 and 8.44 ± 1.33 (mean + standard deviation) for perceived utility and overall impression and satisfaction, respectively, of the simulator on the Likert scale (1-10, with 10 being the highest score). CONCLUSION: Personal ultrasound simulators are technically feasible. These are well received by first-year radiology residents and perceived as useful to their education.

Sonographic Evaluation of Complications of Extracranial Carotid Artery Interventions.

Carotid endarterectomy and carotid artery stenting are among the most common peripheral vascular procedures performed worldwide. Sonography is the initial and often only imaging modality used in the evaluation of iatrogenic carotid arterial injuries. This pictorial essay provides an overview of the clinical and sonographic findings of complications after interventions in the extracranial carotid arteries, including dissection, fluid collections, pseudoaneurysm, thrombosis, thromboembolism, restenosis, and stent deformation. Grayscale, color, and pulsed Doppler imaging findings are reviewed, and correlations with computed tomography, magnetic resonance imaging, and angiography are provided.

Right Upper Quadrant Pain: Ultrasound First!

Acute right upper quadrant (RUQ) pain is a common presenting symptom in emergency departments and outpatient medical practices, and is most commonly attributable to biliary and hepatic pathology. Ultrasound should be used as a first-line imaging modality for the diagnosis of gallstones and cholecystitis, as it allows the differentiation of medical and surgical causes of upper abdominal pathology, and in many circumstances is sufficient to guide patient management. Knowledge of strengths and limitations of ultrasound in the evaluation of RUQ is paramount in correct diagnosis. A spectrum of RUQ pathology for which a RUQ ultrasound examination should reasonably be considered as the initial imaging modality of choice will be reviewed.

US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation.

Ultrasonography (US) has a fundamental role in the initial examination of patients who present with symptoms indicating abnormalities of the inguinal canal (IC), an area known for its complex anatomy. A thorough understanding of the embryologic and imaging characteristics of the contents of the IC is essential for any general radiologist. Moreover, an awareness of the various pathologic conditions that can affect IC structures is crucial to preventing misdiagnoses and ensuring optimal patient care. Early detection of IC abnormalities can reduce the risk of morbidity and mortality and facilitate proper treatment. Abnormalities may be related to increased intra-abdominal pressure, which can result in development of direct inguinal hernias and varicoceles, or to congenital anomalies of the processus vaginalis, which can result in development of indirect hernias and hydroceles. US is also helpful in assessing postoperative complications of hernia repair, such as hematoma, seroma, abscess, and hernia recurrence. In addition, it is often the modality initially used to detect neoplasms arising from or invading the IC. US is an important tool in the examination of patients suspected of having undescended testes or posttraumatic testicular retraction and is essential for the examination of patients suspected of having torsion or infectious inflammatory conditions of the spermatic cord. Online supplemental material is available for this article. ©RSNA, 2016.

Carotid stent deformation: sonographic findings and CT correlation.

Carotid artery dissection is a rare but potentially serious complication of endovascular procedures in the carotid arteries. Stent deformation or incomplete expansion may occur following endovascular repair of an iatrogenic carotid artery dissection and may mimic stent fracture. We report an unusual case of deformation of a common carotid artery open cell design stent following endovascular repair of an iatrogenic dissection, which resulted in persistent blood flow between the stent and the wall of the common carotid artery. Sonographic features are described and correlation with intravascular ultrasound and CT is provided.

Breast ultrasonography: state of the art.

Ultrasonography (US) is an indispensable tool in breast imaging and is complementary to both mammography and magnetic resonance (MR) imaging of the breast. Advances in US technology allow confident characterization of not only benign cysts but also benign and malignant solid masses. Knowledge and understanding of current and emerging US technology, along with the application of meticulous scanning technique, is imperative for image optimization and diagnosis. The ability to synthesize breast US findings with multiple imaging modalities and clinical information is also necessary to ensure the best patient care. US is routinely used to guide breast biopsies and is also emerging as a supplemental screening tool in women with dense breasts and a negative mammogram. This review provides a summary of current state-of-the-art US technology, including elastography, and applications of US in clinical practice as an adjuvant technique to mammography, MR imaging, and the clinical breast examination. The use of breast US for screening, preoperative staging for breast cancer, and breast intervention will also be discussed.

Advances in transcranial Doppler US: imaging ahead.

