Resident pre-dictation of ED case delay signoff of those reports, but overall, residents improve report turnaround time.

PURPOSE: In academic radiology departments, attendings and resident are increasingly working together overnight for Emergency Department (ED) radiology coverage. The purpose of this study was to quantify reporting turnaround time for overnight cases read by residents and for overnight shifts with residents on duty. METHODS: A retrospective study was performed at a hospital system where one overnight attending covers two hospitals with a 2nd/3rd year overnight resident, and a second overnight attending covers two other hospitals 80% of the time independently and 20% of the time with a fourth-year resident. In the first analysis, the median difference in turnaround time, from the time when the case was completed by the technologist to the time the attending finalized it, between cases read independently by attendings and cases pre-dictated by residents was calculated. In the second analysis, the median difference in turnaround time for all cases performed at the second two hospitals was compared on nights when an attending was on duty alone versus nights when a fourth-year resident was also on duty, regardless of if the resident had pre-dictated the case. RESULTS: For computed tomography (CT), radiographs (XR), and ultrasound (US), there was a significant delay in turnaround time for cases pre-dictated by residents compared to cases read independently by attendings, ranging between 11 and 49 min depending on resident seniority and modality (p ≤ 0.001). For all cases on nights with a 4th year resident working, overall median report turnaround time decreased by 7 min (p < 0.001). CONCLUSION: Resident pre-dictation causes delay in the finalization of individual CT, US, and XR reports; however, overall, working with residents results in a significant decrease in report turnaround time supporting the belief that overnight resident education does not delay patient care.

CT of the Neck: Image Analysis and Reporting in the Emergency Setting.

Interpreting findings seen at CT of the neck is challenging owing to the complex and nuanced anatomy of the neck, which contains multiple organ systems in a relatively small area. In the emergency department setting, CT is performed to investigate acute infectious or inflammatory symptoms and chronic processes. With few exceptions, neck CT should be performed with intravenous contrast material, which accentuates abnormally enhancing phlegmonous and neoplastic tissues and can be used to delineate any abscesses or necrotic areas. As part of the evaluation, the vascular structures and aerodigestive tract must be scrutinized, particularly for patency. Furthermore, although the patient may present because of symptoms that suggest non-life-threatening conditions involving structures such as the teeth or salivary glands, there may be serious implications for other areas, such as the orbits, brain, and spinal cord, that also may be revealed at the examination. With a focus on the emergency setting, the authors propose using an approach to interpreting neck CT findings whereby 12 areas are systematically evaluated and reported on: the cutaneous and subcutaneous soft tissues, aerodigestive tract and adjacent soft tissues, teeth and periodontal tissues, thyroid gland, salivary glands, lymph nodes, vascular structures, bony airspaces, cervical spine, orbits and imaged brain, lung apices, and superior mediastinum. The use of a systematic approach to interpreting neck CT findings is essential for identifying all salient findings, recognizing and synthesizing the implications of these findings to formulate the correct diagnosis, and reporting the findings and impressions in a complete, clear, and logical manner.Online supplemental material is available for this article.©RSNA, 2019.

Implantable Electronic Stimulation Devices from Head to Sacrum: Imaging Features and Functions.

Electronic stimulation devices are implanted in various locations in the body to decrease pain, modulate nerve function, or stimulate various end organs. The authors describe these devices using a craniocaudal approach, first describing deep brain stimulation (DBS) devices and ending with sacral nerve stimulation (SNS) devices. The radiology-relevant background information for each device and its imaging appearance are also described. These devices have a common design theme and include the following components: (a) a pulse generator that houses the battery and control electronics, (b) an insulated lead or wire that conveys signals to the last component, which is (c) an electrode that contacts the end organ and senses and/or acts on the end organ. DBS electrodes are inserted into various deep gray nuclei, most commonly to treat the symptoms of movement disorders. Occipital, trigeminal, and spinal nerve stimulation devices are used as second-line therapy to control craniofacial or back pain. For cardiac devices, the authors describe two newer devices, the subcutaneous implantable cardioverter defibrillator and the leadless pacemaker, both of which avoid complications related to having leads threaded through the venous system. Diaphragmatic stimulation devices stimulate the phrenic nerve to restore diaphragmatic movement. Gastric electrical stimulation devices act on various parts of the stomach for the treatment of gastroparesis or obesity. Finally, SNS devices are used to modulate urinary and defecatory functions. Common complications diagnosed at imaging include infection, hematoma, lead migration, and lead breakage. Understanding the components, normal function, and normal imaging appearance of each device allows the radiologist to identify complications. ©RSNA, 2019.

Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations.