Transcranial Doppler ultrasonography (US) is a noninvasive, portable technique for evaluating the intracranial vasculature. It has found its most useful clinical application in the detection of vasospasm involving the cerebral vessels after subarachnoid hemorrhage due to aneurysm rupture. The technique has become an integral part of monitoring and managing patients with subarachnoid hemorrhage in the neurologic intensive care unit. In addition, it has proved useful for evaluating the intracranial vasculature in patients with sickle cell disease, stroke, or brain death. Transcranial US originated as a "blind" nonimaging study in which pulsed Doppler technology was used. Identification of the major intracranial vessels and evaluation of those vessels for vasospasm relied on spectral waveforms obtained in each vessel and was based on the depth of the vessel from the skull, the direction of blood flow, and the orientation of the transducer. Recent advances in US technology allow the use of gray-scale, spectral Doppler, and color Doppler flow imaging to directly visualize intracranial vessels, thereby simplifying flow velocity measurements and enhancing their accuracy for vasospasm detection. In particular, measurements of peak systolic velocity and mean flow velocity and calculation of the Lindegaard ratio facilitate the identification of vessels that may be in vasospasm and help differentiate vasospasm from physiologic conditions such as hyperemia and autoregulation. Thus, gray-scale and color Doppler flow imaging offer many advantages over the original pulsed Doppler technique for evaluating the intracranial vasculature.

Carotid intima-media thickness provides evidence that ascending aortic aneurysm protects against systemic atherosclerosis.

Previous evaluation of total aortic calcium score suggests that mutations promoting ascending aortic aneurysm development may protect against atherosclerosis. However, calcium score is a late indicator of atherosclerosis. We evaluated carotid intima-media thickness (IMT), an earlier marker, to assess the degree of atherosclerosis in ascending aortic aneurysm patients compared to controls. Images of right and left common carotid arteries were obtained in 52 patients with ascending aortic aneurysms and 29 controls using a Sonosite MicroMaxx ultrasound. IMT was measured with Sonosite Sonocalc IMT software, a computer-based algorithm with manual override. Six IMT measurements were obtained for each patient (right and left proximal, mid and distal common carotid artery) by a single observer and averaged. A multiple linear regression analysis was applied to test for an association between aneurysm and IMT. Patients with ascending aortic aneurysms had 0.131-mm lower carotid IMT values than controls (p = 0.0002), independent of risk factors for atherosclerosis (age, BMI, gender, family history, smoking, dyslipidemia, race, diabetes and hypertension). The average IMT was 0.50 ± 0.13 mm for individuals with aneurysm and 0.60 ± 0.11 mm for controls. Age increased the IMT by 0.005 mm per year (p = 0.0003). BMI, male gender, positive family history, dyslipidemia, diabetes and hypertension also increased the IMT, but did not reach statistical significance. This investigation provides further evidence that ascending aortic aneurysm provides protection against the development of atherosclerosis, supporting the hypothesis that proaneurysmal genetic mutations may also be antiatherogenic.

Ultrasound Image Optimization for the Interventional Radiologist.

Understanding the basics and nuances of the functionality of ultrasound (US) equipment and of its various knobs and modes will enable the interventional radiologist to acquire higher quality US images. This, in turn will potentially allow US-guided procedures to be performed safely, and with greater operator confidence, and may also allow certain procedures to be performed with US instead of CT or fluoroscopic guidance. In this article, we review the practical aspects of US image optimization for the interventional radiologist, including equipment and transducer selection, depth, focal zone and gain setting adjustment, as well as special considerations for imaging the obese patient. Color Doppler image optimization and recent developments in ultrasound imaging are briefly discussed.

Are Women Disproportionately Represented in Education Compared to Other Roles in Academic Radiology?

RATIONALE AND OBJECTIVES: Women in academic medicine, and radiology specifically, are underrepresented in departmental leadership roles and achieve fewer professional metrics of success. We have observed, however, that women are more broadly represented in medical education leadership. The purpose of this study was to determine if women in academic radiology are overrepresented in educational scholarship and educational leadership compared to general research scholarship and leadership positions, and to determine if there is any difference in the distribution of women in these roles compared to internal medicine. MATERIALS AND METHODS: We performed a PubMed search of education articles in radiology and internal medicine over the last 5 years, and the gender of the authors was determined. Data on gender for authorship of general research topics, departmental leaders, and society leadership was obtained via literature and internet searches and the data was aggregated. Representation ratios (RR of 1.0 = parity) were obtained via risk ratio calculation to compare education versus general scholarship, and the distribution of leadership roles within and between these fields. RESULTS: Women make up 28.5% of academic radiologists and 40.1% of academic internists. A higher proportion of education articles were first authored by women than would be expected in both fields with an RR of 1.46 (p < 0.001) in radiology and 1.23 (p < 0.001) in internal medicine. This overrepresentation was significant compared to general research scholarship in both fields (p < 0.001). In both fields, women were overrepresented in the position of Medical Student Director (RR of 1.47 and 1.22, respectively). For Program Directors, women were overrepresented in radiology (RR of 1.12) and underrepresented in internal medicine (RR of 0.69-0.75). Women in radiology were overrepresented in education society leadership (RR = 1.63) compared to general society leadership (0.98, p = 0.001). CONCLUSION: We found that women in radiology are overrepresented in authorship of education articles, and in departmental and society education leadership roles. This trend was also seen in internal medicine, suggesting that women are more broadly represented in medical education.

Nongynecologic Causes of Pelvic Pain: Ultrasound First.

Ultrasonography (US) is often the first-line imaging study used to evaluate women who present with acute or chronic pelvic pain. Detection of nongynecologic causes of pelvic pain is critical, because delay in diagnosis can cause significant morbidity and mortality. Evaluation of these entities requires a variety of transducers to achieve optimal imaging depth and changes in patient positioning. Specific imaging techniques (such as graded compression) may be required if bowel pathology is suspected. Contrast-enhanced ultrasonography is increasingly used to improve detection of certain entities. The US appearance of common gastrointestinal and urinary tract-related causes of pelvic pain is reviewed.

Carotid Ultrasound.

Doppler ultrasound (US) is the primary noninvasive imaging modality for detecting, grading, and monitoring extracranial internal carotid artery (ICA) stenosis, which is a well-established surrogate marker for stroke risk. In addition, Doppler US is the primary imaging modality for surveillance of patients following carotid intervention with endarterectomy or stent placement. This article reviews the pathophysiology and epidemiology of stroke, technique for performing a carotid US examination, normal findings, and diagnostic US criteria for evaluating carotid plaque, grading stenosis in the native ICA and following intervention, as well as waveform analysis of the carotid arteries.

Vertebral Artery Ultrasound.

There is renewed interest in ultrasound imaging of the vertebral artery due to the increasing use of stent placement for treating vertebral artery stenosis. Changes in vertebral artery waveforms are helpful in detecting pathologic processes involving the proximal and distal neurovascular circulation. We review the normal anatomy, scanning technique, normal gray scale, and color Doppler ultrasound appearance and differential diagnosis of spectral Doppler waveform changes in the extracranial vertebral artery. We review the ultrasound criteria for diagnosing vertebral artery stenosis, and the imaging appearance of non-atherosclerotic pathology that may affect the vertebral artery, including dissection, pseudoaneurysm, and arteriovenous fistula.

Automated Test-Item Generation System for Retrieval Practice in Radiology Education.

OBJECTIVE: To develop and disseminate an automated item generation (AIG) system for retrieval practice (self-testing) in radiology and to obtain trainee feedback on its educational utility. MATERIALS AND METHODS: An AIG software program (Radmatic) that is capable of generating large numbers of distinct multiple-choice self-testing items from a given "item-model" was created. Instead of writing multiple individual self-testing items, an educator creates an "item-model" for one of two distinct item styles: true/false knowledge based items and image-based items. The software program then uses the item model to generate self-testing items upon trainee request. This internet-based system was made available to all radiology residents at our institution in conjunction with our didactic conferences. After obtaining institutional review board approval and informed consent, a written survey was conducted to obtain trainee feedback. RESULTS: Two faculty members with no computer programming experience were able to create item-models using a standard template. Twenty five of 54 (46%) radiology residents at our institution participated in the study. Twelve of these 25 (48%) study participants reported using the self-testing items regularly, which correlated well with the anonymous website usage statistics. The residents' overall impression and satisfaction with the self-testing items was quite positive, with a score of 7.89 ± 1.91 (mean ± SD) out of 10. Lack of time and email overload were the main reasons provided by residents for not using self-testing items. CONCLUSION: AIG enabled self-testing is technically feasible, and is perceived positively by radiology residents as useful to their education.