BACKGROUND: Children presenting to the emergency department with acute psychosis or hallucinations sometimes undergo a head CT to evaluate for a causative lesion. The diagnostic yield of head CT in this scenario has not been reported. OBJECTIVE: To determine the yield for head CT in children with acute psychosis or hallucinations. MATERIALS AND METHODS: We retrospectively searched the radiology report database over a 7.5-year period for head CT reports for pediatric emergency department patients using the following keywords: hallucination, psychosis, psychotic or "hearing voices." All reports were categorized as normal or abnormal, and we reviewed and categorized the abnormal cases. We calculated the 95% confidence interval for abnormal CTs using the method of Clopper and Pearson. RESULTS: We identified 397 pediatric emergency department head CTs. We excluded one non-diagnostic exam. We excluded 34 additional cases (which were all normal) because of clinical indications that might have independently triggered a head CT. Of the remaining 362 cases, 12 reports described abnormalities or variants and we reviewed them individually. Based on consensus review, four were normal, four had congenital malformations, three had encephalomalacia versus demyelination and one demonstrated cortical atrophy. There were no cases with actionable findings such as mass, hemorrhage, infection or hydrocephalus. The 95% confidence interval for a CT demonstrating causative findings was calculated at 0-0.82%. CONCLUSION: In the absence of concerning factors such as focal neurological deficits, evidence of central nervous system infection, trauma or headache, routine screening head CT might not be warranted in children presenting with acute psychosis or hallucinations.

New CT-based diagnoses of torso cancer is low in the emergency department setting.

PURPOSE: The incidence of new CT-based torso cancer diagnoses and the most commonly diagnosed cancer types in the emergency department (ED) setting are unknown. The purpose of our study was to determine the incidence and types of new CT-based torso cancer diagnoses in the ED. METHODS: A total of 19,496 CT reports including all or parts of the torso from 2017 were searched for the keywords: "mass", "tumor", "neoplasm", "malignancy", or "cancer". Each report and corresponding medical record was evaluated for presence of a new cancer. Cases were scored as no cancer, subcentimeter lung nodule, known cancer, new cancer, or suspicious, but unconfirmed for new cancer. Each mass was characterized as symptom-related or incidental. RESULTS: At least one keyword was found in 2086 reports. Of these 706, 126 and 905 were known cancer cases, subcentimeter lung nodules, and non-cancerous cases, respectively. There were 251 confirmed new cancers and 98 suspicious cases which lacked adequate diagnostic workup. Depending on whether only definite or definite and suspicious cases were included together, the number of new cancer cases per 100 torso CT exams was 1.3 or 1.8, respectively. Gastrointestinal, lung, pancreaticobiliary, urinary, and gynecologic cancers were most common. Only 58 of the confirmed cases (23%) were deemed as incidental findings. CONCLUSION: CT-diagnosis of new torso cancers was uncommon in our setting. Still, while extensive knowledge of cancer staging may not be necessary for ED radiologists, knowledge of the most common types of cancer including gastrointestinal, lung, pancreaticobiliary, urinary, and gynecologic cancers may improve sensitivity for these diagnoses and may expedite appropriate referrals for the newly diagnosed patients.

Causes of pneumocephalus and when to be concerned about it.

Intracranial gas is commonly detected on neuroimaging. The recognition of this finding can at first blush be unsettling. Being able to localize this gas to a specific compartment: intraarterial, intravenous, intraparenchymal, subdural, epidural, subarachnoid and intraventricular, is the first step in determining the importance of the gas. Determination of the route of entry: through the skull, extension from a paranasal sinus or the mastoid air cells, via the spine, or trans-vascular, is the other important factor in determining potential consequences. Understanding these parameters allows for a confident determination of etiology. More importantly, it generally provides guidance as to what must be done: either to disregard (e.g., subarachnoid gas following lumbar puncture and intravenous gas following IV placement), obtain follow-up (e.g., postoperative gas), or administer emergent treatment (e.g., intraarterial gas and epidural abscess). In this review, we use gas location and route of entry to classify the various causes of pneumocephalus and provide examples of each of these etiologies.

Discrimination of capsular stage brain abscesses from necrotic or cystic neoplasms using diffusion-weighted magnetic resonance imaging.

OBJECT: The authors' aim was to assess the ability of apparent diffusion coefficient (ADC) ratios in distinguishing brain abscesses from cystic or necrotic neoplasms. METHODS: Fifty-three patients with rim-enhancing masses in the brain observed on T1-weighted MR images were included: 26 had abscesses (14 bacterial, six nonbacterial, and six of unknown origin), 11 had glioblastoma multiforme, and 16 had rim-enhancing metastasis. The ADC values, derived from diffusion-weighted imaging, were measured in the most homogeneous portion of the cystic component of the mass. The ADC ratios were calculated by dividing the ADC values from the nonenhancing cystic portion of the mass by the ADC values from contralateral normal-appearing white matter. Lesions were further differentiated based on presence, absence, or incompleteness of a T2 hypointensity rim. The mean (+/- standard deviation) ADC ratios were significantly higher in neoplasms than in abscesses (2.45 +/- 0.91 compared with 1.12 +/- 0:53, p < 0.01). The accuracy of ADC ratios in discriminating abscesses from neoplasms, determined by the area under the receiver operating characteristic curve (Az), was high: 0.91 +/- 0.04 (mean +/- standard error of the mean [SEM]). The threshold of 1.7 was associated with highest efficiency (87%) in discriminating abscesses from neoplasms. If only bacterial abscesses were analyzed compared with neoplasms, the Az increased to 0.96 +/- 0.03 (SEM). Using ADC ratios and T1 rim characteristics, 50 of 53 lesions were correctly classified (efficiency 94.3%). CONCLUSIONS: The accuracy of ADC ratios in discriminating brain abscesses from cystic or necrotic neoplasms is very high and can be further improved using T2 rim characteristics.